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63,852
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52058
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Discharge summary
|
report
|
Admission Date: [**2123-6-22**] Discharge Date: [**2123-6-25**]
Date of Birth: [**2066-10-26**] Sex: F
Service: UROLOGY
Allergies:
Actifed / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Hypotension, Tachycardia
Major Surgical or Invasive Procedure:
Ureteroscopy & Lithotripsy [**2123-6-22**]
History of Present Illness:
56 yo F with history of UTIs and h/o nephrolithiasis who was
transferred to [**Hospital1 18**] from [**Hospital3 417**] [**2123-6-17**] for fever up
to 100.7, chills, and resistent E coli infection (amp, cipro,
Bactrim, levofloxacin). She completed a 10 day course of Keflex
on [**6-7**]. By [**2123-6-16**], she has recurrence of her symptoms,
including fever, chill, nausea, back pain, dysuria, and urinary
frequency. She endorsed loss of 20 lbs since this month because
of loss of appetite.
She went to [**Hospital3 417**] on [**6-17**] and then has received IV
ceftriaxone in the OSH, with discharge over the weekend but
continued to receive IV abx in OSH ED until today. She came in
today for a planned ureteroscopy/laser lithotripsy proceudre
today.
.
Of note, she was recently evaluated by urology, Dr. [**Last Name (STitle) 3748**], on
[**2123-6-4**]. Per OMR, it was decided that she was going to
undergo ureteroscopy for 1.2 cm right renal calculus and
followed by a stent 1 week after. It was noted that it may take
a couple procedures to break up the stones afterwards.
.
She underwent the scheduled procedure and received 2 g Anceph
and gentamycin prior to procedure for resistent E. coli (to amp
and cipro). She was noted to have tachycardia up to the 120s
with SBP in the 90s and temperature of 100.2 which then rose to
103.9 with rigor prior to transfer. She received 4 L of IVF in
OR/PACU and 650 mg of Tylenol po. She is transferred to [**Hospital Unit Name 153**]
for concern of urosepsis.
.
On the floor, she reports feeling better than earlier this
afternoon, but has lower pelvis/abd pain and urinary urgency.
Mild lightheadedness if sitting up too fast. Has baseline SOB
with climbing stairs. Also had some rash and leg cramps with
some antibiotics over the last 6 months. Reports baseline SBP
mostly in the 120s
.
Of note, last colonoscopy was [**2117**] which was normal and has
regular GYN exam, normal as well.
.
Review of sytems:
(+) Per HPI
(-) Denies weight gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied cough. Denied chest pain or
tightness, palpitations. Denied current nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits.
Past Medical History:
- History of UTI with E. coli resistant to ampicillin, Cipro,
Bactrim, and Levaquin.
- History of nephrolithiasis
- History of bronchitis
- s/p right ureteroscopy with laser lithotripsy 10 years ago
- Asthma
- Osteoarthritis
- Anal fissure
- post-menopausal since [**2115**]
Social History:
- has 1 son- [**Name (NI) 8516**]
- lives with life time partner- [**Name (NI) 3613**]
- a social worker at [**Location (un) 14221**] Mental Health
- smokes [**1-24**] ppd since [**32**] (23 pack-year)
- occasional alcohol once a month
- denies drug use
Family History:
- nephrolithiasis in sister
- uterine cancer in mother, aunt, grandmother
Physical Exam:
Vitals: T:101.6 BP:82/50 P:112 R:21 O2: 93% on 4L NC
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, mucous membrane dry, + dental caries
and missing teeth, otherwise no lesions in OP
Neck: supple, JVP not visible, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm, tachycardic, normal S1 + S2, unable to
appreciate murmurs, rubs, gallops
Abdomen: soft, diffuse tenderness, mostly in the lower
mid-abdomen/pelvic area, BS+, no rebound, no guarding, no
organomegaly
GU: no foley
Back: tender to palpation in the flanks bilaterally
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2123-6-22**] 03:50PM BLOOD WBC-2.9*# RBC-3.73* Hgb-11.7* Hct-34.5*
MCV-93 MCH-31.4 MCHC-33.9 RDW-13.8 Plt Ct-225
[**2123-6-22**] 03:50PM BLOOD Neuts-72* Bands-3 Lymphs-22 Monos-1*
Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-0
[**2123-6-22**] 03:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2123-6-22**] 03:50PM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-142
K-3.8 Cl-103 HCO3-27 AnGap-16
[**2123-6-22**] 03:50PM BLOOD Albumin-3.8 Calcium-9.0 Phos-2.7 Mg-1.4*
[**2123-6-22**] THEOPHYLLINE <2.5 L
[**2123-6-22**] 10:52PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2123-6-22**] 10:52PM URINE Blood-LG Nitrite-POS Protein-100
Glucose-TR Ketone-NEG Bilirub-SM Urobiln-2* pH-6.0 Leuks-LG
[**2123-6-22**] 10:52PM URINE RBC->182* WBC-171* Bacteri-NONE
Yeast-NONE Epi-1
[**2123-6-22**] 10:52PM URINE CastHy-12*
[**2123-6-22**] 10:52PM URINE Mucous-OCC
Microbiology
[**6-22**]
- blood cultures x2
- urine culture x1
[**6-23**]
- blood cultures x2
Brief Hospital Course:
56 yo F with history of nephrolithiasis and recurrent resistent
E. coli UTIs presents with urosepsis after recent UTI and
scheduled ureteroscopy/laser lithotripsy.
Pt was transferred to ICU from PACU for tachycardia, high fever
to 102.5, and hypotension. Cultures were sent from blood and
urine. IVF boluses were administered to maintain pressures with
systolics in 90s. Her tachycardia improved with fluid
resuscitation. Cefepime IV was given empirically. Tylenol and
narcotic pain medication were given as needed. A foley was
placed given the large amount of urine the patient was making.
She initially required O2 upon arrival in the [**Hospital Unit Name 153**], but this was
weaned after autodiuresis and a 20mg dose of lasix. She
continued her home asthma medications. A CXR showed no acute
process. Her electrolytes were watched closely with serial labs
and repleted as necessary. Her fever curve trended down and she
was transferred to the floor when her hemodynamics remained
stable without intervention for 24h period. She remained
afebrile on the floor and was dc'd with antibiotics. We will
f/u her culture results and alter these PRN. She was
ambulating, voiding, without requiring oxygen, with adequate
pain control and afebrile prior to d/c. She will f/u with Dr.
[**Last Name (STitle) 3748**] as an outpatient.
Medications on Admission:
Benicar- recently stopped
ranitidine 150 mg [**Hospital1 **]
Uniphyl 200 mg daily
ibuprofen prn
Tylenol prn
Pyridium
Advair 250/50 [**Hospital1 **]
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, symptomatic fever.
Disp:*30 Tablet(s)* Refills:*1*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. phenazopyridine 100 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for dysuria for 3 days.
Disp:*24 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
tachycardia and fever following lithotripsy
Discharge Condition:
stable, afebrile, oriented, ambulating
Discharge Instructions:
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequecy over the next month.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-complete your full course of antibiotics
Followup Instructions:
-Call Dr.[**Name (NI) 11306**] office ([**Telephone/Fax (1) 8791**] for follow-up AND if
you have any questions (page Dr. [**Last Name (STitle) 3748**] at [**Telephone/Fax (1) 2756**]).
|
[
"493.90",
"592.0",
"458.9",
"305.1",
"780.62",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.74",
"59.8",
"56.0"
] |
icd9pcs
|
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[
[]
]
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5072, 6415
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328, 372
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7594, 7635
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4010, 5049
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8384, 8573
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6613, 7477
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7659, 8361
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3323, 3991
|
264, 290
|
2370, 2648
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400, 2352
|
2670, 2946
|
2962, 3217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,260
| 157,479
|
52239
|
Discharge summary
|
report
|
Admission Date: [**2166-5-14**] Discharge Date: [**2166-5-26**]
Date of Birth: [**2100-10-22**] Sex: M
Service: MEDICINE
Allergies:
Darvocet-N 50
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Hypotension, dark stools
Major Surgical or Invasive Procedure:
Upper [**First Name3 (LF) **] [**2166-5-23**] with argon-plasma coagulator
History of Present Illness:
65 yo M with h/o CAD and MI s/p ICD and stents, s/p mechanical
AVR, h/o CVA x4 on warfarin complicated by freqeunt hemorrhagic
gastritis presents today to the ED with hypotension in the
setting of getting blood transfusion because of a hematocrit
drop from the mid 20s to 19.7 and INR of 2.5. Per the
transfusion clinic note, patient was getting 2 units of pRBC,
but after 1 unit, dropped SBP 98/60 to 82/49, mentating well.
He denied any melanic stools. No symptoms of lightheadedness,
dizziness, SOB, chest discomfort, nausea, vomiting, diarrhea.
In the ED, initial vs were: T 99.2, P 86, BP 92/45, R 18, O2
100%, 4L NC. Labs were drawn in the ED and given his relative
hypotension and complex medical history, including GIB, patient
was transferred to the ICU for closer monitoring.
On the floor, patient reports having generalized weakness that
has persisted since his last admission. He denies any new DOE,
chest discomfort, abdominal pain, nausea, vomiting, or diarrhea.
His BM has been regular, once a day, and the color has been
dark, but slightly lighter than during his last admission. He
reports taking all of his medications, including the new ones,
since the day prior to admission. He denies NSAID use or
alcohol consumption.
Past Medical History:
- CVA x 4 (most recent [**7-9**] while on warfarin, ASA and plavix -
though this CVA was not proven on MRI; last MRI in '[**59**] showed
microvascular disease but no signs of embolic stroke)
- hemorrhagic gastritis
- Benign Hypertension
- CAD - single vessel distal LAD, s/p MI [**2164**], 3 stents unknown
type unknown date
- s/p ICD implantation [**2163-12-8**] Parciology PC [**Telephone/Fax (1) 107924**]
- Diastolic CHF - preserved EF, diastolic
- AVR - Mechanical valve [**2159-3-31**]
- Diabetes mellitus, type II
- COPD
- Low Back Pain
- Nephrolithiasis
- Duodenal ulcer on EGD [**2161-9-28**]
Social History:
- Smoking/Tobacco: 60 pack years, quit 2 years ago.
- EtOH: seldom.
- Illicits: IV drugs once in his life when young, never again.
- Lives at/with: daughter and her family. She assists with his
medications. Independent with ADLs and ambulates with cane. From
[**2162**]-[**2164**] he lived in [**State 9512**] and so we have no records of his
care at that time. He states that he has never been in the
military, never been incarcerated although he has been around
individuals who have. He is not currently sexually active and
has had female partners in the past.
Family History:
There is diabetes mellitus, hypertension and dyslipidemia in
several immediate family members. His sister had CHF/?MI
begining in her late 40s. His mother had breast cancer and CHF.
Physical Exam:
ADMISSION EXAMINATION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to the ear lobes
Lungs: clear to ausculation with very faint crackles at the
bases
CV: irregular rhythm at times, 4/6 systolic murmur through all
fields, best heard in the RUSB and LUSB.
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis.
2+ pitting edema up to the thighs bilaterally
DISCHARGE EXAMINATION:
VS: Afebrile, SBP 90-100's, HR 70-80's
GEN: NAD
CV: RRR, mechanical valve systolic murmur
CHEST: CTAB
ABD: Soft, nontender, nondistended, bowel sounds normal
NEURO: Alert and oriented x3, attentive, fluent speech
PSYCH: Calm, appropriate
Pertinent Results:
1. Labs on admission:
[**2166-5-14**] 07:20PM BLOOD WBC-6.3 RBC-2.39* Hgb-7.7* Hct-22.3*
MCV-93 MCH-32.2* MCHC-34.6 RDW-18.1* Plt Ct-135*
[**2166-5-14**] 11:30AM BLOOD PT-26.6* INR(PT)-2.5*
[**2166-5-14**] 07:20PM BLOOD Glucose-135* UreaN-35* Creat-0.9 Na-138
K-3.9 Cl-107 HCO3-22 AnGap-13
[**2166-5-15**] 02:37AM BLOOD ALT-18 AST-36 LD(LDH)-209 CK(CPK)-42*
AlkPhos-63 TotBili-1.9*
[**2166-5-15**] 02:37AM BLOOD Lipase-87*
[**2166-5-14**] 07:20PM BLOOD cTropnT-<0.01
[**2166-5-15**] 02:37AM BLOOD CK-MB-3 cTropnT-<0.01
[**2166-5-15**] 02:37AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.4 Mg-1.8
2. Labs on discharge:
[**2166-5-26**] 04:04AM BLOOD WBC-8.3 Hgb-8.4* Hct-25.6* MCV-97
RDW-16.9* Plt Ct-141*
[**2166-5-26**] 04:04AM BLOOD INR-1.6*
[**2166-5-26**] 04:04AM BLOOD Glu-167* UreaN-18 Cr-0.9 Na-141 K-3.8
Cl-108 HCO3-26
[**2166-5-14**] ECG:
Sinus rhythm with top normal P-R interval, approximately 200
milliseconds.
Ventricular premature depolarizations. Inferior myocardial
infarction of
indeterminate age. Diffuse non-diagnostic repolarization
abnormalities.
Compared to the previous tracing of [**2166-4-29**] right bundle-branch
block is no longer evident.
[**2166-5-14**] CXR: Cardiomegaly with bilateral pleural effusions and
mild pulmonary edema. PICC line tip appears to be located within
the cavoatrial junction
[**2166-5-16**] CXR: Increased moderate bilateral pleural effusions with
persistent mild pulmonary edema.
[**2166-5-17**] SHOULDER X RAY: Clustered periarticular calcifications
in keeping with clinically suspected calcific tendinitis
[**2166-5-20**] HEAD CT W/O CONTRAST:
No acute intracranial hemorrhage and no CT evidence of an acute
major vascular territorial infarction. MRI would be more
sensitive for an
acute infarction, if clinically warranted.
[**2166-5-23**] EGD
Many angioectasias were seen in the stomach. The lesions were
distributed in a watermelon-stomach pattern, consistent with
GAVE. An Argon-Plasma Coagulator was applied for hemostasis
successfully. Otherwise normal EGD to 3rd part of duodenal.
Brief Hospital Course:
65 year old man with coronary artery disease and stenting in the
distal LAD, mechanical AVR, and CVA x4 on warfarin complicated
by frequent hemorrhagic gastritis (also has known gastric AVM
and colon diverticulosis) who presented to the ED with
hypotension during outpatient regular blood transfusion. He was
at high risk for GI bleeding given his history and
anticoagulation with warfarin despite decreased therapeutic goal
to INR = [**1-2**]. His most likely source of bleeding was from upper
GI tract given his history of hemorrhagic gastritis and gastric
AVM. He had a recent colonoscopy in [**Month (only) 116**] that showed
diverticulosis, which can also potentially bleed. His INR was
2.6 on admission. He was treated with pantoprazole IV then PO.
From [**5-14**] to [**5-23**], he received a total of 7 units of PRBC
transfusion for continually dropping hematocrit. After much
discussion with GI, Cardiology, and the patient, the decision
was made to pursue EGD with possible use of argon-plasma
coagulator. Coumadin stopped and INR allowed to drift down to
1.5. EGD performed on [**5-23**] revealing angioectasia.
Argon-plasma coagulator treatment was applied. Heparin gtt
started after the EGD and Coumadin started the day after the
procedure. For the 72 hours following the procedure, the
patient's HCT remained stable even while the PTT was in or above
the therapeutic range. Dr. [**First Name (STitle) 437**], the patient's cardiologist
said it was okay to stop heparin once the INR was close to the
therapeutic range. Specifically, INR 1.6 was okay for heparin
to be stopped. The reason is that clot formation on a
prosthetic valve in the aortic position is relatively low. The
patient was discharged home with slightly subtherapeutic INR
with instructions to continue taking warfarin only for
anticoagulation.
The patient does have borderline hypotension and SBP in the
outpatient setting is usually 100-120. He was initially
euvolemic on exam but CXR showed some edema and bilateral
pleural effusions. We continued on atorvastatin but initially
held metoprolol and diuretics in the setting of borderline
hypotension. He then developed some dyspnea and chest pain.
Repeat EKG showed old unchanged posterior, inferior and lateral
q waves and cardiac enzymes were normal. Repeat CXR showed
increased moderate bilateral pleural effusions with persistent
mild pulmonary edema. Extra doses of Lasix were used. He was
then restarted on his home dose of torsemide. He continued to
have edema but was not actively diuresed until after his
bleeding was controlled.
He is off aspirin but can restart if chest pain. However,
currently the patient's more acute and life threatening probelm
is bleeding, and he is already on coumadin for his aortic valve,
which should offer some but not ideal protection against
recurrent MI. He then developed shoulder pain consistent with
calcific tendenitis/capsulitis. He had severe tenderness and an
X ray confirmed calcific tendonitis. He was seen by orthopedics
who stated this was either tendonitis or arthritis and he was
developing frozen shoulder so he was treated with steroid
injection which over time in conjunction w/ po oxycodone
improved his symptoms. He should follow up in shoulder clinic in
[**12-1**] weeks post discharge.
Problem [**Name (NI) **]:
# GI bleed [**1-1**] angioectasias s/p EGD with APC on [**5-23**]. GI
recommends continuing Pantoprazole and Sucralfate until patient
seen again in [**Hospital **] clinic in [**Month (only) 216**].
# Acute blood loss anemia: Recommend close outpatient monitoring
of HCT.
# Mechanical AV valve: Heparin gtt used until INR only slightly
subtherapeutic. Dr. [**First Name (STitle) 437**] (cardiology) recommends lowering INR
target to 2.0-2.5. He also said that heparin bridge no longer
needed with INR 1.6 because the risk of clot formation with a
prosthesis in the aortic position is relatively low. Warfarin
administration history:
- [**5-24**] Coumadin 1mg
- [**5-25**] Coumadin 1 mg
- [**5-26**] Coumadin 3 mg
INR [**5-26**] 1.6. [**Hospital3 271**] is aware that the patient
discharged home with Warfarin dose of 3mg.
# Diastolic heart failure, chronic, stable: Patient diuresed
with Torsemide
# L shoulder pain with active/passive movement, question of
arthritis vs. calcific tendonitis and developing frozen
shoulder, s/p steroid/lido injection by ortho. Improved w/PO
oxycodone. Patient to follow-up with ortho as outpatient.
# Delirium, stable and slowly improving. Oxycodone exacerbates
his delirium, so wean off this med as soon as possible. Head CT
negative and no focal deficits. Mental status much better when
not on oxycodone.
# CAD: Continue Metoprolol, Atorvastatin. No aspirin [**1-1**] on
warfarin. Aspirin may be restarted if patient starts having
anginal symptoms.
# TRANSITION OF CARE ISSUES:
- Monitor HCT very closely
- [**Hospital3 271**] to help manage Warfarin dosing and INR
checks
- Assess volume status and adjust diuretic regimen as indicated
Medications on Admission:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Citracal + D Petites 200 mg calcium -250 unit Tablet Sig:
Three (3) Tablet PO Every Morning.
3. Citracal + D Petites 200 mg calcium -250 unit Tablet Sig: Two
(2) Tablet PO At Night.
4. Bactroban Nasal 2 % Ointment Sig: One (1) application Nasal
twice a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-1**] Sprays Nasal
[**Hospital1 **] (2 times a day).
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for pain.
10. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual PRN as needed for chest pain: Please call your doctor
if you use this medication.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
16. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
18. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day:
Please have your INR checked weekly to adjust dose of warfarin.
Your goal INR is 2.0-3.0. [**Hospital1 **]:*90 Tablet(s)* Refills:*2*
19. iron 325 mg (65 mg iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day. [**Hospital1 **]:*30 Capsule,
Extended Release(s)* Refills:*2*
20. Vitamin B-12 1,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day. [**Hospital1 **]:*30 Tablet Extended
Release(s)* Refills:*2*
21. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day: Please take with iron
to increase absorption. [**Hospital1 **]:*30 Capsule, Extended Release(s)*
Refills:*2*
22. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citracal + D Petites 200 mg calcium -250 unit Tablet Sig:
Three (3) Tablet PO every morning.
3. Citracal + D Petites 200 mg calcium -250 unit Tablet Sig: Two
(2) Tablet PO every night.
4. Bactroban Nasal 2 % Ointment Sig: One (1) application Nasal
twice a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
6. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-1**] Sprays Nasal
[**Hospital1 **] (2 times a day).
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for pain.
10. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Please call your doctor if you have chest pain.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-1**] puff Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
16. warfarin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime.
17. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
18. Vitamin B-12 1,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
19. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day: Take with iron to help
increase iron absorption.
20. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute on chronic blood loss anemia from GI bleed
Angioectasias
SECONDARY DIAGNOSES:
Mechanical aortic valve
Coronary artery disease
Diastolic heart failure
Diabetes mellitus, type II
Calcific tendonitis, left shoulder
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 for bleeding from your stomach which required
blood transfusions. An [**Name (NI) **] on [**5-23**] revealed a condition in
your stomach called Angioectasias which is the cause of your
bleeding. This condition was controlled during the [**Month/Year (2) **].
Since the procedure, your blood count has been stable.
Heparin and Warfarin were restarted after the procedure and you
did not have any bleeding. You are being discharged with an INR
1.6 and your cardiologist, Dr. [**First Name (STitle) 437**], says it is okay to come
off the Heparin at that level.
Please weigh yourself every morning, call your primary doctor if
weight goes up more than 3 lbs.
MEDICATION CHANGES:
1. START Metoprolol 25 mg once daily for blood pressure control
2. DOSE CHANGE Warfarin 3 mg once daily until otherwise directed
by the Anticoagulation (Coumadin) Clinic.
3. All other medications are unchanged.
Followup Instructions:
Regarding your anticoagulation, you should contact the
[**Hospital3 **] at [**Telephone/Fax (1) 2173**] to determine when your
next INR check should be.
Department: LIVER CENTER
When: WEDNESDAY [**2166-5-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
When: THURSDAY [**2166-5-29**] at 11:00 AM
With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up
Department: INFUSION/PHERESIS UNIT
When: WEDNESDAY [**2166-5-28**] at 1 PM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFUSION/PHERESIS UNIT
When: WEDNESDAY [**2166-6-4**] at 8:15 AM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: ORTHOPEDICS
When: TUESDAY [**2166-6-10**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2166-6-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2166-6-23**] at 1:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GASTROENTEROLOGY
When: [**2166-7-29**] at 9:30 AM
With: DR. [**First Name8 (NamePattern2) 21154**] [**Name (STitle) **] [**Telephone/Fax (1) 463**]
Building: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"428.0",
"V43.3",
"412",
"280.0",
"726.11",
"414.01",
"537.83",
"428.33",
"V45.82",
"250.02",
"401.1",
"348.30",
"496",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
15643, 15714
|
5972, 10979
|
300, 376
|
15996, 15996
|
3901, 3909
|
17112, 19947
|
2875, 3058
|
13496, 15620
|
15735, 15818
|
11005, 13473
|
16179, 16857
|
3073, 3882
|
15839, 15975
|
16877, 17089
|
236, 262
|
4515, 5949
|
404, 1654
|
3923, 4496
|
16011, 16155
|
1676, 2279
|
2295, 2859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,920
| 157,485
|
33980
|
Discharge summary
|
report
|
Admission Date: [**2118-3-29**] Discharge Date: [**2118-4-1**]
Date of Birth: [**2035-7-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Jaw Pain
Major Surgical or Invasive Procedure:
[**3-29**]: Cardiac catheterization
[**3-29**]: Balloon angioplasty
[**3-30**]: Transthoracic [**Month/Year (2) **]
History of Present Illness:
82 year old female with hx of Diabetes Mellitus II diet
controlled transferred from OSH with STEMI. Patient states that
yesterday evening she developed jaw pain. She admits to having
had jaw pain once 6 years ago and was told by her PCP that it
was 'angina'. She was given pills (nitroglycerin?) but decided
to take herbal medications instead, [**Location (un) 42317**] extract. She had
no subsequent events until yesterday. She was getting ready to
take a shower when she developed the jaw pain yesterday. She was
worried as it was similar to her previous 'angina' episode and
went to the ED. Her pain was associated with diaphoresis. She
denies chest pain, DOE, SOB, N/V, fevers, chills, orthopnea, PND
or ankle swelling.
.
Patient was seen at [**Hospital3 2737**] for evaluation of her jaw
pain. EKG's were notable for STEMI. She was given ASA 81mg x 4,
NTG, Lopressor IV, Plavix 600mg x 1, Heparin gtt and transferred
here for cardiac catheterization which was notable for
thrombotic occlusion distally of OM2 without collaterals and
received PTCA of the OM2. No stent was placed. By report she
developed hypotension and VT while in the cath lab. However,
there is no documentation of this event. She was transferred to
the CCU for further management.
.
On arrival to the CCU the patient was chest pain free. She
denies any SOB, N/V, diaphoresis or palpitations.
Past Medical History:
Diabetes Mellitus - Diet controlled
Benign Skin Nodule resections
Social History:
Denies tobacco use. Occasional alcohol use, no illicit drug
use. Lives with her son [**Name (NI) **] and daughter-in-law. [**Name (NI) 4906**] is
deceased.
Family History:
Non-contributory
Physical Exam:
V/S Temp 98.3 BP 138/53 HR 66 RR 12 99% RA
Gen: NAD, lying comfortably in bed
HEENT: OP clear, MMM
Neck: no JVD
CVS: +S1/S2, II/VI blowing systolic murmur, RRR
Lungs: CTAB, no wheezes, crackles or ronchi
ABD: +BS, NT/ND, no hsm
EXT: no clubbing, cyanosis or edema
Pulses: +2 right femoral pulse, no hematoma/ecchymoses over cath
site, no bruit. +2 bilateral tibial/DP
Pertinent Results:
[**2118-3-29**] 11:15PM GLUCOSE-300* UREA N-21* CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
[**2118-3-29**] 11:15PM CK(CPK)-1504*
[**2118-3-29**] 11:15PM CK-MB-84* MB INDX-5.6
[**2118-3-29**] 11:15PM HCT-23.4*
.
[**2118-3-29**] Cardiac Catheterization:
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated
single vessel coronary artery disease. The LMCA and LAD had no
angiographically apparent flow-limiting disease. The LCx had a
thrombotic occlusion of the distal OM2 without collaterals. The
RCA had
mild luminal irregularities.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with a RVEDP of 14 mmHg and a mean PCWP of 23 mmHg.
There was
mild pulmonary arterial hypertension with a PA pressure of 40/20
mmHg.
There was mild systemic arterial hypertension with a central
aortic
pressure of 154/65 mmHg. The cardiac index was normal at 2.8
L/min/m2.
3. Successful PTCA of the upperpole of the second obtuse
marginal.
Final angiography demonstrated no angiographically apparent
dissection.
There was TIMI III flow at the PTCA site. However, there was a
distal
cut-off at the upper pole of the OM2. The lower pole of the
second
obtuse marginal remained totally occluded (See PTCA comments).
4. Successful closure of the right femoral arteriotomy site with
a 6F
Angioseal closure device.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Biventricular diastolic dysfunction.
3. Mild pulmonary arterial hypertension.
4. Mild systemic arterial systolic hypertension.
5. Acute inferoposterior myocardial infarction managed by acute
PTCA
to the upper pole of the obtuse marginal.
.
[**2118-3-30**] TTE:
Finding: The left atrium is elongated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with distal lateral hypokinesis. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. 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 mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
This is an 82 year old female (Jehovah's witness) with history
of Diabetes Mellitus Type II diet controlled who presents from
OSH with STEMI, now s/p cardiac catheterization with PCTA of
OM2.
Hospital course as outlined by problem below:
# CAD/Ischemia: Patient was admitted with STEMI to Obtuse
Marginal 2 artery as above. Her presenting symptom was jaw
pain. She was taken for cardiac catheterization and balloon
angioplasty was performed. No stent was placed as this would
necessitate long-term anticoagulation. Given the patient's
desire to avoid possible blood transfusions if necessary
(Jehovah's witness), it was decided to not place a stent in this
patient. Upon arrival to the floor, the patient had persistent
chest pain with deep inspiration. Her cardiac enzymes did not
rise and repeated ECG showed no signs of ischemia. The chest
pain was alleviated with Tylenol and began to subside by
hospital day 3. She was started on Aspirin 325mg daily, Toprol
XL 100mg daily, Atorvastatin 80mg daily, Lisinopril 2.5mg daily
and Nitroglycerin 0.3mg SL PRN.
# Rhythm: Upon completion of the catheterization procedure, the
patient reportedly developed ventricular tachycardia and
hypotension. She was stabilized and transferred to the CCU for
further care. The patient developed a tachyarrythmia to the
120/130's on hospital day 2 thought to represent atrial
tachycardia. She was initially treated with diltiazem without
resolution of tachyarrhythmia. Carotid massage was unsuccessful
in breaking the arrhytmia. She developed some hypotension with
diltiazem and therefore, diltiazem was titrated down and the
patient was started on increasing doses of metoprolol. Her
arrhythmia was eventually controlled with metoprolol and
returned to [**Location 213**] sinus rhythm. She was discharged on Toprol
XL as above.
# Pump: No history of CHF. Post-MI [**Location **] on [**2118-3-30**] showed LVEF
55% with mild regional LV systolic dysfunction with distal
lateral hypokinesis. She was continued on Metoprolol and
Lisinopril as above.
# Valves: 1+MR [**First Name (Titles) **] [**Last Name (Titles) 113**] ([**2118-3-30**])
# Anemia: Upon presentation the patient had a normocytic anemia
of unknown origen. Her hematocrit at the outside hospital was
29. Post catheterization her hematocrit was 23.4 without
obvious signs of bleeding. The following morning her hematocrit
was stable and her catheterization site showed no evidence of
hematoma or large ecchymosis. Iron, B12 and folate studies were
all within normal limits. No further blood draws were obtained
as assessment would not have changed management, as pt refused
the possibility of transfusion. She denied BRBPR or melena and
reported that she had never had a colonoscopy. Given her
continued anemia, she should have a screening colonoscopy for
evaluation. This should be followed by her PCP.
# DM: diet controlled at home. Poor control while inpatient so
sliding scale insulin increased. HbA1c 7.1 ([**2118-3-30**]). Diabetes
should be followed by her PCP as an outpatient.
Medications on Admission:
Multivitamins
[**Location (un) 42317**] extract
Cinnamon pills
Vitamin A and D
Glucosamine
Vitamin C
Coenzyme Q-10
Kutin
Discharge Medications:
1. Aspirin 325 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*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Please take one tablet every 5 minutes as needed. Do not exceed
3 doses in 15 minutes.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
5. Toprol XL 100 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:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Myocardial Infarction
.
Secondary Diagnosis:
Diabetes Mellitus Type II
Discharge Condition:
Hemodynamically stable, chest pain free
Discharge Instructions:
You were admitted to the hospital because you had jaw pain. You
were found to have had a heart attack. You underwent cardiac
catheterization and the blocked artery in your heart was opened
with a small balloon. After your procedure you had an
arrhythmia (abnormal heart beat) and low blood pressure, so you
were transferred to the cardiac intensive care unit. Once you
were stable, you were transferred out of the intensive care unit
and onto a normal hospital floor. However, you developed
another cardiac arrhythmia known as atrial tachycardia. You
were given a beta blocker to slow your heart rate. This was
successful and your heart beat returned to [**Location 213**].
You were seen by physical therapy and they thought that you were
safe to return home.
.
***We have made the following changes to your medications:
(1) Aspirin 325mg by mouth daily
(2) Atorvastatin 80mg by mouth daily
(3) Toprol-XL 150mg by mouth daily
(4) Lisinopril 2.5mg by mouth daily
(5) Nitroglycerin 0.3mg under the tongue as needed
.
Otherwise, we have not changed your medications.
.
Please go to all scheduled follow-up appointments as listed
below (PCP, [**Name Initial (NameIs) **]).
.
Please return to the ED if you develop jaw pain, chest pain,
palpitations, shortness of breath, nausea, vomiting or any other
concerning symptoms.
Followup Instructions:
Please present to the following appointments which have already
been scheduled for you:
.
DR. [**First Name4 (NamePattern1) 1955**] [**Last Name (NamePattern1) **] (Cardiology): Tuesday, [**4-12**] at 4 PM.
LOCATION: [**State **], [**Location (un) 2498**], [**Numeric Identifier 34093**]
PHONE: ([**Telephone/Fax (1) 20481**]
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (your primary physician): [**Last Name (LF) 2974**], [**4-15**] at
11:15 AM.
LOCATION: [**2118**], [**Location (un) 40609**], [**Numeric Identifier 78474**].
PHONE: ([**Telephone/Fax (1) 78475**]
|
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"997.1",
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icd9cm
|
[
[
[]
]
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[
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"88.56",
"00.66",
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icd9pcs
|
[
[
[]
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9128, 9134
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5081, 8151
|
278, 395
|
9268, 9310
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2495, 3884
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8323, 9105
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2106, 2476
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230, 240
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423, 1791
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9219, 9247
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|
1813, 1881
|
1897, 2057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,093
| 163,645
|
38467
|
Discharge summary
|
report
|
Admission Date: [**2174-7-15**] Discharge Date: [**2174-7-29**]
Date of Birth: [**2108-5-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Drainage from abdominal wound incision
Major Surgical or Invasive Procedure:
[**2174-7-15**]: 1. Exploratory laparotomy with extended right
hemicolectomy.
2. End ileostomy.
3. Mucous fistula.
4. Mobilization of splenic flexure.
5. Wide debridement and re-closure of right subcostal incision.
.
[**2174-7-22**]: EGD and cliping of anastamotic blood leak
.
[**2174-7-28**]: Bedside wound debridement
History of Present Illness:
HPI: Pt is a 66 yo male who is s/p side-to-side
gastrojejunostomy, open cholecystectomy, open wedge liver
biopsy, and multiple pancreatic biopsies for unresectable
Pancreatic cancer on [**2174-7-5**]. He did well post operatively(
please see previous discharge summary) and prior to discharge
had minimal erythema and small amount of serosanguinous drainage
from the abdominal wound. He was discharged on [**2174-7-11**]. Pt
presented to clinic today with increased drainage and erythema
at the R lateral edge of his wound. He has been afebrile at home
with no increase in abdominal pain.
Past Medical History:
- hypertension
- hyperlipidemia
- CAD s/p MI [**4-/2174**] s/p DES, also s/p CABG x5 [**6-/2173**]
- carotid stenosis (70% left carotid)
- pancreatic head adenocarcinoma s/p staging lap [**3-/2174**], s/p
gastrojejunostomy, open CCY, open wedge liver Bx, pancreatic Bx
[**2174-7-5**]
Social History:
Married, has 3 kids. Quit smoking and EtOH ~ 1 year ago
Family History:
Noncontributory
Physical Exam:
On Discharge:
VS: 98.2, 60, 130/54, 18, 97% RA
GEN: Pleasant man in NAD
CV: RRR
Lungs: CTA bilat, no r/rh/wh
Abd: Bilateral and midline incision with retantion sutures.
Incision packed with dry sterile gauze and covered with
[**Location (un) **] straps.
Extr: Warm, no c/c/e
Pertinent Results:
[**2174-7-15**] 10:06PM TYPE-ART PO2-228* PCO2-42 PH-7.41 TOTAL
CO2-28 BASE XS-2
[**2174-7-15**] 10:06PM GLUCOSE-129* LACTATE-1.4 NA+-131* K+-4.4
CL--101
[**2174-7-15**] 10:06PM HGB-10.4* calcHCT-31
[**2174-7-15**] 10:06PM freeCa-1.01*
[**2174-7-15**] 03:20PM GLUCOSE-90 UREA N-14 CREAT-0.6 SODIUM-139
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-33* ANION GAP-11
[**2174-7-15**] 03:20PM estGFR-Using this
[**2174-7-15**] 03:20PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-153*
AMYLASE-20 TOT BILI-0.6
[**2174-7-15**] 03:20PM LIPASE-36
[**2174-7-15**] 03:20PM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.2
[**2174-7-15**] 03:20PM WBC-14.2* RBC-3.33* HGB-9.3* HCT-28.9* MCV-87
MCH-27.9 MCHC-32.1 RDW-14.9
[**2174-7-15**] 03:20PM NEUTS-84.7* LYMPHS-8.8* MONOS-3.7 EOS-2.4
BASOS-0.4
[**2174-7-15**] 03:20PM PLT COUNT-503*#
[**2174-7-15**] 03:20PM PT-14.2* PTT-27.1 INR(PT)-1.2*
[**2174-7-26**] 02:59AM BLOOD WBC-12.8* RBC-3.48* Hgb-9.9* Hct-30.9*
MCV-89 MCH-28.6 MCHC-32.2 RDW-16.5* Plt Ct-395
[**2174-7-28**] 04:47AM BLOOD Glucose-131* UreaN-21* Creat-0.6 Na-136
K-4.0 Cl-106 HCO3-22 AnGap-12
[**2174-7-24**] 05:23PM BLOOD LD(LDH)-172
[**2174-7-28**] 04:47AM BLOOD Calcium-7.4* Phos-3.8 Mg-1.9
MICROBIOLOGY:
[**2174-7-16**] 4:26 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-7-22**]**
Blood Culture, Routine (Final [**2174-7-22**]): NO GROWTH.
[**2174-7-22**] 5:40 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2174-7-24**]**
MRSA SCREEN (Final [**2174-7-24**]): No MRSA isolated.
[**2174-7-15**] ABD CT:
IMPRESSION:
1. Large feculent collection in the right upper quadrant
communicating with the surgical incision, apparently arising
from a broad-based defect in the adjacent hepatic
flexure/proximal transverse colon, where there are findings
consistent with colonic ischemia/infarction.
2. Pancreatic head mass compatible with pancreatic
adenocarcinoma, as
previously demonstrated.
3. New bilateral pleural effusions, right greater than left.
4. Cholecystectomy and gastrojejunostomy.
[**2174-7-16**]: CHEST PORT:
FINDINGS: In comparison with the study of [**7-5**], the
intraperitoneal gas has totally resolved. Endotracheal tube has
been placed with its tip just above the clavicular level,
approximately 8 cm above the carina. Extensive
opacification at the right base with silhouetting the
hemidiaphragm and right heart border is consistent with collapse
of the right middle and lower lobe with associated pleural
effusion. There is also extensive opacification at the left base
medially, consistent with volume loss in the left lower lobe.
There is continued area of ill-defined opacification in the left
upper zone laterally with preservation of pulmonary markings.
Much of this could represent the overlapping shadow of the
scapula. Is there any clinical suspicion for loculated effusion
in this region?
[**2174-7-18**] CHEST PORT:
IMPRESSION: AP chest compared to [**7-17**]:
Moderate right pleural effusion has decreased. Lateral aspect
left lower
chest is excluded, but the remaining left pleural surface is
unremarkable. Previous left perihilar consolidation has
cleared. Heart size normal.
[**2174-7-22**] CHEST:
FINDINGS: ET tube is 13.3 cm from the carina. Right PIC catheter
tip projects over low SVC. NG tube is in nondistended stomach,
tip out of view. Sternotomy wires appear intact.
Moderate right pleural effusion is unchanged when compared to
[**2174-7-19**] exam. Bibasilar opacities, likely atelectasis,
are stable. No pulmonary edema or pneumothorax. Hilar,
mediastinal, and cardiac silhouettes are stable.
[**2174-7-26**]: CHEST:
The right central venous line has been removed. The right PICC
line tip is at the level of low SVC. There is no change in the
cardiomediastinal silhouette, right pleural effusion and
bibasilar atelectasis. There is interval improvement of the
aeration of the right upper lung. No evidence of pneumothorax
has been noted.
[**2174-7-16**] EKG:
Sinus rhythm with atrial premature beats. Consider left atrial
abnormality. Consider left ventricular hypertrophy. ST-T wave
abnormalities are non-specific. Since the previous tracing of
the same date no significant change.
[**2174-7-22**] EKG:
Sinus rhythm with atrial premature beats. Consider left atrial
abnormality. Left ventricular hypertrophy. ST-T wave
abnormalities may be due to left ventricular hypertrophy. Since
the previous tracing of [**2174-7-20**] no significant change.
[**2174-7-28**] EKG:
Normal sinus rhythm with occasional ventricular premature beats.
Consider left ventricular hypertrophy. ST-T wave changes in
leads II, III, aVF and V5-V6. Compared to the previous tracing
of [**2174-7-22**] these changes are similar to those noted at that time.
There is no diagnostic interval change.
Brief Hospital Course:
Patient is a 66 yo male who is s/p side-to-side
gastrojejunostomy, open cholecystectomy, open wedge liver
biopsy, and multiple pancreatic biopsies for unresectable
pancreatic cancer on [**2174-7-5**]. He did well post operatively(
please see
previous discharge summary) and prior to discharge had minimal
erythema and small amount of serosanguinous drainage from the
abdominal wound. He was discharged on [**2174-7-11**]. Pt presented to
clinic today with increased drainage and erythema at the R
lateral edge of his wound. He has been afebrile at home with no
increase in abdominal pain. On [**2174-7-15**] patient returned into
the hospital with increased drainage from his incision. On [**7-15**]
abdominal CT was obtained and demonstrated a feculent collection
in the RUQ communicating with surgical incision, arising from
broad-based defect in the adjacent hepatic flexure/proximal
transverse colon, complected with colonic ischemia/infarct.
Patient went to the OR at the same day and underwent exploratory
laparotomy with extended right hemicolectomy, end ileostomy,
mucous fistula, mobilization of splenic flexure and wide
debridement and re-closure of right subcostal incision. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor NPO, on IV fluids and antibiotics, with a foley catheter,
and Dilaudid PCA for pain control. The patient was
hemodynamically stable.
Neuro/Pain: The patient received Dilaudid PCA with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV/HEME: The patient has cardiac history significant for CAD s/p
CABG [**2172**] and MI s/p DES 6/[**2173**]. Patient takes Plavix and 325 mg
ASA daily. Patient was restarted on ASA on POD # 1, and his
Plavix was restarted on POD # 6. In evening POD # 6, patient
started to have bloody emesis, his Hct dropped to 24.4 from
30.1. Patient received 2 units of RBC and Hct improved to 26.5.
Patient continued to have bloody emesis and was transferred in
ICU.
ICU Course: Patient began coughing up blood ~9pm [**7-21**] and then
had about 125cc of bright red bloody emesis followed by 325cc of
bloody output from his ostomy at 3:30am [**7-22**]. Hct fell from 30.1
at 9pm to 24.8 at 3:30 am. Patient has been mildly tachycardic
from 88->105, however blood pressure has been stable sBP 130's.
Patient was started on ASA and Plavix [**7-21**], he received one dose
of each. GI was asked to see the patient urgently for an upper
endoscopy. During the EGD the the area of the efferent loop
demonstrated heaped up mucosa, and the bleeding seemed to be
coming from that area. Ultimately, after clips were placed, it
appeared that there was a long longitudinal vessel that, when a
clip was placed on it, would bleed from another site. After
multiple clips were placed, it appeared that there was necrosis
at the edge of the gastrojejunostomy that would continue to
bleed. No clear ulceration ever visualized. It appeared that
there was still oozing of blood at the time of removal of the
endoscope, after multiple clips were placed to the site of
bleeding. Sixteen endoclips were deployed at the bleeding site
at the gastrojejunostomy, approximately twelve applied to the
mucosa, but unsuccessful at achieving complete hemostasis. Five
injections of epinephrine 1/[**Numeric Identifier 961**] (total 6.5 cc) were injected
unsuccessfully for hemostasis. Patient was started on a Protonix
GTT and transfused 5u PRBC, 2u FFP, 1u platelets for this
episode of hematemesis. Serial Hct's were monitored and Serial R
IJ and R radial aline placed. On [**7-23**] patient started on
metoprolol for rate control and extubated. Vitamin K 10mg IV x1
given on [**7-24**] and, Hct remained stable at 28.9. NGT was
subsequently discontinued. Patient remained in the ICU for
monitoring on [**7-25**] and continued on TPN. On [**7-26**] patient was
stable transfer back to the floor.
On the floor, patient was stable from cardiac standpoint. He was
restarted on [**2174-7-26**], patient will restart his Plavix on
[**2174-8-1**]. Patient underwent several EKGs during hospitalization,
all results were stable and within patient's baseline.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Patient was started on TPN on POD # 4 and discontinued
on POD # 11. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. Patient
underwent ostomy teaching while in hospital, he needs to
continue teaching in rehab.
ID: Patient was started on vancomycin, Flagyl and Ciprofloxacin
on HD #1 empirically. He continued on antibiotics until
discharge in rehab facility. Patient remained afebrile during
hospitalization, WBC curve was monitored closely, and cultures
were negative. Wound care was done on daily bases and included
debridement and dressing changes, no signs or symptoms of
infection were noticed.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
low residue diet with supplements, ambulating with walker,
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Medications: Metoprolol Succinate ER 50', Lisinopril 2.5',
Simvastatin 40', Colchicine 0.6', Indomethacin 25TID,
Pantoprazole 40', Aspirin 325', Clopidogrel 75'
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
Heartburn.
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for Insomnia.
11. 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.
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. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: START
ON [**2174-8-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
1. Unresectable pancreatic cancer.
2. Extensive right colonic perforation.
3. Anastamosis bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with abdominal binder on only-
requires assistance or aid (walker).
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 [**3-28**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*Your dressing will be changed twice a day in Rehab with dry
sterile gauze.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2174-8-8**]
9:15 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Completed by:[**2174-7-29**]
|
[
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"272.4",
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"557.0",
"569.83",
"262",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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"99.15",
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icd9pcs
|
[
[
[]
]
] |
14326, 14397
|
6805, 12713
|
353, 676
|
14537, 14537
|
2020, 6782
|
16025, 16252
|
1693, 1710
|
12925, 14303
|
14418, 14516
|
12739, 12902
|
14742, 15321
|
15336, 16002
|
1725, 1725
|
1739, 2001
|
274, 315
|
704, 1295
|
14552, 14718
|
1317, 1603
|
1619, 1677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,136
| 172,029
|
41895
|
Discharge summary
|
report
|
Admission Date: [**2162-12-31**] Discharge Date: [**2163-1-7**]
Date of Birth: [**2102-3-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
[**2162-12-31**]
Laparoscopic/thoracoscopic minimally-invasive
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagogastrectomy, laparoscopic jejunostomy tube
placement, pericardial fat pad buttress
[**2163-1-6**]
I&D J tube site
History of Present Illness:
Mr. [**Known lastname 7168**] is a 60 year-old man with history of bleeding
peptic ulcer 1 year ago and during endoscopy he was found to
have
Barrett's esophagus. Biopsies showed High Grade Dysplasia. A
repeat Endoscopy with Dr. [**Last Name (STitle) 90957**] at [**Hospital1 2025**] in [**Month (only) **]/[**2162**] confirmed
HGD.
He reports occasional heartburn, approximately once a week. No
dysphagia, nausea, vomiting or change on bowel habits. No
abdominal pain. He reports normal appetite and no change in
weight.
Past Medical History:
PMH: PUD
PSH: None
Social History:
Cigarettes: [x] never [ ] ex-smoker [ ] current Pack-yrs:____
quit: ______
ETOH: [ ] No [x] Yes drinks/day: _18 beers/wk____
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation: owns and operates a restaurant in [**Location (un) 8117**] NH
Marital Status: [x] Married [ ] Single
Lives: [ ] Alone [x] w/ family [ ] Other:
Other pertinent social history:
Travel history:
Family History:
Father + colon Ca
Physical Exam:
PHYSICAL EXAM: Height: 67'' Weight: 221.2
lbs
Temp: 97 HR: 92 BP: 146/92 RR: 18 O2
Sat:96%
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2162-12-31**] 09:37AM GLUCOSE-188* LACTATE-2.2* NA+-136 K+-4.9
CL--102
[**2162-12-31**] 09:37AM HGB-14.0 calcHCT-42
[**2162-12-31**] 11:08AM GLUCOSE-185* LACTATE-3.2* NA+-136 K+-4.2
CL--103
[**2163-1-6**] Ba swallow :
No leak
[**2163-1-6**] CT abd/pelvis :
Subcutaneous air and possible extravasation of contrast through
jejunostomy tube in the deep subcutaneous tissue of the left
lateral aspect of the abdominal wall. Extensive surrounding soft
tissue edema and fat stranding. No intraabdominal fluid
collection or free air. Residual barium in neoesophagus without
evidence of extravasation. Expected small amount of free air in
the pleural spaces and interlobar septa.
Brief Hospital Course:
Mr. [**Known lastname 7168**] was admitted to the hospital and taken to the
Operating Room where he underwent a minimally invasive
laparoscopic/thorascopic [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagogastrectomy. He
tolerated the procedure well and returned to the PACU in stable
condition. He had an epidural catheter placed for pain control
which was effective. His hemodynamics remained stable.
Following transfer to the Surgical floor he continued to make
good progress. He had cyclic tube feedings started via his J
tube and were gradually increased to goal. His right
thoracotomy incision was healing well and he was able to
effectively use his incentive spirometer effectively. His
epidural catheter was removed on [**2163-1-5**] and Roxicet was given
via his J tube for pain control. He was able to void without
his catheter.
On [**2163-1-5**] he underwent a J tube study as he had significant
tan drainage from around the tube with surrounding cellulitis.
The study confirmed proper placement and no fractures in the
tube. He also had a barium swallow which showed no anastomotic
leak. After spiking a temperature to 101.6 he was pan cultured
and placed on Unasyn and Fluconozole. The area continued to be
cellulitic and firm. An abdominal CT showed subcutaneous air
and possible extravasation of contrast through
jejunostomy tube in the deep subcutaneous tissue of the left
lateral aspect of
the abdominal wall. Extensive surrounding soft tissue edema and
fat stranding was also noted. Given this finding, he
subsequently had the J tube removed at the bedide and the area
was I&D'd for a mod amount of pus. Deep cultures were taken and
the wound was loosely packed with saline moist to dry nu gauze.
Gram stains of these samples were positive for Gram positive
cocci and Gram negative rods, with cultures pending at the time
of discharge. Mr. [**Known lastname 90958**] blood cultures from [**2163-1-5**] remained
negative for growth by the time of discharge on [**2163-1-7**].
Following Mr. [**Known lastname 90958**] bedside incision and drainage of the
J-tube site, his wound appeared moderately improved, with slight
improvement noted in induration surrounding the site.
Given Mr. [**Known lastname 90958**] normal upper GI/swallow study, his chest tube
and JP drain were removed on [**2163-1-6**] without issue. His
post-pull CXR was unremarkable, and without evidence of residual
pneumothorax.
He began full liquids on [**2163-1-6**] and tolerated them well and
his pain was controlled with oral Roxicet. His port sites were
healing well. On the day of discharge, Mr. [**Known lastname 7168**] was ambulating
at baseline, with normal bowel/bladder function, mentating
appropriately, and reported well-controlled pain. He was stable,
with normal vital signs. Given his clinical status, he felt well
enough to be discharged home. Prior to discharge, he was
educated regarding his post-discharge follow up plans, diet, and
medications, and he verbally expressed understanding and
agreement with these plans.
Medications on Admission:
Protonix 40 mg daily
MVI 1 daily
Discharge Medications:
1. Roxicet 5-325 mg/5 mL Solution Sig: 5-10 mls PO every four
(4) hours as needed for pain.
Disp:*500 mls* Refills:*0*
2. Colace 60 mg/15 mL Syrup Sig: Twenty (20) mls PO twice a day.
Disp:*250 mls* Refills:*2*
3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*100 Tablet, Rapid Dissolve(s)* Refills:*2*
4. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig:
Ten (10) mL PO every twelve (12) hours for 10 days.
Disp:*200 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
AllcareVNA
Discharge Diagnosis:
Esophageal cancer.
J tube site infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting (take anti-nausea medication)
-Increased abdominal pain
-Incision develops drainage
-Remove chest tube bandage Saturday and replace with a bandaid,
changing daily until healed.
_ The VNA will help with your abdominal wound dressing changes.
Pain
-Roxicet as needed for pain
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Full liquid diet, may increase to soft solids over the next few
days as tolerated.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2163-1-13**] 2:00
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2163-1-20**] 2:00
Please report to the [**Location (un) **] Radiology Department in the
[**Hospital Ward Name 23**] Clinical Center 30 minutes before your appointment for a
chest xray.
Completed by:[**2163-1-7**]
|
[
"E878.8",
"682.2",
"996.69",
"427.1",
"530.85",
"150.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.52",
"42.41",
"96.6",
"46.32",
"46.41"
] |
icd9pcs
|
[
[
[]
]
] |
8062, 8103
|
4360, 7425
|
319, 570
|
8188, 8188
|
3651, 4337
|
9447, 9877
|
1675, 1695
|
7508, 8039
|
8124, 8167
|
7451, 7485
|
8339, 9424
|
1734, 3632
|
270, 281
|
598, 1122
|
8203, 8315
|
1144, 1165
|
1641, 1659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,181
| 102,801
|
41038
|
Discharge summary
|
report
|
Admission Date: [**2147-3-22**] Discharge Date: [**2147-3-24**]
Date of Birth: [**2069-10-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Carotid Stenosis
Major Surgical or Invasive Procedure:
Right carotid artery balloon and stenting
History of Present Illness:
Mr. [**Known lastname 6164**] is a 70 yo male with a history of DM2, PVD, HLD, s/p
CVA [**2136**] with residual left-sided weakness, multifactorial gait
disorder, chronic left ICA total stenosis, who presented for
carotid stenting for critical stenosis (>80%) of the right ICA,
enrolled in the CREATE study. There was some discrepancy between
CTA and carotid dupplex regarding severity of stenosis but both
studies referred to it as "high grade". Carotid stenting was
originally planned for yest but canceled due to patient anxiety.
Stenting was done successfully today and pt is coming to the CCU
for hemodynamic monitoring s/p CEA as surgery immediately next
to carotid sinus and concern that might be temporarily affected
post-op.
.
Currently, pt says he feels tired. He states he is just coming
to after his surgery and still isn't completely clear what all
has happened although he knows his carotid was fixed. Pt denies
any current dizziness, lightheadedness, change in vision,
nausea, chest pain, shortness of breath, neck pain, abdominal
pain, lower extremity numbness tingling or pain.
.
On review of systems, s/he denies any prior history bleeding at
the time of surgery, hemoptysis, or red stools. He does report
last bowel movement was yesterday and was black in color. He
denies black stools prior to that and states he has never had an
EGD and has no history of GI bleeding (pt is also on oral iron).
S/he denies recent fevers, chills or rigors. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
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:
- CVA [**11/2136**] at [**Hospital1 2025**] with mild residual left sided weakness and
STM deficits
- Chronic gait disturbance pre CVA, now worse ? related to
diabetic
neuropathy versus alcohol peripheral neuropathy. Uses walker and
not allowed to navigate stairs.
- Alcohol related peripheral neuropathy
- Prior alcohol abuse with abnormal liver function tests -> had
been off statins as a result
- Current tobacco use
- Depression - flat affect. Not currently on meds
- PVD
- Type 2 Diabetes - managed with diet and oral agents
- Chronic left ICA occlusion
- Hypertrigylceridemia
- Chronic skin ulcer
- Phalanx fracture
- Esophagitis - on Bx. Started on prilosec [**2143-2-14**]
- Hyperplastic Colon polyps - last [**Last Name (un) **] [**2143-2-14**] with 4
hyperplastic polyps with next [**Last Name (un) **] rec [**2148**]
- Anemia (Iron deficient with low transferrin sat 10.2%)
- Mild peripheral edema (thought [**2-8**] to venous insufficiency)
Social History:
He lives a [**Hospital1 **] House [**Hospital3 400**] in [**Hospital1 8**]. He has
never been married and does not have any children. His lawyer is
his health care proxy and is presently out of state. Patient is
able to consent for himself. He uses a walker for his chronic
gait disturbance. His case manager is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6330**] (cell)
[**Telephone/Fax (1) 89497**]; she will accompany him to the procedure. The house
manager is [**Doctor First Name **] [**Telephone/Fax (1) 89498**]. He does have some short term
memory deficits. He has had falls in the past andreports last
fall approximately 6 months ago.
ETOH: none at present. Prior alcohol abuse stopped after his CVA
Tobacco: Current use of [**1-8**] PPD with 10 pack yr hx
HCP: Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 89499**] [**Telephone/Fax (1) 89500**]
Contact upon discharge: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6330**]
[**Last Name (NamePattern1) **] Care Services: none
Family History:
Unknown
Physical Exam:
Admission:
VS: T=99.2 BP= 122/61 non-invasive and 123/56 on A-line (outside
baseline 110-120s/60s) HR=83 RR=[**12-24**] O2 sat= 96-98% on 2L NC
GENERAL: elderly male in NAD. Some difficulty with orientation
but answering questions appropriately and mood, affect
appropriate.
HEENT: Tongue midline, pupils equal and reactive, Sclera
anicteric. EOMI but lateral nystagmus. Conjunctiva were pink.
NECK: Supple with JVD barely visible above clavicle.
CARDIAC: RRR, normal S1, S2. [**2-12**] early systolic peaking murmur
best heart at RUSB. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB in
anterior and lateral fields, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, mildly distended. No HSM or tenderness.
EXTREMITIES: A-line in place on L wrist. Small surrounding
bleeding from placement. No c/c/e. Cath site in L groint with
small surrounding bleeding from palcement but no palpable
hematoma and no femoral bruit. Intact sensation bilateral lower
ext. No pain to palp
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Discharge Exam:
t: 98.4, P: 86, BP: 132/58, RR: 19, 98% on RA
GENERAL: elderly male in NAD. answering questions appropriately
and mood, affect appropriate.
HEENT: Tongue midline, pupils equal and reactive. EOMI but
lateral nystagmus.
NECK: Supple with JVD barely visible above clavicle.
CARDIAC: RRR, normal S1, S2. [**2-12**] early systolic peaking murmur
best heart at RUSB. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
ant/lat fields
ABDOMEN: Soft, mildly distended. No HSM or tenderness.
Normoactive BS
EXTREMITIES: A-line in place on L wrist. Small surrounding
bleeding from placement. No c/c/e. Cath site in L groint with
small surrounding bleeding from palcement but no palpable
hematoma and no femoral bruit.
PULSES:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Pertinent Results:
Admission Labs ([**2147-3-23**]):
Hct-33.8*
Glucose-156* UreaN-30* Creat-0.9 Na-140 K-4.1 Cl-107
Glucose-135* Lactate-2.4* Na-140 K-3.4* Cl-108
freeCa-1.04*
.
Hct Trend:
[**2147-3-23**] 07:05AM BLOOD Hct-33.8*
[**2147-3-23**] 08:18PM BLOOD Hct-27.7*
[**2147-3-24**] 01:02AM BLOOD Hct-27.1*
[**2147-3-24**] 05:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-13.5 Plt Ct-219
.
Operative Report:
- Pending
.
Discharge Labs ([**2147-3-24**]):
[**2147-3-24**] 05:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-13.5 Plt Ct-219
[**2147-3-24**] 05:15AM BLOOD PT-12.3 PTT-24.9 INR(PT)-1.0
[**2147-3-24**] 05:15AM BLOOD Glucose-149* UreaN-21* Creat-0.7 Na-138
K-3.9 Cl-107 HCO3-24 AnGap-11
[**2147-3-24**] 05:15AM BLOOD CK(CPK)-22*
[**2147-3-24**] 05:15AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1
Brief Hospital Course:
77 yr/o M with DM, PVD, past CVA, and bad carotid disease now
S/p R CEA today being transfered to CCU for hemodynamic
monitoring after surgery near carotid sinus currently with vital
signs stable.
CCU Course:
# Carotid Stenting:
Pt was transfered to the CCU after being extubated post-op from
carotid stenting earlier in the day. Due to fact that R carotid
stent was placed near the carotid body, there was concern that
pt might have labile BP post-op and he was admitted to CCU for
close monitoring and possible nitro or dobutamine drips. At time
of arrival to unit, BP in 110-120s without aid of medications.
Pt not reporting any symptoms and with good peripheral pulses
and good post-angioseal groin exam. Pt monitored on tele
overnight with Q4hr neuro checks. He was continued on ASA/plavix
as well as other home medications. Neurochecks were normal and
mental status stable.
# Hct drop:
Pt with vague report of one dark stool day prior to admission
while on ASA/Plavix. Pt also on oral iron and with no Hx of GI
bleed, no bright red blood, and no past EGD so black stool most
likely [**2-8**] to iron supplements. Baseline Hct in Atrius records
form [**3-17**] showed Hct 38, down to 33 on day of admission and 27
the following afternoon. Hct trended for 24hrs and stayed stable
around 27. Pt should have follow-up Hct check a few days after
discharge.
# Diabetes:
Pt with A1C well controlled at 4.9 on [**Hospital1 **] metformin as outpt.
Metforming held while in hospital in 48hrs post-proceedure. Pt
should restart this medication on Saturday either in hospital if
still here or at [**Hospital1 **] if already discharged.
# Tobacco Use:
Pt still smoking a few cigarettes each day at home, but with no
symptoms or signs of nicotine withdrawal so no nicotine patch
initiated as pt did not think he neeeded this.
Medications on Admission:
clopidogrel [Plavix] 75 mg daily (had been on aggrenox until
recently)
colestipol 5 gram daily
metformin 500 mg [**Hospital1 **] (stopped [**3-21**])
omeprazole 20mg EC daily
aspirin 325 mg daily
iron 325 mg [**Hospital1 **]
colestipol 5gm packets
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. colestipol 5 gram Packet Sig: One (1) PO once a day.
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Please restart on [**3-25**].
4. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice
a day.
7. Outpatient Lab Work
Please check CBC on [**2147-3-27**]. Please fax results to Dr. [**Last Name (STitle) 60967**] at
[**Telephone/Fax (1) 6808**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
-Bilateral Carotid Artery Stenosis
Secondary:
-Diabetes Mellitus
-Peripheral Vascular 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:
Dear Mr. [**Known lastname 6164**],
It was a pleasure taking part in your care. You were admitted to
the hospital for placement of a stent in your right carotid
artery. You were monitored in the cardiac intensive care unit
after the procedure for close monitoring and you had no
complications.
No changes were made to your medications. It is very important
that you continue take all medications as prescribed,
particularly your aspirin and Plavix to prevent re-stenosis of
the carotid artery.
Followup Instructions:
You will need to follow-up with your cardiologist Dr. [**Last Name (STitle) 33746**]. We
have scheduled the following appointment for you:
[**2147-4-18**]
Carotid ultrasound at 9:30 am
Appointment with Dr. [**Last Name (STitle) 33746**] at 11:30 am
Phone: [**Telephone/Fax (1) 2258**]
[**Location (un) **] Center Office
[**Location (un) 2129**]
[**Location (un) 86**], MA
|
[
"790.01",
"729.89",
"308.2",
"781.2",
"305.1",
"401.9",
"357.5",
"V64.1",
"433.30",
"250.00",
"433.10",
"438.89",
"443.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"88.41",
"00.40",
"38.91",
"00.45",
"00.61"
] |
icd9pcs
|
[
[
[]
]
] |
9931, 10001
|
7141, 8965
|
322, 366
|
10149, 10149
|
6273, 7118
|
10852, 11228
|
4307, 4316
|
9264, 9908
|
10022, 10128
|
8991, 9241
|
10332, 10829
|
4331, 5445
|
2173, 2246
|
5461, 6254
|
266, 284
|
4167, 4291
|
394, 2063
|
10164, 10308
|
2277, 3232
|
2085, 2153
|
3248, 4151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,818
| 182,134
|
22057+57307
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-4-20**] Discharge Date: [**2136-4-27**]
Date of Birth: [**2056-4-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cortisone / Lisinopril
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**4-23**] Coronary artery bypass graft x5 (Left internal mammary
artery > left anterior descending, saphenous vein graft > RAMUS,
saphenous vein graft > obtuse marginal > obtuse marginal 2,
saphenous vein graft > posterior descending artery)
History of Present Illness:
80 year old male, who was swimming and acutely short of breath
with shoulder and neck pain. Was transported to outside
hospital via ambulance and underwent cardiac catherization that
revealed coronary artery disease. referred for surgical
evaluation
Past Medical History:
Coronary artery disease
Hypertension
Elevated lipids
Diabetes mellitus type 2
Chronic renal insufficiency
Shoulder arthritis
Social History:
Retired chemist
smoked cigars ~ 35years (3cigars/day)
lives alone
ETOH 2 drinks per week
Family History:
none
Physical Exam:
General HR 86, 124/83
Skin unremarkable
HEENT unremarkable
Neck supple Full ROM
Chest lung clear bilat anteriorly
Heart RRR
Abdomen soft, NT, ND, +BS
Ext warm well perfused no edema
Pulses +2
Pertinent Results:
CHEST (PORTABLE AP) [**2136-4-25**] 8:01 AM
CHEST (PORTABLE AP)
Reason: [**Month (only) **] hct
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
[**Month (only) **] hct
AP CHEST 8:33 A.M. [**4-25**]
HISTORY: CABG. Declining hematocrit.
IMPRESSION: AP chest compared to [**4-23**] and 18:
Mediastinal vascular engorgement has improved and small left
pleural effusion decreased substantially. Left lower lobe
atelectasis is better. Upper lungs are clear. Heart size normal,
unchanged. No pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 57697**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 57698**]
(Complete) Done [**2136-4-23**] at 9:04:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2056-4-16**]
Age (years): 80 M Hgt (in): 69
BP (mm Hg): 112/64 Wgt (lb): 200
HR (bpm): 52 BSA (m2): 2.07 m2
Indication: Intr-op TEE for CABG
ICD-9 Codes: 786.51, 410.91, 424.1, 424.0, 440.0
Test Information
Date/Time: [**2136-4-23**] at 09:04 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW03-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.2 cm
Left Ventricle - Fractional Shortening: *0.24 >= 0.29
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderate regional LV
systolic dysfunction. Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Mildly dilated descending aorta. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Moderate (2+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
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. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
1. The left atrium and right atrium are normal in cavity size.
No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. There
is moderate regional left ventricular systolic dysfunction with
anterior, antero septal, anterolateral mid to apical
hypokinesis. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %).
3. Right ventricular chamber size is normal. with mild global
free wall hypokinesis.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including epinephrine and
phenylephrine.
1. Biventricular function is improved.
2. MR is mild to moderate with further improvement on after load
reduction.
3. Aorta is intact post decannulation.
4. Other findings are unchanged
Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation,
and underwent preoperative workup. On [**4-23**] was taken to the
operating room for coronary artery bypass graft surgery; see
operative report for further details. He was treated with
vancomycin for peri operative antibiotics since he was in the
hospital greater than twenty four hours prior to surgery. He
was transferred to the intensive care unit for further
hemodynamic monitoring. He was weaned from sedation, awoke
neurologically intact and was extubated in the first twenty four
hours. He continued to progress and on post operative day 1
transferred to the floor.
He creatinine rose from baseline of 1.9 to 2.5, and then slowly
improved. Chest tubes and pacing wires removed without
incident.He was transfused. He was started on coumadin and
amiodarone for atrial fibrillation. Target INR 2.0-2.5. Cleared
for discharge to rehab on POD #4. Pt. is to make all followup
appts. as per discharge instructions.
Medications on Admission:
ASA 162 daily
Nifedipine 30 daily
metformin 850 [**Hospital1 **]
folic acid 1 daily
Slow MAg 64 daily
lasix 40 daily
Tricor 145 daily
Citracal
Glucosamine Chondroitin
Glipizide 10 [**Hospital1 **]
Lisinopril 40 daily
Vytorin 80/10 daily
Discharge Medications:
1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*0*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: 400 mg [**Hospital1 **] for one week, then 200 mg [**Hospital1 **] for
one week, then 200 mg daily ongoing.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: dose for today [**4-27**] only;all further dosing by rehab
provider. [**Name10 (NameIs) **] INR 2.0-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Coronary artery disease s/p cabg x5
Hypertension
Elevated lipids
Diabetes mellitus type 2
Chronic renal insufficiency
arthritis
postop A fib
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions and pat dry.
No baths or swimming.
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
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
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr [**Last Name (Prefixes) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) 3271**] in 1 week ([**Telephone/Fax (1) 35142**]) please call for appointment
Dr [**Last Name (STitle) 6254**] in [**3-11**] weeks -please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2136-4-27**] Name: [**Known lastname 10811**],[**Known firstname **] J Unit No: [**Numeric Identifier 10812**]
Admission Date: [**2136-4-20**] Discharge Date: [**2136-4-27**]
Date of Birth: [**2056-4-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cortisone / Lisinopril
Attending:[**First Name3 (LF) 674**]
Addendum:
On review of Mr. [**Known lastname 10813**] recent admission ending on [**2136-4-27**],
it was determined that he had acute renal failure, which
resolved.
Major Surgical or Invasive Procedure:
[**4-23**] Coronary artery bypass graft x5 (Left internal mammary
artery > left anterior descending, saphenous vein graft > RAMUS,
saphenous vein graft > obtuse marginal > obtuse marginal 2,
saphenous vein graft > posterior descending artery)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4886**] Long Term Health - [**Location (un) 4887**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2136-5-12**]
|
[
"584.9",
"403.90",
"997.1",
"585.9",
"E878.2",
"272.4",
"250.40",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11204, 11431
|
6321, 7304
|
10936, 11181
|
9397, 9404
|
1339, 1439
|
1106, 1112
|
7591, 9099
|
1476, 1506
|
9233, 9376
|
7330, 7568
|
9428, 9908
|
9959, 10898
|
5040, 6298
|
1127, 1320
|
250, 271
|
1535, 4991
|
582, 835
|
857, 983
|
999, 1090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 147,922
|
43271+58569
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-8-19**] Discharge Date: [**2182-8-23**]
Date of Birth: [**2148-4-23**] Sex: M
Service: [**Hospital1 212**] MEDICINE
CHIEF COMPLAINT:
1. Abdominal pain.
2. Hypertension.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is a 34-year-old
male with a history of type 1 diabetes, autonomic
dysfunction, gastroparesis, status post multiple admissions
for diabetic ketoacidosis and hypertensive urgency who
presents with similar symptoms. The patient states that he
had a low-grade fever the night before admission and in the
morning developed nausea and vomiting and felt terrible. He
decided to come into the Emergency Department for evaluation.
He denied chills, diarrhea, constipation, shortness of
breath, or chest pain. He noted that his blood sugar had
been 470 the night prior to admission. He was not sure why
his blood sugar had been so high. In the Emergency
Department, his vital signs revealed a temperature of 97.5,
blood pressure 254/163, heart rate 108, respiratory rate 20,
oxygen saturation 100% on room air, and fingerstick blood
glucose 463. He was given 5 liters of normal saline, IV beta
blocker and started on an insulin drip and admitted to the
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Diabetes type 1 followed by Dr. [**Last Name (STitle) 978**] at the [**Hospital 3208**]
Clinic, neuropathy, autonomic dysfunction, gastroparesis.
2. Hypertensive urgency. The patient has had an extensive
workup for his hypertensive urgency including renal MRAs
which showed multiple accessory renal arteries but no obvious
etiology for his hypertension. He has been worked up twice
for pheochromocytoma which has been negative.
3. Coronary artery disease, ejection fraction 50-60%.
4. Gastroparesis, status post J tube placement, J tube
removed after peritube infection.
5. Depression.
6. History of gastritis with hematemesis in [**2182-7-14**].
7. Umbilical hernia.
8. History of [**Doctor First Name **]-[**Doctor Last Name **] tears.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Clonidine 0.2 patch once weekly.
2. Metoclopramide 10 mg q.i.d.
3. Amlodipine 5 mg daily.
4. Desipramine 25 mg daily.
5. Labetalol 400 mg b.i.d.
6. Glargine 14 units per night.
7. Humalog insulin sliding scale.
8. Celexa 10 mg daily.
FAMILY HISTORY: One family member with diabetes type 2.
SOCIAL HISTORY: The patient is engaged to be married. he
has several children. No history of alcohol, IV drug abuse,
or tobacco use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 97.5, heart
rate 108, blood pressure 252/163, respiratory rate 20, oxygen
saturation 100% on room air. General: Lying in bed, sleepy,
in no acute distress. HEENT: Pupils were equal, round, and
reactive to light. Extraocular muscles were intact. Dry
mucosal membranes. No JVD. Cardiovascular: Regular rate
and rhythm, no murmurs, rubs, or gallops. Lungs: Clear to
auscultation bilaterally. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Rectal: Guaiac
positive stool. Extremities: No clubbing, cyanosis or
edema. There were 2+ dorsalis pedis pulses, intact
bilaterally. Neurologic: Alert and oriented to person and
place, to month, day, but inappropriate year. Somnolent but
able to follow commands. Moves all extremities well.
LABORATORY/RADIOLOGIC DATA ON ADMISSION: White blood cell
count 10.9, hematocrit 33.7, platelets 214,000. CK 264.
troponin T 0.11. Sodium 134, potassium 4.3, chloride 102,
bicarbonate 17, BUN 40, creatinine 1.8, glucose 466.
Chest x-ray showed no pneumonia.
EKG showed sinus tachycardia at 115, normal axis, no Q waves,
some T wave flattening.
HOSPITAL COURSE: 1. DIABETIC KETOACIDOSIS: The patient had
elevated blood sugar, decreased bicarbonate and a small anion
gap. He was given IV fluid hydration and started on an
insulin drip. His ketoacidosis resolved quickly and his
long-acting insulin was restarted in addition to Humalog
insulin sliding scale. The Josyln Diabetes Team was
consulted since they follow this patient as an outpatient.
It was determined that the patient will continue his 14 units
Glargine and that he will be placed on a slightly tighter
Humalog sliding scale with starting blood sugar of 150-200
with 2 units.
2. HYPERTENSION: The patient was in hypertensive urgency
with no signs of end-organ damage. The patient was given IV
labetalol and eventually a labetalol drip and in addition
several doses of IV hydralazine. The patient's baseline
blood pressure ranges in the 140s to 170s systolic. This has
been thoroughly worked up including renal MRAs, workup for
rule out of pheochromocytoma and it is felt that his
hypertensive urgency and baseline hypertension is related to
autonomic dysfunction secondary to his diabetes mellitus.
On the date of discharge, the patient's blood pressure was
150s/80s. The patient will follow-up with his primary care
provider to have outpatient antihypertensives titrated as
needed.
3. CORONARY ARTERY DISEASE: The patient was placed on
telemetry. Daily EKGs were checked. Serial cardiac enzymes
were followed. The patient had a slight elevation of
troponin which resolved over the course of the first two days
of admission. It was felt that the patient's increased CK
and troponin was most likely secondary to ischemia from his
hypertension but was not felt to be acute coronary syndrome.
He was given aspirin. He was continued on his beta blocker.
4. RENAL INSUFFICIENCY: The patient's renal insufficiency
was felt to be from volume contraction after receiving
several liters of IV fluids. The patient's creatinine
corrected. On the date of discharge, his creatinine had
improved to 1.2.
5. ANEMIA: The patient was transfused to keep his
hematocrit above 30. His stools were found to be Guaiac
positive. He had a recent admission this past [**Month (only) **] for
gastritis with hematemesis. The bleeding was felt to be
secondary to this gastritis. He was continued on a proton
pump inhibitor for GI prophylaxis.
6. GASTROPARESIS: The patient was continued on his
metoclopramide 10 mg q.i.d. He was able to tolerate three
meals a day with adequate caloric intake.
7. DEPRESSION: The patient was continued on Celexa.
8. DEEP VENOUS THROMBOSIS PROPHYLAXIS: The patient was
placed on subcutaneous heparin throughout his admission.
9. IV ACCESS: The patient has very poor peripheral IV
access. Upon transfer from the MICU, a line was placed in
his left upper arm under interventional radiology. The
patient had initially had a right femoral venous catheter
that was placed while in the Intensive Care Unit.
CONDITION ON DISCHARGE: Good.
DISCHARGE INSTRUCTIONS: Please follow-up with Dr. [**Last Name (STitle) 978**] at
the [**Hospital 3208**] Clinic, telephone number [**Telephone/Fax (1) 93196**] in the next
one to two weeks. Please follow-up with your primary care
physician within the next week to have your blood pressure
checked.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Hypertension.
3. Coronary artery disease.
4. Gastroparesis.
5. Depression.
6. Anemia.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D. [**MD Number(2) 12441**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2182-8-23**] 09:11
T: [**2182-8-27**] 22:35
JOB#: [**Job Number 93197**]
Name: [**Known lastname 400**], [**Known firstname 749**] Unit No: [**Numeric Identifier 14564**]
Admission Date: [**2182-8-19**] Discharge Date: [**2182-8-23**]
Date of Birth: [**2148-4-23**] Sex: M
Service: [**Hospital1 1098**]
FOLLOW UP APPOINTMENTS: The patient was given three follow
up appointments.
1. Dr. [**Last Name (STitle) 14565**] on [**8-26**] at 4:00 p.m. at the [**Hospital 616**] Clinic.
2. Dr. [**First Name (STitle) 6942**] at the [**Hospital 14566**] Clinic on [**8-28**] at
1:00 p.m.
3. Dr. [**Last Name (STitle) 14567**] at [**Hospital 112**] Clinic on [**9-4**] at 3:00 p.m.
The patient was instructed to continue his outpatient insulin
regimen consisting of 14 units of Glargine at night and a
Humalog insulin sliding scale starting with 2 units given for
a blood sugar of 150 to 200.
Hypertension, the patient was initially started on Captopril,
however, on the day of discharge his potassium was high
normal and his creatinine was 1.8. His ace inhibitor was
discontinued, however, it was felt that this was not an
adequate trial to fully exclude this medication from this
patient's regimen. An ace inhibitor should be added by his
primary care physician as necessary, however, the patient's
serum creatinine and potassium should be monitored closely.
The patient was discharged on his Clonidine .2 patch q week,
Labetalol 600 mg po b.i.d. and Amlodipine 5 mg daily.
The patient was instructed to call his gastroenterologist or
his primary care physician if he develops nausea, vomiting or
for any reason unable to take his medication. It was felt
that the inability to take his medications may have led to
his hypertensive urgency and his emergent presentation on
this admission.
[**First Name8 (NamePattern2) 46**] [**Doctor First Name 258**], M.D. [**MD Number(1) 259**]
Dictated By:[**Last Name (NamePattern1) 9571**]
MEDQUIST36
D: [**2182-8-23**] 05:02
T: [**2182-8-28**] 08:37
JOB#: [**Job Number 14568**]
|
[
"401.9",
"311",
"285.9",
"410.71",
"250.11",
"535.51",
"593.9",
"276.5",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2357, 2398
|
7028, 7687
|
3719, 6673
|
6730, 7007
|
2095, 2341
|
174, 1244
|
7712, 9446
|
3393, 3701
|
1266, 2072
|
2415, 2556
|
6698, 6705
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,852
| 139,654
|
50266
|
Discharge summary
|
report
|
Admission Date: [**2127-4-27**] Discharge Date: [**2127-4-30**]
Date of Birth: [**2065-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Albuterol
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
62-year-old Cape-Verdian female with history of atrial
fibrillation, PE on coumadin, and diastolic CHF (EF 50% on TTE
on [**2127-4-22**]) with recent CCU admit for CHF exacerbation requiring
intubation admitted to the CCU with respiratory distress under
similar circumstances.
Per records the patient was discharged on [**2127-4-25**]. She had been
admitted with a similar presentation to today with respiratory
distress and flash pulmonary edema in the setting of
hypertensive emergency. On that admission she was diuresed with
lasix 150mg IV X 2 and extubated to 4L O2 by NC within one
afternoon. Her medications were titrated as follows: Clonidine
was weaned and she continued the wean at home, metoprolol was
changed to labetolol, lasix was increased from 80 to 100mg [**Hospital1 **].
Discharge weight: 132.3 kg.
Per the daughter the patient was home and feeling ok but she did
not have the "little yellow pill" that she was supposed to have
at home. Review of pill cards also notable for not taking
afternoon medications the day prior to admission including
labetalol. The VNA was to bring the clonidine today but she went
without them last night. This morning the family called 911 for
respiratory distress. Per EMS was slumped over in acute dyspnea,
initial BP 260/140. Received 6 double-sprays of Nitro and
intubated in field with 7.0 ETT. She came into ED not sedated
but intubated.
In the ED initial VS were 113 205/105 21 91% on CMV 450X14 FiO2
100% PEEP 10. ECG reportedly showed ST@106, LAD, but in leads
V1-V3, there are more pronounced changes of the bundle branch
block in addition to borderline hyperacute T waves in V3 (nearly
10 mm) different from prior. CXR showed bilateral pulmonary
edema but poor film. She was given lasix 120mg IV as well as
propofol and nitro gtt. HEr BP went from 205/105 -> 130s/70s.
She had virtually no UOP with placement of the foley but with
lasix did begin to have some UOP in the ED. ABG acidotic and
hypercarbic so increased the peep per the ED. ABG on repeat:
pH:7.35 pCO2:55 pO2:109 on CMV 450X14 FiO2 100% PEEP 10 with
patient overbreathing @ 22.
.
On arrival to the floor, the patient remained intubated. Family
present, and the plan for patient care was explained.
.
ROS: Not able to be performed. Patient intubated/sedated.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes (DM), +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: CATH '[**23**] (no intervention)
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Costochondritis
Coronary Artery Disease
Pulmonary Hypertension
h/o PE
Diastolic Congestive Heart Failure (EF >55% 03/09)
OSA (cpap 7cm H2o at home with O2)
Bradycardia
DM II
Hypertension
Dyslipidemia
AFib on coumadin (recently started on lovenox for a colonoscopy)
Possible renal infarct presumably due to cardiac source of
embolus
s/p hysterectomy ~20 yrs ago for fibroids
.
Social History:
No tobacco, EtOH, substance abuse. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] 5 children, 15 grandchildren. Previously a
preschool teacher, but working to get disability d/t her MMP.
Family History:
mother: brain tumor, osteoporosis
father: lung CA (smoker) 8 sisters, 2 brothers; one sister with
"[**Last Name **] problem, smoker", HTN; another sister with "tumor removed
from brain, breast, stomach"
Physical Exam:
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar, Wheezes : expiratory)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Normal
Pertinent Results:
Imaging: CXR ([**2127-4-27**]):
INDICATION: 64-year-old female referred for evaluation of
endotracheal tube
placement.
COMPARISON: None.
SUPINE PORTABLE CHEST:
An endotracheal tube is identified at the thoracic inlet,
positioned
approximately 5-6 cm above the carina. There are diffuse
pulmonary
opacities, which in conjunction with cardiomegaly most likely
represent
pulmonary edema, though multifocal infection or ARDS could have
a similar
appearance. There is blunting of the left costophrenic angle and
obscuration
of the left hemidiaphragm, suggesting effusion. There is no
pneumothorax.
There are no acute osseous abnormalities detected. Clinical
correlation and
followup imaging after diuresis are recommended.
CXR ([**4-27**]) - repeat
HISTORY: Nasogastric tube placement.
FINDINGS: In comparison with the earlier study of this date,
there is now a
nasogastric tube in place that extends at least to the mid body
of the stomach
where it crosses the lower margin of the image. The degree of
pulmonary edema
appears worse on the current study.
2D-ECHOCARDIOGRAM:
- Portable TTE (Complete) Done [**2127-4-22**] at 1:00:00 PM
FINAL
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Lateral Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *27 < 15
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 2.40
Mitral Valve - E Wave deceleration time: 211 ms 140-250 ms
TR Gradient (+ RA = PASP): *36 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2125-3-5**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline
dilated LV cavity size. Suboptimal technical quality, a focal LV
wall motion abnormality cannot be fully excluded. Low normal
LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded,
although in the short-axis views there is a suggestion of focal
inferoseptal hypokinesis. 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
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Hypertrophied and mildly dilated left ventricle with
borderline systolic function, most consistent with hypertensive
heart. No clinically-significant valvular disease seen. Mild
pulmonary hypertension.
- ETT [**3-/2124**]: IMPRESSION: Possible anginal equivalent with
uninterpreable EKG for ischemia. Nuclear report sent separately.
IMPRESSION: 1. Interval development of a mild, reversible defect
of the posterolateral wall. 2. Mild global hypokinesis. 3. LVEF
38%.
.
- CARDIAC CATH [**3-/2124**]: Coronary angiography of this right
[**Year (4 digits) **] system revealed no angiographically evident flow
limiting CAD of the LMCA, LAD, LCx, and RCA.
2. Resting hemodynamics revealed elevated right and left sided
filling pressures with RVEDP of 22 mm Hg and LVEDP of 37 mm Hg.
Mean PCWP was elevated at 21 mm Hg. PASP was severely elevated
at 71 mm Hg. Systemic arterial pressures were moderately
elevated at 163 mm Hg. Cardiac index was mildly depressed at 1.9
l/min/m2.
3. Left ventriculography was not performed.
.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severe pulmonary arterial hypertension.
3. Biventricular diastolic dysfunction.
Brief Hospital Course:
62-year-old female with history of atrial fibrillation, history
of pulmonary embolism on coumadin, pulmonary hypertension on
home Bipap at night, and diastolic CHF (EF 50%) re-admitted with
flash pulmonary edema secondary to hypertensive emergency in
setting of medication non-adherence.
.
# Hypertensive emergency with flash pulmonary edema: Has hx of
diastolic heart failure; s/p recurrent episodes of flash edema
requiring intubation, in setting of severely elevated BPs as
trigger. Admitted now for similar picture, Initial BP in the
field was 260/140 per Ems, patient was found in respiratory
failure and was intubated in the field by EMS. Uncontrolled HTN
is likely [**1-29**] medication non-compliance vs lack of medications
at home. Respiratory status and CXR findings significantly
improved with diuresis with furosamide IV 120mg daily (LOS fluid
balance > -2L) and control of her hypertension w/ PO
anti-hypertensive regimen: amlodipine, labetalol, valsartan.
Clonidin was weaned off as it was felt that her elevated BP's on
admission may be related to withdrawal of clonidine in the
context of inconsistent adherence. Hypoxia and hypercapnea
improved, patient was extubated after 1.5 days and was
subsequently able to maintain good saturations on room air.
Patient appears clinically euvolmeic at discharge with SBP
reasonably well-controlled at 120-140 mm Hg. She is discharged
on her home doses of furosemide, amlodipine, labetolol and
valsartan. ICU team communicated with patient's out patient
pharmacy to insure availability of medications at home and also
verified that blister packs do not contain clonidine. Pnt was
educated regarding medication adherence. She will continue
follow-up with PCP and cardiology. Renal ultrasound
non-diagnostic for evaluation of renal artery stenosis given
patient's body habitus. If hypertension remains refractory in
outpatient setting, MRA of renal arteries may be considered.
.
# Fever/UTI: Isolated fever to 101 on arrival to CCU, without
recurrence. Leukocytosis initially 14K, trending down to normal.
UA postive for bacteria and WBC, urine culture grew
pan-sensitive E.coli, pt was started on ciprofloxacin (Day 1
[**4-28**]). Her sputum grew GNR which is yet to be speciated. She did
not have further respiratory complaints or fever but in the
setting of recent respiratory failure and intubation and
continue sputum production changed antibiotic coverage to PO
cefpodoxime on [**4-30**] to cover both urinary and potential
respiratory organism. Speciation of repsiratory GNR's is still
pending upon discharge. She is discharged with 7 days of
cefpodoxime at home.
.
# Chronic diastolic heart failure (last EF 50 %): Presumed [**1-29**]
chronic severe hypertension. c/w furosemide, beta blocker, [**Last Name (un) **].
.
# Chronic kidney disease, Stage 3 (MDRD GFR 50)
Baseline Cr 1.1 - 1.3, now stably elevated to 1.3, in setting of
volume overload/hypertensive emergency and UTI. Renal US without
hydronephrosis however limited secondary to habitus and unable
to assess renal artery flows. MRA of the renal arteries may be
attempted in the out patient setting if HTN continues to be
uncontrolled.
.
# Rhythm: Patient can alternate between normal sinus rhythm and
atrial fibrillation. Currently in NSR. On chronic warfarin
therapy for afib and past PE, requiring very high doses,
suggestive of relative warfarin resistance. Patient will
continue on warfarin with outpatient follow-up in [**Hospital 197**]
Clinic
.
# Diabetes Type II (A1c 11.2 in [**3-7**]) patient was on ISS plus
long acting while in house and is discharged on home regimen of
insulin for continued PCP follow up. Would consider diabetic
clinic consultation in the outpatient setting as hypertension
and uncontrolled diabetes will place at high risk for
accelerated micro-and macrovascular complications. Given issues
with non-adherence, may benefit from regimen enabling better
adherence such as 70/30 dosing.
.
# Hypothyroidism: labs on most recent admission suggest sick
euthyroid. Levothyroxine was continued at home dose.
.
# Lost tooth: The patient's left superior incisor fell out of
her mouth during prior hospitalization. [**Month (only) 116**] benefit from out
patient dental evaluation to determine if replacement can be
made and if there has been any underlying trauma to jaw.
.
# Healthcare maintenance:
- colonoscopy: Patient initially presented during last admission
while undergoing preparation for colonoscopy. Last colonoscopy
was 3 years ago and revealed adenomas. Unable to complete
colonoscopy secondary to above events. Recommend continue
appropriate screening including colonoscopy in the outpatient
setting.
.
# CODE: code status was Full Code during this admission
.
# Transitions of care
- d/c'ed clonidin, careful BP follow-up.
- Dental visit to evaluate tooth trauma during intubation
- consider outpatient MRA of renal arteries to r/o RAS if BP
remains difficult to control (with patient adherence).
- As an outpatient, perform colonoscopy
- consider outpatient diabetic clinic ([**Last Name (un) **]) consult
- continue 7 days Abx rx with PO cefpodoxime
Medications on Admission:
MEDICATIONS: (from discharge on [**2127-4-25**])
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 3 days: Then decrease to 0.1 mg daily for 3 days, then
d/c.
3. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO twice a day.
5. insulin glargine 100 unit/mL Solution Sig: Fifty Two (52)
units Subcutaneous once a day.
6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous four times a day: per sliding scale .
8. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
11. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): take twice daily until [**Doctor First Name **]
at coumadin clinic tells you to stop.
Disp:*8 syringe* Refills:*2*
12. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
13. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
14. warfarin 5 mg Tablet Sig: Eight (8) Tablet PO Once Daily at
4 PM.
15. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. furosemide 40 mg Tablet Sig: 2.5 Tablets PO twice a day.
8. insulin glargine 100 unit/mL Solution Sig: Fifty Two (52)
Subcutaneous once a day.
9. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO twice a day.
10. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: 0-12 units
Subcutaneous four times a day: per sliding scale .
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 5 mg Tablet Sig: Eight (8) Tablet PO once a day: at
4pm.
14. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Please have INR checked in 2-3days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Hypertensive Emergency
UTI
.
Secondary:
Atrial Fibrillation
Obesity
Diabetes
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 13983**] it was a pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] for evaluation of shortness of breath
and high blood pressure. You blood pressure has found to be very
high and as a result your heart wasn't able to pump forward
effectively and fluid pooled in your lungs making it difficult
to breath. We diuresised you with Lasix and your breathing
improved.
.
Also, while hospitalized you were found to have a urinary tract
infection. In addition there was concern that you could have a
brewing infection in your lungs. You were started on antibiotics
with planned 7 day treatment course to treat both UTI as well as
any potential infection in your lungs.
.
CHANGES TO YOUR MEDICATIONS:
To treat your hypertension:
STOP taking your Clonidine
** Continue taking your the remainder of your presciption
medication as prescribed**
.
To treat your infection:
START Cefpodoxime 200mg tablets. Take one tablet twice daily for
total of seven days; end date [**5-6**].
.
Again it was a pleasure taking care of you. Please feel free to
contact with any questions or concerns.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2127-5-19**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2127-5-1**]
|
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"250.00",
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
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] |
17649, 17707
|
9772, 14891
|
308, 347
|
17852, 17852
|
4445, 9609
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19146, 19495
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3522, 3726
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17728, 17831
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3741, 4426
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18742, 19123
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248, 270
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375, 2661
|
17867, 17979
|
2906, 3285
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2683, 2753
|
3301, 3506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,752
| 111,611
|
46343
|
Discharge summary
|
report
|
Admission Date: [**2146-9-28**] Discharge Date: [**2146-10-1**]
Date of Birth: [**2083-8-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
<B>DIVISION OF CARDIOLOGY COMPREHENSIVE NOTE</B>
Initial Visit, Cardiology Service
Date: [**2146-9-28**]
.
OUTPATIENT CARDIOLOGIST: n/a
PCP: [**Name Initial (NameIs) **] ([**Hospital3 4262**] Group)
.
Ms. [**Known lastname 26172**] is a 63 yo female with no significant past medical
history who presents following acute onset of chest pain and
shortness of breath at 1 a.m. following a fight with her sister.
She states that she initially developed chest pressure that did
not radiate, followed by shortness of breath. She became
lightheaded and states that she felt as though she was going to
pass out. She vomited multiple times. EMS was called and she
took ASA 324 mg as instructed. Per EMS report, she was hypoxic
and tachycardic.
.
On arrival to ED, BP 140/90, HR 110, spO2 89% on 100% NRB, RR
89. She was placed on NIPPV 10/5/100% and immediately had one
episode of vomiting, requiring suctioning, but reportedly no
aspiration. She received Zofran 4 mg IV and CPAP mask was
replaced. A nitro gtt initiated with symptomatic improvement,
then weaned to off. A foley was placed and 20 mg IV lasix was
given with ~1.2 liters UOP in response. With finding of
pulmonary edema on CXR and positive troponin (1.10), she
received Plavix 600 mg PO and was started on integrillin and
heparin drips given concern for cardiac ischemia. She
subsequently became transiently bradycardic with HR 40, BP 50/p
and a dopamine drip was started. BP improved to 88/57. Patient
was transferred directly to cath lab.
.
In the cath lab, patient was found to have clean coronaries and
high biventricular filling pressures; no intervention was
performed. ABG was performed 7.31/42/54, and NIPPV was resumed
prior to transfer to CCU.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative. Patient denies any
recent tick bites or rashes.
.
Patient reports two episodes of transient left sided chest
pressure this past weekend, which lasted 5 minutes and occurred
while lying in bed. She has had some mild shortness of breath
with exertion for the past two weeks. Cardiac review of systems
is notable for absence of paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, or syncope.
Past Medical History:
Multinodular goiter
s/p recent concussion
Social History:
Social history is significant for the absence of current tobacco
use. Patient smoked 1.5 PPD until [**2122**]. There is no history of
alcohol abuse. She states that she drinks only one glass of wine
when she goes out to dinner with friends. Travel history for
recent visit to [**Hospital3 **]. She currently resides with her
sister. She states that she feels safe at home, but states that
she has asked her sister to move out.
Family History:
She states that her paternal grandfather had an MI in his 70's.
Her brother died of a sudden MI at the age of 67. Sister has
bipolar disorder.
Physical Exam:
VS: T 96, BP 111/82, HR 90, RR 28, O2 94% on NIPPV 8/8/50%
Gen: WDWN middle aged female in NAD, in supine position,
tolerating NIPPV mask. Oriented x3. Mood, affect appropriate.
Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP to level of mandible.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral rales [**3-13**] of
the way up.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. Right groin with clean, dry
dressing intact.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated NSR, HR 100. Normal axis and normal intervals.
TW flattening in AvL. [**Street Address(2) 4793**] elevation in, II, III, ? AvF.
V5-V6. Q wave present in leads I, II. No prior EKG available for
comparison.
.
TELEMETRY demonstrated: sinus rhythm with 5-beat run of NSVT, HR
94
.
CARDIAC CATH performed on [**2146-9-28**] demonstrated:
Right-dominant system with no angiographically apparent CAD in
LMCA, LAD, LCx, RCA.
Profound elevation of right and left sided filling pressures.
No Mitral regurgitation.
LVEF 20%
Apical balloning.
.
HEMODYNAMICS:
CO 4.73
CI 2.22
PCWP 38
PA 38
RA 21
RV 59/18
.
CXR (my read): diffuse infiltrates bilaterally, consistent with
pulmonary edema
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
Ms. [**Known lastname 26172**] is a 63 yo female with no significant past medical
history who presents with pulmonary edema in the setting of
new-onset cardiomyopathy
.
# Pump: Patient presents with pulmonary edema, found to have a
cardiomyopathy with EF 20%, with no evidence of active ischemia.
Development of cardiomyopathy follows acute stressful event in
this middle-aged female, supporting possible diagnosis of
Takotsubo's cardiomyopathy. This diagnosis is also supported by
characteristic left ventricular apical ballooning. Other
possible etiologies of cardiomyopathy include thyroid
dysfunction in this patient with h/o goiter vs. lyme myocarditis
given recent travel to [**Hospital3 **]. History does not support
alcoholic cardiomyopathy vs. other drug-induced cardiomyopathy.
- wean dopamine as able, maintaining MAP>65
- initiate AceI and beta-blocker once BP able to tolerate
- aggressive diuresis as tolerated by BP and renal function
- check lyme serology
- check TSH
- Social work consult
Pt was closely observed during her hospitalization, ambulation
was gradually increased, and she was ultimately discharged in
stable condition.
.
# CAD/Ischemia: Patient with no evidence of CAD on cardiac
catheterization.
- continue ASA daily
- d/c Plavix
.
# FEN:
- Goal I/O: 2 liters negative.
- Replete K>4, Mg>2
- Low sodium diabetic diet
.
# Prophylaxis:
- SQ heparin as DVT prophylaxis
- GI prophylaxis not indicated
.
# Code status: Full code, confirmed with patient at time of
admission to CCU.
.
# Communication: with patient.
Medications on Admission:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Takotsubo cardiomyopathy
Myocardial Infarction
Heart Failure, Acute Systolic
Thyroid Nodule
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for shortness of breath with associated chest
pain. After being admitted to the hospital, you had a procedure
done on your heart to determine the anatomy and pressures in
your heart called a cardiac catheterization. During the
procedure, it was found that the apex of your heart was bigger
than it should be. As a result, a diagnosis of takotsubo
cardiomyopathy was made, which is a condition in which you can
go into congestive heart failure and have acute changes in the
anatomy of your heart based on acute changes in emotion or
anxiety. You were given medications to remove fluid from your
lungs (which you will be started on at home) and medications to
control your heart. You have an appointment with a cardiologist
(Dr. [**Last Name (STitle) **] and one that you must make with your primary care
provider. [**Name10 (NameIs) **] you experience any acute shortness of breath,
cough up pink tinged sputum, chest pain, loss of consciousness,
or extreme lightheadedness/dizziness, please call your primary
care physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 608**].
In addition: weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs and adhere to 2 gm sodium diet every day.
Followup Instructions:
1) DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2146-10-14**]
9:20.
2) Follow-up with patient's PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) 8207**] [**Name Initial (NameIs) **]. [**Telephone/Fax (2) 608**]to be arranged by patient.
|
[
"429.83",
"241.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.53",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6880, 6886
|
5196, 6825
|
303, 326
|
7021, 7029
|
4478, 5173
|
8314, 8658
|
3374, 3519
|
6907, 7000
|
6851, 6857
|
7053, 8291
|
3534, 4459
|
232, 265
|
354, 2845
|
2867, 2910
|
2926, 3358
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,739
| 174,268
|
10098
|
Discharge summary
|
report
|
Admission Date: [**2150-6-9**] Discharge Date: [**2150-6-10**]
Date of Birth: [**2092-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Atrial Fibrilliation /SOB
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation procedure
History of Present Illness:
57M with multiple cardiac risk factors (prev MI, CABG, FH of
IHD, Hyperlipidemia, HTN) presents post elective PVI with
significant HTN onweaning sedation admitted to r/o intracranial
event.
.
Patient is a 57 year old male with a history of CAD s/p
CABG in [**2139**], PCI of SVG-PDA in [**2148**], atrial fibrillation
(diagnosed in [**2-4**]) on coumadin who had progressive increase of
shortness of breath and was found to have congestive heart
failure with an EF of 20% with severely decreased left
ventricular systolic function. This was thought to be due to
tachycardia induced cardiomyopathy as his EF was normal until
now. He underwent successfull PVI today with conversion to NRS.
After the procedure while they were weaning off sedation, with
propofol, but he was not responding appropriately and was found
to have SBP in the 200's mmHg (BP 90-100's during procedure).
This was thought to have caused flash pulmonary edema, he was
given lasix 20 mg IV x2, hydralazine 5 mg IV, started on a nitro
gtt and propofol was re-started. He quickly responded with SBP
lowering to 80-90 but it was decided to maintain him intubated
and sedated until an acute intracranial process was ruled out.
.
On admission to CCU he was intubated, sedated with SBP in the
80's. Post-procedure CT-head revealed no intracranial pathology.
Sedation was weaned and he was safely extubated at 00:30.
Normalneurological exam.
Past Medical History:
1. CARDIAC RISK
FACTORS:(-)Diabetes,(+)Dyslipidemia,(+)Hypertension
MI age 32. Angina since 2x/month on exertion, short-lived.
2. CARDIAC HISTORY:
-CABGx3: in [**2139**] with LIMA to LAD, SVG to OM, SVG to PDA
-PERCUTANEOUS CORONARY INTERVENTIONS: PCI [**2148**] of SVG-PDA
[**2149-3-20**]
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation since [**2150-1-26**] - paroxysmal prior but did
not seek medical attention
Non-ischemic cardiomyopathy
Hypothyroidism 2o to XRT
Hypertension
Hyperlipidemia
? COPD no formal dx made
Depression/anxiety
Hodgkin's disease age 31 received XRT to chest and ?? no
chemo??. On thyroxine post XRT as irradiation of thyroid.
Obesity
Social History:
Lives with wife [**Name (NI) **] [**Name (NI) 33729**].Semi-retired parking garage
staff at [**Location (un) 6692**] Airport.
ETOH: socially 28-30 units/week
-Tobacco history: Ex-smoker quit 5 months ago. Prev 30/day since
teenage.
-Illicit drugs: Denies.
Family History:
Father - MI ?? PE.
Mother died from a ruptured cerebral aneurysm ? SAH.
Sister - MI age 64.
Physical Exam:
VS: T=98.8 BP=116/78 HR=77 RR=16 O2 sat=98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, HS I+II +0. Systolic flow murmur. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. BS normal.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
NEURO: GCS 15/15. UL and LL exam normal. CN II-XII normal - no
fundoscopy performed.
Pertinent Results:
Admssion Labs
[**2150-6-9**] 10:45AM PT-30.9* INR(PT)-3.1*
[**2150-6-9**] 10:45AM PLT COUNT-399
[**2150-6-9**] 10:45AM WBC-9.3 RBC-4.50* HGB-14.2 HCT-41.9 MCV-93
MCH-31.6 MCHC-33.9 RDW-15.8*
[**2150-6-9**] 10:45AM estGFR-Using this
[**2150-6-9**] 10:45AM GLUCOSE-119* UREA N-18 CREAT-1.0 SODIUM-142
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-19
[**2150-6-9**] 08:17PM PT-34.0* PTT-31.0 INR(PT)-3.5*
[**2150-6-9**] 08:17PM PLT COUNT-371
[**2150-6-9**] 08:17PM WBC-11.0 RBC-4.20* HGB-13.5* HCT-39.1* MCV-93
MCH-32.1* MCHC-34.5 RDW-15.9*
[**2150-6-9**] 08:17PM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-1.8
[**2150-6-9**] 08:17PM CK-MB-6 cTropnT-0.92*
[**2150-6-9**] 08:17PM GLUCOSE-150* UREA N-18 CREAT-1.2 SODIUM-141
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
[**2150-6-9**] 08:36PM HGB-13.5* calcHCT-41 O2 SAT-96
[**2150-6-9**] 08:36PM LACTATE-2.6*
[**2150-6-9**] 08:36PM TYPE-ART PO2-96 PCO2-36 PH-7.38 TOTAL CO2-22
BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
.
Discharge Labs
.
[**2150-6-10**] 03:57AM BLOOD WBC-9.6 RBC-4.12* Hgb-13.6* Hct-38.5*
MCV-93 MCH-33.0* MCHC-35.4* RDW-16.0* Plt Ct-396
[**2150-6-10**] 03:57AM BLOOD Plt Ct-396
[**2150-6-10**] 03:57AM BLOOD Glucose-141* UreaN-21* Creat-1.2 Na-141
K-4.7 Cl-107 HCO3-23 AnGap-16
[**2150-6-9**] 08:17PM BLOOD CK-MB-6 cTropnT-0.92*
[**2150-6-10**] 03:57AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.7
[**2150-6-9**] 08:36PM BLOOD Lactate-2.6*
[**2150-6-9**] 08:36PM BLOOD Hgb-13.5* calcHCT-41 O2 Sat-96
.
Reports
.
CT Head [**6-9**]:
There is no acute intracranial hemorrhage, edema, or mass
effect.
There is preservation of normal [**Doctor Last Name 352**]-white matter
differentiation. The
ventricles and sulci are normal in size and configuration. There
is mild
mucosal thickening of the maxillary and sphenoid sinuses, and
opacification of
multiple ethmoid air cells, which could be related to the
endotrachial
intubation.
IMPRESSION: No evidence of an acute intracranial abnormality.
Brief Hospital Course:
57 yo male with CAD s/p CABG and PCI, AF, possible tachycardia
induced cardiomyopathy, who underwent successful pulmonary vein
isolation but was unable to be extubated after procedure due to
episode of significant hypertension and flash pulmonary edema on
weaning sedation. Successfully extubated and appears well.
.
# Atrial Fibrillation: Pt with symptomatic AF since [**2150-1-26**].
Initiated on Coumadin at that time. INR today 3.1 on [**6-9**]. The
PVI successful - converted to SR. INR was 3.2 [**6-10**] and he was
continued on warfarin.
.
#Hypertension while lightening sedation and pulmonary edema. He
was safely extubated with no neurological deficits. His CT-head
was normal. We repeated his chest X ray as well and monitored
his hemodynamics. His urinary catheter was removed and he was
given bolus 40mg IV Lasix to encourage urination. The lasix was
continued p.o as outpatient.
.
# Dyslipidemia:
- Continued Simvastatin 80mg daily
.
# Cardiomyopathy/ Chronic HF: Prev MI, recently found to have an
EF
20% on echocardiogram with severely decreased left ventricular
systolic function. Pt reports SOB with minimal activity.
We Continued Metoprolol 50mg daily, Lisinopril 10mg daily,
Furosemide 40mg daily
.
FEN:
- Low Na diet, daily weights, monitor I+O's. IV KCL sliding
scale was carried out.
.
ACCESS: PIV's
.
PROPHYLAXIS:
-DVT ppx with TEDs. There was no need for sc heparin as INR
3.5.
- Discharged home on [**6-10**].
.
CODE: FULL
Medications on Admission:
Furosemide 40 mg daily
Levothyroxine 137 mcg daily
Lisinopril 10 mg daily
Metoprolol Succinate 50 mg daily
Pantoprazole 40 mg daily
Paroxetine 40 mg QHS
Potassium Chloride 20 mEq daily
Simvastatin 80 mg daily
Warfarin 5 mg
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr 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. Paroxetine Mesylate 40 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
CAD
Cardiomyopathy
Dyslipidemia
Hypothyroid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pulmonary vein isolation procedure for your atrial
fibrillation.
You should continue all your current medications you were taking
before coming to the hospital.
Your INR on [**6-9**] was 3.1. You repeat INr on [**6-10**] is 3.2. You
should continue your Coumadin at 5mg/daily. You will need to
have your INR checked once/ week for the next one month.
.
Please get your INR checked [**6-11**] at C Labs and have the results
faxed over to your primary cardiologist.
.
Followup Instructions:
Cardiology Appointment: [**Last Name (LF) 2974**], [**7-3**] at 3:15pm
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Location: Cardiovascular Consulting of [**Hospital3 **] View Map
Address: [**Location (un) 33730**], [**Location (un) 9101**], [**Numeric Identifier 33731**]
Phone: [**Telephone/Fax (1) 33732**]
.
Provider :[**Last Name (NamePattern4) **]. [**Last Name (STitle) 33733**]
Date: [**2150-6-18**]:15AM
Location:[**Location (un) 33730**], [**Location (un) 9101**], [**Numeric Identifier 33731**]
.
PCP [**Name Initial (PRE) **]: Wednesday, [**6-17**] at 11am
Name:ZOUHDI [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 33734**],MD
Location: APEX HEALTH
Address: 923 ROUTE 6A, BLDG 7, [**Location (un) 19655**],[**Numeric Identifier 19656**]
Phone: [**Telephone/Fax (1) 33735**]
|
[
"V45.81",
"278.00",
"425.4",
"V15.3",
"427.32",
"428.0",
"244.9",
"V10.72",
"427.31",
"428.20",
"414.00",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
8464, 8470
|
5852, 7304
|
340, 377
|
8578, 8578
|
3842, 5829
|
9232, 10067
|
2791, 2885
|
7577, 8441
|
8491, 8557
|
7330, 7554
|
8729, 9209
|
2900, 3823
|
1981, 2124
|
275, 302
|
405, 1812
|
8593, 8705
|
2155, 2501
|
1834, 1961
|
2517, 2775
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,205
| 101,869
|
22658
|
Discharge summary
|
report
|
Admission Date: [**2144-3-18**] Discharge Date: [**2144-3-25**]
Date of Birth: [**2068-1-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 76 yo woman with known h/o HTN, hypercholesterolemia, PVD,
B12 deficiency and recent diagnosis of positive anti-[**Doctor Last Name **] antibody
with cranial neuropathy and respiratory failure secondary to
paraneoplastic disorder related to a neuroendocrine tumor.
Patient was recently admitted to [**Hospital1 18**] [**Hospital Unit Name 153**] for progressive
respiratory failure from progressive diaphragmatic weakness, and
returns from rehab 9 days after discharge with a new multifocal
pneumonia. Patient is sent here for further work-up of her PNA
and possible bronchoscopy.
Per daughter, patient was noted to have increased respiratory
effort over the last week and on CXR was found to have a
white-out of the left lung, thought to be secondary to pna. She
also was with low grade temps to 100 and O2 desaturations
requiring ventilator adjustments and increased FiO2. Patient is
scheduled for chemo early next week at [**Hospital3 **] (Dr. [**Last Name (STitle) 2036**].
She is hard of hearing, but otherwise oriented and at baseline,
denies any pain or other complaints. Per daughter patient is
more comfortable today than yesterday. She also notes that she
has had increased secretions over last few days. ED nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 58716**]a since admission as well, although was constipated last
week and started on bowel meds. She was started on Ceftaz on
[**3-14**] and then on amikacin on [**3-15**] for presumed double coverage
for pseudomonas. Of note on arrival from rehab she came on SIMV
450/18/7.5/80%
Past Medical History:
- Paraneoplastic disease as above with cranial neuropathy and
respiratory failure
- Respiratory failure, trach and vented
- HTN and bilateral renal artery stenosis
- High cholesterol
- PVD
- eye surgery?
- Hyponatremia/SIADH
- Depression
- Iron deficiency anemia
- B12 deficiency
- DVT left leg, [**11/2143**], on coumadin
- S/p PEG tube
- perivascular white matter changes on MRI consistent with small
vessel disease.
- adenexal cyct seen on CT at OSH, not further explored
surgically
Social History:
currently at [**Hospital6 58717**], had been living independently
previously. No tobacco, rare EtOH. Supportive family. Daughter
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16844**] is HCP, phone [**Telephone/Fax (1) 58711**]
Family History:
No stroke, seizure, neurological disease. No DM. +MI in sister
age 79. [**Name2 (NI) **] cancer in sister, age 16.
Physical Exam:
VS: T 98.8 BP146/63 P63 R18 Currently on AC 550/18/5/100% with
Sats of 93-95% and PIPS of 28 and plateau 25 and ABG
7.56/43/56/40/94%
Gen: Pleasant elderly woman in NAD, sleepy but arousable
HEENT: PERRL, 3mm bilaterally, anicteric, MMM
Neck: Supple, floppy, trach in place
Cardiac: RRR, S1, S2 no murmur
Lungs: coarse BS throughout, good air mvmt on vent
Abd: Soft,+BS, slightly distentded, G tube inplace, no
tenderness
Extr: no edema, R heel ulcer wrapped, dropped foot on right
Neuro: sleepy but arousable, decrease strength of all muscles,
but sensation intact and withdraws foot to touch
Pertinent Results:
[**2144-3-18**] 10:51PM TYPE-ART TEMP-37.6 RATES-16/0 TIDAL VOL-450
PEEP-10 O2-50 PO2-90 PCO2-49* PH-7.51* TOTAL CO2-40* BASE XS-13
-ASSIST/CON INTUBATED-INTUBATED
[**2144-3-18**] 09:58PM TYPE-ART TEMP-37.6 TIDAL VOL-550 PEEP-10
O2-100 PO2-317* PCO2-38 PH-7.60* TOTAL CO2-39* BASE XS-14
AADO2-375 REQ O2-65 -ASSIST/CON INTUBATED-INTUBATED
[**2144-3-18**] 09:54PM URINE HOURS-RANDOM CREAT-51 SODIUM-<10
[**2144-3-18**] 09:54PM URINE OSMOLAL-674
[**2144-3-18**] 04:20PM TYPE-ART O2-100 PO2-56* PCO2-43 PH-7.56*
TOTAL CO2-40* BASE XS-14 AADO2-631 REQ O2-100 -ASSIST/CON
INTUBATED-INTUBATED COMMENTS-TRACH/VENT
[**2144-3-18**] 04:20PM LACTATE-1.4
[**2144-3-18**] 04:20PM O2 SAT-94
[**2144-3-18**] 03:23PM TYPE-[**Last Name (un) **] PO2-43* PCO2-45 PH-7.54* TOTAL
CO2-40* BASE XS-13
[**2144-3-18**] 12:15PM LACTATE-1.6
[**2144-3-18**] 12:08PM GLUCOSE-113* UREA N-47* CREAT-0.4 SODIUM-131*
POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-40* ANION GAP-7*
[**2144-3-18**] 12:08PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2144-3-18**] 12:08PM WBC-38.1*# RBC-3.31* HGB-10.0* HCT-29.6*
MCV-89 MCH-30.1 MCHC-33.6 RDW-16.6*
[**2144-3-18**] 12:08PM NEUTS-73* BANDS-19* LYMPHS-4* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2144-3-18**] 12:08PM PLT COUNT-273
[**2144-3-18**] 12:08PM PT-19.1* PTT-45.7* INR(PT)-2.3
[**2144-3-18**] 11:36AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2144-3-18**] 11:36AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2144-3-18**] 11:36AM URINE RBC-[**12-13**]* WBC-[**12-13**]* BACTERIA-MANY
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2144-3-18**] 11:36AM URINE WAXY-<1 WBCCAST-<1
.
.
CXR: new multifocal opacities RUL, LUL and peri-hilar area with
possible left sided effusion
*
EKG: NSR @81, nl axis, flat t in III, twi V1. no prior ekg.
Brief Hospital Course:
A/P: 76 yo woman transferred to [**Hospital1 18**] from [**Hospital **] rehab after
developing new multifocal pneumonia, leukocytosis and low grade
temps.
.
# Respiratory Failure: secondary to multifocal pneuomia, on top
of her underlying diaphragmatic weakness caused by the
paraneoplastic syndrome. While in the hospital she was
maintained on a ventillator via her tracheostomy. A
bronchoscopy was performed and showed normal airways. Her
sputum grew out serratia and pseudomonas and she was treated
with zosyn. The patient was initially also treated with
gentamycin for double pseudomonas coverage but her culture
showed gentamycin resistance.
.
# Leukocytosis: in addition to the pneumonia as a source of
infection, the patient had one blood culture positive for
klebsiella on [**2144-3-18**]. The klebsiella was also sensitive to
zosyn. Her blood cultures from [**2144-3-19**] were negative. The plan
for antibiotics was to continue zosyn for a total of 2 weeks. A
PICC line was placed by IR on [**2144-3-23**].
.
# Paraneoplastic syndrome secondary to neuroendocrine tumor:
Discussed plan with Dr [**First Name (STitle) **] who agreed that chemo therapy should
be held until after the patient completes her course of
treatment.
*
# HTN: The patient's ACEI was initially held given the
questionable history of bilateral renal artery stenosis, labile
BPs which were thought to be secondary to her autonomic
dysfunction from paraneoplastic source, and concern for
infection/sepsis. Her ACEI was restarted while in hospital and
she maintained normal blood pressures.
.
# DVT in [**2143-11-25**]: The patient was continued on her home dose of
coumadin. Her INR rose to 4.8 on [**2144-3-24**] and her coumadin was
held. On [**2144-3-25**] her INR was 4.2. The presumption was that the
increasing INR was secondary to antibiotics and decreased GI
flora. No external signs of blood loss and hct stable at 27.
Patient was discharged to an acute care rehab where her coumadin
can be held and her INR can be rechecked in 2 days. Plan to
hold coumadin for an INR > 3.5. Goal INR [**2-27**].
Medications on Admission:
Norvasc 5mg qd
Lisinopril 10mg qd
Ceftaz 1gm q8hrs
Amikacin 500mg qd x10days
Robitussin 10ml qid
lasix 40mg qd
mucomyst nebs q4hrs
vitamin c 500mg [**Hospital1 **]
Prozac 20mg qd
senakot 2tabs qd
neupogen 300mcg/ml q24
simethicone 80mgqid
lactulose 30ml tid
coumadin 5mg qd
FeSO4 325 daily
Colace 100mg [**Hospital1 **]
compazine 5mg q6hrs
morphine sulfate 2mg q4hrs
dulcolax/fleet prn
hepartin 500units
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for INR > 3.5.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Albuterol 90 mcg/Actuation Aerosol Sig: 2-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed. treatment
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1)
treatment Miscell. Q4-6H (every 4 to 6 hours).
16. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
17. Zosyn 4.5 g Recon Soln Sig: 4.5 gram Intravenous every
eight (8) hours: last day of antibiotics will be [**2144-4-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
Pneumonia
-- paraneoplastic disease secondary to neuroendocrine tumor
-- HTN
-- DVT in left LE
-- hyperlipidemia
-- PVD
-- SIADH/hyponatremia
-- Small vessel disease on MRI
-- Stage II decubitus ulcer
-- right heel with ulcer and drop foot
-- Anemia
Discharge Condition:
Stable on trach ventillation
Discharge Instructions:
Take all your medications as prescribed
Call your primary care doctor or go to the ER if you are having
trouble breathing, fevers, lethargy, or any other worrisome
symptoms
Followup Instructions:
Call Dr. [**First Name8 (NamePattern2) 7810**] [**Last Name (NamePattern1) **] for a follow up appointment after you are
discharged from the rehab hospital. Please call for an
appointment: [**Telephone/Fax (1) 18067**].
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]
|
[
"518.83",
"482.1",
"V44.0",
"272.4",
"707.14",
"401.9",
"790.7",
"041.3",
"199.1",
"440.1",
"266.2",
"197.0",
"736.79",
"443.9",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9401, 9479
|
5349, 7450
|
323, 330
|
9774, 9804
|
3456, 5326
|
10026, 10367
|
2710, 2827
|
7904, 9378
|
9500, 9753
|
7476, 7881
|
9828, 10003
|
2842, 3437
|
276, 285
|
358, 1924
|
1946, 2433
|
2449, 2694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,533
| 148,821
|
23082
|
Discharge summary
|
report
|
Admission Date: [**2167-11-7**] Discharge Date: [**2167-11-16**]
Date of Birth: [**2136-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
31M with hx of familial dyslipidemia, HTN, acute pancreatitis
(98, 03) and nephrolithiasis who presents from OSH after being
dx with acute pancreatitis. [**11-6**] the pt began to have severe
epigastric pain which radiated over his entire abdomen and
traveled to his back, left shoulder. The pain reminded him of
his prior episodes of acute pancreatitis. He also had diarrhea,
N/V, and one episode of chills, no fevers. He was unable to eat
or drink anything the entire day.
His initial labs at the OSH included: WBC 15.7, Triglyceride
2881, Amylase 747, Lipase 486, and normal LFT's. Also of note,
the pt's CK rose from 347 -> 1812) with low MB and troponin. CT
without pancreatic necrosis. The pt was made NPO, given IVF, and
demerol/morphine for pain. He was given levo/flagyl x1dose and
then transitioned to imipenem.
Upon presentation to the [**Hospital1 **] ICU, he had [**7-28**] pain with guarding
and N but no V. The pt denied any CP, SOB, fever, numbnes,
tingling, weakness, dizzines, dysuria, or cough. He admits not
taking his dyslipidemia medication for the past month (crestor,
tricor).
Past Medical History:
Dyslipidemia
Nephrolithiasis
HTN
Pancreatitis
Social History:
Married
Occasional EtOH but none in 2 weeks
No tobacco
No drugs
Family History:
Dyslipidemia on mother's side
Physical Exam:
T 100.1 BP 128/74 P 125 R 20 O2 99 @ 2L NC (all taken with
patient in pain)
Gen- A+Ox3, lying in bed in pain
Skin- C/D/I, no rashes
HEENT- pinpoint pupils, dry MM, OP clear
Neck - Supple, no LAD
Cor- RRR no m/r/g
Chest- CTA B
Abd- +BS, tense and tender to palpation diffusely, worst in LUQ,
+guarding, no rebound. +pain with shaking bed. Decr BS.
Ext- w/wp, no c/c/e, groin line in R thigh
Pertinent Results:
At OSH ([**2167-11-7**] 8am)
-WBC 15.7 (P65, L13, M5, Band 16, E1) HCT 50.2 Plt 282
-NA 133 K 4.1 CL 104 CO2 19 BUN 14 CR 1.2 GLU 163 CA 6.7
MG 2.1 PO4 2.6
-CHOL 477 TRIGLY 2881 HDL 11 LDL not calc
-ALB 2.8 AST 62 ALT 33 TBIL 0.8 DBIL 0.4 AP 55
-LDH 433 [**Doctor First Name 674**] 747 LIP 486
-CK 1893, MB 5.13, TROP <0.10, LACTATE 3.6
-ABG 7.39/36/52/90%
OSH Studies:
-CT Abd - severe pancreitis, no necrosis, illeus, bibasilar
atelectasis
-RUQ US - no gallstones
Labs Here:
[**2167-11-7**] LIPASE-499*
[**2167-11-7**] TRIGLYCER-1445* HDL CHOL-30 CHOL/HDL-11.4
[**2167-11-7**] WBC-14.6 PLT COUNT-300
[**2167-11-7**] INR-1.5
--EKG: Sinus Tach @120 bpm, nl axis, nl int, S in I, Q in III,
TWI in III, no prior available
--CTA Chest ([**11-10**]): R lower lobe pulmonary emboli.
Wedge-shaped consolidation in the posterior right lower lobe,
concerning for pulmonary infarct. Bilat pleural effusions.
Extensive fluid and stranding at the tail of the pancreas,
consistent with pancreatitis, incompletely imaged.
--Echocardiogram: within normal limits
--Chest X-ray with likely LLL consolidation
INR therapeutic in [**1-19**].2 range x several days prior to d/c
Brief Hospital Course:
31M with hx of familial dyslipidemia, HTN, acute pancreatitis
('[**60**], '[**65**]) and nephrolithiasis who presents from OSH after being
dx w/acute pancreatitis. On admission TG > 1200 and patient
admits to poor compliance with lipid lowering med. Was observed
in ICU then transferred to floor. Continued to be tachy & ECG
w/S1Q3T3 & CTA revealed PE so started on heparin gtt & coumadin.
Also likely PNA so tx w/Abx.
# Pulmonary Embolus: Pt was hypoxic and tachycardic upon
transfer from the ICU. His ECG demonstrated sinus tachycardia
with S1Q3T3. A CTA of his lung revealed right lower lobe
pulmonary arterial branch and posterior basal segmental branch
emboli along with a wedge-shaped area of consolidation in the
posterior right lower lobe, concerning for pulmonary infarct. He
was started on a heparin gtt and coumadin. We obtained an echo
which demonstrated normal right ventricle function and size.
Once he attained a therapeutic INR of 2.1 his heparin drip was
discontinued and he was continued on his coumadin.
The medical team spoke to pt's PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**] ([**Telephone/Fax (1) 59461**]) and informed him of the [**Hospital **] medical issues and pulmonary
embolus. PCP will follow his INR upon discharge. The patient
also developed a pulmonary emblolus while on SC heparin
prophylaxis. No recent plane travel, surgery, or LE injury. Pt
did have a R femoral line upon transfer from the outside
hospital. We would like him to have a hypercoagulability work up
as an outpt & pt agrees to call Dr. [**Last Name (STitle) 6160**] of heme/onc.
# Fevers, leukocytosis and LLL consolidation on CXR: Pt
continued to have low grade fevers which we at first attributed
to his pulmonary embolus. He then developed a WBC which peaked
at 19K raising our suspicion for potential infection. Repeat
CXR along with relook at CTA of lung demonstrated LLL
collapse/atelectasis/consolidation which was concerning for
pneumonia. We thus started him on levofloxacin but then switched
it to cefpodoxime (out of concern about the effect of
levofloxacin and the patient's INR) with plan to complete a
[**10-1**] day course for his pneumonia. We also searched for other
potential sites of infection--his blood cultures are without
growth to date, his UA was negative. He was having [**2-19**] BMs of
formed stool a day without cramping thus we were concerned about
C Diff and his stool was negative for C.diff toxin x 2.
# Acute pancreatitis/Dyslipidemia: Pt transferred from OSH
w/acute pancreatitis and hypertriglyceridemia. This was likely
secondary to the patients severe dyslipdemia in setting of
medicine non-compliance. No excessive EtOH use. Pt was educated
several times about the importance of being compliant with his
meds to prevent futher attacks of acute pancreatitis. He
received agressive fluid repletion in the ICU- > 7 L and was
then transferred to the floor. Serum calcium was low at 6.4 upon
transfer but normalized as his pancreatitis resolved. His diet
was slowly advance and is currently tolerating a house diet.
# Hypertriglyceridemia: he is currently on tricor with good
effect. His triglycerides have decreased from 1445 to 238 with
this medication.
# Elevated CK: Etiology of this unclear, but it continued to
decrease. We did not think that it was cardiac in origin given
cardiac enzymes. We also thought that it was unlikely to be due
to his crestor since he has not taken it in a month. He denied
muscle aches.
# HTN: The patient is reported to have a history of hypertension
but while in the hospital his blood pressures remaind well
controlled without anti-hypertensive medications.
# Prophylaxis: on PPI for heparin gtt.
Medications on Admission:
At home:
TriCor
Crestor
At OSH:
imepenem
pepcid
lovenox
morphine
demerol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
2. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID PRN as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. Fenofibrate Micronized 54 mg Tablet Sig: Two (2) Tablet PO
TWO TABLETS QHS
Disp:*60 Tablet(s)* Refills:*0*
4. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Warfarin Sodium 1 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily): have INR checked and dose adjusted if needed.
Disp:*300 Tablet(s)* Refills:*2*
6. Outpatient Lab Work: INR check within 1 week
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Famililal Dyslipidemia
2. Acute pancreatitis
3. Pulmonary embolus
4. Pneumonia
5. Poor compliance with crestor and tricor
Secondary:
1. H/o pancreatitis in [**2160**] and [**2165**]
2. H/o hypertension
Discharge Condition:
stable, tolerating POs, ambulating
Discharge Instructions:
1. Please contact MD or go to emergency room if you develop:
shortness of breath, fever/chills, palpitations, chest pain,
severe nausea, vomiting, abdominal pain.
2. Please take all medications as prescribed.
3. IT IS EXTREMELY IMPORTANT THAT YOU KEEP TAKING YOUR
TRICOR!!!!
4. Please continue eating a low fat diet.
5. Please follow-up as directed.
Followup Instructions:
-follow-up with primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 2643**] at [**Telephone/Fax (1) 59462**]
by Friday [**11-20**] to have your INR checked and your dose of
coumadin altered if necessary.
-Please call the Dr. [**Last Name (STitle) 6160**] at the hematology clinc at ([**Telephone/Fax (1) 31456**] to schedule an appointment.
Please call ([**Telephone/Fax (1) 9478**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**] or the Pancreas resident clinic.
Completed by:[**2167-11-16**]
|
[
"272.4",
"401.9",
"415.19",
"577.0",
"486",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7890, 7896
|
3301, 7050
|
328, 335
|
8153, 8189
|
2101, 3278
|
8587, 9161
|
1642, 1673
|
7174, 7867
|
7917, 8132
|
7076, 7151
|
8213, 8564
|
1688, 2082
|
276, 290
|
363, 1476
|
1498, 1545
|
1561, 1626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,224
| 199,295
|
43500+58630
|
Discharge summary
|
report+addendum
|
Admission Date: [**2201-9-2**] Discharge Date: [**2201-9-21**]
Service:
The patient is an 83-year-old Russian speaking male.
PAST MEDICAL HISTORY: Coronary artery disease, status post
left anterior descending stent in [**2201-2-28**] and a recent
admission from [**2201-8-21**] to [**2201-8-27**] for chest pain and
pulmonary edema which required intubation and a cardiac
catheterization with a stent to the right coronary artery.
The patient's catheterization course at that time was
complicated by hypotension requiring brief Dopamine drip.
The patient was quickly weaned off and discharged on [**8-27**] to
[**Hospital **] Rehabilitation.
On the night prior to admission the patient developed
shortness of breath and chest pain. He was then transferred
to [**Hospital3 **] where he was treated with intravenous
Lasix and rule out for myocardial infarction was begun. Of
note, the patient had not received any Lasix after discharge
from [**Hospital1 69**] on [**8-27**] and had a 7
pound weight increase at the time.
PAST MEDICAL HISTORY: Congestive heart failure with ischemic
cardiomyopathy, moderate left ventricular systolic
dysfunction, apex akinetic, septum hypokinetic. Coronary
artery disease, status post left anterior descending stent in
[**2201-2-28**] and status post an right coronary artery stent in
[**2201-8-27**]. Status post a DDD- pacer for bradycardia, increased
cholesterol, hypertension and chronic renal insufficiency,
diastolic dysfunction for vascular disease, status post an
aortobifemoral bypass, Chronic obstructive pulmonary disease,
back pain, history of sundowning, glaucoma, gout, prostate
carcinoma.
SOCIAL HISTORY: Lives with his wife who has [**Name (NI) 2481**], two
daughters, occasional alcohol use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Positive for constipation.
PHYSICAL EXAMINATION: On admission temperature 96.7, blood
pressure 112/58, pulse 65 sating 100% on two liters.
General: Elderly Russian speaking male in no acute distress.
Head, eyes, ears, nose and throat shows moist mucous
membranes, jugular venous distention with increase to the
ear, Lungs are clear to auscultation bilaterally.
Cardiovascular: Distant heart sounds. Regular rate and
rhythm with a 2/6 systolic murmur in the left upper sternal
border without radiation. Abdomen is soft, nontender,
nondistended, positive bowel sounds. Liver is palpable 2 to
3 cm below the costal margin. Extremities showed 2+ edema
bilaterally.
LABORATORY: White count 15.7, hematocrit 36.5, platelets
319, potassium 5.8, BUN 38, creatinine 1.7, albumin 2.9, TSH
9.03 wit a normal Free T4. Troponin .07 and .1.
MEDICATIONS ON TRANSFER:
1. Aspirin 325 mg once a day.
2. Lopressor 25 mg twice a day.
3. Amiodarone 200 mg q day.
4. Protonix 40 mg once a day.
5. Lipitor 40 mg once a day.
6. Captopril 25 mg three times a day.
7. Plavix 75 mg once a day.
8. Colace 100 mg twice a day.
10. Bisacodyl 10 mg once a day.
HOSPITAL COURSE:
1. Congestive heart failure. The patient was felt to be
fluid overload and congestive heart failure exacerbation.
Diuresed with Nitrocor and Lasix and Dopamine transiently.
On [**2201-9-6**] the patient developed hypotension with systolic
blood pressures down to the 40's and 50's and became hypoxic
requiring 100% non-rebreather. The patient was subsequently
transferred to the CCU for further care. While in the CCU
the patient's blood pressure was maintained with Dopamine and
Neo-Synephrine initially and then changed to Dobutamine and
Nitroprusside. A Swann Ganz catheter was placed for
hemodynamic tailored therapy. The patient initially showed
values of a cardiac output of 2.6 and an index of 1.6. His
wedge was 10. The patient was felt therefore to be
over-diuresed and intravenous fluids were started with a goal
of 12 to 13, 5 liters of fluids were given. The patient
subsequently improved while on Dobutamine and Nitroprusside.
Nitroprusside was weaned off secondary to the duration of
treatment. The Nesiritide was restarted. On [**2201-9-11**] the
Dopamine was weaned off and the patient was restarted on ACE
inhibitor which was titrated upward to Captopril 75 mg three
times a day. The patient was then diuresed gently. On [**9-13**]
the Swann Ganz catheter was discontinued and the patient was
weaned of the Nesiritide. His final Swann numbers showed a
cardiac output of 2.4 with an index of 1.5.
Following the hypotensive episodes requiring his transfer to
the CCU the patient developed heme positive stools with an
increase lactate and increased amylase and complaints of
abdominal pain. CT scan done showed thickening of the
ascending colon. Surgery was consulted regarding possible
ischemic colitis. They felt that there was no need for
surgery at this time especially based on patient's cardiac
status. Treatment was bowel rest, TPN nutrition and serial
exams. The patient was treated with Zosyn and Flagyl. At
the time the patient was transferred to the floor he was off
antibiotics. However, abdominal exam still showed distension
with hypoactive bowel sounds.
On transfer to the floor the patient appeared fluid
overloaded once again, the patient was therefore restarted on
Astreotide and Lasix and Captopril was reduced in order to
keep the patient's systolic blood pressure greater than 90
while on Nitrocor therapy. The patient subsequently had an
episode of pulselessness and possibly hypotension. It was
felt at this time that treatment was most likely futile. A
family meeting was called for discussion of code status.
2. Code Status. Family meeting was held and the goals of
therapy were discussed. The patient was unable to contribute
to the discussion of future care secondary to delirium. The
patient's daughter and son were present at this meeting.
Initially a decision to make the patient DNR/DNI was reached,
subsequent Comfort Care was decided.
3. Delirium. From day one of the [**Hospital 228**] hospital stay
the patient suffered from a delirious state. He had a
history of sundowning however his delirium seemed to be
constant, it was thought secondary to his medical problems
most likely to his congestive heart failure and very low
cardiac output. Initially treated with Zyprexa at bedtime
with Haldol p.r.n. however, there is little improvement post
CCU stay and hypotension. The patient's mental status was
depressed and he remained somnolent for many days prior.
Following a decision of DNR/DNI comfort care only when care
was withdrawn the patient seemed to wake up however, remained
quite delirious.
4. Gastrointestinal. Ischemic colitis. The patient was
treated conservatively with bowel rest, TPN. Decision was
made to allow food to be given to the patient after he was
Comfort Care Only if he so desired.
Palliative care consult was called to help with management of
end-of-life issues.
The remainder of this hospital course will be dictated in a
subsequent addendum.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2201-9-21**] 18:51
T: [**2201-9-21**] 21:31
JOB#: [**Job Number 93619**]
Name: [**Known lastname 12966**], [**Known firstname 14777**] Y Unit No: [**Numeric Identifier 14778**]
Admission Date: [**2201-9-2**] Discharge Date: [**2201-9-23**]
Date of Birth: [**2118-7-16**] Sex: M
Service:
It was decided that patient would be comfort measures only
and will be transferred to [**Hospital3 901**] in [**Location (un) 382**] for
comfort care. IVs were removed as well as Foley catheter and
rectal tube. Patient would receive hospice care with
discharge medications of sublingual Morphine prn discomfort
or pain, olanzapine 5 mg dissolvable tablets once a day or as
needed for delirium. Scopolamine patch once as needed for
excessively secretions, aspirin 325 once a day, lactulose as
needed for constipation. Docusate as needed for
constipation. Tylenol as needed.
Patient was discharged on [**2201-9-23**] to [**Hospital3 959**]. Instructions were to please place on fall precautions
and may tolerate p.o. diet with comfort measures only if
decided by family since the patient has a history of
aspiration. Patient may resume followup medical appointments
if so desired by primary care physician.
DR.[**Last Name (STitle) 578**],[**First Name3 (LF) 577**] 12-ABZ
Dictated By:[**Last Name (NamePattern1) 685**]
MEDQUIST36
D: [**2201-9-23**] 12:49
T: [**2201-9-23**] 13:02
JOB#: [**Job Number 14779**]
|
[
"496",
"410.91",
"557.9",
"414.8",
"785.51",
"414.01",
"428.0",
"584.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"00.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1779, 1835
|
3022, 8647
|
1906, 2694
|
1855, 1883
|
2719, 3005
|
1058, 1655
|
1672, 1762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,782
| 116,431
|
54496+54329
|
Discharge summary
|
report+report
|
Admission Date: [**2114-4-10**] Discharge Date: [**2086-4-15**]
Date of Birth: [**2056-10-30**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 57 year-old female
with a history of inflammatory breast cancer, morbid obesity,
obesity hypoventilation syndrome, obstructive sleep apnea,
systolic and diastolic heart failure, hypertension,
gastroesophageal reflux disease and anemia who felt short of
breath on the morning of [**2114-4-10**]. The patient reports that
at baseline she has shortness of breath, however, on the day
of admission the patient's shortness of breath did not
resolve with supplemental oxygen. She reports low grade
fevers with chills and sweats with reported temperature to
100.1 with increased fatigue. She reports cough occasional
production of clear sputum. She denies chest pain, abdominal
pain, diarrhea, nausea or vomiting. She denies urinary tract
infection like symptoms. Denies recent sick contacts, travel
or varying from her routine. She reports medical compliance
with her medications. Consequently she was brought to the
Emergency Department this a.m. where she was found to be
hypoxic with O2 sats in the approximately 75%, hypotensive
with blood pressure 90/50 and was treated with supplemental
oxygen, intravenous fluids, broad spectrum antibiotics
initially on Dopamine drip and started on a sepsis protocol.
PAST MEDICAL HISTORY:
1. Asthma.
2. Obesity hypoventilation syndrome.
3. Obstructive sleep apnea.
4. Morbid obesity.
5. Congestive heart failure systolic and diastolic
dysfunction with an EF of approximately 30 to 35%.
6. Inflammatory breast cancer recently treated with
Herceptin and Navelbine.
7. Hypertension.
8. Gastroesophageal reflux disease.
9. Anemia.
10. Depression.
MEDICATIONS:
1. Lisinopril 40 q.d.
2. Aspirin 325 q.d.
3. Lasix.
4. Flovent.
5. Protonix.
6. Lactulose.
7. Toprol XL 12.5 q.d.
8. Epogen.
ALLERGIES: Penicillin causes hives.
SOCIAL HISTORY: Smoked one pack per day times 10 to 15
years. She quit approximately 20 years ago.
PHYSICAL EXAMINATION: The patient was afebrile on Intensive
Care Unit evaluation. Tachycardic to 106. Blood pressure
92/50, 25, 96% on 2 liters. She was comfortable. She was
described as mild tachypneic with some accessory muscle use.
JVD was difficult to assess. She had coarse breath sounds
anteriorly with moderate air flow throughout. Heart
tachycardic, regular rhythm, normal S1 and S2. No audible
murmurs, rubs or gallops. Belly was soft, nontender,
nondistended with active bowel sounds. She had 1 to 2+ edema
peripherally and evidence of chronic venostasis. No rash was
present.
LABORATORY: White blood cell count 2.9, 59 polys, 32
lymphocytes, hematocrit 23.9, platelets 404. Her chem 7 was
within normal limits. CKs of 167, troponin 0.07. She had a
chest x-ray, which showed a question of a retrocardiac
opacity. She had a CTPA, which was a poor quality study, but
was negative for any obvious signs of PE. She had an
electrocardiogram that was alternating between normal sinus
rhythm and ventricular bigeminy. No acute changes or
ischemia were noted.
HOSPITAL COURSE: In summary this is a 57 year-old female
Jehovah's witness with a history of morbid obesity,
obstructive sleep apnea requiring BiPAP at night, congestive
heart failure, hypertension, anemia and inflammatory breast
cancer who was originally admitted [**4-10**] from her nursing home
for hypoxia and hypotension and treated in the Intensive Care
Unit. The patient was initially treated with Levofloxacin
for pneumonia, BiPAP and noninvasive pressure ventilation for
hypoxia without intubation. She was subsequently transferred
to the floor to continue treatment for pneumonia and hypoxia.
CTPA was negative for evidence of PE. She was doing well on
the floor until [**4-14**] when the patient was again noted to
become dyspneic with oxygen saturations into the 80%. Repeat
chest x-ray showed worsening shortness of breath. She was
treated with Lasix for diuresis and moderate improvement of
respiratory status. Given her complex medical history she
was transferred to the Intensive Care Unit for closer
monitoring. On representation to the Intensive Care Unit
[**2114-4-15**] the patient spiked a fever to 104, developed
significant respiratory distress and was then emergently
intubated semiemergently admitted and initially treated with
broad spectrum antibiotics for her continued respiratory
distress.
1. Respiratory failure: The patient is currently being
treated for multifactorial respiratory failure in the setting
of congestive heart failure, marked obesity, obesity
hypoventilation syndrome and obstructive sleep apnea who was
semiemergently intubated [**3-/2039**] for progressive hypercarbic
respiratory failure and a newly developing sepsis. The
patient's blood gas prior to intubation was 7.23, 68 and 385.
The patient was intubated and continued on her settings. She
ultimately had tracheostomy performed on [**2114-4-26**] per the ENT
Service. The goal had been to attempt a trial of extubation
on the patient on recovery of her MRSA/sepsis. However, she
remained difficult intubation and exacerbated primarily by
her recurrent congestive heart failure and over 30 liters
positive, fluid balance since her admission. At this point
in time she remains trached on pressure support ventilation
and has been doing quite well. The goal would be to continue
diuresis gently approximately 500 cc to negative one liter
per day in order to avoid intravascular of the patient and
acute renal failure. Additionally the patient was treated
aggressively for her MRSA sepsis. She completed a course of
antibiotics for presumed pneumonia and subsequent treatment
for urinary tract infection as well. She continues with
trach care and nebulizers prn and aggressive suctioning as
needed.
2. Congestive heart failure: The patient has known
congestive heart failure with an EF of approximately 30 to
35% with no systolic and diastolic dysfunction. She was
approximately 30 liters positive for fluid following
treatment for MRSA sepsis and remains volume overloaded at
this time. Goal has been for gentle diuresis. She was
initially started on a Lasix drip and subsequently developed
acute renal failure and that was discontinued and the patient
was started on Nesiritide with minimal effect on diuresis.
Ultimately Nesiritide was discontinued minimizing her fluid
intake and she responded to Lasix intravenously prn as needed
for goal as stated above. She was seen on the CH Service by
Dr. [**First Name (STitle) 2031**] and upon resolution of her hypotension the patient
was started on low dose beta blocker and treatment of her
congestive heart failure.
3. MRSA/sepsis: On readmission to the Intensive Care Unit
the patient had a temperature of 104 and blood pressures in
the 70s. She ultimately had a positive right IJ culture tip
for MRSA and positive blood cultures from the [**2-12**] for MRSA bacteremia 4 out of 4 bottles. The patient
was treated with Vancomycin and subsequent surveillance
cultures were negative. The patient's antibiotics course
will be extended for a minimum of four to six weeks
intravenous Vancomycin for an underlying right IJ clot that
is being followed serially. The patient was enrolled in the
sepsis protocol. She was given intravenous fluids, starting
on intravenous Hydrocortisone 50 gallop or murmur
intravenously q.i.d. and required Dopamine for blood pressure
support. As stated the patient's sepsis resolved and
surveillance cultures were negative. She will be continued
on Vancomycin for approximately one month.
4. Urinary tract infection: The patient had a urinary tract
infection from the 28th that was positive for E-coli that was
sensitive to Ceftazidine. The patient was treated with a
seven day course of Ceftazidine. Repeat urine cultures were
negative.
5. Hypotension: The patient had known hypotension in
relation to her sepsis, however, her hospital course was
complicated by persistent hypotension following resolution of
her sepsis. Empirically while the patient did not
demonstrate evidence of adrenal insufficiency removal of
intravenous steroids complicated the patient's picture and
she subsequently became hypotensive. In addition, the
patient responded poorly to Natrecor requiring Dopamine for
blood pressure support in attempt for diuresis. With
subsequent discontinuation of the Natrecor and continuing of
the intravenous Hydrocortisone the patient was effectively
diuresed and continued to be diuresed at the time of this
dictation without significant hypotension.
6. Acute renal failure: The patient has a baseline
creatinine of .5 to .7 and subsequently developed acute renal
failure with a creatinine rising to 2.1 with diuresis
presumed to be prerenal. With gentle diuresis her creatinine
slowly improved and it was approximately 1.3 at the time of
this dictation. Goal was to continue diuresis gently in
order to avoid acute renal failure.
7. Right IJ thrombus: The patient has a known right IJ
thrombus as a presumed complication from right IJ line
placement in the setting of sepsis. The clot is being
followed serially with weakly ultrasound with noticeable
resolution in the proximal right subclavian clot that is no
more seen as of the ultrasound from [**2114-4-30**]. The patient was
not anticoagulated given her Jehovah's witness status and
will be continued to follow serially with ultrasounds.
8. Inflammatory breast cancer: The patient is a patient of
Dr. [**First Name (STitle) **]. She has a recent history of inflammatory breast
cancer and had been receiving weekly Navelbine and Herceptin.
The plan was to try to reduce the size of her left breast
mass so she could become a candidate for a mastectomy.
However, given her repeated decline in her physical condition
her chemotherapy has been changed multiple times. She is
unable to be staged appropriately because of her weight.
However, recent CTPA did not show any obvious metastatic
disease. There was some concern that her preexisting lower
extremity edema prior to this admission was secondary to a
carcinous meningitis, however, that seems to be unfounded and
neurology was unable to obtain LP for diagnostic purposes.
Consequently the plan at this point in time is that the
patient will be reconsidered for additional chemotherapy if
she is able to become discharged from the hospital and
improves her performance status.
9. Anemia: The patient is a known Jehovah's witness and
would significantly benefit from blood transfusions. On
presentation her hematocrit was approximately 23 had
decreased to 19. Heparin products had been avoided and she
has not been anticoagulated. She continues on Epogen and
iron and her hematocrit seems to stabilize between the 23 and
26 range.
10. Vaginal spotting: During her hospitalization in the
Intensive Care Unit the patient had repeated vaginal spotting
with an associated drop in her hematocrit. Gynecology was
consulted and it was thought that this bleeding was unrelated
to her anemia. She does have multiple risk factors for
endometrial cancer and the goal would be to image her with a
transvaginal ultrasound to sample her endometrium again,
however, at this point in time any additional studies were
deferred and she is to be contact[**Name (NI) **] for follow up in the
[**Hospital 111518**] Clinic as her condition improves and she
becomes an outpatient.
11. Rectal fistula: The patient had a noticeable perirectal
fistula on examination with concern that this may have been
contributing to her fever and sepsis. Surgery was consulted
and determined this unlikely as the nidus of infection based
on clinical examination findings. No perirectal cellulitis
and no obvious abscess formation. Unfortunately imaging
studies were unable to be obtained given the patient's body
habitus. Perirectal swab was polymicrobial in nature
including MRSA, however, it was thought that this was
unlikely to be the source of the patient's MRSA bacteremia
though should be considered if the patient has recurrent
event without additional line placement. The patient
continues to be followed serially with examinations with no
obvious signs of infection.
12. FEN: The patient remained NPO and during the initial
part of her hospitalization was started on tube feeds. The
patient continues with tube feeds at this time. She
unfortunately was not a candidate for PEG or open G tube
placement given her [**Doctor Last Name **] habitus and potential surgical
risks. She continues on her tube feeds at this time.
13. Code status: The patient is a Jehovah's witness and
remains full code at the time of this dictation.
DISPOSITION: The patient's disposition is pending based upon
improvement in her respiratory status with a goal for
subsequent transfer to a nursing facility for continued trach
care and pulmonary rehabilitation.
The remainder of this dictation will be completed by the next
medical Intensive Care Unit intern.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2114-5-5**] 04:08
T: [**2114-5-7**] 08:28
JOB#: [**Job Number 111519**]
Admission Date: [**2114-4-10**] Discharge Date: [**2114-5-10**]
Date of Birth: [**2056-10-30**] Sex: F
Service: ICU
ADDENDUM TO THE HOSPITAL COURSE:
1. Respiratory failure: The patient has been continued on
treatment for her Methicillin resistant Staphylococcus aureus
pneumonia and has been increasingly weaned from the
ventilator. She has in general been kept on a pressure
support ventilation with pressure supports of [**11-27**] and a
PEEP of 5 with an FIO2 of 35%. However, she has tolerated
several trials of transition to a trachea mask. She has gone
several hours at a time with a trachea mask after which she
has maintained adequate oxygenation and ventilation, though,
started to feel tired after several hours and has been
returned to the ventilator. Her goal remains diuresis at 500
cc to 1 L negative per day. The patient has been maintained
on trachea care, as well as nebulizers prn and aggressive
suctioning though her level of secretions has not increased.
2. Congestive heart failure: The patient as mentioned above
has continued to be diuresed 500 cc to 1 L per day. She was
started on diamox 250 b.i.d. Has also been diuresed with
intravenous Lasix of 20 intravenous b.i.d. as tolerated and
has had Captopril started with a dose that has been titrated
up to 25 mg t.i.d.
3. Methicillin resistant Staphylococcus aureus infection:
The patient has been maintained on vancomycin. Due to
supratherapeutic levels, her vancomycin has been held and on
the morning of the 25th, her vancomycin level was still 20.
She will be given vancomycin for trough levels less than 15.
She will be requiring vancomycin through the [**7-14**],
which will be one month after her last positive Methicillin
resistant Staphylococcus aureus blood culture. The patient
has for the most part remained afebrile, though, did have a
temperature of 102 briefly the morning of the 25th after
which point she defervesced spontaneously.
4. Acute renal failure: The patient's creatinine remained
slightly above her baseline and on the morning of the 25th,
her creatinine was 1.5. It is felt that the creatinine
elevation from her baseline may be secondary to prerenal
physiology as the patient has been diuresed with Lasix, and
overall remains total body water overloaded.
5. Hypotension: The patient's pressures have been stable in
the 120-150 systolic range. Her hydrocortisone dosing is now
being tapered and on the 25th she has been weaned to a dose
of 25 mg b.i.d. of hydrocortisone. It is felt that she will
likely require at least 30 mg a day replacement for her
adrenal insufficiency for some time and so following
discharge her hydrocortisone should be weaned down to 20 mg
in the morning and 10 mg at night.
6. Anemia: The patient is a Johovas Witness as mentioned
before and does not allow blood transfusions, therefore, she
has been maintained on 20,000 units twice a week of Procrit,
as well as iron replacement, and her hematocrit has remained
stable.
7. Breast cancer: The patient's chemotherapy has continued
to be held and her oncologist, Dr. [**First Name (STitle) **], was contact[**Name (NI) **]
regarding plans for possible re-initiation of treatment. The
oncologist noted that the patient should not be restarted on
any treatment for her breast cancer at present and should
follow-up with her in clinic to discuss the possibility of
re-initiation of therapy.
DISCHARGE CONDITION: The patient is discharged in stable
condition.
DISCHARGE DIAGNOSES:
1. Upper respiratory failure.
2. Sepsis.
3. Methicillin resistant Staphylococcus aureus bacteremia.
4. Methicillin resistant Staphylococcus aureus pneumonia.
5. Methicillin resistant Staphylococcus aureus urinary tract
infection.
6. Anemia.
7. Hypotension.
8. Inflammatory breast cancer.
9. Endometrial hyperplasia.
10. Rectal fistula.
11. Obstructive sleep apnea.
12. Morbid obesity.
13. Hypoventilation syndrome.
14. Congestive heart failure.
DISCHARGE MEDICATIONS:
1. Fluoxetine 40 mg po q.d.
2. Heparin subcutaneous 5,000 mg t.i.d.
3. Acetaminophen [**Telephone/Fax (1) 1999**] mg po q. 4-6 hours prn.
4. Fluticasone 110 6 puffs b.i.d.
5. Lansoprazole 30 mg q.d.
6. Albuterol nebulizers q. 4 hours as needed.
7. Albuterol inhaler q. 4 hours, 4-6 puffs.
8. Haldol .5 po t.i.d. prn anxiety.
9. Lactulose 30 prn constipation.
10. Metoclopramide 10 mg po q.i.d.
11. Multivitamin.
12. Ferrous sulfate 325 mg t.i.d.
13. Erythropoietin alpha 20,000 units twice a week
subcutaneously. Given on Monday and Thursday.
14. Ascorbic acid 500 mg q.d.
15. >...........<250 mg q. 12 hours.
16. Lorazepam .5-2 mg prn anxiety.
17. Captopril 25 mg po t.i.d.
18. Furosemide 20 mg intravenously b.i.d.
19. Hydrocortisone 20 mg q.a.m. and 10 mg q.p.m.
20. Regular insulin sliding scale as needed.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-959
Dictated By:[**First Name3 (LF) 111279**]
MEDQUIST36
D: [**2114-5-10**] 01:16
T: [**2114-5-10**] 10:24
JOB#: [**Job Number 111280**]
|
[
"518.81",
"428.40",
"278.01",
"482.41",
"599.0",
"038.11",
"428.0",
"780.57",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"96.04",
"99.23",
"96.72",
"96.6",
"03.31",
"31.1",
"38.93",
"38.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
16790, 16838
|
16859, 17314
|
17337, 18389
|
13519, 16768
|
2117, 3176
|
146, 168
|
197, 1420
|
1442, 1992
|
2009, 2094
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,841
| 123,538
|
4510
|
Discharge summary
|
report
|
Admission Date: [**2164-4-9**] Discharge Date: [**2164-4-11**]
Date of Birth: [**2100-10-3**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol / Plavix / Percocet / Omeprazole / Metoprolol
/ Morphine
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
acute delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63F w/ DM, HTN, recent left great toe injury c/b left great toe
osteomyelitis s/p OR debridement x2 and distal SFA stenting with
course complicated by poor wound healing, [**Last Name (un) **], acute on chronic
systolic CHF presents from rehab with AMS.
.
At baseline, per report and per electronic records, the patient
is fully oriented x3. Per EMS report and facility documentation,
the patient shortly before arrival became acutely agitated. She
also complained of left lower quadrant abdominal pain. The
facility gave her 1 mg of morphine IM for this pain. They then
realized that she has a documented allergy to morphine, which is
altered mental status, no anaphylaxis. The records clearly state
that the altered mental status proceeded the morphine
administration. She was placed on a nonrebreather mask, though
it is not clear if the pt was ever hypoxic. At baseline, she
uses 2 L nasal cannula oxygen for her COPD.
.
Admission from [**Date range (3) 19258**]:
# Left great hallux MRSA osteomyelitis: The patient was
admitted with a left great hallux ulceration that probed to bone
following traumatic injury to her foot. Wound culture was
positive for MRSA, and the patient was started on vancomycin on
[**2164-3-5**]. The patient's wound was debrided by podiatry in the
OR. However, she had poor wound healing, and development of dry
gangrene at the incision site. Due to poor wound healing, she
underwent ABI/PVRs that showed poor vascular flow to the distal
left extremity. She underwent distal SFA stent placement and
was started on prasugrel and aspirin. The patient was taken
back to the OR by podiatry for further toe debridement.
Following the second debridement, both clean and dirty margins
of bone grew MRSA. She was seen by infectious disease, who
recommended 6 weeks of IV vancomycin for persistent
osteomyelitis. A PICC line was placed. The patient was
discharged on vancomycin. She should undergo daily dressing
changes with betadine, gauze, and Kerlix to foot and ankle. She
should follow up with vascular, infectious disease, and podiatry
as an outpatient. Final clean margin bone pathology pending at
discharge.
.
# Acute on chronic systolic CHF with EF 35%: The patient
developed dyspnea and hypoxia after receiving PRBCs and pre-cath
hydration in preparation for angiogram. Chest X-ray showed
pulmonary vascular congestion and bilateral pleural effusions.
The patient was started on IV diuresis with lasix, and her
symptoms improved. However, at the time of discharge, she still
had a mild O2 requirement. The patient was discharged on lasix
20 mg PO daily. She was continued on aspirin, carvedilol,
simvastatin, and fish oil throughout admission. The patient is
not on an ACEI due to acute kidney injury.
.
# Acute kidney injury: Following first OR debridement of
osteomyelitis, the patient developed ATN, with muddy brown casts
on urine microscopy. Her creatinine increased from baseline 0.9
to 2.9, and slowly improved to 1.4. Creatinine remained at 1.4
for remainder of admission. Medications were renally dosed.
.
# Anemia: The patient had progressive anemia during admission,
with nadir HCT of 22. She was found to be guaiac positive, with
brown stool. Prior to vascular procedure, the patient was
transfused 3 units PRBCs for cardiac optimization. Hematocrit
remained stable following transfusion. The patient should
follow up with gastroenterology as an outpatient for
colonoscopy.
.
# COPD: Patient with occasional wheezing at baseline. Has had
many COPD exacerbations in the past. The patient was continued
on standing ipratropium bromide throughout admission. Albuterol
nebs were increased to q4hrs for increased wheezing in the
setting of fluid overload. If wheezing worsens, may consider
increasing frequency of nebs. Steroids not started during
admission, as patient thought to have primary cardiac source of
wheeze. [**Month (only) 116**] consider steroids for short course if respiratory
status worsens, but would avoid if possible given MRSA
osteomyelitis and wound healing.
.
In the ED, initial VS were:
98 ??????F (36.7 ??????C), Pulse: 77, RR: 20, BP: 105/46, O2Sat: 100
On arrival, the patient was altered and obtunded. She opened her
eyes to voice and answered very short questions, but immediately
falls back asleep. She has poor air movement and diffuse
wheezing. She was given nebulizers, and 125mg of IV
Methylprednisone. ED course:
.
- VBG pH 7.37 pCO2 62 pO2 46 HCO3 37 BaseXS 7, Lactate:1.5
- ABG pH 7.41 pCO2 52 pO2 154 HCO3 34 BaseXS 7
- Placed on BiPAP
- CXR with pulm edema, R pleural effusion
- Rectal temperature 103.7.
- Pan cultured
- Gave Zosyn for empiric treatment of unclear source
- She received vancomycin at 1700 at the nursing facility.
- UA with only small leuks
- Lumbar puncture opening pressure 24 in left lateral decubitus
position with legs flexed. CSF negative.
- CT scan of abdomen
- CT head noting acute sinusitis.
- Lines & Drains: R AC #18 PIV, L PICC
.
On arrival to the MICU, VS were:
T 98 BP 102/43 HR 77 RR 18 O2 Sat 93% 2L NC
She appeared comfortable and BiPAP was discontinued without
incident.
Past Medical History:
- CHF (EF 35% in [**4-/2162**])
- CAD s/p MI, s/p stent ([**2153**]; mid LCx, mid and distal RCA)
- Asthma/ COPD (h/o bronchospasm requiring albuterol w/URIs)
- Diabetes Type 2 (last A1C 11.7%, [**2-15**]), on insulin, c/b
neuropathy
- HTN
- Lumbar spinal stenosis with L5-S1 radiculopathy (frequent
injections through [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic, most recently [**2162-12-13**])
- Depression
- Anxiety with agoraphobia
- Hypothyroidism
- Hyperlipidemia
- H/o upper GI bleeding and gastric ulcers (most recent, [**9-13**])
- ORIF left proximal humerus nonunion with left iliac crest bone
grafting, [**2163-12-26**]
Social History:
Recently d/c'ed from [**Hospital1 18**] to rehab. Retired as secretary at
the [**Hospital1 18**], then Red Cross. Boyfriend, [**Name (NI) **], of 26 years. Has
one daughter, [**Name (NI) **], and 2 grandchildren who live in [**Hospital1 1474**].
Independent with administering her own medications. Active
smoker, 0.5 -1 PPD x 30-35 years. Denies EtOH, drugs. Walks
with a walker.
Family History:
Mother had CAD, [**Name (NI) 2320**] with neuropathy and nephropathy, leg
amputation, died at age 68. Father died of MI (age of death
uncertain).
Physical Exam:
Admission Exam:
T 98 BP 102/43 HR 77 RR 18 O2 Sat 93% 2L NC
Gen: NAD, resting comfortably
HEENT: EOMI, MMM
Neck: Unable to asses JVP 2/2 habitus
Cardiac: RRR, normal S1, S2, no murmurs, rubs or gallops
Resp: Decreased breath sounds in bases bilaterally;
basilar crackles; otherwise mild end-expiratory wheezing with
moderate air movement
Abd: Normoactive bowel sounds; Obese, soft, non-tender,
non-distended
Ext: Non-edematous; left great toe s/p resection x 2; toe pink
with evidence of good healing; no erythema of foot
Neuro: Alert and oriented to person only, obtunded but
arousable to voice. Moves all 4 extremities, responds to
commands.
Discharge Exam:
Fully alert and oriented times 3. mild basilar crackles.
otherwise similar to admission.
Pertinent Results:
Admission Labs:
[**2164-4-8**] 07:35PM BLOOD WBC-7.9 RBC-3.30* Hgb-9.2* Hct-27.5*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.9* Plt Ct-171
[**2164-4-8**] 07:35PM BLOOD Neuts-74.4* Lymphs-15.6* Monos-6.6
Eos-2.8 Baso-0.6
[**2164-4-8**] 08:29PM BLOOD PT-11.4 PTT-31.6 INR(PT)-1.1
[**2164-4-8**] 07:35PM BLOOD Glucose-123* UreaN-56* Creat-1.7* Na-137
K-4.4 Cl-94* HCO3-33* AnGap-14
[**2164-4-8**] 07:35PM BLOOD ALT-125* AST-79* LD(LDH)-314*
AlkPhos-421* TotBili-0.9
[**2164-4-8**] 07:35PM BLOOD Lipase-11
[**2164-4-9**] 02:51AM BLOOD proBNP-6180*
[**2164-4-8**] 07:35PM BLOOD Calcium-9.1 Phos-4.6* Mg-2.2
[**2164-4-8**] 07:50PM BLOOD Type-[**Last Name (un) **] pO2-46* pCO2-62* pH-7.37
calTCO2-37* Base XS-7 Comment-GREEN TOP
[**2164-4-8**] 07:57PM BLOOD Type-ART pO2-154* pCO2-52* pH-7.41
calTCO2-34* Base XS-7
Discharge labs:
[**2164-4-11**] 05:15AM BLOOD WBC-6.9 RBC-3.19* Hgb-8.7* Hct-27.6*
MCV-87 MCH-27.2 MCHC-31.5 RDW-16.3* Plt Ct-175
[**2164-4-9**] 02:51AM BLOOD Neuts-83.0* Lymphs-14.2* Monos-1.2*
Eos-0.2 Baso-1.4
[**2164-4-11**] 05:15AM BLOOD Glucose-158* UreaN-80* Creat-1.6* Na-140
K-4.7 Cl-99 HCO3-34* AnGap-12
[**2164-4-11**] 05:15AM BLOOD ALT-71* AST-49* AlkPhos-342* TotBili-0.4
[**2164-4-9**] 02:51AM BLOOD Lipase-7 GGT-469*
[**2164-4-11**] 05:15AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.5
Notable labs:
[**2164-4-10**] 03:46AM BLOOD Vanco-21.1*
[**2164-4-9**] 06:29AM BLOOD Vanco-26.4*
[**2164-4-9**] 02:51AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-4-9**] 02:51AM BLOOD HCV Ab-NEGATIVE
[**2164-4-8**] 07:50PM BLOOD Lactate-1.5
[**2164-4-9**] 02:51AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
Blood cultures 3/4, [**4-9**] NGTD
Urine culture [**4-8**], [**4-10**] NGTD
RPR [**4-8**] NEGATIVE
[**2164-4-8**] 10:52 pm CSF;SPINAL FLUID TUBE#3.
GRAM STAIN (Final [**2164-4-9**]):
1+ (<1 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 (Preliminary): NO GROWTH.
CXR ([**2164-3-10**]):
1. Moderate pulmonary edema with possible small right pleural
effusion.
Consider repeat radiograph after diuresis to evaluate for
underlying
pneumonia.
2. Increased left shoulder dislocation/displacement since
[**2164-3-23**] and
[**2164-1-4**], which may in part be due to technique. Dedicated
shoulder
radiographs could be obtained if clinically indicated.
.
CT Head ([**2164-3-10**]):
1. No CT evidence for acute intracranial process.
2. Partial opacification of the ethmoid air cells bilaterally,
which is new compared to [**2164-3-5**], with aerosolized secretions
in the left ethmoid air cells, could relate to possibility of
acute sinusitis.
.
CT Abd/Pelvis ([**2164-3-10**]):
1. Small consolidation at right lung base with small right
pleural effusion, which could represent infection.
2. Small amount of pericardial fluid.
3. No acute intra-abdominal or pelvic pathology detected; normal
appendix, two cecal diverticula without evidence for
inflammation.
4. Large amount of air in the bladder, which could be related to
instrumentation.
Arterial Duplex US LEFT LE [**2164-4-8**]:
Patent left common femoral, superficial femoral, and popliteal
arteries. They present with monophasic Doppler waveforms which
is a sign of arterial disease/distal ischemia. No evidence of
critical stenosis within the arteries studied
LEFT FOOT, THREE PLAIN VIEWS [**2164-4-9**]:
Three views of the left foot demonstrate similar appearance of
distal first ray resection to the level of distal proximal
phalanx. Joint
spaces are preserved. No new fracture. Vascular calcifications
are noted.
Brief Hospital Course:
Primary Reason for Admission: 63 y/o woman with recent admission
for AMS found to have L great toe osteomyelitis s/p discahrge
with PICC on vanc presenting from rehab with AMS requiring MICU
admission for noninvasive ventilation.
.
Active Problems:
1. Acute Delirium: Likely drove the initial need for BiPAP,
which was immediatley stopped upon transfer from the ED to the
MICU. Likely multifactorial: 1) medication effect and 2)
toxic/metabolic encephalopathy. She was given Morphine at rehab
and has a documented allergy to Morphine, which causes AMS.
Fever and R lung base consolidation and overlying pleural
effusion raise possibility for HAP, though no WBC count. She has
sngnificant MR with a posterior jet, which may also be the cause
of the fluid at her R lung base, in which case pneumonia is
unlikely. Her mental status improved rapidly overnight and she
had no further episodes of delirium. Her CSF was negative for
meningitis. She was at her baseline mental function at the time
of discharge
2. Fever: Given high grade (>103), consider infectious cause vs
medication effect. There are case reports of Prasugrel causing
high grade fever and cholestatic hepatits; we therefore stopped
her Prasugrel. Blood and urine cultures were negative. She
defervesced without further incident
3. Abnormal LFTs: Likely medication effect from Prasugrel which
was the only recent medication addition. Upon its
discontinuation, her LFTs slowly started to improve. Lab
results are most consistent with a cholestatic picture given
markedly elevated Alk Phos and GGT. Hepatitis virus serologies
were negative. CT abd/pelvis showed no biliary or hepaitc
disease. LFTs should be checked again in a week to ensure
downtrend. Her statin was held in light of transaminitis- this
needs to be restarted when LFTs improve.
4. sCHF: LVEF 35%. Pt was volume overloaded on prior admission
and was started on Lasix 40mg po qday at the time of d/c. She
was diuresed with IV lasix in the MICU, and appeared euvolemic
thereafter. Her Creatinine elevated following this trial, so she
was placed back on lasix 40mg PO at discharge.
5. DM2: Pt with poorly controlled DM, last A1C 11.7%.
Complications include nephropathy, retinopathy and neuropathy.
She was initially called out on HD #1, but had markedly elevated
BG (>500), which was difficult to control. Her Lantus and ISS
were incresed with improvement in her BG.
6. Acute on Chronic Renal Failure: She had recent ATN earlier in
the month post-operatively, and possible contrast-induced
nephropathy several weeks ago. Creatinine fluctuated up to
1.6-1.8, appeared somewhat dry and sodium avid on urine lytes
with euvolemic exam, so continued outpatient lasix regimen.
7. MRSA L Hallux Toe Osteo: Pt followed by ID; currently on 6
week course of Vancomycin based on culture and sensitivity data.
Due to fluctuating renal function, was discharged on 1000mg
EVERY 48 hours, next dose [**2164-4-12**] with stop date [**2164-4-26**]. Will
be followed in [**Hospital 4898**] clinic.
Chronic Problems:
1. CAD: Pt is s/p MI and PCI ([**2153**]; mid LCx, mid and distal
RCA). No e/o acute coronary event on this admission. EKG was at
baseline, no ST-T wave changes.
2. PVD: Pt is s/p SFA stent on prior admission for poorly
healing L hallux toe osteo. Her toe is well healing today, no
e/o worsening infection. Vascular consulted, agreed with
stopping prasugrel though will continue aspirin. Dopplers of
the left leg arterial system showed patent stents.
3. Respiratory Acidosis/COPD: Pt with multiple COPD
exacerbations and significant smoking history, though current
presentation is not c/w an acute COPD exacerbation. No
indication for steroids at this time. Pt did receive 125mg IV
Methypprednisone in the ED. Was continued on albuterol and
ipratropium.
4.Hypothyroidism:cont home Levothyroxine
Pending tests at discharge:
-blood culture [**4-8**], [**4-9**]
-urine culture [**4-10**]
-CSF culture [**4-8**]
Transitional Issues:
- ID followup of MRSA osteomyelitis
- check LFTs in 1 week to ensure downtrend
- weightbearing OK per podiatry on affected foot
Medications on Admission:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. diazepam 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
8. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
12. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qHS ().
13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to left arm for pain.
15. ascorbic acid 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO once a
day.
22. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
24. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q48H (every 48 hours).
25. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
26. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
27. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ml Intravenous every eight (8) hours as needed for line
flush: for picc.
28. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous once a day.
29. insulin glargine 100 unit/mL Cartridge Sig: Five (5) units
Subcutaneous at bedtime.
30. insulin aspart 100 unit/mL Cartridge Sig: as directed units
Subcutaneous four times a day: per sliding scale.
31. Outpatient Lab Work
please check vancomycin trough on [**3-28**], prior to vancomycin dose
(4th dose on current regimen). Check weekly thereafter.
32. Outpatient Lab Work
Please check electrolytes on [**3-26**], and weekly thereafter for
potassium and renal function in setting of lasix
33. Gauze Sponges 4 X 4 Sponge Sig: [**2-6**] sponges Topical once a
day: apply to left foot wound daily.
34. Betadine 10 % Solution Sig: QS drops Topical once a day:
apply to 4x4 gauze and apply to left great hallux wound daily.
35. Kerlix 3.4 X 3.6 -yard Bandage Sig: One (1) bandage Topical
once a day: around left foot and ankle.
Discharge Medications:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. diazepam 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for wheeze.
7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
12. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to L shoulder, 12hr on, 12hr off.
14. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. omega-3 fatty acids Capsule Sig: One (1) Capsule PO once
a day.
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
20. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
21. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous EVERY 48 HOURS: Next dose: [**4-12**], stop date: [**4-30**].
22. Outpatient Lab Work
Please check the following weekly, All laboratory results should
be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All
questions regarding outpatient antibiotics should be directed to
the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD
in when clinic is closed
CBC w/diff BUN/Creatinine Vanco trough ESR CRP
23. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-11**]
hours as needed for fever or pain.
24. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
25. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous once a day.
26. insulin lispro 100 unit/mL Solution Subcutaneous
27. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily): apply to L toe ulcer daily .
28. 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.
29. 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:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
1. acute delirium
2. transaminitis- possibly drug induced
3. Left hallux osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 19248**],
You were admitted to the hospital with confusion which may have
happened after you received morphine. You needed extra oxygen,
which is why you were in the intensive care unit, where you
stayed due to elevated blood sugars.
You had abnormalities of your liver tests which may have been
caused by a medicine called prasugrel. This medicine was
stopped. You were seen by the vascular surgery teams who felt
this was safe. You will continue aspirin to protect your stents
in your legs from clotting.
The following changes were made to your medications:
1. STOP PRASUGREL
2. INCREASE LANTUS to 25 units at breakfast, and icnrease
sliding scale as the attached sheet suggests
3. START ASPIRIN 325mg daily
No other changes were made to your medications, please continue
all other previously prescribed medications
Followup Instructions:
Please call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 250**] when you leave rehab to
follow up
You have the following important appointments:
Department: PODIATRY
When: MONDAY [**2164-4-23**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2164-5-1**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
|
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icd9cm
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,232
| 123,797
|
54345
|
Discharge summary
|
report
|
Admission Date: [**2158-9-15**] Discharge Date: [**2158-9-21**]
Date of Birth: [**2080-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Failure to thrive, weight loss and decreased appetite
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
History of Present Illness:
HPI:
Patient reports history of diarrhea 1 month ago, lasting 5 days
and resolving with kaopectate. He continued to take a dose or
two and then stopped. Since, then he has not had a BM x about 2
weeks off this medication. He does state he has had recurrent
diarrhea last night and this am but it was associated with po
intake. However, he has not been eating much due to lack of
appetite with mild GERD. He has been on aspirin for the past
couple years but denies any other NSAID use. He has no history
of peptic ulcer disease, bright red blood per rectum, black
stools, or hematemesis. He has never had a colonoscopy or EGD in
the past. Of note, he does complain of mild suprapubic pain
([**2163-1-20**]) x 2-3 weeks, 30 lb wt loss over the past 2-3 weeks,
lightheadedness for a couple days, and severe fatigue limiting
his ability to tend to ADL x 2-3 weeks. He denies chest pain,
headache, cough, shortness of breath, or lower extremity edema.
He also is not aware of any fevers.
Past Medical History:
.
PMHx:
1. Hypertension
2. Diabetes Type II: hgb A1c 8.2% in [**3-23**]
3. Hypercholesterolemia
4. Enlarged prostate w/ elevated PSA, s/p neg bx x1, has not f/u
for 2nd bx
5. DJD of the right hip, undergoing PT to defer surgery
6. Left inguinal hernia (reducible)
7. CRI (baseline 1.3)
Social History:
SH:
+ h/o tobacco: [**12-22**] yrs, quit 50 yrs ago
No h/o ETOH / drug use
Patient is a retired post office worker. He lives alone in
[**Location (un) **] and was receiving meals on wheels. He has never been
married and has no kids. He has no family, other than a cousin
who has moved out of the area. He has not identified anyone as
his HCP.
Family History:
FH: Mother died in her 70s due to unknown causes, Father died in
his 70s due to MI, no siblings
Physical Exam:
PE: T 97.6 bp 106/39 hr 59 rr 16 O2 95% RA
genrl: in nad
heent: perrla (3->2 mm), dry mm, poor dentition
cv: rrr, no m/r/g
pulm: cta bilaterally
abd: nabs, soft, no increase tenderness when suprapubic region
palpated, left inguinal hernia
extr: no [**Location (un) **]
neuro: a, o x 3, strength approx [**3-23**] bilaterally in UE/LE,
sensory intact to soft touch bilaterally
Pertinent Results:
[**2158-9-17**] 01:32PM BLOOD CK-MB-9 cTropnT-0.15*
[**2158-9-17**] 02:05AM BLOOD CK-MB-13* MB Indx-11.7* cTropnT-0.14*
[**2158-9-16**] 06:48AM BLOOD CK-MB-9 cTropnT-0.07*
[**2158-9-15**] 01:55PM BLOOD cTropnT-0.03*
[**2158-9-15**] 01:55PM BLOOD ALT-11 AST-16 CK(CPK)-49 AlkPhos-123*
TotBili-0.6
[**2158-9-15**] 01:55PM BLOOD Glucose-156* UreaN-121* Creat-3.1*#
Na-143 K-4.4 Cl-105 HCO3-21* AnGap-21*
[**2158-9-21**] 05:50AM BLOOD Glucose-137* UreaN-13 Creat-1.3* Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
[**2158-9-16**] 06:48AM BLOOD Glucose-39* UreaN-85* Creat-2.1* Na-143
K-4.0 Cl-110* HCO3-21* AnGap-16
[**2158-9-15**] 12:00PM BLOOD Plt Smr-VERY LOW Plt Ct-74*#
[**2158-9-21**] 05:50AM BLOOD PT-12.8 PTT-38.0* INR(PT)-1.1
[**2158-9-21**] 05:50AM BLOOD Plt Ct-119*
[**2158-9-20**] 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Schisto-OCCASIONAL
[**2158-9-15**] 12:00PM BLOOD Neuts-89.0* Bands-0 Lymphs-4.9* Monos-5.1
Eos-0.9 Baso-0.1
[**2158-9-20**] 05:45AM BLOOD Neuts-83.5* Bands-0 Lymphs-9.6* Monos-5.0
Eos-1.7 Baso-0.2
[**2158-9-15**] 12:00PM BLOOD WBC-4.9 RBC-1.27*# Hgb-3.6*# Hct-11.5*#
MCV-90 MCH-28.7 MCHC-31.7# RDW-16.0* Plt Ct-74*#
[**2158-9-15**] 01:55PM BLOOD WBC-12.2* RBC-3.17*# Hgb-9.5*# Hct-27.3*#
MCV-86 MCH-29.9 MCHC-34.7 RDW-16.0* Plt Ct-181
[**2158-9-16**] 03:18AM BLOOD WBC-8.8 RBC-2.53* Hgb-7.5* Hct-21.3*
MCV-84 MCH-29.8 MCHC-35.5* RDW-16.0* Plt Ct-125*
[**2158-9-21**] 05:50AM BLOOD WBC-7.7 RBC-3.91* Hgb-11.9* Hct-32.6*
MCV-83 MCH-30.3 MCHC-36.4* RDW-15.6* Plt Ct-119*
[**2158-9-21**] 05:50AM BLOOD Calcium-8.2* Phos-1.7* Mg-1.8
[**2158-9-15**] 01:55PM BLOOD Calcium-8.5 Phos-6.4* Mg-2.9*
[**2158-9-19**] 05:50AM BLOOD Triglyc-100 HDL-35 CHOL/HD-2.7 LDLcalc-41
[**2158-9-17**] 02:05AM BLOOD TSH-0.49
[**2158-9-16**] 06:48AM BLOOD TSH-0.46
[**2158-9-16**] 09:24AM BLOOD Cortsol-45.3*
[**2158-9-16**] 06:48AM BLOOD Cortsol-22.8*
[**2158-9-15**] 01:55PM BLOOD PSA-32.4*
[**2158-9-17**] 02:05AM BLOOD Gastrin-101
[**2158-9-15**] 01:35PM BLOOD Type-ART pO2-243* pCO2-37 pH-7.32*
calHCO3-20* Base XS--6
[**2158-9-15**] 02:04PM BLOOD Lactate-2.2*
[**2158-9-15**] 07:54PM BLOOD Lactate-1.7
[**2158-9-19**] 07:01AM BLOOD freeCa-1.18
[**2158-9-21**] 03:40PM BLOOD CA [**71**]-9 -PND
[**2158-9-19**] 09:20AM BLOOD INSULIN-Test
Brief Hospital Course:
78 yo male with history of hypertension, diabetes,
hypercholesterolemia, recent 30 pounds weight loss, decreased
appetite and abnormal PSA with negative biopsy who was admitted
with hypotension (88/43) and hypothermia (93.2).
Problems:
# Metastatic Pancreatic Cancer: Given his weight loss, a CT of
the abdomen was obtained. This demonstrated a mass 3.5cmx5.5cm
in the pancreatic head that extended into the duodenal wall and
entirely encircled the gastroduodenal artery. There were
innumerable lesions (likely metastatic lesions) in the liver and
mesenteric lymph nodes. The patient was evaluated by the
gastroenterology service and it was thought that given the
extent of disease, involvement of vascular structures, there was
likely no surgical intervention needed at this time. The GI team
would defer further management to the oncologists. The patient
was scheduled to follow-up with Dr. [**Last Name (STitle) **] (oncology) for
evaluation of candidacy for chemotherapy. No urgent consults was
obtained given his poor functional status and need for
rehabilitation regardless of treatment chosen. The patient may
need palliative stenting/stone removal from distal pancreatic
duct if symptoms worsen (he has an 8mm stone obstructing the
distal pancreatic duct).
# Melena:
The patient was noted to have melena. He underwent EGD and
multiple upper GI sources sources were identified: gastritis,
antral erosions, duodenitis, and metastatic pancreatic cancer
encircling gastroduodenal artery. Some of these findings were
likely secondary to the consumption of aspirin on an empty
stomach in the month prior to presentation. During the hospital
stay aspirin was held and the patient's coagulopathy was
corrected with vitamin K. He was maintained on a proton pump
inhibitor. He required several transfusions to keep his HCT >30.
# Hypothermia/leukocytosis:
There was concern for sepsis on admission given elevated
lactate, hypotension, hypothermia. The hypotension was likely
secondary to hypovolemia in setting of melena and poor po
intake. The patient's lactate trended down with IVF. He was
initially treated with a warming blanket after which he remained
normothermic. Since he never had a febrile episode, blood
culture, urinalysis and urine culture were noted to be
unremarkable he was not started on any antibiotics. His CXR did
not show any evidence of pneumonia. The pt had compalined about
loose stools a month prior to presentation but his stool for
C.difficile and stool cx were noted to be neagtive. There was no
evidence of prostatitis on rectal exam. The pt had no headaches
or acute mental status changes to suggest a CNS infection. The
hypothermia and leukocytosis gradually resolved with treatment.
## Abnormal PSA:
Pt has a long-standing history of enlarged prostate whihc has
been evaluated with biopsy in the past (negative). On CT
abdomen, the patient's prostate was noted to be 10cm x 9cm in
diameter and abutting the bladder. The pt had no obstructive
symptoms and continued to have adequate urine output. However,
he remains at a risk for outlet obstruction/urinary retention if
the prostate size continues to increase.
## Hypotension:
-Previous hypotension likely due to hypovolemia given melena
with history of poor po intake. The hypotension gradually
resolved. Due to concern for adrenal insufficiency, a cortisol
stimulation test was performed and was found to be within normal
limits.
## Acute on chronic renal failure
Pt had an elevation of creatinine from his baseline of 1.3-1.7
to a peak of 3.1. The Cr eventually improved to 1.3 with blood
transfusions and IVF. The pt continued to have good urine
output. During his hospitalization he was also noted to have
positive urine eosinophils which likely indicate a drug-induced
tubulointerstitial nephritis (secondary to aspirin or related
family of drugs).
## NSTEMI
During his hospitalization, the pt was noted to have an
asymptomatic NSTEMI with elevated cardiac enzymes (0.03->0.15).
This likely occurred in the setting of demand ischemia. The pt
was restarted on half-dose b-blocker (Atenolol 50mg daily),
statin (lipitor 80 daily; previously on 40mg daily) and low dose
ACE inhibitor (lisinopril 10mg daily) for cardio-protection. The
pt was noted to have no ECG changes during this time.
## Hypoglycemia:
Pt has a history of diabetes mellitus. He responded
appropriately to treatment and his blood glucose remained
controlled on insulin sliding scale. His admission hypoglycemia
was likely due to poor po intake on glyburide in setting of
acute on chronic renal failure. Due to concern for hypoglycemia
in the setting of abnormal EGD (stenosis of second part of the
duodenum) and possible gastrinoma, a gastrin level was obtained
that turned out to be within normal limits.
## Elevated INR:
Resolved with gradual PO intake and supplemental Vitamin K.
Likely nutritional in etiology.
## Diabetes mellitus:
The patient's hoome gylburide was held and he was placed in
insulin sliding scale. He had no recurrent episodes of
hypoglycemia.
## Hypertension
The patient's blood pressure gradually responded to the IVF. He
was sustaining adequate blood pressure. His HCTZ was held and
may be restarted pending Dr, [**Name (NI) **] approval on an
out-patient basis.
## Hypercholesterolemia:
Pt was maintained on statin (80mg QD Lipitor).
## FEN:
Pt had PRN replation of electrolytes. He was restarted on a
liquid diet which was transitioned to a soft diet (to be
uptitrated to regular solids as tolerated).
## Prophylaxis:
Heparin, proton pump inhibitors
## CODE STATUS:
-DNR/DNI
-Patient has not indicated a health care proxy. [**Name (NI) **] does not have
any family nearby (one cousin in [**State 2690**] with whom he has not been
in contact recently) nor does he have any friends (except for a
female friend who is admitted to a nursing home in [**Location (un) 16824**]).
Medications on Admission:
Meds:
atenolol 100 mg po qd
lisinopril
lovastatin 40 mg po qd
HCTZ 25 mg po qd
glyburide 10 mg po qd
ASA 325 mg po qd
ALLERGIES: No known drug allergies.
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): Please see attached
sliding scale for dosing instructions.
Disp:*qs attached* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
Disp:*90 ml* Refills:*2*
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Metastatic pancreatic cancer
Discharge Condition:
Stable
Discharge Instructions:
Please report to the nearest emergency department if you have
lightheadedness, fever, diarrhea, black/tarry stools, nausea or
vomiting.
Followup Instructions:
The patient needs to call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office ([**Telephone/Fax (1) 6301**] to get an appointment within the next week. He also has
the following appointments set up for him:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-9-25**] 1:30
Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2158-9-25**] 1:30
Completed by:[**2158-9-21**]
|
[
"197.7",
"535.61",
"550.90",
"250.80",
"157.0",
"196.2",
"197.4",
"584.9",
"401.9",
"715.35",
"280.0",
"276.52",
"593.9",
"577.8",
"410.71",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11818, 11888
|
4938, 10816
|
368, 397
|
11961, 11970
|
2608, 4915
|
12154, 12777
|
2099, 2197
|
11021, 11795
|
11909, 11940
|
10842, 10998
|
11994, 12131
|
2212, 2589
|
275, 330
|
425, 1412
|
1434, 1722
|
1738, 2083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,805
| 172,258
|
44911+58767
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-12-20**] Discharge Date: [**2159-1-1**]
Service: MEDICINE
Allergies:
Quinolones / Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
EGD, colonoscopy
PEG tube placement
History of Present Illness:
87 yo woman with history of SBO s/p ex lap [**10-25**], HTN, breast
CA, giant cell arteritis, GERD, diverticulosis and recent
hospitalization (with discharge on [**2158-12-18**]) for presumed c.
diff colitis vs. diverticulitis presented from nursing home with
hypotension.
.
During her past admission, abdominal CT demonstrated only
diverticulosis, no evidence of diverticulitis or any acute
infectious process. She had serial negative c. diff toxins, but
was treated empirically for c. diff colitis with Vanc and
Flagyl. She has chronically elevated WBC count with ? if this
was [**2-22**] steroids. Her antibiotic regimen was then changed to
meropenem (given a history of penicillin and quinolone allergy)
for empiric diverticulitis coverage (started on [**12-13**]). She also
had evidence of a UTI, and was treated with Bactrim. On day of
admission, pt found hypotensive at NH with SBP in the 60's, and
was reported to appear [**Doctor Last Name 352**] and lethargic. She was given IVF in
the field.
.
In the ED, she was normotensive. She was transfused 1unit PRBC
for a Hct of 23. On the floor, she again became hypotensive to
the 80's systolic and had a dark, guaiac positive stool. She was
given 500cc NS bolus, and her sbp increased to 120. She was also
given one dose of vancomycin, ceftriaxone, and azithromycin for
broad coverage with suspision of sepsis. In total, she received
three units of PRBC on the floor, and her Hct trended down from
23.1 -> 29.7 -> 25.6 -> 22.0. She was transfered to the [**Hospital Unit Name 153**] for
further management.
.
In [**Hospital Unit Name 153**] the pt underwent a bleeding scan which showed a jejunal
bleed. A angiogram showed no active bleeding. Pt underwent an
EGD and colonoscopy which showed mult duodenal ulcers, one very
close to the artery. Colonoscopy showed flecks of blood but no
active bleeding. Pt received total of 5 units of PRBC while in
the [**Hospital Unit Name 153**]. Hct has now been stable for > 24 hours.
Past Medical History:
PMH:
1. SBO secondary to adhesion on [**10-25**]
2. Abd surgery for release of adhesion on [**10-25**] at [**Hospital1 2025**]
3. Cdiff: pt dxed after abd surgery on [**10-25**] at [**Hospital1 2025**]
4. Giant Cell Arteritis: Pt on prednisone (taper to 20 mg on
[**12-5**])
5. Chronic constipation: Pt usually takes metamucil at home.
6. GERD
7. Breast cancer: XRT and lumpectomy in [**2153**]
8. C section (?adhesion secondary to c section)
9. Depresson
10. Decrease energy/appetite: Pt given ritalin and pt is now
more alert with improved appetite.
11. HTN: HCTZ, metoprolol, lisinopril
12.?Urinary incontinence: takes ditropan
.
Social History:
SocHx: Pt used to live with her son in [**Name (NI) **] before
admission to [**Hospital1 2025**] [**10-25**]. Pt Apparently elder services screened
her home environment during [**Hospital1 2025**] admission and was found unfit
for her to return. There was also a concern that her son would
not be able to care for her appropriately. She was therefore
admitted to [**Hospital1 599**] [**Location (un) **] after [**Hospital1 2025**] D/C.
Family History:
Noncontributory.
Physical Exam:
VS: 98.2, 76, 145/59, 16, 94% on 2L
Gen: elderly woman, NAD, answers questions/ follows all
commands, gives poor history.
HEENT: NCAT, PERRL, EOMI, anicteric, MM dry, OP clear,
ecchymosis on bottom lip.
Neck: supple, full ROM, no LAD, R IJ
Chest: decreased BS at bilateral bases to 1/3 up.
Cor: RRR with faint 1/6 systolic murmur appreciated over apex.
Abd: soft, NT/ND, +BS, no masses or organomegaly, multiple
ecchymoses
Extr: cool extremities. 3+ pitting edema.
Neuro: Alert and oriented x3. Not able to relate why she is in
the hospital.
Pertinent Results:
[**2158-12-24**] 03:09PM BLOOD Hct-33.1*
[**2158-12-24**] 05:07AM BLOOD WBC-15.4* RBC-3.92* Hgb-12.1 Hct-33.7*
MCV-86 MCH-31.0 MCHC-36.0* RDW-16.4* Plt Ct-131*
[**2158-12-22**] 03:12AM BLOOD Neuts-95* Bands-0 Lymphs-1* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2158-12-24**] 05:07AM BLOOD Plt Ct-131*
[**2158-12-24**] 05:07AM BLOOD PT-13.5* PTT-26.3 INR(PT)-1.2
[**2158-12-24**] 05:07AM BLOOD Glucose-84 UreaN-12 Creat-0.4 Na-141
K-3.3 Cl-106 HCO3-29 AnGap-9
[**2159-1-1**] 04:40AM BLOOD WBC-10.8 RBC-3.29* Hgb-10.5* Hct-30.4*
MCV-93 MCH-31.8 MCHC-34.4 RDW-16.0* Plt Ct-129*
[**2158-12-31**] 04:20AM BLOOD WBC-12.5* RBC-3.55* Hgb-11.5* Hct-33.0*
MCV-93 MCH-32.2* MCHC-34.7 RDW-17.9* Plt Ct-145*
[**2158-12-20**] 11:30AM BLOOD WBC-14.7* RBC-2.36* Hgb-7.6* Hct-23.1*
MCV-98 MCH-32.1* MCHC-32.9 RDW-16.6* Plt Ct-338
[**2158-12-21**] 07:52AM BLOOD Ret Aut-2.0
[**2159-1-1**] 04:40AM BLOOD Glucose-132* UreaN-11 Creat-0.3* Na-131*
K-3.6 Cl-96 HCO3-28 AnGap-11
[**2158-12-31**] 04:20AM BLOOD Glucose-138* UreaN-11 Creat-0.3* Na-134
K-3.9 Cl-100 HCO3-29 AnGap-9
[**2158-12-20**] 11:30AM BLOOD Glucose-113* UreaN-25* Creat-0.4 Na-137
K-3.9 Cl-103 HCO3-29 AnGap-9
[**2158-12-22**] 03:12AM BLOOD ALT-26 AST-23 LD(LDH)-345* AlkPhos-51
Amylase-38 TotBili-0.7
[**2158-12-21**] 12:41AM BLOOD LD(LDH)-279* TotBili-0.2
[**2158-12-20**] 11:30AM BLOOD ALT-22 AST-23 LD(LDH)-298* CK(CPK)-27
AlkPhos-58 Amylase-45 TotBili-0.2
[**2158-12-22**] 03:12AM BLOOD Lipase-31
[**2158-12-20**] 11:30AM BLOOD Lipase-49
[**2158-12-20**] 11:30AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2159-1-1**] 04:40AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.5*
[**2158-12-26**] 06:00AM BLOOD Gastrin-238*
[**2158-12-20**] 09:03PM BLOOD Lactate-0.8
[**2158-12-20**] 11:46AM BLOOD Lactate-1.1
.
Bleeding scan: IMPRESSION: Findings most consistent with a
jejunal bleed.
.
CTA chest: IMPRESSION:
1. No evidence for pulmonary embolus.
2. Large right and small left pleural effusion with associated
subsegmental compressive atelectasis.
3. Atherosclerotic disease throughout the visualized aorta.
2. Radiation changes most evident in the left upper lobe
consistent with the patient's history of radiation for breast
cancer.
.
Abd angio: IMPRESSION: Arteriography was performed of the
celiac, superior mesenteric, inferior mesenteric, ileocolic,
middle colic and three jejunal arteries. No source of bleeding
was identified.
.
CXR [**2158-12-20**]:IMPRESSION: New small right pleural effusion.
.
right LENI [**2158-12-26**]:IMPRESSION: Segmental region of nearly
occlusive thrombus in the right common femoral vein.
-patient had IVC filter placed on [**2158-12-26**] after this was
discovered
.
CXR [**12-28**]:IMPRESSION:
1. NG tube with tip in the GE junction.
2. Decrease in bilateral pleural effusions with interval
improvement of previously seen pulmonary edema.
Brief Hospital Course:
.
87 yo woman with recent admission for abdominal pain, discharged
with treatment for diverticulitis and UTI, readmitted after
episode hypotension/pre-syncope and found to have upper GI bleed
with exposed duodenal artery. Currently hemodynamically stable
but found to have difficulty swallowing.
.
*GI bleed: Had GI bleed with exposed duodenal artery found on
EGD. Patient has been hemodynamically stable with stable hct for
several days. Pt completed 14 day course of meropenem for
possible diverticulitis. H. Pylori Ab was negative. Pt was
continued on [**Hospital1 **] PPI. No further interventions necessary at this
time. Gastrin level was found to be elevated and patient should
follow-up with GI as an outpatient to have Gastrin level
repeated.
.
*Failed speech and swallow: Patient had failed speech and
swallow after discharge from ICU. Per prior notes, pt has
evidence of old CVA on head CT. Per family, patient had no
difficulty swallowing prior to admission. Had NG tube placed for
tube feeds and meds. Patient then agreed to have PEG tube placed
for long term nutrition, with possibility of removal if her
swallowing improved. Her difficulty swallowing was thought
likely secondary to deconditioning. PEG was placed on [**2158-12-29**]
and tube feeds were started on [**12-30**].
.
*Leukocytosis: Had h/o leukocytosis that had not been clearly
attributed to an infectious process. More likely related to her
chronic corticosteroid use. Patient continued to be afebrile
throughout her stay. WBC trended down. All cx were neg on this
admission. Pt was continued for full course of Meropenem. Plan
will be to taper her steroids which is on for treatment of
temporal arteritis.
.
* Pleural effusions: Pt with bilateral pleural effusions with
R>L. Attemped to tap in [**Hospital Unit Name 153**] but pt unable to sit up. Pt was
aggressively diuresed and effusions resolved. Her O2 sats were
stable throughout her admission.
.
* h/o presumed Temporal Arteritis:
Has been on long steroid taper. Received stress dose IV steroids
in [**Hospital Unit Name 153**]. Changed back to PO prednisone 17.5mg on transfer to
medical floor and continue taper. Pt was continued on 10 mg PO
and was discharged on a prednisone taper.
.
*HTN: Patient was on HCTZ, lisinopril and metoprolol as an
outpatient prior to last admission and then discharged on
metoprolol and Losartan at last admission. These meds were
initially held secondary to hypotension. Pt was re-started
Metoprolol, Losartan and HCTZ during her admission.
.
* Code: full (confirmed with daughter)
.
* contact: daughter ([**Name2 (NI) **]) - [**Telephone/Fax (1) 96064**]
Medications on Admission:
Meds:
1. Docusate Sodium 100 mg [**Hospital1 **]
2. Bisacodyl 10mg daily prn
3. Acetaminophen 325 mg 1-2 Tablets PO Q4-6H prn
4. Methylphenidate 5 mg PO BID
5. Aspirin 81 mg
6. Senna 8.6 mg
7. Gabapentin 100 mg [**Hospital1 **]
8. Meropenem 1 g q8 (to complete 14 day course)
9. Pantoprazole 40 mg
10. Lorazepam 0.5 mg q4-6prn
11. Calcium Carbonate 500 mg TID
12. Prednisone 17.5mg daily
14. Metoprolol Tartrate 25 mg po BID
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H prn
16. Losartan 50 mg daily
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) cc PO Q4-6H
(every 4 to 6 hours) as needed for pain.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed: Per PEG.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed.
4. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Vie PEG.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
via PEG.
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: Taper: start after 10mg dose finished. .
8. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Start after 5mg taper. Then stop prednisone. .
9. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1)
PO twice a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Per PEG.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Duodenal ulcer
Upper GI bleed
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience chest pain,
shortness of breath, lightheadedness/ dizziness,
nausea/vomiting/diarrhea or any other severe symptoms. Please
call your doctor if you have any questions about your symptoms.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-22**] weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Name: [**Known lastname 12728**],[**Known firstname 3441**] Unit No: [**Numeric Identifier 15251**]
Admission Date: [**2158-12-20**] Discharge Date: [**2159-1-1**]
Date of Birth: [**2071-7-23**] Sex: F
Service: MEDICINE
Allergies:
Quinolones / Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 1305**]
Addendum:
Lower extremity pain: Patient had some bilateral lower extremity
swelling and pain that improved with diuresis with lasix. She
has a bilateral lower extremity venous ultrasound and was found
to have a clot in her right femoral vein. Since she could not
be anti-coagulated b/c of the GI bleed she had an IVC filter
placed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] of [**Location (un) 729**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1307**]
Completed by:[**2159-1-1**]
|
[
"562.11",
"530.81",
"453.41",
"401.9",
"446.5",
"276.52",
"532.40",
"V10.3",
"511.9",
"285.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.7",
"38.93",
"96.6",
"88.47",
"43.11",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
12374, 12594
|
6862, 9494
|
256, 293
|
11152, 11161
|
4025, 6839
|
11444, 12351
|
3429, 3447
|
10073, 10983
|
11099, 11131
|
9520, 10050
|
11185, 11421
|
3462, 4006
|
209, 218
|
321, 2302
|
2324, 2960
|
2976, 3413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,230
| 197,979
|
42101
|
Discharge summary
|
report
|
Admission Date: [**2177-9-30**] Discharge Date: [**2177-10-4**]
Date of Birth: [**2104-9-19**] Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered mental status
Transplant evaluation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
(per OMR and report)
7e yo F with autoimmune hepatitis dx [**2173**] initially on
azathioprine and Imuran, complicated by cirrhosis transferred
from OSH for persistent altered mental status with question of
possible transplant evaluation.
.
Per OMR and OSH record, patient was doing well until she was
taken off of azathioprine [**1-15**] pancytopenia few weeks prior to
presentation. This was done because of pancytopenia. Since
then, she had increased abdominal girth as well as elevated
bilirubin and amoonia. She was placed on rifaximin and
restarted azathioprine 75 mg daily, and prednisone. However,
there was worsening confusion, lethargy, and weakness. She was
admitted to the outside hospital on [**2177-9-18**] because of
worsening confusion and unable to answer questions
appropriately. She was found to have hyponatremia 125, low
serium osmolality at 254, urine sodium < 30, creatinine of 0.5.
Initial CT head was ? temporal lobe infarct. Abd X ray showed
constipation. In addition to the AMS, she was also found to
have UTI. EEG showed encephalopathy and left hemisphere
pathology. She was treated with rifaximin, azathioprine 75 mg,
prednisone 50 mg, lactulose, ciprofloxacine. Given her poor po
intake, she was started on enteral feeding. Per patient's
husband, patient appeared well about a week prior to transfer,
then started to become more somnolent again.
.
Per Dr. [**Last Name (STitle) 5456**], patient was transferred in the hope that she
will be able to get a liver transplant. She received FFP and
platelets today prior to transfer. Per him, patient has been on
lactulose and rifaximin. Mental status not improved despite
negative CT/MRI. Apparently was tried on TF but with high
residual. VSS but on 2L NC.
.
Of note, patient was referred to Dr. [**First Name (STitle) 679**] in [**Month (only) 216**] for
management of the flair in the setting of d/c of azathioprine
[**1-15**] pancytopenia as part of the cataract work up. She was
restarted on prednisone 60 mg and 50 mg azathioprine
.
On the floor, patient is somnolent, unable to answer questions
but opens eyes to commands
Past Medical History:
Past Medical History: per OMR and OSH record
- Autoimmune hepatitis
- HLD
- Depression
- GERD & gastritis
- osteoporosis
- s/p breast biopsy for benign lesion
- s/p tonsillectomy
- s/p bilateral carpal tunnel surgery
- h/o pericarditis [**2156**]
Social History:
per OMR and husband
- lives at home with husband of 43 years
- no children
- Tobacco: denies
- Alcohol: rare
Family History:
Mother: CHF, bladder CA died early 90s.
Father: died age 48 MI.
No children
Physical Exam:
Admission Physical Exam:
Vitals: T: 96.4, BP: 122/62, P: 73, R:16, O2: 95%, 3L NC
General: eyes closed, bronze in color, NAD, opens eyes to
command
HEENT: Sclera icteric, PERRLA, mucous membrane dry
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly bilaterally, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, I/II mid systolic
murmur best at LUSB, no rubs, gallops
Abdomen: distneded, NT, BS+, no HSM, no rebound tenderness or
guarding, + fluid wave
GU: + foley
Ext: cool, 1+ DP pulses and 2+ radial pulses bilaterally, no
clubbing, pitting edema to the thighs bilaterally
Skin: weepy, multiple ecchymosis on the arms bilaterally
Neuro: does not follow all commands, but opens eyes to voice
On arrival to medicine floor patient is comfort measures only:
VS - CMO RR:14
GENERAL - Patient is obtuned, appears comfortable, breathing at
14 bpm, non-labored. She does not appear to be in pain. She is
unresponsive.
.
Pertinent Results:
OSH labs
[**9-30**]
WBC 4.9, Hgb 11.3, Hct 33.1, Plt 59, MCV 124.9
Na 152, Cl 119, K not performed (hemolyzed), CO2 31, BUN 35, Crt
0.3, Ca8.8
total bili 11.7, alk phos 129, AST 211, ALT 151
ammonia 63 PT 21.8, INR 2.1, PTT 35.5
Micro:
- blood cultures: no growth since [**2177-9-18**]
- urine culture [**9-24**]: no growth
- urine culture [**9-18**]: E. coli > 100,000, pan-sensitive
EKG at OSH [**9-26**]: NSR, no PR prolongation, narrow QRS, no ST, or
T changes. However, does have significant baseline artifact. T
wave is flatten throughout
Images:
- CT head w/o contrast [**2177-9-19**]: mild global cerebral atrophy c/w
age. Previous right frontal burhole. Relative hypodensity to
the right temporal lobe, ? acute vs. old, given no prior
imaging. Asymmetric to the left. No midline shift or mass
effect. Scattered periventricular and subcortical white matter
hypodensities, nonspecific, but can be seen in small vessel
disease. Mild mucosal thickening within the sphenoid sinuses.
- MRI head [**9-20**]: findings on CT likely artifact. no evidence of
infarct or acute abnormality within the brain parenchyma. No
evidence of abnormality within the right temporal lobe.
Findings on CT likely artifactual. Mild periventricular and
subcortical white matter FLAIR signal hyperintensities,
non-specific, can be seen in small vessel ischemic change
- CT head [**2177-9-23**]: no midline shifts. prominent [**Doctor Last Name 352**]-white
matter junctions but symmetric
- Abd X ray [**2177-9-19**]: increased density to the abdomen may
suggest underlying ascites
- EEG [**9-28**]: grossly abnormal recording suggesting bihemispheric
cerebral dysfunction. Most consistent with encephalopathy
regardless of cause. + left sided greater preponderance of
slowing as well as phase reversing activity suggesting
underlying structural pathology in this distribution. Can
represent neoplasm, stroke, other, or nidus for paroxysmal
irritability and requires clinical and radiologic correlation.
- AP CXR [**9-28**]: proximal port over the fundus of the stomach,
diffuse prominence of the interstital markings bilaterally,
perhaps with increased ensity at the left lung base.
- CXR portable [**9-28**]: increased density at the left lung base
compatible with atelectasis in the LLL, infiltrate in the LLL,
and perhaps pleural fluid. Minor atelectasis in the right
mid-lower lung
[**Hospital1 18**] labs
[**2177-9-30**] 08:20PM BLOOD WBC-3.3* RBC-2.48* Hgb-10.6* Hct-32.5*
MCV-131* MCH-42.9* MCHC-32.7 RDW-19.1* Plt Ct-55*
[**2177-9-30**] 08:20PM BLOOD Neuts-87.9* Lymphs-6.6* Monos-5.0 Eos-0.2
Baso-0.3
[**2177-9-30**] 08:20PM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Target-OCCASIONAL Acantho-OCCASIONAL
[**2177-9-30**] 08:20PM BLOOD PT-20.0* PTT-34.3 INR(PT)-1.8*
[**2177-9-30**] 08:20PM BLOOD Ret Aut-4.5*
[**2177-9-30**] 08:20PM BLOOD Glucose-244* UreaN-41* Creat-0.4 Na-157*
K-3.7 Cl-119* HCO3-27 AnGap-15
[**2177-9-30**] 08:20PM BLOOD ALT-144* AST-173* LD(LDH)-540*
AlkPhos-152* TotBili-13.2* DirBili-5.1* IndBili-8.1
[**2177-9-30**] 08:20PM BLOOD Albumin-3.3* Calcium-9.8 Phos-2.3* Mg-2.6
Iron-243*
[**2177-9-30**] 08:20PM BLOOD calTIBC-260 VitB12-GREATER TH Folate-5.6
Ferritn-481* TRF-200
[**2177-9-30**] 08:45PM BLOOD Ammonia-70*
[**2177-9-30**] 08:52PM BLOOD Lactate-3.8*
[**2177-10-1**] 10:15AM BLOOD Triglyc-50 HDL-54 CHOL/HD-2.8 LDLcalc-85
[**2177-10-1**] 10:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-PND
IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2177-10-1**] 10:15AM BLOOD CEA-7.4* AFP-2.0
[**2177-10-1**] 10:15AM BLOOD IgG-1392 IgA-403* IgM-373*
[**2177-10-1**] 10:15AM BLOOD HCV Ab-NEGATIVE
[**2177-10-1**] 02:36AM BLOOD Type-ART Rates-/18 O2 Flow-3 pO2-62*
pCO2-44 pH-7.48* calTCO2-34* Base XS-8 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2177-9-30**] 10:40PM ASCITES TOT PROT-0.2 GLUCOSE-248 ALBUMIN-LESS
THAN
[**2177-9-30**] 10:40PM ASCITES WBC-16* RBC-26* POLYS-41* LYMPHS-40*
MONOS-12* MESOTHELI-4* MACROPHAG-3*
CSF
WBC 0, RBC 1, tot prot 55, prot 120, tbili 0.1
[**2177-10-1**] 5:07 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
YEAST. BUDDING YEAST.
Aerobic Bottle Gram Stain (Final [**2177-10-2**]):
BUDDING YEAST.
Brief Hospital Course:
73 yo F with cirrhosis secondary to autoimmune hepatitis who
presented to an outside hospital with altered mental status and
was transferred for consideration of liver transplant. Her
hospital course was complicated by worsening mental status and
fungemia. She was determined to not be a candidate for liver
transplant. Given her poor status and overwhelming infection,
goals of care were transitioned to CMO.
Prior to transitioning to CMO, she was undergoing evaluation
for altered mental status which was felt most likely secondary
to hepatic encephalopathy vs metabolic. MRI and LP negative for
stroke, infection. Intially treated with antibiotics, lactulose,
rifaximin and free water repletion. The hepatology service was
following for the decompensation which was felt perhaps
secondary to recent weaning of the prednisone in [**Month (only) 216**] and
later the discontinuation of azathioprine in the setting of
pancytopenia or infection or worsening of underlying disease.
Her azathiprine was held and steroids were reduced. She was
followed by transplant surgery until it was determined that she
was not a tranplant candidate. She was found to have DVTs in her
RUE and was started on heparin though this was stopped when she
had coffee grounds emesis from her NG tube. She was then found
to be fungemic at which point we readdressed goals of care.
Patient was made comfort measures only and was transferred to
general medicine floor. On the floor she remained subjectively
comfortable with RR 5-10 appearing apnic at times. She was
maintained on Morphine 2-10mg Q2HRS titrating RR<15 or
subjective signs of pain.
Patient expired on [**2177-10-4**] at 0815 am.
Chief Cause of Death: Hepatic Failure (Days)
Immediate Cause of Death: Autoimmune Hepatitis (Years)
Other Antecedent Cause: Fungemia (Days)
Medications on Admission:
per OSH record Home meds
- aciphex 20 mg daily
- prednisone 50 mg daily
- azathioprine 75 mg daily
- calcium and vitamin D 600 mg [**Hospital1 **]
- rifaximin 550 mg [**Hospital1 **]
- lactulose 20 mg (30 mL) TID
.
per OSH record Transfer Meds
- ciprofloxacin 250 mg [**Hospital1 **]
- methylprednisolone 75 mg q8h
- lactulose 30 g q2h
- KCL 20 meq in dextrose 5 %
- pantoprazole
- amino acids
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatic Failure
Autoimmune hepatitis
Fungemia
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"284.19",
"572.8",
"276.0",
"276.52",
"790.29",
"572.2",
"530.81",
"571.5",
"789.59",
"571.42",
"311",
"518.0",
"733.00",
"112.5",
"578.9",
"272.4",
"486",
"V49.86",
"453.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10578, 10587
|
8287, 10102
|
318, 324
|
10677, 10694
|
3972, 8118
|
10758, 10899
|
2891, 2969
|
10546, 10555
|
10608, 10656
|
10128, 10523
|
10718, 10735
|
3009, 3953
|
8162, 8264
|
235, 280
|
352, 2476
|
2521, 2748
|
2764, 2875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,186
| 188,014
|
43170
|
Discharge summary
|
report
|
Admission Date: [**2189-5-24**] Discharge Date: [**2189-5-27**]
Date of Birth: [**2123-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement
History of Present Illness:
65 y/o male c PMH signif for CAD s/p CABG, DM, HTN, GIB, Anemia,
Depression, multiple DVTs s/p recent hospital admission for
revision of thrombosed AV graft ([**2189-5-16**] -[**2189-5-19**]). At this time
a VDD pacemaker was placed [**2-19**] Mobitz I c bradycardia to 30s.
Recent stress test prior to discharge on [**2189-5-18**] showed
reversible defect in cicrcumflex and posterior descending
territories. An elective cardiac catheterization was arranged
for later this week.
.
Then this am at 0500 pt awoke from sleep c sudden onset SOB. Pt
noted dyspnea improved on laying flat. He attests to steady 2
pillow orthopnea and PND. He denies any CP, N/V, diaphoresis, or
leg swelling. The night prior he ate a salty meal but otherwise
denies any dietary indiscretions. No F/C, cough, diarrhea, or
dysuria.
.
At baseline pt is able to walk 15 steps s difficulty. He does
not use home oxygen.
.
In the [**Name (NI) **] pt c Tn of 3, MB of 29 c MBI of 20, BNP of [**Numeric Identifier **]. He
was given 80mg IV lasix, 325 of ASA, 12.5 of lopressor, and 5 of
lisinopril. Pt's sBP improved from 200s to 170s and sats
improved to mid 90s.
Past Medical History:
1. Coronary artery disease status post coronary artery
bypass graft in [**2187-1-18**].
2. s/p VDD PM placement [**2189-5-15**] for AV block c bradycardia to
30s
3. s/p failed cadaveric renal transplant [**2-19**] end stage FSGS on
HD
4. Hypertension: developed during teenage year
5. Diabetes.
6. Multiple gastrointestinal bleed requiring ICU admission
7. Deep venous thrombosis- UE graft and LEs; s/p IVC filter
placement [**3-21**]
8. Anemia.
9. Depression.
10. Gout.
11. Appendectomy.
12. Hx of TB infection as a teenager
Social History:
The patient is married and lives with his wife at home. No
tobacco use. He owns a medical delivery company.
Family History:
FH: Noncontributory. Father died when pt was 12 years old
Physical Exam:
VS98.2 82 175/64 28 92%RA
HEENT- PERRL, EOMI, OP clr, mm dry, JVP to 6cm
L- Crackles [**1-19**] way up
CV- RRR, nl S1S2
Abd- Sft, NT, ND
Ext- wwp, no c/c/e
Pertinent Results:
[**2189-5-24**] 12:30PM PT-12.2 PTT-26.4 INR(PT)-1.0
[**2189-5-24**] 12:30PM PLT COUNT-223
[**2189-5-24**] 12:30PM WBC-8.7 RBC-3.70* HGB-11.6* HCT-35.0* MCV-95
MCH-31.3 MCHC-33.0 RDW-15.6*
[**2189-5-24**] 12:30PM CK-MB-29* MB INDX-19.9* cTropnT-3.08*
proBNP-[**Numeric Identifier 39020**]*
[**2189-5-24**] 12:30PM CK(CPK)-146
[**2189-5-24**] 12:30PM GLUCOSE-96 UREA N-72* CREAT-8.0* SODIUM-138
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-18
[**2189-5-24**] 12:44PM K+-4.6
CXR: Midline sternotomy wires and
right-sided pacemaker lead unchanged since [**2189-5-17**].
Increased
pulmonary vascular markings with pulmonary hilar prominence and
bilateral pleural effusions, left probably greater than right.
Lateral view shows fluid in major and minor fissures. Probable
left retrocardiac opacity. Thoracic spine difficult to evaluate
due to prominence of pulmonary vascular markings. No fractures
identified. Bowel gas pattern normal.
.
CXR (later in course):
IMPRESSION: AP chest compared to [**5-24**], 8 and [**5-13**]:
Lung volumes are lower, and moderate pulmonary edema, moderate
cardiomegaly and mediastinal vascular engorgement have all
worsened since [**5-25**] consistent with volume overload and/or
cardiac decompensation. Transvenous right ventricular pacer lead
follows its expected course. There is no pneumothorax. Leftward
tracheal deviation of the thoracic inlet due to enlarged right
lobe of thyroid gland is longstanding.
.
EKG: Sinus rhythm with atrial sensed - ventricular pacing. No
change since the previous tracing of [**2189-5-25**].
.
Echo:
Conclusions:
The left atrium is moderately dilated. The inferior vena cava is
dilated (>2.5 cm). The left ventricular cavity size is normal.
There is mild to moderate regional left ventricular systolic
dysfunction. LV systolic function appears depressed. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Tissue velocity
imaging E/e' is elevated (>15) suggesting increased left
ventricular filling pressure (PCWP>18mmHg). Resting regional
wall motion abnormalities include inferolateral akinesis and
inferior hypokinesis. The anterior and anterolateral segments
were not fully visualized. Estimated left ventricular ejection
fraction ?40%. There is mild global right ventricular free wall
hypokinesis. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve shows characteristic rheumatic
deformity. Moderate (2+) 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.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2187-7-27**] the
left
ventricular function is now mildy depressed, the pulmonary
pressures are
slighly higher.
.
Cardiac catheterization:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
severe native 3 vessel disease. The LMCA had a 90% distal
stenosis. The
LAD was totally occluded after a small D1. The distal LAD filled
via a
patent LIMA graft. The LCX was totally occluded after a ramus.
The left
PL branch filled via collaterals from the RCA. The RCA had a 70%
proximal stenosis with diffuse disease throughout (FFR was
0.76).
2. Graft angiography showed a patent LIMA to LAD. The SVG to OM1
and SVG
to LPL were totally occluded proximally.
3. Limited hemodynamics on entry showed severe LV systolic
dysfunction.
There was no gradient across the aortic valve on pullback.
4. Left ventriculography revealed severe systolic dysfunction
with 3+
MR. There was global hypokinesis with severe posterobasal and
inferior
hypokinesis.
5. The proximal RCA lesion was predilated with a 3.0 X 15mm
Voyager
balloon and stented with a 3.0 X 18mm Vision stent with lesion
reduction
from 70% to 0%. The final angiogram showed TIMI III flow with no
dissection and no embolisation. (see PTCA comments)
FINAL DIAGNOSIS:
1. Severe native 3 vessel disease.
2. Patent LIMA to LAD. Occluded SVG-OM and SVG-LPL.
3. Severe LV diastolic and systolic dysfunction.
4. Moderate to severe MR.
5. Successful stenting of the proximal RCA lesion.
.
Brief Hospital Course:
65YO M CAD s/p 3 vessel CABG, DM, HTN, GIB, Anemia, Depression,
multiple DVTs p/w worsening DOE. Symptoms, labs, exam, and
imaging all c/w fluid overload from CHF.
.
#Dyspnea
Unclear inciting event for pulmonary edema, most likely from
volume overload (vs. ischemia given bump in CEs from prior
visit). However, it is difficult to interpret these enzymes in
the setting of the pt's extreme renal failure. Pt's EKG paced.
PE was considered given the pt's apparent prothrombotic
tendencies and relative hypoxia. However, on exam there was no
evidence of RV overload, and the pt is not tachycardic (although
he is beta blocked and paced, so this might be masked). Also,
his dyspnea improved after HD. Pneumonia was entertained
initally due to a retrocardiac opacity, but without fever and
the prompt resolution with medical management and HD, this
diagnosis was exceedingly unlikely. Also, the patient did not
complain of a cough nor was one noted during his hospital
course.
The patient was managed with HD, nitrates, ASA, beta blockade,
heparin (initially until the diagnosis of ischemia became less
likely and the patient was catheterized). The cath showed a RCA
lesion which was stented. He had other significant flow limiting
lesions with collaterals. The patient's Troponins were elevated.
The CK and CKMB peaked and trended downward shortly after cath.
.
#CRI
Pt on hemodialysis and followed by Dr. [**Last Name (STitle) 1860**]. S/p kidney
transplant that has failed. The patient received dialysis
frequently during his hospitalization.
.
#HTN
Pt was hypertensive on outpatient regimen. Nitro gtt started and
increased BB. Will have patient followed as outpatient.
.
#GIB
Pt had history of multiple prior GIBs on anticoagulation. In the
setting of what appeared to be probably ischemia, heparin was
started and then discontinued after the patient went to the cath
lab. He was initially guaiac positive.
.
#Depression
Continued citalopram. Patient was in a stable mood during his
stay. Continue regimen as outpatient.
.
# Functional status
Pt lives with wife. PT was consulted to ensure that the patient
was safe for home, which was our assessment. PT agreed that
there was no further need for PT.
.
F/U care
Cardiologist- Dr. [**Last Name (STitle) 911**]; Nephrologist- Dr. [**Last Name (STitle) 1860**]
Medications on Admission:
ALLOPURINOL 100MG [**Hospital1 **]
FLOMAX 0.4MG Capsule, QD
LIPITOR 10MG Tablet QD
LISINOPRIL 2.5MG Tablet QD
NORVASC 5MG Tablet QD
PREDNISONE 5MG Tablet QD
PROTONIX 40MG Tablet, [**Hospital1 **]
Calcium acetate 1334 TID
Citalopram 10 mg daily
B vitamins-folate PO daily
metoprolol 12.5 mg [**Hospital1 **]
Discharge Medications:
1. continuation of medication
continue to take your B vitamins and folate as you did before
hospitalization
2. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS). Capsule(s)
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 14 days: Do not take if you have more than 1
bowel movement daily.
Disp:*28 Capsule(s)* Refills:*0*
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 14 days: Do not take if you have more than 1 bowel
movement daily.
Disp:*28 Tablet(s)* Refills:*0*
14. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
16. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. B Complex-Folic Acid 0.5-5-0.2 mg Tablet Sig: One (1) Tablet
PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure.
Discharge Condition:
Improved
Discharge Instructions:
You have congestive heart failure. The echo studies that look at
the heart and the cardiac catheterization show that your heart
has decreased ability to pump. You also had a blockage of one
artery that was "stented" open (a piece of hardware the keep the
vessel open). Some of your medications were changed. See the
information below for the adjustments.
We have added the following medications to your regimen:
- Isosorbide Mononitrate (trade name: Imdur)
- Senna
- Docusate
- Clopidogrel (trade name: Plavix)
- Aspirin
- Metoprolol long acting (trade name: Toprol XL). This takes
the place of your old metoprolol, which was short acting - do
not take the metoprolol that you have at home anymore.
- atorvastatin (trade name: Lipitor): You were on this
medication before, but we have increased the dose from 10 mg
daily to 20 mg daily. You may continue taking the bottle you
have at home, but take 2 pills daily to equal 20 mg, and then
get your new prescription filled for the higher dose.
You should continue to take your other medicines as you did
before:
- Allopurinol
- Calcium acetate (trade name: phoslo)
- Escitalopram (trade name: Celexa)
- Lisinopril
- Pantoprazole (trade name: Protonix)
- Prednisone
- Tamsulosin (trade name: Flomax)
- B vitamin/folate pill
CALL YOUR DOCTOR OR GO TO THE ER IF:
You have black or bloody bowel movements.
You have a temperature over 100.5 degrees F
Your blood pressure is less than 100 or over 50
Your pulse (heartbeat) is less than 50 beats each minute or over
100 beats each minute.
You have swelling in your ankles, feet, hands, face, or neck.
You have gained more than three pounds in one day, or five
pounds in one week.
You are lightheaded or dizzy, sweaty, or feel sick after you
take your medicine.
You cough up yellow, green, or pink sputum.
You have a dry cough that does not go away.
You are wheezing (a high pitched noise when breathing in or
out).
You do not have an appetite and do not want to eat.
You have any questions or concerns about your illness or
medicine
SEEK CARE IMMEDIATELY IF:
You have more trouble breathing than usual or cannot sleep or
rest because of breathing problems.
[**Name (NI) **] are too dizzy to stand up.
You have signs and symptoms of a heart attack. These may include
the following:
Chest pain or discomfort that spreads to your arms, jaw, or
back.
Nausea (sick to your stomach).
Trouble breathing.
Sweating.
This is an emergency. Call 911 or 0 (operator) for an ambulance
to take you to the nearest hospital or clinic. Do not drive
yourself!
Followup Instructions:
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-5-28**] 1:10
Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) **], [**Name Initial (PRE) **].D., PH.D. Date/Time:[**2189-9-24**] 1:00
You should see your cardiologist, Dr. [**Last Name (STitle) 911**], in the next [**2-20**]
weeks. Call ([**Telephone/Fax (1) 7236**] to schedule a follow up appointment.
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"403.91",
"410.71",
"585.6",
"250.00",
"996.72",
"414.01",
"396.3",
"397.0",
"274.9",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.53",
"88.55",
"00.40",
"36.06",
"00.66",
"00.45",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11563, 11569
|
6951, 9261
|
335, 382
|
11639, 11650
|
2490, 6694
|
14239, 14827
|
2238, 2298
|
9626, 11540
|
11590, 11618
|
9287, 9603
|
6711, 6928
|
11674, 14216
|
2313, 2471
|
276, 297
|
410, 1548
|
1570, 2097
|
2113, 2222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,094
| 195,371
|
21057+21058
|
Discharge summary
|
report+report
|
Admission Date: [**2108-7-24**] Discharge Date: [**2108-7-29**]
Date of Birth: [**2041-9-14**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 66-year old female
with a history of coronary artery disease and myocardial
infarction in approximately the [**2094**], status post
angioplasty, who presents with gallstone cholelithiasis.
The patient was undergoing preop for cholecystectomy and was
found to have a positive stress test. The patient underwent
cardiac catheterization which showed 3-vessel disease with
moderate-to-severe mitral regurgitation. The patient's
ejection fraction was 45 percent, and the patient had left
atrial enlargement, with a left anterior descending with
approximately 80 percent stenosis, and left circumflex with
80 percent stenosis, and the right coronary artery with 80
percent ostial stenosis.
PAST MEDICAL/SURGICAL HISTORY: Myocardial infarction.
Coronary artery disease.
Cholelithiasis.
Congestive heart failure.
Mitral valve prolapse.
Hypercholesterolemia.
Paroxysmal atrial fibrillation.
Osteoarthritis.
Hysterectomy.
Status post bladder repair.
MEDICATIONS ON ADMISSION:
1. Ecotrin 325 mg by mouth once per day.
2. Evista 60 mg by mouth once per day.
3. Lanoxin 0.375 mg by mouth once per day.
4. Atenolol 25 mg by mouth once per day.
5. Vasotec 2.5 mg by mouth twice per day.
6. Lipitor 40 mg by mouth once per day.
7. Nitrostat as needed.
8. Multivitamin by mouth every day.
9. Lasix 20 mg by mouth every other day.
10. Calcium 1200 mg.
ALLERGIES: The patient is allergic to PERCOCET, SULFA,
AMPICILLIN, and NEOMYCIN.
FAMILY HISTORY: The patient's father at the age of 39 of
myocardial infarction. The patient's mother died at the age
of 57 of a myocardial infarction.
SOCIAL HISTORY: The patient is retired. The patient lives
with her husband. The patient denies the use of alcohol or
smoking.
PHYSICAL EXAMINATION: The patient's heart rate was 56,
saturating 95 percent on room air, the patient's blood
pressure was 112/64 on the right and 120/64 on the left. The
patient was alert and oriented with pink, warm, and dry skin.
The patient had no lymphadenopathy and no carotid bruits.
The patient's heart was regular in rate and rhythm. There
was a 3/6 systolic ejection murmur. The patient's chest was
clear to auscultation bilaterally. The patient's abdomen was
soft, flat, nontender, and nondistended. The patient's
extremities were without any edema. The patient moved all
extremities. The patient's neurological examination was
grossly intact. The patient had palpable dorsalis pedis and
posterior tibial pulses bilaterally.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Cardiac Surgery Service for a mitral valve replacement and
coronary artery bypass grafting times two. The patient
underwent mitral valve repair and coronary artery bypass
grafting times two with left internal mammary artery to left
anterior descending and supraventricular tachycardia to first
obtuse marginal. Please see the operative note for details
of the operation.
Postoperatively, the patient did well. The patient was
extubated without any difficulties. The patient received a
fluid bolus and was put on Neo-Synephrine for a low cardiac
index. Postoperatively, the patient remained afebrile with
stable vital signs with a good cardiac index and was making
good urine. The patient's hematocrit was 22.5, for which the
patient received 2 units of packed red blood cells.
Otherwise, the patient was weaned off of Neo-Synephrine,
which was used for pressure support.
On postoperative day two, the patient had some issues of low
urine output. The patient was started on Lasix which the
patient responded without any difficulties. The patient
continued to remain with heart rates in the 110s - in sinus -
with a good blood pressure. The patient was saturating well
on 2 liters, and the patient had a low-grade temperature of
100.4 with a white count of 13. The patient's hematocrit
responded very well to the transfusion and was up to 29. The
patient had normal kidney function. On examination, the
patient was doing well. The patient was started on
metoprolol 12.5 mg by mouth twice per day and was advanced to
a cardiac diet. The Foley was removed then, and the patient
was transferred to the floor.
On postoperative day three, the patient remained afebrile
with stable vital signs, with sinus tachycardia up to 103.
The patient continued to have some high output from the chest
tube which was continued. The patient's hematocrit was
stable. The patient worked with Physical Therapy vigorously
and continued to be diuresed.
On postoperative day four, the patient remained afebrile with
stable vital signs. The patient's chest tubes were removed.
Post chest tube pull films showed no pneumothorax, and the
patient was doing well. Postoperatively, the patient worked
with Physical Therapy and was cleared from a Physical Therapy
standpoint in terms of being able to discharge home.
DISCHARGE STATUS: On postoperative day five, the patient was
in good condition and was discharged home with services.
DISCHARGE DIAGNOSES: Myocardial infarction.
Coronary artery disease.
Congestive heart failure.
Mitral valve prolapse.
Hypercholesterolemia.
Paroxysmal atrial fibrillation.
Osteoarthritis.
Cholelithiasis.
Hysterectomy.
Status post bladder repair.
Status post mitral valve repair and coronary artery bypass
grafting times two.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 25 mg by mouth twice per day.
2. Lasix 20 mg by mouth twice per day (for seven days).
3. K-Dur 20 mEq by mouth twice per day (for seven days).
4. Colace 100 mg by mouth twice per day.
5. Zantac 150 mg by mouth twice per day.
6. Aspirin 325 mg by mouth once per day.
7. Plavix 75 mg by mouth once per day (for three months).
8. Atorvastatin 40 mg by mouth once per day.
9. Dilaudid 0.2 mg to 2 mg by mouth q.4-6h. as needed (for
pain).
DISCHARGE DISPOSITION: Home with Visiting Nurses
Association.
CONDITION ON DISCHARGE: Stable.
DISCHARGE FOLLOW-UP PLANS: Please follow up with Dr.
[**Last Name (STitle) 55920**] in two to three weeks.
Please follow up with Dr. [**Last Name (STitle) 1655**] in two to three weeks.
Pl[**Last Name (STitle) 55921**]ollow up with Dr. [**Last Name (Prefixes) **] in three to four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2108-7-28**] 17:06:52
T: [**2108-7-28**] 18:04:00
Job#: [**Job Number 55922**]
Admission Date: [**2108-7-24**] Discharge Date: [**2108-8-1**]
Date of Birth: [**2041-9-14**] Sex: F
Service: CSU
REASON FOR ADMISSION: Ms. [**Known firstname **] [**Known lastname 14875**] is an outpatient
admission to the Cardiothoracic Surgery Service for mitral
valve repair/replacement and coronary artery bypass grafting.
HISTORY OF PRESENT ILLNESS: Ms. [**Known firstname **] [**Known lastname 14875**] is a 66-
year-old woman with a history of coronary artery disease
(status post myocardial infarction and right coronary
angioplasty in [**2094**]) who presented with gallstones needing
surgery and was found to have 3-vessel disease and moderate-
to-severe mitral regurgitation on preoperative cardiac
workup.
Cardiac catheterization data revealed an ejection fraction of
45 percent, moderate-to-severe mitral regurgitation, left
atrial enlargement, left anterior descending 80 percent
lesion, left circumflex 80 percent lesion, right coronary
artery small caliber with an 80 percent ostial stenosis.
PAST MEDICAL HISTORY: Significant for a myocardial
infarction and an angioplasty in [**2094**], congestive heart
failure, mitral valve prolapse, hypercholesterolemia,
paroxysmal atrial fibrillation, osteoarthritis of the left
thumb, cholelithiasis, hysterectomy, with prolapse cystocele
and rectocele, and bladder repair in [**2080**].
MEDICATIONS PRIOR TO ADMISSION:
1. Ecotrin 325 mg by mouth once per day.
2. Evista 60 mg by mouth once per day.
3. Lanoxin 0.375 mg once per day.
4. Atenolol 25 mg by mouth once per day.
5. Vasotec 2.5 mg by mouth twice per day.
6. Lipitor 40 mg by mouth once per day.
7. Nitrostat as needed.
8. Multivitamin by mouth every day.
9. Lasix 20 mg by mouth every other day.
10. Calcium 1200 mg by mouth once per day.
ALLERGIES: PERCOCET (which causes gastrointestinal upset),
SULFA (which causes a rash), AMPICILLIN (which causes
flushing), NEOMYCIN (which causes itching), and ELECTROLYTE
GLUE (which causes hives).
FAMILY HISTORY: Father at the age of 39 of a myocardial
infarction. Mother died at the age of 57 of a myocardial
infarction.
SOCIAL HISTORY: The patient is a retired nurse. She lives
with her husband. She denies alcohol or tobacco use as well
as other recreational drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Heart rate was 56
(sinus rhythm), her blood pressure was 112/64, her
respiratory rate was 20, and her oxygen saturation was 95
percent on room air. Her height was 5 feet 3 inches. Her
weight was 140 pounds. In general, alert and oriented times
three. A nonfocal examination. Head, eyes, ears, nose, and
throat examination the pupils were equal, round, and reactive
to light. The extraocular movements were intact. The neck
was supple. There was no lymphadenopathy. There were no
carotid bruits. Cardiovascular examination revealed a
regular rate and rhythm. First heart sounds and second heart
sounds. There was a 36systolic ejection murmur. Respiratory
examination revealed the lungs were clear to auscultation
bilaterally. The abdomen was flat, soft, nontender, and
nondistended. The extremities were warm and well perfused.
No varicosities. There were positive spider veins. Femoral
pulses were 1 plus bilaterally, dorsalis pedis pulses were 2
plus bilaterally, posterior tibial pulses were 1 plus on the
right and 2 plus on the left, and radial pulses were 2 plus
bilaterally.
RADIOLOGY: A chest x-ray showed cardiomegaly without acute
cardiopulmonary abnormalities.
An electrocardiogram showed sinus bradycardia with Q waves in
leads II, III, and F. There were flipped T waves in leads
II, III, and F as well. The rate was 52 beats per minute. P-
R interval was 18, QRS was 98, QT interval was 400.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 8.5, her hematocrit was 40, and her platelets
were 287. Prothrombin time was 13.1, her partial
thromboplastin time was 27.4, and her INR was 1.1.
Urinalysis with small leukocytes. Negative nitrites. White
blood cells of 0. No bacteria. Sodium was 142, potassium
was 3.9, chloride was 100, bicarbonate was 30, blood urea
nitrogen was 15, creatinine was 1, and blood glucose was 104.
Alanine-aminotransferase was 21, her aspartate
aminotransferase was 22, her alkaline phosphatase was 72, her
total bilirubin was 0.5, her total protein was 7.3, and her
albumin was 4.4. Her hemoglobin A1C was 5.5.
SUMMARY OF HOSPITAL COURSE: As stated previously, the
patient was a direct admission to the operating room where
she underwent a mitral valve repair with number 26
annuloplasty ring and a coronary artery bypass grafting times
two with a left internal mammary artery to the left anterior
descending and saphenous vein graft to the obtuse marginal.
Her bypass time was 82 minutes with a cross-clamp time of 68
minutes. Please see the Operative Report for full details.
The patient tolerated the procedure well and was transferred
from the Operating Room to the Cardiothoracic Intensive Care
Unit.
At the time of transfer, the patient was in a sinus rhythm at
80 beats per minute with a central venous pressure of 5 and a
pulmonary artery pressure of 23/11. She had epinephrine at
0.4 mcg/kilogram per minute, and Neo-Synephrine at 1.25
mcg/kilogram per minute, and propofol at 20 mcg/kilogram per
minute.
The patient did well in the immediate postoperative period.
She was rapidly weaned from the epinephrine drip. Her
anesthesia was reversed. She was weaned from the ventilator
and successfully extubated. She remained hemodynamically
stable throughout the course of her operative day.
On postoperative day one, she remained hemodynamically
stable. Her Neo-Synephrine drip was weaned to off. She was
noted to have a hematocrit of 23 and was therefore transfused
with 2 units of packed red blood cells. The chest tubes
remained in, and she stayed in the Cardiothoracic Intensive
Care Unit for further hemodynamic monitoring.
On postoperative day two, the patient remained
hemodynamically stable. She was begun on beta blockade as
well as diuretics. Her Foley catheter and chest tubes were
removed, and she was transferred to the floor for continued
postoperative care and cardiac rehabilitation. Once on the
floor, the patient's activity level was gradually increased
with the assistance of the nursing staff as well as Physical
Therapy.
On postoperative day five, the patient remained somewhat
tachycardic with a baseline heart rate of 90 to 100 rising to
130 to the 150s with any kind of activity; all as a sinus
rhythm. The patient was hemodynamically stable with a blood
pressure in the 100s. However, she was again noted to have a
hematocrit of less than 30 and was therefore transfused with
packed red blood cells.
Over the next two days the patient's beta blockade was
gradually increased in an attempt to control her tachycardia
without much affect. On postoperative day seven, the patient
was begun digoxin with a further attempt to control the
patient's tachycardia. At that point, she was given 0.5 mg
orally in two divided doses and then begun on 0.25 mg once
per day. The following day the patient's tachycardia had
largely resolved. She was found to have a heart rate/sinus
rhythm in the 80s even with activity. At that point, the
decision was made that the patient was stable and ready to be
discharged to home at this time.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: Vital signs
revealed her temperature was 98, her heart rate was 86 (sinus
rhythm), her blood pressure was 108/62, her respiratory rate
was 18, and her oxygen saturation was 96 percent on room air.
Weight preoperatively was 64 kilogram and on discharge was
62.8 kilogram. Physical examination revealed the patient was
alert and oriented times three. She was moving all
extremities and followed commands. Respiratory examination
revealed the lungs were clear to auscultation bilaterally.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sounds and second heart sounds.
No murmurs. The sternum was stable. The incision with Steri-
Strips, open to air, clean and dry. The abdomen was soft and
nontender. There were positive bowel sounds. The
extremities were warm and well perfused with trace edema.
PERTINENT LABORATORY VALUES ON DISCHARGE: White blood cell
count was 10.2, her hematocrit was 35.1, and her platelets
were 305. Sodium was 141, potassium was 4.6, chloride was
102, bicarbonate was 28, blood urea nitrogen was 15,
creatinine was 0.9, and her blood glucose was 92.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Plavix 75 mg by mouth once per day.
3. Atorvastatin 40 mg by mouth once per day.
4. Metoprolol 50 mg by mouth twice per day.
5. Digoxin 0.25 mg by mouth once per day.
6. Dilaudid 1 mg to 4 mg q.4-6h. as needed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Coronary artery disease; status post
coronary artery bypass grafting times two (with a left
internal mammary artery to the left anterior descending and
saphenous vein graft to the obtuse marginal).
Mitral regurgitation; status post mitral valve repair with a
number 26 annuloplasty ring.
Hypercholesterolemia.
Paroxysmal atrial fibrillation.
Mitral valve prolapse.
Osteoarthritis of the left thumb.
Cholelithiasis.
Hysterectomy.
Bladder repair.
DISCHARGE DISPOSITION: The patient was to be discharged to
home with visiting nurses.
DISCHARGE FOLLOWUP: The patient was to have followup with
Dr. [**Last Name (STitle) 1655**] in two to three weeks and followup with Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2108-8-1**] 15:12:18
T: [**2108-8-1**] 16:46:58
Job#: [**Job Number 55923**]
|
[
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"272.0",
"997.1",
"998.89",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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"35.12",
"36.11",
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] |
icd9pcs
|
[
[
[]
]
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15959, 16024
|
8601, 8712
|
15481, 15935
|
15170, 15427
|
1156, 1614
|
11040, 14890
|
7994, 8584
|
1921, 2644
|
14905, 15144
|
6075, 6939
|
16045, 16486
|
6968, 7624
|
7647, 7962
|
8729, 11011
|
15452, 15459
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,832
| 187,094
|
2093
|
Discharge summary
|
report
|
Admission Date: [**2133-3-16**] Discharge Date: [**2133-3-19**]
Date of Birth: [**2050-3-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 11327**] is an 83 M with a history of systolic CHF, s/p MVR on
coumadin, chronic kidney disease, and dementia who experienced
the sudden onset of abdominal pain this morning around 9:00 AM
while at his podiatrist's office. He was referred to the ED
where he was noted to have pain out of proportion to exam. He
underwent CT scan which did not reveal acute cause of his pain.
While in the ED, he had a bowel movement with a small amount of
bright red blood, then another with more blood, then a third
with more blood. He simultaneously became tachycardic to the
120s though maintained his blood pressure. After administration
of a dose of IV morphine, his pain resolved.
.
Upon arrival to the ED vitals were: T 96.8, HR 88, BP 116/64, RR
16, 100% on RA. He received 4 mg IV morphine for pain and 500
cc IVF, after which he dropped O2 sat to upper 80s which
improved with deep breaths to mid-90s. GI team was consulted
from ED and stated they would consult on patient tomorrow, no
urgent intervention unless decompensates. His PCP/cardiologist
Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] from the [**Name (NI) **] and recommended giving FFP
in the setting of bleed despite his mechanical valve. While in
the ED, he received 4 mg IV mophine, 500 cc IVF, IV Zofran, 1
unit FFP (started). He was ordered for a unit of pRBCs but did
not receive it. Vitals prior to transfer to the MICU were:
Afebrile, HR 124, BP 122/80, O2 sat 94% on RA.
.
MEDICINE HPI:
In brief, this is a 83M with dementia, chronic systolic CHF with
an EF of 30-35%, Afib and MVR on warfarin, and dementia who
presented with BRBPR. He was taken to the ED where he received a
bolus of NS 500 mL x1 and became more hypoxic. Given his
abdominal pain and bleeding, a CT scan was done of his abdomen
and GI and General Surgery were consulted. The CT showed no
acute abdominal process and severe cardiomegaly with mixing
artifact in the spleen. Given his comorbidities, borderline BP,
and risk of bleeding he was admitted to the MICU for further
management. In the MICU overnight his H/H were stable and he was
ultimately called out to Medicine for further management. Of
note, review of notes and history shows that the patient had
been having severe abdominal pain, but he does not relate that
history.
.
On the floor he is oriented to person only. He denies any pain
or SOB but is on oxygen. He reports that he is thirsty. He
cannot fully explain why he is here, but reports "all kinds of
problems" as leading to his admission.
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No cough, shortness of breath, or
wheezing. GI: No nausea, vomiting, + diarrhea. GUI: No dysuria
or change in bladder habits. MSK: No arthritis, arthralgias, or
myalgias. DERM: No rashes or skin breakdown. NEURO: No
numbness/tingling in extremities. PSYCH: No feelings of
depression or anxiety. All other review of systems negative.
Past Medical History:
- Chronic systolic CHF (last echo in our system LVEF 30-35% in
[**2127**]; EF 15%per last discharge summary [**2128**])
- Dementia
- Hyperlipidemia
- Paroxysmal atrial fibrillation
- Hypertension
- Diabetes mellitus type II (diet-controlled, not on meds)
- Multiple prior UTI
- Multiple prior CVA (last ~[**2119**])
- S/p MVR ([**2116**]; on coumadin)
- S/p left inguinal hernia repair ([**2117**])
Social History:
- Lives with his wife [**Name (NI) 8797**]. Daughter [**First Name8 (NamePattern2) **] [**Known lastname 11327**] lives upstairs
(can be reached at [**Telephone/Fax (1) 11330**]); son [**Name (NI) **] [**Name (NI) 11327**] lives downstairs
([**Telephone/Fax (1) 11331**]). Retired dispatcher. Walks with a cane since his
stroke.
- Tobacco: Denies
- etOH: Denies
- Illicits: Denies
Family History:
- Mother had hypertension and diabetes
Physical Exam:
MICU admission:
GEN: Resting in bed. Responding to questions appropriately,
somewhat confused about details of his medical care but states
that his daughter helps him.
HEENT: Conjunctiva are pink. Swelling of left upper eyelid, not
botehrsome to patient. Dry mucous membranes.
NECK: JVP not elevated.
PULM: CTA bilaterally, though somewhat poor cooperation with
exam
CARD: Tachycardic to 110s, regular, + mechanical MV sounds
ABD: Soft, distended somewhat asymetrically above umbilicus, no
TTP, + BS, no rebound/guarding
EXT: Trace pedal edema, palpable DP pulses
PSYCH: Appropriate, cooperative as able
Medicine Admission:
VS: T 96.1 P 54 BP 126/52 R 22 945 on 2L NC O2
GEN: NAD
HEENT: Dry MM, JVP to 10 cm, neck supple, no cervical,
supraclavicular, or axillary LAD
Cards: Irregular, loud S1, low pitched holosystolic murmur II/VI
at the mid left sternal border, PMI difficult to assess
?displaced to the anterior axillary line
Pulm: No dullness to percussion, bibasilar crackles, no wheezes
Abd: BS+, soft, NT, no rebound/guarding, liver palpable just
below the costal margin
Limbs: No LE edema, no tremors or asterixis
Skin: No rashes or bruising
Neuro: CNs II-XII intact. 4/5 strength diffusely, toes up
bilaterally, +palmomental but - [**Doctor Last Name **] and Tremner frontal
signs, reflexes diffusely 1+, gait not assessed
Discharge:
GEN: NAD. on RA
VS: T 96.2 Tm 98.8 P 70(56-135) BP 114/61 (104-131/61-85) R 21
94% on RA
HEENT: MMM, no OP lesions, no LAD, JVP 9cm
CV: Irregular, II/VI holosystolic murmur, PMI in the axillary
line
PULM: CTAB
ABD: BS+, NTND, no HSM
LIMBS: no LE edema, no tremors or asterixis
NEURO: Grossly nonfocal, A and O x 3
Pertinent Results:
Admission
[**2133-3-16**] 12:10PM BLOOD PT-28.9* PTT-26.3 INR(PT)-2.9*
[**2133-3-16**] 12:10PM BLOOD Glucose-133* UreaN-34* Creat-1.6* Na-141
K-5.9* Cl-104 HCO3-22 AnGap-21*
[**2133-3-16**] 12:10PM BLOOD Albumin-4.7 Calcium-9.2 Phos-4.2 Mg-2.2
Discharge
[**2133-3-19**] 06:45AM BLOOD WBC-7.5 RBC-4.04* Hgb-12.8* Hct-37.5*
MCV-93 MCH-31.7 MCHC-34.2 RDW-14.5 Plt Ct-75*
[**2133-3-19**] 06:45AM BLOOD PT-25.5* PTT-27.6 INR(PT)-2.5*
[**2133-3-19**] 06:45AM BLOOD Glucose-127* UreaN-40* Creat-1.5* Na-146*
K-3.8 Cl-112* HCO3-22 AnGap-16
[**2133-3-19**] 06:45AM BLOOD Calcium-8.2* Phos-1.6* Mg-2.1
Cardiac enzymes
[**2133-3-16**] 12:10PM BLOOD cTropnT-0.09*
[**2133-3-16**] 03:55PM BLOOD cTropnT-0.09*
[**2133-3-16**] 08:15PM BLOOD CK-MB-5 cTropnT-0.10*
[**2133-3-17**] 03:44AM BLOOD CK-MB-4 cTropnT-0.11*
[**2133-3-16**] 12:10PM BLOOD ALT-20 AST-48* AlkPhos-71 TotBili-0.8
[**2133-3-16**] 08:15PM BLOOD CK(CPK)-112
Transaminases, amylase, LDH
[**2133-3-17**] 03:44AM BLOOD LD(LDH)-307* CK(CPK)-108 Amylase-132*
[**2133-3-17**] 09:35PM BLOOD ALT-22 AST-31 LD(LDH)-286* Amylase-111*
TTE (Complete) Done [**2133-3-18**] at 4:26:22 PM The interatrial
septum is aneurysmal. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis (LVEF =
[**10-15**] %). Overall left ventricular systolic function is severely
depressed. Right ventricular chamber size is normal. with normal
free wall contractility. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. Mild to
moderate ([**12-28**]+) aortic regurgitation is seen. A mechanical
mitral valve prosthesis is present. The transmitral gradient is
normal for this prosthesis. No mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2128-12-15**],
left ventricular systolic function has declined. The severity of
aortic regurgitation has increased.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2133-3-16**] 1:51 PM No
suspicious pulmonary nodules or pleural effusions are seen in
the imaged lung bases. There is severe enlargement of the heart,
predominantly involving the left atrium. The patient is status
post mitral valvular replacement. There is no pericardial
effusion. The liver enhances homogeneously, without focal
lesions. Minimal pneumobilia, especially in the left hepatic
lobe, relates to prior history of sphincterotomy. Multiple small
gallstones are present, without evidence for acute
cholecystitis. The adrenal glands and pancreas are unremarkable.
The spleen demonstrates multiple peripheral hypoattenuation
areas, which may be related to early phase of the scan or
chronic splenic infarcts. There is no perisplenic fluid
collection. Both kidneys demonstrate mild cortical atrophy. Both
kidneys enhance and excrete contrast symmetrically, without
evidence of hydroureteronephrosis or concerning renal masses.
There is a small hiatal hernia. The stomach, small and large
bowel are unremarkable, without evidence of bowel wall
thickening or obstruction. Extensive colonic diverticulosis is
seen in the descending and sigmoid colon, without evidence of
acute diverticulitis. There is no intra-abdominal free fluid or
air. The abdominal aorta is tortuous with moderate
atherosclerotic calcification, without aneurysmal dilation.
There is no intra abdominal free fluid or air. CT OF THE PELVIS
WITH INTRAVENOUS CONTRAST: The urinary bladder is relatively
empty with a Foley catheter in place. The prostate gland is
enlarged measuring 6.9 x 6.1 x 6.8 cm. The rectum is
unremarkable. No significant pelvic lymphadenopathy or free
fluid is seen. BONES AND SOFT TISSUES: No bone lesions
suspicious for infection or malignancy are detected. IMPRESSION:
1. Severe cardiomegaly, especially involving the left atrium.
The patient is status post mitral valve replacement. 2. No acute
intraabdominal pathology. 3. Cholelithiasis without evidence of
acute cholecystitis. 4. Colonic diverticulosis, without evidence
of acute diverticulitis. 5. Hypodense areas in the spleen, may
represent early mixing artifact versus splenic infarcts.
Brief Hospital Course:
MEDICINE COURSE:
83M with chronic systolic CHF EF 30% several years ago, Afib and
MVR on warfarin, and dementia admitted with a hematochezia and
abdominal pain. It seems likely the hematochezia was due to
transient mesenteric ischemia which resolved likely from
improved hemodynamics. Colitis or diverticulosis are also
possible but less consistent with imaging. Given the patients
numerous comorbidities and symptomatic improvement, the care
team and family decided to pursue supportive measures rather
than invassive procedures to address this issue. He stabilized
clinically and was DCed to home with 24 hour supervision by his
family with VNA assistance.
# Hematochezia: Differential includes bleeding diverticuli on
warfarin, AVM, UGIB, colitis, and ischemic bowel. Given that he
has pain and severe CHF, ischemic bowel seems likely. He has
known diverticuli and a relatively high INR, so this too is a
possible source of bleeding. UGIB, colitis, and AVM seem less
likely given his symptomology and labs. GI and General Surgery
consulted. GI recommended outpatient colonoscopy given the
clinical scenario. Because of his comorbidities and given his
H/H was stable on anticoagulation without any loss of blood or
hematochezia, it seems the bleed has resolved and it was decided
to proceed with watchful waiting.
# Abdominal pain: Completely resolved. Could be due to colitis
or ischemic bowel. No cholelithiasis on CT and AP is WNL.
Lactate normal but AST moderately elevated to 46 on admission.
LDH and amylase were elevated to 307 and 132 respectively which
suggests bowel ischemia, but could be due to many causes. As
above, given his comorbidities it seems unlikely he could
tolerate a mesenteric bypass for ischemia or sigmoidectomy for
diverticulosis.
# Hypoxia: Received IVF and FFP in the ED and has very dilated
cardiomyopathy. Improved with diuresis. PE is unlikely given INR
>3, and ACS was ruled out.
# Chronic systolic CHF: EF in [**2128**] was 30%. Clinically appears
to be having some component of acute on chronic systolic CHF.
ECHO this admission showed worsened EF to 10-20%. Continued home
Furosemide 40 mg PO QSat/Mon/Wed/Fri. Continued home Metoprolol
Tartrate 50 mg PO/NG [**Hospital1 **].
# s/p MVR: Very high risk for CVA if subtherapeutic INR. Goal
INR is 2.5 to 3.5.
.
# Afib: Continue warfarin as above and rate control as above
.
# Troponin leak: On admission had slightly elevated TnT with
stable low MB. Likely baseline elevation or demand without true
ischemia.
# Chronic renal insufficiency: Baseline creatinine 1.4 mg/dL in
[**2128**]. Creatinine more or less at baseline at 1.5-1.6 mg/dL as of
discharge.
DNR DNI
MICU COURSE:
Mr. [**Known lastname 11327**] is an 83 gentleman with a systolic CHF, atrial
fibrillation, s/p MVR on Coumadin, who presents with a one-day
history of abdominal pain and then developed BRBPR in ED.
1. ABDOMINAL PAIN/GIB: Most likely etiology is episode of
ischemic bowel, less likely infectious invasive entorocolitis.
Appreciate GI and ACS recs. CTAP without evidence of colitis.
No hemodynamic instability during admission with stable
hematocrits. GI consult on admission with decision to hold off
on diagnostic or therapeutic interventions. C.diff toxin [**Doctor First Name **]
negative.
2. TROPONIN ELEVATION: Troponinemia in setting of CKD with flat
MB. If true elevation, more likely manifestation of demand
ischemia rather than ACS with plaque rupture.
3. HYPOXIA: Room air challenge with SaO2 of low 90s. Exam
without overt evidence of pulmonary edema or volume overload.
Given cardiomegaly and kyphosis, has element of restrictive
physiology with V/Q mismatch. CT chest demonstrating
cardiomegaly.
4. CHRONIC KIDNEY DISEASE: Unknown baseline; most recent
creatinine range 1.0-1.2 in [**2128**]. Prerenal etiology is likely in
setting of decreased perfusion from GIB.
5. SYSTOLIC CHF: Most recent echocariogram with EF of 30-35% in
[**2127**], though more recent discharge summary states 15% ([**2128**]). He
has significant cardiomegaly on CT abdomen.
6. ATRIAL FIBRILLATION: Tachycardic to 120s (from 70s-80s on
arrival). Improved to 70s-90s after 250 mg IV digoxin. Home
nodal blocklade restarted during admission.
7. MITRAL VALVE REPLACEMENT: Goal INR 2.5-3.5. Receieved 5 mg PO
vitamin K and FFP. Coumadin and heparin initially.
Medications on Admission:
- buspirone 10 mg PO Twice Daily
- metoprolol tartrate 50 mg Twice Daily
- doxazosin 4 mg PO Twice Daily
- simvastatin 20 mg PO at bedtime
- warfarin 5 mg Tab Oral 1 Tablet(s) Once Daily on Wed and
Friday
- warfarin 5 mg Tab Oral 0.5 Tablet(s) Once Daily on
Sun/Mon/Tues
- furosemide 40 mg Tab Oral once every other day -
Sat/Mon/Wed/Fri
Discharge Medications:
1. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. doxazosin 4 mg Tablet Sig: One (1) Tablet PO twice a day.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Wed Fri.
8. warfarin 5 mg Tablet Sig: 0.5 Tablet PO Sun Mon Tues.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
- Ischemic colitis v diverticulosis as a cause of GI bleeding
- Chronic systolic CHF (EF 10-20% this admission), NYHA III to
IV
Secondary
- Dementia
- Hyperlipidemia
- Paroxysmal atrial fibrillation
- Hypertension
- Diabetes mellitus type II (diet-controlled, not on meds)
- Multiple prior UTI
- Multiple prior CVA
- S/p MVR ([**2116**]; on coumadin)
- S/p left inguinal hernia repair ([**2117**])
- Aortic insufficiency
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
You were admitted for abdominal pain and bleeding in your gut.
It is likely that this was caused by either low blood flow in
your intestines, a diverticuli (a common defect in the wall of
the colon which is prone to bleeding), or inflammation in the
intestine. We did tests for infectious causes of your symptoms,
and these were negative. Ultimately, you improved clinically
with supportive care.
We have not made any changes to your home medications.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Appt: We are working on an appt for you within the next week.
The office will call you at home with an appt. If you dont hear
from them by tomorrow, please call them directly to book.
Completed by:[**2133-3-20**]
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
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10443, 14771
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319, 325
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16231, 16231
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16246, 16391
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3474, 3875
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3891, 4277
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,928
| 109,211
|
50864
|
Discharge summary
|
report
|
Admission Date: [**2159-9-26**] Discharge Date: [**2159-10-3**]
Date of Birth: [**2086-6-5**] Sex: M
Service: C-MED
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with a long history of coronary artery disease
(including multiple coronary artery bypass grafts in [**2128**], in
[**2132**], and in [**2159-8-16**]; and several percutaneous
transluminal coronary angioplasties) who was transferred to
the C-MED Service from the Coronary Care Unit.
The patient was initially admitted to the [**Hospital3 2358**] on
[**2159-9-25**] for an episode of substernal chest
discomfort while driving his car to a family event. In
addition to the chest discomfort, the patient also had the
abrupt onset of shortness of breath and nausea. All of his
symptoms, except the shortness of breath, were relieved with
sublingual nitroglycerin.
The patient states he had been doing well since his prior CT
surgery back in [**2159-8-16**]; denying any chest pain since
discharge. He has not noticed any significant decrease in
his exercise tolerance; however, he does admit to some mild
lower extremity swelling and some shortness of breath at
night while lying flat.
An echocardiogram performed at the [**Hospital3 2358**] was
significant for a dilated left ventricle with severe left
ventricular dysfunction with an ejection fraction of 15% to
20%, 4+ mitral insufficiency, and trace aortic insufficiency.
He was subsequently transferred to the [**Hospital1 190**] for cardiac catheterization.
A diagnostic cardiac catheterization at [**Hospital1 190**] revealed multivessel disease with elevated
pulmonary capillary wedge pressure of 34. He was transferred
to the Coronary Care Unit without any intervention at that
time, where he was aggressively diuresed with intravenous
Lasix with a subsequent relief of his shortness of breath
symptoms. Secondary to decreased blood pressures while in
the Coronary Care Unit, his dose of beta blocker was lowered,
and his blood pressure subsequently normalized.
The patient was then transferred to the C-MED Service for
repeat cardiac catheterization with definitive intervention
and perfusion study.
PAST MEDICAL HISTORY:
1. Coronary artery disease with acute myocardial infarction
complicated by ventricular fibrillation arrest in [**2128**];
status post coronary artery bypass graft in [**2128**] of the
saphenous vein graft to the left anterior descending artery.
A redo coronary artery bypass graft in [**2132**] with saphenous
vein graft to right coronary artery and saphenous vein graft
to first diagonal. A redo coronary artery bypass graft in
[**2159-8-16**] with left internal mammary artery to the left
anterior descending artery, radial to posterior descending
artery, saphenous vein graft to first diagonal, saphenous
vein graft to first obtuse marginal to second obtuse
marginal.
2. Hepatitis B (acquired through a blood transfusion).
3. Hypertension.
4. Left bundle-branch block.
5. Congestive heart failure by echocardiogram with 15%
ejection fraction.
6. Mitral regurgitation (4+ by echocardiogram in [**2159-8-16**]).
ALLERGIES: The patient states he has a PENICILLIN allergy
which causes a rash. He also states that MORPHINE drops his
blood pressure significantly. CODEINE, SULFA, IODINE, and
new allergy to RAPID INTRAVENOUS BENADRYL INFUSION; stating
that he had throat tightness.
MEDICATIONS ON TRANSFER: Enteric-coated aspirin 325 mg p.o.
q.d., Lopressor 25 mg p.o. b.i.d., captopril 12.5 mg p.o.
t.i.d., Lipitor 20 mg p.o. q.d., Protonix 40 mg p.o. q.d.,
Plavix 75 mg p.o. q.d., Colace 100 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital
signs revealed a temperature of 98, blood pressure
was 100/64, heart rate was 89, respiratory rate was 18. He
had an oxygen saturation of 95% on room air. In general, he
was a very pleasant man, sitting in a chair, in no acute
distress. Head, eyes, ears, nose, and throat examination
revealed no carotid bruits that were identifiable. No
jugular venous distention was appreciated. His neck was
supple, and sclerae were anicteric. Cardiovascular
examination revealed a diminished first heart sound, second
heart sound, and a possible third heart sound gallop heard
occasionally. Tachycardic with a [**2-21**] to 3/6 systolic
ejection murmur heard best at the left upper sternal border
and right upper sternal border radiating to the carotids.
The murmur was heard over the entire precordial region.
There was also a possible diastolic component as well. Lung
examination revealed lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended, with present bowel sounds. The extremities
revealed 1+ lower extremity edema, cool, but well perfused,
with 1 to 2+ pedal pulses bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
findings on transfer revealed the patient had a white blood
cell count of 4.3, hematocrit was 34.1, platelets were 178.
Sodium was 141, potassium was 4, chloride was 106,
bicarbonate was 25, blood urea nitrogen was 21, creatinine
was 0.6, with a blood glucose of 100.
HOSPITAL COURSE: On hospital day seven, the patient was
returned to the cardiac catheterization laboratory for
definitive treatment of his substernal chest discomfort.
His first diagnostic cardiac catheterization revealed an 80%
stenosis at the saphenous vein graft to obtuse marginal jump
graft at the touchdown of the second obtuse marginal. A
functional assessment of the stenosis was performed using a
pressure wire showing a pressure gradient across the stenosis
decreased from 0.79 to 0.69. The patient underwent
successful percutaneous transluminal coronary angioplasty
plus stent of the saphenous vein graft to first obtuse
marginal to second obtuse marginal at the touchdown of the
second obtuse marginal segment. Overall, he tolerated the
procedure quite well.
On arrival to the floor, the patient was somewhat dizzy and
moderately hypotensive; however, this quickly resolved
without any intervention needed. Subsequent electrolytes,
and hematocrits, and cardiac enzymes were all stable and
within normal limits.
On hospital day eight, the patient was chest pain free, doing
quite well, fully ambulatory, and without any symptoms of
shortness of breath. He was felt to be stable for discharge
home at this time.
During his hospital course, the patient did have one episode
of nonsustained ventricular tachycardia (a 6-beat run). He
was asymptomatic during this episode and spontaneously
converted to a normal sinus rhythm. No further intervention
was necessary at this time.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] in his outpatient cardiac clinic as needed for
adjustment of his blood pressure medications.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Zestril 5 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. (times 30 days).
4. Lopressor 25 mg p.o. b.i.d.
5. Lipitor 20 mg p.o. q.d.
6. Sublingual nitroglycerin as needed for chest pain.
DISCHARGE STATUS: Discharge status was to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post three coronary
artery bypass grafts.
2. Status post percutaneous transluminal coronary
angioplasty plus stent to the saphenous vein graft to first
obtuse marginal to second obtuse marginal at the second
obtuse marginal touchdown.
3. Hepatitis B.
4. Hypertension.
5. Left bundle-branch block.
6. Congestive heart failure by echocardiogram with 15%
ejection fraction.
7. Mitral regurgitation (4+ on echocardiogram).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Doctor Last Name **]
MEDQUIST36
D: [**2159-10-3**] 16:12
T: [**2159-10-9**] 11:26
JOB#: [**Job Number 105749**]
|
[
"V45.81",
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"412",
"414.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
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"99.20",
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] |
icd9pcs
|
[
[
[]
]
] |
7274, 8004
|
6911, 7202
|
5225, 6705
|
7217, 7253
|
6727, 6885
|
251, 2252
|
3491, 5206
|
2274, 3465
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,052
| 171,636
|
46323
|
Discharge summary
|
report
|
Admission Date: [**2120-5-1**] Discharge Date: [**2120-5-10**]
Date of Birth: [**2033-3-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Referral from OSH for Aortic Stenosis.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 87 year old gentleman with afib, CVA, GI bleed, AS,
iron dificiency anemia who presented to an OSH s/p fall and on
TTE was found to have aortic stenosis.
.
The patient reports he was trying to get up from the toilet and
fell and hit the back of his head sustaining a laceration. He
reports that he believes that while standing he felt
light-headed which caused him to fall. He believes he had
transient loss of consciousness after the fall. He denied CP,
palpitations, melena, hematochezia at the time. He does report
shortness of breath that has been worsening over time. He is
unsure of how far he can walk, b/c he simply does not walk
frequently anymore, limited by generalized fatigue. He reports
he is on 2L oxygen at home.
.
At the OSH, he was initially admitted for managment and
evaluation of mechanical fall and failure to thrive. A chest
xray revealed bilateral pleural effusions. He subsequently had a
CT of the chest which confirmed significant bilateral pleural
effusions with compressive atelectasis, old granulomatous
disease and an enlarged heart. A thoracentesis was performed
under ultrasound and 1050 cc of clear yellow fluid was drained
consistent w/ transudate effusion. Gram stain and culture of the
pleural fluid were negative. It appears there was discussion
whether the patient could be in failure. A BNP reportably was 29
around the time of admission. Cardiology was consulted
(Papgeorgio). He was diuresed approximately 2.5 Liters w/ IV
lasix 30mg q12 hs. A TTE demonstratd aortic stenosis and mitral
regurgitation. Arrangements for transfer to [**Hospital1 18**] were made for
w/u for possible AVR.
.
On arrival to [**Hospital1 18**], initial vitals were 97.5 108/60 96 18 98%
on 3L. He was comfortable and denied CP, shortness of breath at
rest.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of myalgias,
joint pains, cough, hemoptysis, black stools or red stools. He
denied recent fevers, chills or rigors. He denied 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,
paroxysmal nocturnal dyspnea, orthopnea, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: no records of this
-PERCUTANEOUS CORONARY INTERVENTIONS: no records of this
-PACING/ICD: no records of this
3. OTHER PAST MEDICAL HISTORY:
- atrial fibrillation
- CVA
- GI bleeding
- Aortic Stenosis
- Iron Deficiency Anemia
- BPH
- Asthma
- GERD
Social History:
-Tobacco history: negative, quit 50 years ago
-ETOH: 3 beers per week
-Illicit drugs:
Lives in [**Hospital3 **] alone since his wife died in [**Month (only) 359**]
[**2119**]. Uses a walker. Home oxygen requirement is 2 liters.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 108/60 96 18 98% on 3L
GENERAL: Cachectic appearing, NAD, Alert and oriented x 2.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No JV distention on exam
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic ejection murmur loudest at
RUSB.
LUNGS: Kyphosis. Resp were unlabored. Poor air movement, w/
decreased breath sounds at bilateral lung bases and crackles to
mid lung fields bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No pedal edema, peripheral pulses are present and
faint 1+ bilaterally. Extremities are cool but not cyanotic
appearing. There is a clean and dry dressing on the left shin
.
DISCHARGE PHYSICAL EXAM:
unchanged except:
respiration are less labored without accessory muscle use
Pertinent Results:
ADMISSION LABS:
[**2120-5-2**] 07:40AM BLOOD WBC-6.4 RBC-2.76* Hgb-9.2* Hct-27.6*
MCV-100* MCH-33.2* MCHC-33.1 RDW-18.2* Plt Ct-210
[**2120-5-2**] 07:40AM BLOOD PT-10.0 PTT-28.4 INR(PT)-0.9
[**2120-5-2**] 07:40AM BLOOD Glucose-106* UreaN-39* Creat-0.7 Na-144
K-5.1 Cl-99 HCO3-43* AnGap-7*
[**2120-5-2**] 07:40AM BLOOD proBNP-1675*
[**2120-5-2**] 07:40AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.2 Mg-2.5
[**2120-5-2**] 07:40AM BLOOD RheuFac-9
[**2120-5-2**] 07:40AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2120-5-2**] 10:43AM BLOOD Type-ART pO2-68* pCO2-60* pH-7.46*
calTCO2-44* Base XS-15
[**2120-5-2**] 10:43AM BLOOD Lactate-0.9
.
DISCHARGE LABS:
[**2120-5-9**] 06:20AM BLOOD WBC-7.5 RBC-2.81* Hgb-9.1* Hct-29.1*
MCV-103* MCH-32.2* MCHC-31.2 RDW-19.1* Plt Ct-239
[**2120-5-9**] 06:20AM BLOOD Na-147* K-3.6 Cl-111*
.
IMAGING:
[**2120-5-4**] CXR: FINDINGS: Cardiac silhouette remains enlarged, but
there is no evidence of pulmonary edema. Moderate pleural
effusions persist bilaterally, right greater than left, with
adjacent basilar atelectasis and/or consolidation.
Mild-to-moderate gastric distension is seen in the upper
abdomen.
.
[**2120-5-3**] CT HEAD: IMPRESSION: No acute intracranial injury.
.
[**2120-5-3**] TTE: LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (area
0.8-1.0cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Calcified tips of papillary
muscles. Moderate to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**1-29**]+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL CMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest.
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. 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 root is mildly dilated at the
sinus level. There are three aortic valve leaflets. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric LVH with normal global and regional
biventricular systolic function. Severe calcific aortic
stenosis. Moderate to severe mitral regurgitation. Mild
pulmonary hypertension.
.
[**2120-5-7**]: VIDEO SWALLOW EVALUATION:
FINDINGS: Barium passes freely through the oropharynx without
evidence of a stenosis. There was aspiration with thin barium as
well as penetration with all consistencies of barium
administered.
IMPRESSION: Aspiration with thin barium and penetration with all
consistencies of barium. For further details, please refer to
speech and swallow note in OMR.
Brief Hospital Course:
Mr. [**Known lastname 931**] is an 87 year old gentleman with afib, history of
stroke (CVA), GI bleed, aortic stenosis, iron deficiency anemia
who presented to an OSH status post fall and was referred to
[**Hospital1 18**] for evaluation for aortic valve replacement. He was felt
not to be a surgical candidate due to poor nutritional status.
.
ACTIVE ISSUES BY PROBLEM:
# Nutrition: He presented with malnutrion and cachexia. Per
video swallow study, was aspirating everything that he was
eating and speech and swallow recs were to not take anything PO.
This was felt likely to be chronic. After extensive discussion
with his family members, it was decided that he would not want
to pursue feeding tube for nutrition. He was allowed to eat
again, knowing that he would continue to aspirate and that this
would come with complications such as pneumonia or large
aspiration leading to hypoxia and cardiac arrest. He was set up
for a hospice facility to get 24 hour care. When he was NPO
awaiting the decisions of the family, he became hypernatremia to
151 (see below). The family understands that he is not taking
in enough fluids PO to prevent hypernatremia and that the
hospice facility will not supply IV fluids.
.
# AORTIC STENOSIS: Severe aortic stenosis with valve area 0.8
and peak gradient 4.2 m/s. He was diuresed for 3 days with
lasix 20 mg PO daily with acetazolamide 250 mg [**Hospital1 **] with a net
negative of 2.5 L and resolution of his respiratory distress.
TTE also demonstrated preserved ejection fraction and prior
cardiac cath at an outside hospital showed no significant
coronary artery disease. He was evaluated by Cardiac surgery
and Dr. [**Last Name (STitle) **] independently re: surgical repair, however, based
upon overall nutritional status and respiratory difficulty, he
was not a candidate for open valve replacement, core valve, or
valvuloplasty. It was felt that since his symptoms (respiratory
distress) responded well to medical therapy and he was a poor
surgical candidate, it would be more reasonable to manage him
conservatively. Continued his metoprolol succinate 75 mg daily,
furosemide 20 mg PO once daily prn shortness of breath.
.
# BILATERAL PLEURAL EFFUSIONS: The patient was monitored in the
CCU after concern on the floor for worsening respiratory status.
He also developed a contraction alkalosis in the setting of
diuresis with the effusions making it difficult for him to
adjust his respiratory to compensate. After discussion on
rounds, it was decided not to perform thoracentesis, given
previous results indicating transudative effusion. In the
setting of an elevated BNP, it was felt that the patient's heart
failure was related to aortic stenosis and not a primary lung
process. With diuresis, the patient's breathing improved, and
his oxygen was gradually weaned to 2L (home requirement for
years).
.
# ATRIAL FIBRILLATION: CHADS2 score 4 (htn, age, stroke). Atrial
Fibrillation w/ ventricular rate controlled. He is not
anticoagulated in the outpatient setting due to history of GI
bleed while on warfarin. He was continued on metoprolol
succinate 75 mg daily.
.
# Hypernatremia: When he was NPO for one day, his sodium
increased from 144 to 151. He was symptomatic with decreased
alertness and delirium. This resolved with IVF to 147.
.
CHRONIC ISSUES BY PROBLEM:
# ANEMIA: Blood work prior to transfer reveals hematocrit of
27.4 and remained stable during admission. Known iron
deficiency anemia.
# DEPRESSION/ANXIETY: Continued celexa.
# Gastroesophageal reflux disease: discontinued omeprazole and
tums prn. Not eating much to cause reflux
# Benign prostatic hypertrophy: discontinued finasteride, has a
foley in place.
.
TRANSITIONAL ISSUES:
- Please continue to provide ongoing care focused on comfort to
include: oral care and observed feedings, possible antibiotics
as needed for symptomatic pneumonias, pain control, symptom
control such as diuresis, secretion management or
nausea/constipation.
Medications on Admission:
1. Aspirin 81mg daily
2. Calcium carbonate 1000 units daily
3. Captopril 6.25 mg daily
4. Carvedilol 3.125 [**Hospital1 **]
5. Citalopram 20mg daily
6. Proscar 5mg [**Last Name (un) **]
7. Omeprazole 40 mg daily
8. Miralax [**Hospital1 **]
9. Spiriva 18mcg daily
10. Lasix 20mg PO bid
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*0*
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO BID (2 times a day) as needed for
constipaton.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for cough.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for contstipation.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. morphine 10 mg/5 mL Solution Sig: 2.5-10 mg PO Q2H (every 2
hours) as needed for pain, shortness of breath.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for shortness of breath or wheezing.
10. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for agitation, discomfort.
Discharge Disposition:
Extended Care
Facility:
Community Hospice House
Discharge Diagnosis:
PRIMARY DIAGNOSIS
chronic aspiration
failure to thrive
aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 931**],
.
You were admitted to the hospital because you were having
difficulty breathing. This is because of your aortic valve
stenosis which causes heart failure. You had fluid collected
around your lungs due to the heart failure making it difficult
to get a full breath. Your aortic stenosis was managed with
diuresis and your respiratory status returned to [**Location 213**]. The
aortic valve specialists and cardiac surgeons evaluated you,
however, they did not think that you would be a good candidate
for valve work because you are severely malnourished.
.
We were very concerned about your nutritional status. You had a
swallowing evaluation which showed that you were aspirating
everything that you swallowed into your lungs. After
discussions with you and your family, it was decided that a
feeding tube would not help with possible aspirations and so you
should eat whatever you want to continue nutrition. However,
you will continue to aspirate and might develop complications
from this. We think that this aspiration is fairly chronic and
so you were set up with hospice to help make you comfortable.
.
The following changes were made to your medications:
- STOP all of your medications except:
- metoprolol succinate 75 mg daily to control your heart rate
- senna and docusate 1-2 tabs twice daily as needed for
constipation
- acetaminophen (Tylenol) 650 mg per mouth or rectum every 6
hours for pain
- morphine sulfate oral solution 2.5-10 mg every 2 hours as
needed for pain
- citalopram 20 mg daily
- furosemide 20 mg daily as needed for shortness of breath or
tachypnea
- lorazepam 0.5-1 mg every 2 hours as needed for agitation
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Your hospice program will set up a physician for you and will be
in contact with your primary care physician.
|
[
"428.0",
"493.90",
"799.4",
"276.0",
"507.0",
"600.00",
"262",
"428.33",
"280.9",
"530.81",
"V49.86",
"427.31",
"311",
"564.09",
"276.3",
"300.00",
"396.2",
"511.9",
"V85.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13233, 13283
|
7783, 11488
|
343, 350
|
13398, 13398
|
4242, 4242
|
15311, 15424
|
3188, 3303
|
12103, 13210
|
13304, 13377
|
11794, 12080
|
13549, 15288
|
4890, 5392
|
3343, 4121
|
2673, 2788
|
11509, 11768
|
265, 305
|
378, 2565
|
5401, 7760
|
4258, 4874
|
13413, 13525
|
2819, 2927
|
2587, 2653
|
2943, 3172
|
4146, 4223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,704
| 147,127
|
3685
|
Discharge summary
|
report
|
Admission Date: [**2110-2-24**] Discharge Date: [**2110-3-5**]
Date of Birth: [**2037-2-10**] Sex: M
Service: MEDICINE
Allergies:
Infed
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
temporary pacing wire placed
foley catheter
History of Present Illness:
Patient is a 73 y/o M with a h/o ESRD s/p deceased donor
transplant [**2105**], DM2, CAD, PAF and CHF who presents with
weakness. The patient reports that his symptoms started around
3 days ago. At that time he had a fall onto concrete when he
tripped on his shoe and hit his head. he denied LOC or
preceeding symptoms such as CP or SOB. This morning he reports
feeling weak and fell out of his chair and hurt his knee and was
unable to get up. The patient also describes itching "all over"
as well as having decreased PO intake and poor appetite over the
last few days. He endorses one episode of non-bloody emesis 4
days ago but no further nausea or vomiting. He denies melena or
abdominal pain. He does report decreased urine output as well.
.
In ED VS were T 98.3 BP 132/64 HR 40 RR 18 O2 sat 96%. He
received atropine 0.5mg IV x1, glucagon 1mg IV x1 given his
significant bradycardia with no significant HR response. His BP
remained stable. EKG showed a junctional rhythm, rate 38.
Pacer pads placed. Also received levoflox 750mg x1 for ? RLL
PNA. Evaluated by renal transplant fellow in ED, renal US
showed no hydro. R knee films showed ? patellar avulsion fx vs
osteophyte and R knee to be placed in immobilizer. He was
admitted to the MICU for further management. On transport to
MICU HR [**Month (only) **]. to 20s and another 1mg atropine was administered
with HR inc. to 30s.
Past Medical History:
1. DM2
2. HTN
3. ESRD s/p renal Tx [**2105**], baseline Cr 1.5-1.7
4. Hepatitis C
5. CAD- + Hx of NSTEMI, Normal Coronaries on Cath [**11/2105**]
6. CHF- EF>60% 02/07
7. PFO
8. Anemia
9. Follicular Thyroid Neoplasm- Dx [**9-/2107**]
10. PAF
Social History:
Patient lives alone and is not in contact with any family
members. Smokes ~ 1ppd for last 40-50 years. Denies alcohol
use.
Family History:
Sister with DM and renal disease
Physical Exam:
VS: T 95.1 HR 39 BP 134/38 RR 17 O2 sat 100% 2L NC
General: comfortable appearing elderly male, hard of hearing,
NAD
HEENT: MM dry, OP clear, poor dentition, sclera anicteric,
pupils equal, reactive R>L, EOMI, 2 healing excoriations above
and below R orbit with some periorbital swelling
Neck: supple, JVP difficult to assess
Heart: RRR, [**1-23**] diastolic AI murmur
Chest: pacemaker in place in right upper chest with bandage, no
bruising, bleeding or swelling
Lungs: crackles [**11-22**] way up, otherwise cleat
Abdomen: soft, mild epigastric tenderness, +BS, ND
Ext: muscle atrophy in LE, [**Month (only) **]. hair, pedal pulses dopplerable
Skin: warm, no rashes
Neuro: AAO x3, moving all 4 ext.
Pertinent Results:
WBC-4.6 RBC-2.77* HGB-9.1* HCT-29.3* MCV-106* MCH-32.8*
MCHC-31.0 RDW-14.7
PLT COUNT-161
- NEUTS-72.2* LYMPHS-16.7* MONOS-6.2 EOS-4.8* BASOS-0.1
GLUCOSE-108* UREA N-110* CREAT-3.6*# SODIUM-140 POTASSIUM-5.4*
CHLORIDE-104 TOTAL CO2-25
FK506-6.0
TRIGLYCER-68 HDL CHOL-47 CHOL/HDL-2.1 LDL(CALC)-40
CALCIUM-8.7 PHOSPHATE-5.5* MAGNESIUM-2.8* CHOLEST-101
CXR: pulm vasc. congestion, no effusions, RLL opacity
CXR s/p pacemaker placment: Compared with earlier the same day,
no significant change is detected. Again seen is a dual-lead
right-sided pacemaker with lead tips over right atrium and right
ventricle. No pneumothorax is detected. Also again seen is
marked cardiomegaly and pulmonary vascular plethora, with
interstitial edema and
increased retrocardiac density. Probable small left and ?small
right
effusion. Note is made of an unusual density arching over the
upper chest
immediately below clavicles - I suspect this represents
calcification in the aorta.
.
EKG: junctional bradycardia, no ischemic changes
.
Renal US [**2-24**]: The transplanted kidney is identified in the right
lower quadrant. The transplanted kidney measures 13.8 cm. The
renal parenchyma echotexture appears slightly increased. There
is no hydronephrosis or perinephric fluid collection. Small
amount of perihepatic free fluid is seen.
Doppler evaluation of the transplanted kidney demonstrates color
flow
throughout the kidney. There is no diastolic flow with reverse
flow which makes the resistive indices literally 1.
.
R knee xray: Alignment is normal, and no fracture is seen. There
is faint chondrocalcinosis involving both menisci. Incidentally
noted is calcification of the proximal portion of the medial
collateral
ligament (Pellegrini-Stieda lesion) related to old trauma,
extensive
enthesophyte formation involving the inferior more than superior
patellar poles, and extensive vascular calcification.
.
Hip xray: The femoral heads remain well seated in the acetabula,
with no acute fracture seen. There are relatively symmetric
moderate degenerative changes involving both hip joints.
.
CT head: no acute bleed or mass
Brief Hospital Course:
73 y/o M with a h/o ESRD s/p deceased donor transplant [**2105**],
DM2, CAD, PAF and CHF who presents with weakness. Found to be
in ARF with bradycardia.
.
# Bradycardia: Patient was in junctional bradycardia. He had a
temporary pacer wire placed which maintained a rate of 60. His
coreg was held. After two days, he developed sinus initiated
beats and so his pacer threshold was decreased to 30 beats per
minute. He maintained sinus bradycardia at a rate of 50-59, and
so his temporary pacemaker was discontinued on [**2-27**]. During
ambulation, the patient was unable to mount an adequate heart
rate response, and was therefore scheduled for pacemaker
placement. He received a dual chambered pacemaker on [**2-28**]. The
pacemaker was inserted through the right cephalic vein, and
given the patient's uremia and inadequate ability to clot, lost
1 unit of blood during the procedure. The patient was
asymptomatic and there were no other complications. He received
3 days prophylaxtic Keflex s/p pacemaker placement, and has
compelted this course. He should follow up with the pacemaker
device clinic on [**2110-3-11**].
.
# ARF: ESRD s/p tansplant [**2105**]. Baseline Cr 1.5-1.7, presented
with level of 3.6. the renal service believes the precipitant of
ARF was poor renal perfusion from bradycardia. With improved
cardiac output, the patient's creatinine gradually declined. His
tacrolimus was followed and increased to 3mg PO BID. His
cellcept was continued. His diuretics were initially held in
the setting of ARF. Torsemide was restarted on [**2-27**]. He
subsquently developed mild bibasilar crackles, no hypoxia, and
Metolazone was also restarted on [**3-4**]. His tacrolimus was
increased to 3mg Po twice daily. Goal tacrolimus trough is [**3-26**].
He is to follow up in the [**Month/Day (3) **] clinic.
.
#SOB: patient developed several episodes of shortness of breath
and was found to be wheezy on exam. He was treated with
albuterol and ipratropium. As he was found to have mild crackles
and mild pulmonary edema on CXR after pacemaker placement, his
torsemide and metolazone were restarted.
.
# Anemia: patient with chronic anemia. Likely [**12-21**] renal
failure. Had HCT drop related to procedure, transfused 1u [**3-1**],
did not bump appropriately to pRBCs though remained stable
around 24-26. [**Month (only) 116**] need epo as outpatient - renal follow-up.
This will be communicated with his PCP.
.
# CAD: aspirin was continued.
.
# CHF: patient's diuretics and carvedilol were initially held.
His diuretics were restarted on [**2-27**], and his carvedilol was
readministered after is pacemaker placement.
.
# DM: Glypizide was held in the setting of acute on chronic
renal failure. He was maintained on an isulin sliding scale.
Glypizide may be restarted when his creatinine is back to
baseline.
.
# Functional status: Patient worked wth physical therapy and was
found to be unsteady on his feet. He was therefore reccommended
to be discharged to a rehab facility.
.
#) R leg injury- question patellar avulsion vs. osteophyte.
ortho saw him, believed there is no fracture
.
#) Suppressed TSH- has been suppressed in past c/w subclinical
hyperthyroid, known history of multinodular goiter but "cold" on
[**2105**] RAI. Free T4 wnl.
Medications on Admission:
Medications (per recent cardiology note and confirmed with
patient):
metolazone 5 mg q sun, wed
Torsemide 100 mg twice a day
Coreg 12.5 mg twice a day
Vitamin B12 daily
Colace as needed
Gabapentin 300 mg twice a day
Glipizide 2.5 mg twice a day
Hydralazine 50 mg three times a day
CellCept [**Pager number **] mg twice a day
Prazosin 1 mg in the morning and 2 mg at bedtime
Prograf 2 mg twice a day
.
Allergies:
Infed
Iron Dextran, unknown rxn
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Prazosin 1 mg Capsule Sig: One (1) Capsule PO QAM (once a day
(in the morning)).
5. Prazosin 1 mg Capsule Sig: Two (2) Capsule PO QPM (once a day
(in the evening)).
6. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Ipratropium Bromide 0.02 % Solution Sig: [**11-20**] Inhalation Q6H
(every 6 hours).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**11-20**] Inhalation Q2H (every 2 hours) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
12. Torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
16. Insulin
Per attached sliding scale
Discharge Disposition:
Extended Care
Facility:
Park Place - [**Street Address(1) **]
Discharge Diagnosis:
Primary:
Junctional Bradycardia
Acute Renal Failure
.
Secondary:
Chronic Diastolic CHF
DMII
ESRD
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital and found to have a low heart
rate, as well as being in acute renal failure. It is unclear
what precipitated your slow heart rate and acute renal failure.
.
You received a pacemaker to ensure that your heart does not beat
too slowly. You should keep your right arm below shoulder level
and keep movements to a minimum for one week. Do not do any
heavy lifty or excercise. If you have trouble keeping your arm
still, you can keep your arm in a sling particularly at night.
.
Please take your medications as prescribed. Your tacrolimus was
also increased. Your glypizide has been temporarily held because
of acute renal failure. You will need to check with your PCP and
kidney doctor; they will tell you when your kidney function has
normalized. When your kidneys have returned to [**Location 213**], you can
start glypizide again.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000cc
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, or any other
concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2110-4-7**]
1:30
.
Please follow up with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 250**], on
[**Month (only) 547**] Monday 28, 4:40pm.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2110-3-11**]
9:00
.
Provider: [**Name10 (NameIs) 10701**] Clinic with Dr. [**Last Name (STitle) 118**] Date/Time [**2110-3-19**]
3pm
|
[
"996.81",
"584.9",
"285.21",
"E878.0",
"427.31",
"428.0",
"V10.87",
"745.5",
"585.9",
"427.89",
"070.54",
"404.91",
"250.00",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"37.78",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10210, 10274
|
5087, 8355
|
273, 318
|
10415, 10422
|
2950, 5030
|
11600, 12168
|
2174, 2208
|
8849, 10187
|
10295, 10394
|
8381, 8826
|
10446, 11577
|
2223, 2931
|
225, 235
|
346, 1753
|
5039, 5064
|
1775, 2017
|
2033, 2158
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,566
| 144,623
|
50467
|
Discharge summary
|
report
|
Admission Date: [**2153-10-2**] Discharge Date: [**2153-10-6**]
Date of Birth: [**2081-10-10**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
71 yo male with history of COPD, probable lung cancer and known
pericardial effusion presents with worsening shortness of breath
and orthopnea. He was found to have early tamponade physiology
on echocardiogram report from [**Hospital6 1129**]
[**2153-9-12**] where echo revealed LV ejection fraction of 76%
and a moderate to large circumferential pericardial effusion
with fibrin deposition and impaired RV filling consistent with
early tamponade physiology in setting of estimated PASP 36 mmHg.
He refused drainage at that time. He was seen in clinic today
with Dr. [**Last Name (STitle) **] and agreed to come in Wednesday for outpt
drainage.
.
His lung cancer diagnosis was suspected based on imaging
findings and smoking history though he declined biopsy and
future treatment if he did have pathologic diagnosis. He reports
10 pound weight loss and new onset paroxysmal nocturnal dyspnea
and orthopnea as well as episodic loose melena. He has had no
recent falls but that he still is very unstable due to his back
problems and occasional vertigo.
His main complaint is that he feels he still has pneumonia.
.
In the ED, initial vitals were [**6-10**] pain 97.8 101 153/70 28 96%
RA. he complained of worsening SOB, heart racing, unclear story
of chest pain - most currently no chest pain, He denies pain in
his back neck or jaw. He also endorses chronic abdominal pain
times several months that is intermittent he has right now. He
associates this with his recurrent gas pain. No fever chills
nausea or vomiting. Comfortable currently
.
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.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Atrial fibrillation
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HTN
Atrial fibrilation not on coumadin because of prior SDH
dCHF
COPD
GERD
Anxiety
Back surgery after MVA
Social History:
- Tobacco history: Previous 60 pack year smoker, quit 12 years
ago
- ETOH: one glass of wine per night, prior heavier use
- Illicit drugs: Denies
No family live in US, friend [**Name (NI) **] is HCP
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI dry MM. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple.
CARDIAC: RR, normal S1, S2. Not distant. No m/r/g. No thrills,
lifts. No S3 or S4. Pulsus 6 mmHg
LUNGS: Diminished BS bilateral bases, no crackles, or wheezes
ABDOMEN: +BS Soft, distended, tender diffusely, no R/G. Enlarged
liver by scratch test.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
DISCHARGE PHYISICAL EXAM:
GENERAL: NAD.
HEENT: NCAT.
NECK: Supple.
CARDIAC: RR, normal S1, S2. Not distant. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Diminished BS bilateral bases, no crackles, or wheezes
ABDOMEN: +BS Soft, distended, tender diffusely, no R/G.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
Pertinent Results:
ADMISSION LABS:
.
[**2153-10-2**] 03:45PM BLOOD WBC-8.4 RBC-4.80 Hgb-15.1 Hct-47.1 MCV-98
MCH-31.5 MCHC-32.1 RDW-13.5 Plt Ct-175
[**2153-10-2**] 03:45PM BLOOD Neuts-83.0* Lymphs-11.6* Monos-4.0
Eos-0.9 Baso-0.4
[**2153-10-2**] 03:45PM BLOOD PT-12.9 PTT-23.9 INR(PT)-1.1
[**2153-10-2**] 03:45PM BLOOD Plt Ct-175
[**2153-10-2**] 03:45PM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-140
K-4.7 Cl-105 HCO3-27 AnGap-13
[**2153-10-2**] 03:45PM BLOOD ALT-18 AST-31 AlkPhos-101 TotBili-0.5
[**2153-10-2**] 03:45PM BLOOD Lipase-36
[**2153-10-2**] 03:45PM BLOOD proBNP-649*
[**2153-10-2**] 03:45PM BLOOD cTropnT-<0.01
[**2153-10-2**] 05:22PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2153-10-2**] 05:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
PERTINENT LABS:
.
[**2153-10-2**] 03:45PM BLOOD proBNP-649*
[**2153-10-2**] 03:45PM BLOOD cTropnT-<0.01
[**2153-10-4**] 06:04AM BLOOD LD(LDH)-1066*
[**2153-10-3**] 02:14PM OTHER BODY FLUID TotProt-4.4 Glucose-98
LD(LDH)-826 Amylase-21 Albumin-3.2
[**2153-10-3**] 02:14PM OTHER BODY FLUID WBC-1300* RBC-4900* Polys-6*
Lymphs-56* Monos-2* Macro-16* Other-20*
.
DISCHARGE LABS:
.
[**2153-10-5**] 06:56AM BLOOD WBC-8.1 RBC-5.03 Hgb-15.7 Hct-48.8 MCV-97
MCH-31.3 MCHC-32.2 RDW-13.5 Plt Ct-173
[**2153-10-5**] 06:56AM BLOOD PT-13.1 PTT-28.4 INR(PT)-1.1
[**2153-10-5**] 06:56AM BLOOD Plt Ct-173
.
MICRO/PATH:
.
Pericardial Fluid [**2153-10-3**]:
GRAM STAIN (Final [**2153-10-3**]):
1+ (<1 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 (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2153-10-4**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
Pericardial Fluid Cytology: Wetread - Malignant cells
.
Pericardial Fluid Cell Block: Pending
.
IMAGING/STUDIES:
.
ECG [**10-2**]: Atrial fibrillation. Low voltage throughout the
tracing. Consider anterior wall myocardial infarction of
indeterminate age. No previous tracing available for comparison.
.
ECHO [**10-2**]:
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 pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
Compared with the prior study (images reviewed) of [**2153-9-12**],
the pericardial effusion is now larger.
.
CXR Portable [**10-2**]:
IMPRESSION: Opacification of the right middle lobe which may
represent
atelectasis versus possible pneumonia. Small right pleural
effusion.
.
ABD XR [**10-2**]:
FINDINGS: AP and left lateral decubitus radiographs of the
abdomen were
provided. There is a nonobstructive bowel gas pattern and there
is no free
air. There is a meniscus seen in the right chest which is
presumably mobile
pleural effusion. The previously seen right middle lobe opacity
on the recent prior chest radiograph has resolved suggesting
that this was due to
atelectasis.
.
Duplex Doppler Abd/Pelv [**10-2**]:
IMPRESSION:
1. Targetoid lesion measuring 1.8 cm in the right lobe of the
liver is
concerning for malignancy, including metastatic disease.
Abdominal MRI is
recommended for further evaluation.
2. Echogenic liver compatible with fatty infiltration. Other
forms of more
severe liver disease, including hepatic fibrosis/cirrhosis are
not excluded on this study.
3. No ascites.
.
C.Cath [**10-3**]:
FINAL DIAGNOSIS:
1. Pericardial effusion with echo evidence of tamponade
2. Successfully drained via sub-xiphoid approach using an 18 G
pericardial needle and drainage catheter.
.
ECHO [**10-3**]:
FOCUSED STUDY, POST-PERICARDIOCENTESIS: Right ventricular
chamber size and free wall motion are normal. There is a very
small pericardial effusion located adjacent to the right atrial
free wall. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2153-10-2**],
the pericardial effusion is smaller.
.
ECHO [**10-5**]:
.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2153-10-3**],
the findings are similar.
.
CXR PA/LAT [**10-5**]:
.
Correlation with prior reference CT is made. Stable appearing
post-
obstructive RML collapse and likely also atx involving RLL.
Small right
pleural effusion likely unchanged. Cannot exclude supervening
infection in
teh right lower lung in the appropriate clinical setting. Left
lung and right upper lobe clear.
Brief Hospital Course:
71 yo male with history of COPD, AFib, dCHF, probable lung
cancer, and known pericardial effusion presents with worsening
shortness of breath, orthopnea, and tamponade s/p pericardial
drainage.
.
ACTIVE ISSUES:
#Malignant Pericardial Effusion and Tamponade: Presented with
worsening effusion causing radiographic tamponade. He underwent
pericardiocentesis with drain placement. The drain was pulled
after it stopped draining. Pericardial fluid cytology
demonstrated malignant cells. Final cell block interpretation
was pending at time of discharge.
.
#Probable lung cancer: Review of chest CT from [**Hospital1 2025**] showed large
bronchogenic lesion causing complete collapse of the right
middle lobe as well as multiple hilar and mediastinal lymph
nodes. He has declined biopsy, further staging, or treatment.
This may be readdressed after the fianl results of his
pericardial fluid are known. He required O2 to maintain adequate
oxygen saturation and was discharged with home O2. He also
decline PT evaluation and visiting home nursing.
.
#Abdominal pain: he expressed mild abdominal discomfort not
requiring opiate medications. An abdominal US showed liver
lesions likely metastases in this context. He declined further
imaging to better evaluate abdominla disease.
.
CHRONIC ISSUES:
.
#Atrial fibrillation: Continued home ASA and diltiazem. Not on
coumadin because of a prior SDH.
.
#Diastolic CHF: Had mild pleural effusion but otherwise does not
appear volume overloaded.
.
#COPD: Did not appear to be in COPD exacerbation. Continued home
advair.
.
#GERD: Continued home pepcid 20 mg daily
.
#HTN: Continued home diltiazem.
.
#Anxiety: Cont ativan [**Hospital1 **] PRN
.
TRANSITIONAL ISSUES:
.
#Probable Stage IV Lung Ca: Based on the CT chest findings from
[**Hospital1 2025**] and the positive preliminary cytology for malignant cells,
he likely has Stage IV lung cancer. The final cytology and cell
block findings need to be followed-up for more information.
During this hospitalization, Mr. [**Known lastname 105142**] was not amenable to
further staging workup including brain imaging, bronchoscopy for
biospies, or further body imaging.
Medications on Admission:
Diltiazem 120 mg daily
Advair inh [**Hospital1 **]
ASA 81 mg daily
Ativan 0.5 mg daily
Pepcid 20 mg daily
Discharge Medications:
1. Home oxygen
O2 at 2 L per minute per nasal cannula continuously pulse dose
portability to keep O2 Sat above 92%. Patient desatted to <88%
on ambulation.
2. simethicone 125 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed for Bloating.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Anxiety.
4. diltiazem HCl 120 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO BID (2 times a day).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. famotidine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pericardial effusion
.
Secondary diagnosis
Cancer, most likely lung
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 105142**],
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for shortness of breath which was a result of
a large amount of fluid surrouding your heart. You underwent a
procedure to drain the fluid. The fluid did not reaccumulate.
You are also short of breath because part of your lung is
deflated. This is because you have a mass compressing your lung.
This is probably lung cancer but we do not know for sure because
you did not want a biopsy. The cytology may show what type of
cancer you have. These results will be available in about a
week. We started you on oxygen to help your breathing. You
should use this all the time. If you have worsening of your
shortness of breath or change your mind about further work up of
your cancer you should discuss this with your primary care
doctor or Dr. [**Last Name (STitle) **]. We did not make any changes to your
medications.
Followup Instructions:
Department: Primary Care
Name: Dr.[**Last Name (STitle) 80004**] [**Name (STitle) **] for Dr. [**First Name4 (NamePattern1) 20765**] [**Last Name (NamePattern1) 39193**]
When: Thursday [**2153-10-11**] at 2:30 PM
Location: FAMILY MEDICAL ASSOC
Address: [**Location (un) 24577**] [**Apartment Address(1) 91469**], [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 40489**]
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 31533**] office is working on a follow up appointment
for you 1 week after your hospital discharge. If you have not
heard from the office in [**12-3**] business days please call the
office number listed below.
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
|
[
"428.32",
"530.81",
"423.8",
"789.00",
"162.2",
"272.4",
"428.0",
"250.00",
"300.00",
"V15.82",
"401.9",
"518.0",
"427.31",
"496",
"423.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
11907, 11913
|
8796, 8992
|
318, 339
|
12049, 12049
|
3949, 3949
|
13179, 14073
|
2820, 2937
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11104, 11884
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11934, 11934
|
10974, 11081
|
7735, 8773
|
12200, 13156
|
5142, 5679
|
2977, 3930
|
2367, 2448
|
5908, 5908
|
5941, 7718
|
10496, 10948
|
248, 280
|
9007, 10069
|
367, 2262
|
3965, 4767
|
11953, 12028
|
5762, 5871
|
12064, 12176
|
4783, 5126
|
2479, 2586
|
10085, 10475
|
2284, 2346
|
2602, 2804
|
5711, 5726
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,280
| 103,060
|
45650
|
Discharge summary
|
report
|
Admission Date: [**2150-8-29**] Discharge Date: [**2150-9-2**]
Date of Birth: [**2077-9-5**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 15519**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 year old male with h/o type 2 diabetes mellitus who presented
with hyperglycemia, hypertension and seizure. Up until one day
prior to admission, he had been feeling well, then on the day of
admission he noted that his right hand was shaking. That night
he had lethargy, no focal symptoms, just not feeling well and
ate dinner with his wife. [**Name (NI) **] then went to bed. His wife checked
on him at about 21:30 and found him in tonic-clonic seizure.
He was brought to the ED by EMS his VS on arrival were 98.9,
130, 192/122, 17 96%NRB. Got head CT and had another seizure on
the way back from CT. Glucose was critically high. He was
given 2mg ativan, 10 units IV insulin, decadron, ceftriaxone,
and vancomycin. LP was done. He was also given 2.5 liters of
normal saline. Neuro saw him and felt his seizures were most
likely secondary to hyperglycemia, but checked LP and there was
no evidence of infection. LFTs normal. Pt. was noted to be
"post-ictal" in the ED, not responding to commands.
On the floor, he is following commands, but still lethargic and
delerious.
Past Medical History:
- Diabetes mellitus type II, dx'ed 15-20 years ago, followed at
[**Last Name (un) **]
- Chronic renal insufficiency, Cr baseline 1.8-2.2
- Hypertension, patient states BPs in 130s/70s
- Colon cancer, s/p resection
- Gout (proven with joint fluid analysis)
- Cataracts
- Secondary hyperparathyroidism
- Cholelithiasis
- Mild Diastolic Dysfunction
Social History:
Originally from [**Country 2045**], the patient has lived in [**Location 86**] for 40+
years. He retired as a CPA, and lives at home with his wife. His
children are grown. He manages his ADLS. He used tobacco for 5
years many years ago, occasional social alcohol, no IVDU.
Family History:
Family hx of hypertension. Pt denies family hx of CAD, stroke,
cancer.
Physical Exam:
Vitals- BP: 198/108 P: 108 R: 16 100% RA
Gen- AOx 2 says that year is [**2076**], well appearing, well
nourished, NAD
HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No
tongue lesions noted.
Neck: supple, JVP not elevated
Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial,
DP/PT pulses
Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no
supraclavicular or subcostal retractions
Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding,
no organomegaly, negative [**Doctor Last Name 515**] sign
Skin- no rashes, lesions
Extremities/Spine: extremities warm and well perfused, no
clubbing, cyanosis, trace lower extremity edema
Neurologic: no focal deficits, CN II-XII intact, moving all 4
extremities independently, but only intermittently following
commands.
Pertinent Results:
LABORATORY DATA:
[**2150-8-28**] 11:10PM WBC-6.7 RBC-4.20* HGB-11.4* HCT-36.4* MCV-87
MCH-27.2 MCHC-31.4 RDW-16.7*
[**2150-8-28**] 11:10PM PLT COUNT-137*
[**2150-8-28**] 11:10PM GLUCOSE-663* UREA N-37* CREAT-2.8*
[**2150-8-28**] 11:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-8-28**] 11:10PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-133* TOT
BILI-0.2
[**2150-8-28**] 11:10PM LIPASE-37
[**2150-8-28**] 11:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-8-29**] 03:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1*
POLYS-17 LYMPHS-33 MONOS-50
[**2150-8-29**] 03:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-276
CSF:
GRAM STAIN (Final [**2150-8-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2150-9-1**]): NO GROWTH.
IMAGING:
[**2150-8-28**] CT head: No acute hemmorhage. MRI is more senitive for
acute ishemia.
[**2150-8-29**] CXR: Mild volume overload
EEG: This is a mildly abnormal extended routine EEG due to low
voltage of the background rhythm with diffuse beta activity.
There were
no focal, lateralized, or epileptiform features noted.
EKG: Sinus tachycardia, rate 127. There are slight non-specific
ST-T wave changes in leads I, II, aVF and leads V4-V6. Consider
left atrial abnormality. Compared to the previous tracing of
[**2149-3-22**], except for the change in rate, no other diagnostic
interval change.
MRI/MRA Brain:
1. Motion-limited head MRI and MRA.
2. No acute infarction. New chronic microvascular infarcts since
[**2142**].
3. Unremarkable head MRA.
Brief Hospital Course:
72 year old male with history of type 2 diabetes mellitus who
presented with hyperglycemia, hypernatremia, hypertension and
seizures. He was originally admitted to the MICU and once
stabilized, was transferred to the floor.
# Seizures: He presented with two seizures in the setting of
severe hyperglycemia. He had a lumbar puncture and his CSF did
not suggest meningitis or encephalitis. His tox screen was
negative. His seizures could also have been secondary to
hyperosmolality due to both hyperglycemia and hypernatremia. He
had altered mental status after his seizures which cleared prior
to discharge. He had an MRI with no acute changes (although it
did show chronic microvascular infarcts). He also had an EEG
that showed no epileptiform activity. Neurology followed the
patient while he was in the hospital, and recommended to start
dilantin if he were to have another seizure in the future. The
patient was advised not to drive for 6 months. He is scheduled
for outpatient follow-up in epilepsy clinic.
# Hyperglycemia: On admission, his blood sugars were so high
they could not be measured. He was initially on an insulin drip
and then rapidly switched to NPH and sliding scale insulin. His
blood sugars remained slightly labile during the rest of his
admission, and he was transitioned back to his home regimen. It
is not clear what incited this hyperglycemic episode, as he
reports no history of medication or diet changes, recent
insomnia, or recent illness. On discharge, he was instructed to
keep a blood sugar diary and check his blood sugars at least
three times daily.
# Hypertension: Upon arrival to the ICU, he had hypertension
with systolic blood pressures in the 190-200's. Quickly after
admission, his hypertension resolved and he was restarted on his
home medications. He had one episode of relative hypotension
with BP of 100/60 after receiving his morning medications.
Therefore, his clonidine was switched to an evening medication.
He was continued on minoxidil, valsartan, and metoprolol at his
home dosing regimens.
#. Hypernatremia: He was hypernatremic on admission and for a
2-3 days after admission with a serum Na of 145-147. This was
likely caused by osmotic diuresis from his hyperglycemia. Also
there was likely some contribution by impaired access to free
water with change in mental status. Seizures can also cause
intracelluluar osmole generation and transient hypernatremia.
Free water intake was encouraged and his sodium level returned
to normal range by the time of discharge.
#. Diastolic CHF: He has a history of diastolic heart failure
but was thought to be volume depleted on admission. His
torsemide was held throughout the hospitalization and at
discharge.
#. Chronic renal insufficiency: He has a baseline creatinine of
about 2.1 (although fluctuates substantially) and his creatinine
was elevated on admission to 2.8. His urine electrolytes were
consistent with a prerenal etiology and his creatinine came back
to baseline with rehydration.
#. Gout: His allopurinol was initially held due to concern for
worsening renal failure, but he was started back on his home
dose at discharge.
#. Prophylaxis: He was given subcutaneous heparin for DVT
prophylaxis
#. Code Status: He was full code during this hospitalization
Medications on Admission:
-Allopurinol 300 mg once a day on Mon, Wed, Fri and 200mg qd
on other days
-Clonidine 0.3 mg Tablet 1 Tablet(s) by mouth once a day
-Insulin Glargine 9 units at bedtime
-Insulin Lispro
-Metoprolol Tartrate 50 mg Tablet 1 Tablet(s) by mouth twice a
day
-Minoxidil 10 mg Tablet 1 Tablet(s) by mouth twice a day
-Paricalcitol 4 mcg Capsule 1 Capsule(s) once a day
-Simvastatin 20 mg Tablet once a day \
-Torsemide [Demadex] 20 mg Tablet once a day
-Valsartan 160 mg Tablet q day
-Ascorbic Acid 500 mg Tablet once a day
-Aspirin 81 mg Tablet, once a day (OTC)
-Multivitamin with Iron-Mineral once a day
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO once a
day: Take 300mg daily on Monday, Wednesday, and Friday.
2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 200mg daily on Tuesday, Thursday, Saturday, and Sunday.
3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO at bedtime.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Insulin Glargine 100 unit/mL Solution Sig: 9 (nine) units
Subcutaneous at bedtime.
6. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous three times a day: Please take insulin per sliding
scale as you were doing prior to hospitalization.
7. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Zemplar 4 mcg Capsule Sig: One (1) Capsule PO once a day.
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Multivitamin with Iron-Mineral Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Seizures
Hypertension
Diabetes Mellitus
Secondary Diagnosis:
Chronic diastolic heart failure
Discharge Condition:
Good, vital signs stable, ambulating independently
Discharge Instructions:
You were admitted to the hospital with seizures. Your sugar was
found to be very high, which may have contributed to your
seizure. You were evaluated by neurology, and you underwent an
MRI/MRA to evaluate for any acute pathology. You were found to
have very tiny strokes which can be a complication of renal
disease and diabetes. You will follow up with the neurologists
in their clinic.
Weigh yourself every morning, call Dr. [**First Name (STitle) **] if your weight is
increased by 3 lbs or more.
Changes to your medications:
STOPPED torsemide temporarily. If you experience swelling in
your legs, you should restart this medication at your home dose
(20 mg Tablet once a day by mouth)
CHANGE clonidine from 0.3mg by mouth every morning to 0.3mg by
mouth every evening. Start taking this dose on [**2150-9-3**].
You should also check your blood sugars three times per day and
use insulin as you were at home before you were admitted to the
hospital. You should write your blood sugars in a diary and
bring it with you to your follow-up appointment with Dr. [**First Name (STitle) **].
If you find that your blood sugars are higher than normal, you
should call Dr. [**First Name (STitle) **]. If you experience any shaking,
increasing thirst, or increased urination, you should check your
blood sugar. You should also call your primary care doctor. If
you experience any chest pain, shortness of breath, or seizures,
you should call 911 and go to the nearest hospital
You should NOT DRIVE for at least 6 months since you've had a
seizure.
Followup Instructions:
You have the following appointments scheduled:
Primary care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 250**] Date/Time:
[**2150-9-9**] 9:50
Neurology:
Provider: [**First Name11 (Name Pattern1) 3292**] [**Last Name (NamePattern1) 3293**], MD Phone:[**Telephone/Fax (1) 44**]
KS [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), 4TH
FLOORDate/Time:[**2150-9-16**] 1:00
|
[
"585.9",
"584.9",
"345.90",
"428.32",
"403.90",
"588.81",
"366.9",
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"274.9",
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"V10.05"
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icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9760, 9766
|
4636, 7934
|
277, 284
|
9923, 9976
|
2973, 3876
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,664
| 155,219
|
48168
|
Discharge summary
|
report
|
Admission Date: [**2124-8-21**] Discharge Date: [**2124-8-25**]
Date of Birth: [**2051-6-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Cat Hair Std Extract / Codeine / Egg / Ragweed
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2124-8-21**] [**First Name8 (NamePattern2) 17009**] [**Male First Name (un) 923**] tissue MVR/ septal myomectomy
History of Present Illness:
72 year old female with history of
hypertrophic cardiomyopathy with resting LVOT obstruction who
has
had worsening of her baseline dyspnea over the past three four
days. She also presents because she felt somewhat presyncopal at
home. Of note, she was recently seen in the ED with dyspnea on
[**2124-5-4**]; at that time she was seen by the electrophysiology
service, who felt that she was in sinus rhythm with 2:1 AV block
at a rate of 50. Her PR interval at that time was 400
milliseconds, with a normal QRS, and her conduction improved to
3:2 Wenckebach with exercise. She was told to cease her
Atenolol,
and had only recently been instructed to take it again tonight
at
lower dose of 25 mg (from 75 mg), which she did. She has had she
says six episodes over the past two years of dyspnea that were
worse than the current episode. Typically, she notices the
worsened dyspnea when she is climbing stairs and typically has a
heaviness in her chest, which is not present during the current
episode. A TEE was done and he was found to have 3+ mitral
regurgitation and is now being referred to cardiac surgery for
mitral valve replacement.
Past Medical History:
Mitral Regurgitation
PMH:
1. Hypertrophic cardiomyopathy
2. HTN
3. Hypercholesterolemia
4. Diastolic Dysfunction
5. 2:1 heart block
6. Chronic Fatigue Syndrome with possible immune suppression
7. Hx of remote C-Diff
8. Colon CA s/p left hemicolectomy
9. Endometrial CA s/p hysterectomy salpingo bilateral
oophorectomy
10.Basal Cell CA
[**23**].Anxiety
12.Asthma- not on inhalers
13.Cataracts
14.Macular Degeneration
15.PNA- [**5-18**]
16.Brief Afib during recent hospitalization
17.Severe Nose Bleeds s/p cauterization - last 2 weeks ago,
still
mild bleeding
Social History:
Lives with:Alone
Contact:[**Name (NI) 2048**] [**Name (NI) **] (sister) Phone# [**Telephone/Fax (1) 101542**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**3-14**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:61 Resp:20 O2 sat:96/RA
B/P Right:117/57 Left:111/34
Height:61" Weight:100.1 kgs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] SEM grade IV/VI
Abdomen: Obese, Soft [x] non-distended [x] non-tender [x]. Has
midline scar from prior laparotomies and a reducible ventral
hernia.
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2124-8-21**] Intra-op TEE
Conclusions
Pre Bypass: The left atrium is moderately dilated and elongated.
No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage.
There is mild symmetric left ventricular hypertrophy. There is
asymmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. Regional left
ventricular wall motion is normal. There is a severe resting
left ventricular outflow tract obstruction. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal, but leaflet excursion
is limited,possibly due to turbulent flow in LVOT. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with trivial mitral stenosis. 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).
Post Bypass: Patient is AV paced on phenylepherine infusion. A
tissue valve (#25 St. [**Male First Name (un) 923**] per surgeons) is seen in the mitral
position. The new valve appears well seated without perivalvular
leaks and good leaflet motion on 2D and 3D exam. Peak mitral
gradient 8mm Hg, Mean 5 mm Hg. The LVOT has less turbulent flow
with gradients of 4 mm Hg peak and 2 mm Hg mean. The Aortic
valve gradients are peak [**10-19**] and mean 5 mm Hg. Aortic contours
intact. LVEF >55%. Remaining exam is unchanged, all findings
discussed with surgeons at the time of the exam.
.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2124-8-21**] where
she underwent a mitral valve replacement, septal myomectomy.
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 has a history of atrial fibrillation
but was not on coumadin prior to surgery due to hypersentivity
to coumadin per patient and history of epitaxis. She was started
on coumadin 3mg once post-operatively and after one dose of
coumadin her INR increased from normal to 6.8. It decreased to
1.6 with vitamin K. Her cardiologist Dr.[**Name (NI) 3733**] was
contact[**Name (NI) **] and it was decided that coumadin would be discontinued
due to her sensitivity to coumadin and history of epitaxis
requiring cauterization, heavy menstruation, and prolonged
bleeding from trauma. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on post-operative day four the patient
continued to be deconditioned, required frequent reminders to
maintain sternal precautions and rehab was recommended. The
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Location (un) 169**] in [**Location (un) 55**] in
good condition with appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO HS
3. Atenolol 25 mg PO DAILY
4. Amitriptyline 10 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO HS
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 650 mg PO Q4H:PRN fever, pain
6. Bisacodyl 10 mg PR DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider [**Name Initial (PRE) **] [**Name10 (NameIs) 4169**]
with HO before giving
9. Milk of Magnesia 30 ml PO HS:PRN constipation
10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four hours Disp
#*40 Tablet Refills:*0
11. Furosemide 40 mg PO BID Duration: 10 Days
Please titrate per clinical exam
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
Mitral Regurgitation
PMH:
1. Hypertrophic cardiomyopathy
2. HTN
3. Hypercholesterolemia
4. Diastolic Dysfunction
5. 2:1 heart block
6. Chronic Fatigue Syndrome with possible immune suppression
7. Hx of remote C-Diff
8. Colon CA s/p left hemicolectomy
9. Endometrial CA s/p hysterectomy salpingo bilateral
oophorectomy
10.Basal Cell CA
[**23**].Anxiety
12.Asthma- not on inhalers
13.Cataracts
14.Macular Degeneration
15.PNA- [**5-18**]
16.Brief Afib during recent hospitalization
17.Severe Nose Bleeds s/p cauterization - last 2 weeks ago,
still
mild bleeding
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema:1+LE
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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2124-10-11**] at 1:15PM
Cardiologist Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2124-9-26**] 1:00
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 719**] in [**5-11**] 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:[**2124-8-25**]
|
[
"272.0",
"425.11",
"493.90",
"428.32",
"402.91",
"V10.42",
"362.50",
"428.0",
"424.0",
"553.21",
"V10.05",
"429.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"39.61",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
7883, 7975
|
5064, 6865
|
333, 451
|
8578, 8745
|
3404, 5041
|
9617, 10326
|
2517, 2632
|
7193, 7860
|
7996, 8557
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6891, 7170
|
8769, 9594
|
2647, 3385
|
273, 295
|
479, 1619
|
1641, 2202
|
2218, 2501
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,709
| 169,409
|
49904
|
Discharge summary
|
report
|
Admission Date: [**2144-12-3**] Discharge Date: [**2144-12-9**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 y/o male with history of dementia, recent admissions to ED
for aggressive behavior/assault, type 2 diabetes, multiple CVA
with ? vascular dementia, and coronary artery disease, who was
found to be unresponsive to painful stimuli on routine night
time check at his facility ([**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **]). Patient recently
returned to [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **] after a ten day admission in the psych
[**Hospital1 **] of [**Hospital 68117**] Hospital for belligerence and aggressive
behavior. EMS found patient with sat of 80% on RA with
fingerstick that was unmeasureable (>500). Of note, gets
klonopin for sleep. A temperature of 102 was measured at the
facility today. Of note, patient is on prednisone 5 MG daily for
unknown reason.
Initial VS in the ED - not provided. Patient was hypotensive,
with sbps in the 90s and was given dexamethosone 10mg/ml, 1L
IVF, 10 units of regular insulin and vanc and zosyn. He was
placed on an NRB satting in the 90s.
.
Exam notable for unresponsiveness, that did not resolve with ED
managment. Patient was however protecting his airway, thus was
not intubated. Labs were notable for WBC 14.9, Hct 52.3, plt
225, INR 1.3, fibrinogen 816, glucose 676, Na 154, Hco3 17, AG
21, Cr 3.0, lactate 8.3, Stox negative. U/A not possible given
urethral meatus adhesion. EKG showing Sinus Tachycardia w/
non-specific ST changes in the anterolateral leads.
Imaging notable for head CT showing subacute vs chronic changes
to left parietal lobe. Overall, read as "Confluent
hypoattenuation in the left parietal region. Superiorly it
appears to spare the [**Doctor Last Name 352**] matter - suggesting vasogenic edema,
though inferiorly involves both [**Doctor Last Name 352**] and white matter. Unlikely
acute infarct given the time course of symptoms and extensive
abnormality on CT. Encephalomalacia in the superior-posterior
right frontal lobe. No hemorrhage. Cortical atrophy. Small
vessel ischemic changes."
CT torso was read as "bibasilar opacities, left > right, most
consistent with dependent atelectasis. No confluent
consolidation with air bronchograms. No pleural effusions. No
acute intrabdominal pathology. Sigmoid diverticulosis though no
acute diverticulitis." Overall concerning for LLL PNA vs
atelectasis.
.
Neurology was consulted who felt that imaging results were
likely chronic, did not recommend an LP, and recommended
admission to MICU.
Vitals on transfer were HR 87 BP 100/42 RR 20 Satting 94% on 4L.
On arrival to the MICU, the patient was vitally stable and had
two peripherals for access.
Review of systems: unable to obtain given patient
unresponsiveness.
Past Medical History:
DM type 2
CKD w/ baseline Cr of 1.5
Rhuematoid Arthritis
Multiple CVA with progressive memory loss has residual left
facial paresis and word finding difficulty.
[**4-23**]-mri head, no new changes
CAD - Cath in [**2130**] single vessel dz with 100% occluded RCA; 30%
LM; 30-40% LAD. Patient had recent stress test in [**5-20**] -
Ischemic ST segment changes in absence of anginal symptoms.
Moderate to severe predominately reversible perfusion defect @
junction of the basilar and remainder of inf. wall. LVEF = 60%
HTN
Hyperlipidemia
Blind in L eye - retinal vascular occlusion
BPH
vascular dementia
colonic polyps
Social History:
He lives in [**Location 1188**] house. He is a retired autoparts salesman.
He does not drink. He quit smoking 10 years ago, greater than 50
year pack year. No illicits. He is completely dependent in ADL.
Family History:
Unable to obtain.
Physical Exam:
Admission:
Vitals: HR 90 BP 131/56 RR 20 91%
General: patient unresponsive to painful stimuli, name calling
HEENT: Sclera anicteric, MMM, oropharynx dry, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bilateral ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: cold feet, hematoma on left arm, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: patient unresponsive to painful stimuli.
Discharge:
Vitals: Tm 100.5 132/64 70 20 96% 1L
General: sleeping comfortably
HEENT: Sclera anicteric, dry MM, unable to eval OP as wont open
mouth
Neck: JVP not elevated
CV: RR, nl rate, no murmurs, rubs, gallops appreciated
Lungs: CTAB - anterior exam
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm ext, ecchymosis on left hand improved from prior, 2+
pulse, right hand with edema 2+ pulses, trace edema on ext
Neuro: unable to assess
Pertinent Results:
[**2144-12-8**] 05:24AM BLOOD WBC-5.7 RBC-3.19* Hgb-10.2* Hct-29.7*
MCV-93 MCH-32.1* MCHC-34.4 RDW-14.4 Plt Ct-142*
[**2144-12-6**] 04:16AM BLOOD Neuts-81.5* Lymphs-12.0* Monos-3.8
Eos-2.6 Baso-0.1
[**2144-12-6**] 04:16AM BLOOD PT-14.2* INR(PT)-1.2*
[**2144-12-8**] 05:24AM BLOOD Glucose-190* UreaN-12 Creat-1.3* Na-138
K-3.6 Cl-110* HCO3-21* AnGap-11
[**2144-12-3**] 02:35AM BLOOD ALT-26 AST-25 CK(CPK)-55 AlkPhos-93
TotBili-0.4
[**2144-12-8**] 05:24AM BLOOD Calcium-6.9* Phos-1.9* Mg-1.7
[**2144-12-3**] 02:35AM BLOOD %HbA1c-9.0* eAG-212*
[**2144-12-3**] 05:55AM BLOOD TSH-1.3
[**2144-12-3**] 05:55AM BLOOD Cortsol-42.0*
[**2144-12-3**] 02:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-12-4**] 03:34PM BLOOD Lactate-2.2*
CT Torso: 1. Bibasilar consolidations, left slightly greater
than right, findings most consistent with dependent atelectasis.
No pleural effusions.
2. Dense vascular calcifications involving the thoracic and
abdominal aorta
and coronary vasculature. 3. Nonobstructing punctate calculus in
the right kidney. 4. Sigmoid diverticulosis without evidence of
acute diverticulitis. 5. Enlarged prostate gland.
CT head: No acute intracranial hemorrhage or mass effect. Prior
infarcts, as above.
CXR [**2144-12-8**]: Increasing opacity in the left hemithorax is
concerning for an evolving infectious process.
Brief Hospital Course:
Goals of care: The patient was felt by his family to have poor
quality of life that had been ongoing since prior to admission.
A family meeting was had with the health care proxy present. At
that time it was decided to focus on comfort measures only. He
was allowed to eat food. The antibiotics and IVF were
discontinued. He will be discharged with hospice care to
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. He will likely not eat much and sleep multiple
times per day.
Hypotension: The patient was admitted with an elevated lactate
and hypotension. He received 2L of crystalloid in the ED. The
etiology of the hypotension and lactate is most likely
hypovolemia based on clinical signs. There was no intial focus
of infection but was given vancomycin and zosyn empirically and
continued while on the floor. After fluid resusitation the
patient was hemodynamically stable and his lacate downtrended to
normal.
Hypernatremia: Patient had significant hypernatremia on
admission most likely representing severe hypovolemia. After
intial fluid resuscitation with crystalloid he was started on
D5W drip to slowly decrease his serum sodium. At the time of his
transfer his serum sodium had returned to a normal level.
Hyperglycemia: Patient admitted with hyperglycemia around 700.
No evidence of DKA. Patient was given insulin bolus and started
on insulin drip. He was continued until his serum glucose
improved to less than <200. After day one patient was
transitioned to sliding scale insulin. Patient was kept on D5W
for fluids and glucose as he was unable to tolerate any PO
intake secondary to mental status. On discharge the sliding
scale was discontinued and glargine 15u qhs maintained for
comfort.
Altered mental status: Patient has history of vascular dementia
and is aggressive at baseline. Upon admission to the ICU patient
was responsive only to painful stimuli. There was no focal
neurological deficit. CT of the head in the ED did not show any
acute pathology. Lumbar puncture was WNL. His mental status
changes were most likely secondary to his metabolic
abnormalities. His mental status improved mildly after
resolution of his metabolic abnormalities. He improved on the
floor but remained AOx0. He was not aggressive but slept through
much of the day.
Acute renal failure: Patient had evidence of acute kidney
injury. Etiology is most likely his severe hypovolemia. After
fluid resuscitation the patient's kidney function improved
significantly. He had adequate urine output throughout his stay.
The patient had a difficult foley placed by urology.
Transitional issues:
- [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with Hospice Care
Medications on Admission:
Simvastatin 40mg PO daily
cholecalciferol 800 unit PO daily
prednisone 5 mg PO daily
methotrexate sodium 2.5 mg PO qwed
lisinopril 5 mg PO daily
glipizide 5 mg PO daily
folic acid 1 mg PO daily
atenolol 12.5mg PO daily
heparin (porcine) 5,000 unit/mL SC TID
aspirin 325 mg PO daily
depakote 750 PO HS
quetiapine 25 PO HS
quetiapine 12.5 mg PO Q6H PRN agitation
Discharge Medications:
1. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO daily prn as
needed for constipation: Can be administered PO or PR.
2. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for fever or pain: can be given PO or PR.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Pneumonia
Dementia
Dehydration
Hyperglycemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr [**Known lastname 1645**],
You were admitted with altered mental status. You had elevated
blood sugar, dehydration and fevers. You were started on broad
spectrum antibiotics, given insulin and IV fluids. You mental
status improved, however, you were still having fevers and were
not able to eat food.
After extensive discussion with your family/health care proxy it
was decided to focus our efforts on comfort. You were allowed to
eat and your antibiotics were discontinued. You were sent to
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with hospice care.
You were discharged on medications focusing on your comfort
only. Any other medications needed will be determined by the
hospice team at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Followup Instructions:
Hospice care at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
|
[
"995.92",
"438.83",
"275.41",
"V85.0",
"349.82",
"584.5",
"403.90",
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icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9848, 9970
|
6313, 8053
|
268, 275
|
10059, 10059
|
4921, 6090
|
11019, 11108
|
3881, 3900
|
9430, 9825
|
9991, 10038
|
9045, 9407
|
10195, 10996
|
3915, 4902
|
8928, 9019
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2954, 3004
|
212, 230
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303, 2935
|
6099, 6290
|
10074, 10171
|
3026, 3643
|
3659, 3865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,158
| 165,330
|
41764
|
Discharge summary
|
report
|
Admission Date: [**2152-12-17**] Discharge Date: [**2152-12-29**]
Service: MEDICINE
Allergies:
ciprofloxacin
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
Mental status changes and RUQ pain
Major Surgical or Invasive Procedure:
[**2152-12-18**] [**Month/Day/Year **]
[**2152-12-22**] Percutaneous drainage of liver abscess
[**2152-12-28**] PICC
History of Present Illness:
This is an 87 yom with a complicated recent course including a
laparoscopic converted to open cholecystectomy at [**Hospital 8**]
Hospital in [**8-/2152**] , which was complicated by a bile leak and
post-cholecystectomy stricturing. Since then, he has required
six to seven ERCPs due to issues with biliary blockages and
strictures and has had numerous stents placed. He has also had
klebsiella bacteremia in 11/[**2151**]. He was subsequently admitted
from [**2152-11-24**] through [**2152-12-2**] for evaluation of elevated
LFTs and underwent a CT scan which was concerning for pancreatic
mass with EUS/biopsies confirming 2.7 x 2.2 cm ill-defined mass
consistent with pancreatic adenocarcinoma with metastases.
.
He had a recent admission from [**Date range (1) 90717**] for nausea/vomitting
which improved with antiemtics and hydration. This
hospitalization was also complicated by [**Last Name (un) **] and hyperK+ which
stabilized on discharge.
.
The patient presented this admission with AMS, poor appetite,
and leukocytosis. LFTs were also elevated beyond recent baseline
but [**Female First Name (un) 7925**]/AP normal. Per son's report on admission to floor, pt
was feeling better at time of discharge, but developed increased
nausea and poor PO intake after recent discharge, as well as
cough x 3 days (initially dry, now becoming productive). He has
also been weaker than normal in that at baseline he is able to
do is ADLs independently but now his son has had to hold him up
to walk. No fevers at home.
Past Medical History:
Oncologic History:
Mr. [**Known lastname 90716**] initially had a cholecystectomy on [**8-13**]. At
the time of this procedure, it turned into an open
cholecystectomy and since that time he has had discomfort at the
surgical site. Following this, he has required six to seven
ERCPs due to issues with biliary blockages and strictures and
has
had numerous stents placed. He was admitted from [**2152-11-24**]
through [**2152-12-2**] for evaluation of elevated LFTs and during
that time had an [**Year (4 digits) **] and underwent a CT scan on [**2152-11-30**] that
showed a concerning pancreatic mass. Based upon that, he went
on
to undergo an EUS on [**2152-12-1**] that noted a 2.7 x 2.2 cm
ill-defined mass in the body/tail of the pancreas. FNA was
performed at that time.
.
Other Past Medical History:
- Diabetes mellitus, type II, with recent episodes of
hypoglycemia, on insulin
- Hypertension
- Hyperlipidemia
- Coronary artery disease (off aspirin in recent months for
serial procedures)
- Complete heart-block s/p pacemaker
- Chronic pancreatitis
- S/p cholecystectomy [**8-/2152**]
- Post-herpetic neuralgia
- Pulmonary nodules [**5-/2152**]
- Arthritis
- s/p Cataract surgery
Social History:
He is originally from [**Country 63412**] and moved to the United States in
[**2140**]. He is retired, but was involved in USAID when living in
[**Country 63412**]. He currently lives with his wife, son, daughter and his
son's wife. [**Name (NI) **] stopped drinking and smoking approximately 40
years ago, but his son notes that he was a
relatively heavy drinker previously.
.
Family History:
[**Hospital 6961**] medical history unknown.
Physical Exam:
PHYSICAL EXAM:
1. VS T 97 P 110 BP 129/80 RR 24 O2Sat on _95% on 2L liters O2
BS = 473 and 474
GENERAL: Thin elderly male laying in bed. His mental status
waxes and wanes. He is able to speak English at times.
Nourishment: at risk
Grooming: good
Mentation
2. Eyes: [] WNL
PERRL- pupils are sluggish and do not clearly react but he is
recently post cataract surgery, EOMI without nystagmus,
Conjunctiva: clear/injection/exudates/icteric
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[] Regular [X] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[] Edema RLE 2+ [] Bruit(s), Location:
[] Edema LLE 2+ [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
[x] Soft/firm [] Rebound [] No hepatomegaly [] Non-tender [x]
Tender [] No splenomegaly [X] 2cm masses appreciated at site of
CCY.
[] Non distended [x] distended [X] bowel sounds Yes/No []
guiac: brown stool
Large amt of soft stool in the vault. Pt was manually
disempacted.
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [ ]Upper extremity strength 5/5 and symmetrical [
]Other:
[ ] Bulk WNL [] Lower extremity strength 5/5 and symmetrica [
] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[ ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ X] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[X] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer: None
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic [X] delirious
[] Combative
11. Genitourinary [X] WNL
[ ] Catheter present [] Normal genitalia [ ] Other:
TRACH: []present [X]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Pertinent Results:
Admission CXR:
R pleural effusion. Bibasilar streaky opacities reflecting areas
of atelectasis.
.
Admission EKG:Sinus tachycardia at 108 bpm. LBBB, no acute
changes.
.
[**2152-12-17**] 09:15PM GLUCOSE-363* UREA N-50* CREAT-1.3*
SODIUM-129* POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-25 ANION
GAP-15
[**2152-12-17**] 09:15PM estGFR-Using this
[**2152-12-17**] 09:15PM ALT(SGPT)-38 AST(SGOT)-42* ALK PHOS-336* TOT
BILI-0.4
[**2152-12-17**] 09:15PM LIPASE-6
[**2152-12-17**] 09:15PM WBC-14.4*# RBC-2.88* HGB-8.7* HCT-25.8*
MCV-89 MCH-30.1 MCHC-33.7 RDW-13.9
[**2152-12-17**] 09:15PM NEUTS-84.1* LYMPHS-11.3* MONOS-4.5 EOS-0.1
BASOS-0.2
[**2152-12-17**] 09:15PM PLT COUNT-273
[**2152-12-17**] 09:15PM PT-12.0 PTT-26.2 INR(PT)-1.1
.
[**2152-12-17**] 11:19 pm BLOOD CULTURE #2.
**FINAL REPORT [**2152-12-21**]**
Blood Culture, Routine (Final [**2152-12-21**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed by
KirbyBauer. Cefazolin interpretative criteria are based on a
dosage regimen of 2g every 8h.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of
gentamicin. Screen predicts possible synergy with selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of
streptomycin. Screen predicts possible synergy with selected
penicillins or vancomycin. Consult ID for details.. Daptomycin
= 0.064 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- 4 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2152-12-18**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by DR. [**Last Name (STitle) **] [**2152-12-18**] 14:10.
Aerobic Bottle Gram Stain (Final [**2152-12-18**]): GRAM NEGATIVE
ROD(S).
.
[**2152-12-20**] 3:14 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2152-12-26**]**
Blood Culture, Routine (Final [**2152-12-26**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin Sensitivity testing performed by Etest. Daptomycin 3
MCG/ML.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of
gentamicin. Screen predicts possible synergy with selected
penicillins or vancomycin. Consult ID for details. HIGH LEVEL
STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin.
Screen predicts possible synergy with selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2152-12-21**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
[**2152-12-22**] 3:13 pm
FLUID,OTHER LIVER BILOMA/ABSCESS.
GRAM STAIN (Final [**2152-12-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
PAIR AND SHORT CHAINS.
FLUID CULTURE (Preliminary):
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..
WORK UP REQUESTED BY DR. [**Last Name (STitle) 4091**] [**2152-12-25**].
DR. [**Last Name (STitle) 4091**] ([**Numeric Identifier **] REQUESTED ERTAPENEM SENSITIVITIES [**2152-12-28**]
ON ALL GRAM
NEGATIVE RODS.
ENTEROCOCCUS SP.. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h Piperacillin/tazobactam sensitivity testing
available
on request.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| KLEBSIELLA PNEUMONIAE
| | ENTEROBACTER
CLOACAE
| | |
PSEUDOMONAS au
| | | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S 4 S
CEFTAZIDIME----------- <=1 S <=1 S 16 I
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- <=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
LINEZOLID------------- 2 S
MEROPENEM------------- <=0.25 S <=0.25 S 1 S
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2152-12-26**]): NO ANAEROBES ISOLATED.
.
CXR [**2152-12-17**]:Bibasilar streaky opacities likely reflecting areas
of
atelectasis. Small right pleural effusion.
.
CT torso [**2152-12-21**] w/o contrast:[**2152-12-21**]:
1. No evidence of hemorrhage in the chest, abdomen or pelvis.
2. Three nonhemorrhagic fluid collections in the left hepatic
lobe,
concerning for bilomas/abscesses, new from [**2152-11-30**].
3. Stable pancreatic tail mass. Unchanged mesenteric soft tissue
density, likely representing a tumor deposit, and left adrenal
nodule.
4. Multiple bilateral pulmonary nodules, unchanged from [**Month (only) **]
[**2151**]. Small amount of secretions within the distal trachea.
5. Moderate right pleural effusion and small left pleural
effusion, increased from [**2152-11-30**].
6. Moderate nonhemorrhagic intra-abdominal ascites. Diffuse body
wall edema.
.
[**2152-12-24**]: US LUE IMPRESSION: No evidence of deep venous
thrombosis in the left upper extremity.
Brief Hospital Course:
87 y.o. M with h/o recently diagnosed metatstatic pancreatic
cancer s/p multiple ERCPs and stent placements over past few
months who presented with lethargy and mental status changes.
Found to have G+ cocci and G- rod bactermia.
.
# Cholangitis, bacteremia, and hepatic abscess: Patient
developed elevated LFTS (although t.bili remained normal)and
presented with leukocytosis and mental status changes. Blood
cultures grew both klebsiella and enterococcus (two species
including VRE). Treated with pip/tazo and vancomycin, then
unasyn, then daptomycin & Ceftriaxone as sensitivities of
bacteria became available. On [**2151-12-19**] pt underwent an [**Date Range **] and
during the procedure two plastic stent removed. Pus and sludge
were noted at stent removal. Metal stents were placed. During
the procedure patient began vomiting and required intubation for
airway protection. Patient was transferred to the [**Hospital Unit Name 153**] and
extubated on [**12-19**] without difficulty and returned to floor.
Subsequent imaging revealed hepatic abscesses for which patient
underwent percutaneous external drainage on [**2152-12-22**]. Bile grew
the klebsiella and enterococcus with the same sensitivities as
blood cultures. In addition, bile grew pseudomonas. Patient was
changed to Daptomycin and Cefepime ultimately with PICC placed
on [**2152-12-28**]. HE WILL REQUIRE WEEKLY CK'S CHECKED ON DAPTOMYCIN.
.
# Metastatic pancreatic cancer: Underwent a biopsy of
subcutaneous nodules at site of RUQ surgical sutures which were
thought to be the source of pain as an outpatient. Biopsy
positive for adenocarcinoma. Given poor performance status and
ongoing infectious process he was not a candidate for
chemotherapy and goals of care will be supportive with a
transition to more palliative approach. Dr. [**Last Name (STitle) **] had an
initial discussion with the son and have also with primary
oncologist, Dr [**Last Name (STitle) **]. After further discussions with the
patient's son and HCP on [**2152-12-26**], he was made DNR/DNI but will
continue to treat his infection and support his transfusion
needs. After further discussions with the patient's son and
health care proxy on [**2152-12-28**] the patient will not be transferred
to an intensive care unit but care will be focused on his
symptoms should he become acutely ill.
.
# GI bleeding: Stool became guaiac positive on [**2152-12-21**].
Patient's hematocrit has slowly decreased. He was kept typed and
crossed 2 units PRBCs, but remained stable. Suspect blood loss
is from occult metastatic tumor oozing into GI tract. No role
for colonoscopy at this point given palliative approach and his
debilitation. ASA was discontinued in this setting.
.
# Anemia: Gradual decrease in hct. With g+ stool since [**2152-12-21**].
Hemodynamically stable. During [**Month/Day/Year **] no clear evidence of upper
gI bleed. Transfused 4 units PRBCs total all with appropriate
response. .
.
# Acute renal failure/hyperkalemia: On admission . Likely due to
volume depletion. Resolved with IVF.
.
# UE Edema: Developed in setting of fluid resuscitation, now
resolved. Ultrasound LUE [**2152-12-24**] was negative for DVT. Suspect
edema was due to third spacing and albumen<2.
.
# Chest discomfort & dysphagia: Discomfort was related to
dysphagia and eating. EKG with LBBB. Seen by speech and swallow.
Improved on PPI. Plan to continue PPI [**Hospital1 **], change diet to
liquids and mechanical soft. .
.
# Pain: Abdominal pain at operative site and upper abdomen.
Improved over course of hospitalization. Was on oxycontin on
admission which was held because of MS changes. Changed to
oxycodone 5.0 mg q6hrs and increased prn dose 5-10mg because
patient does not reliably ask for prn pain medication.
.
# Transaminitis: ALT and AST fell after [**Hospital1 **] and stent
replacement but alk phos continues to slowly rise likely due to
disease progression. He is assymptomatic and further work up is
not appropriate at this time, since his biliary obstruction is
stented and he has percutaeous drainage of abscesses.
.
# ARF/hyperkalemia: On admission. Likley due to volume
depletion.
-Resolved with IVF fluids.
.
# Diabetes/hyperglycema: Minimally hyperglycemic. Given the
palliative goals of care, his finger sticks have been decreased
to [**Hospital1 **] and insulin sliding scale has been discontinued.
.
# CAD: Cannot tolerate ASA due to GI bleeding.
.
# Hypertension: Normotensive off meds.
.
FEN: Soft solids, diabetic diet
.
DVT PPx: pneumoboots, g+ stool
.
Precautions for: fall.
.
Lines:PICC
.
CODE: DNR/DNI. No ICU transfer
# TRANSITIONAL ISSUES:
- ongoing GI blood loss requiring periodic transfusion
- rising alk phos, likely progressive pancreatic cancer
- transitioning to a more palliative approach to his care, but
still getting IV antibiotics for bacteremic cholangitis with
hepatic abscess formation requiring biliary drainage. Per
conversations with the son (and health care proxy), the patient
would NOT be transferred to an intensive care unit.
- will require weekly monitoring of CK while on daptomycin
Medications on Admission:
Reviewed with son on admission
amlodipine 10 mg Tablet Tablet(s) by mouth once a day
carvedilol 6.25 mg Tablet Tablet(s) by mouth twice a day
insulin lispro protam & lispro [Humalog Mix 75-25]
100 unit/mL (75-25) Suspension- 12 units AM, 6 units pm NO
LONGER TAKING THIS SINCE [**2152-12-13**]
lactulose 10 gram/15 mL Solution
30ml by mouth three times a day as needed for constipation
lidocaine
5 % (700 mg/patch) Adhesive Patch, Medicated
1 Adhesive(s) DAILY (Daily) PRN
lisinopril 20 mg Tablet
Tablet(s) by mouth once a day D/C'ED
omeprazole 20 mg Capsule, Delayed Release(E.C.) Capsule(s) by
mouth once a day ondansetron 4 mg Tablet, Rapid Dissolve One
Tablet(s) by mouth four times a day as needed for nausea
[**2152-12-10**]
oxycodone [OxyContin]
10 mg Tablet Extended Release 12 hr 1 Tablet(s) by mouth twice a
day [**2152-12-8**]
* OTCs *
aspirin
81 mg Tablet, Chewable
1 Tablet(s) by mouth DAILY (Daily) Has not taken inlast 2 weeks
bisacodyl 10 mg Suppository 1 Suppository(s) rectally at bedtime
as needed for constipation [**2152-12-15**]
docusate sodium 100 mg Capsule
glucosamine sulfate 500 mg Tablet 1 Tablet(s) by mouth daily
(OTC) [**2152-11-24**]
multivitamin Tablet 1 Tablet(s) by mouth daily
omega-3 fatty acids-vitamin E [Fish Oil] Dosage uncertain
8.6 mg Tablet 1 Tablet(s) by mouth twice a day (Prescribed by
Other Provider) [**2152-11-20**]
simethicone 80 mg Tablet, Chewable 1 Tablet(s) by mouth four
times a day as
Discharge Medications:
1. Fingerstick
Glucose [**Hospital1 **] and record, [**Name8 (MD) 138**] MD for values > 250 or < 70
2. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**12-11**] Tablet, Rapid
Dissolves PO every eight (8) hours as needed for nausea.
3. oxycodone 5 mg/5 mL Solution Sig: [**4-19**] ml PO Q4H (every 4
hours) as needed for pain including dysphagia.
4. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for belching and gas.
5. daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 10973**]y (330)
Recon Soln(s) mg Intravenous Q24H (every 24 hours) for 3 weeks:
until [**2153-1-19**].
6. cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln(s) grams
Injection Q12H (every 12 hours) for 3 weeks: until [**2153-1-19**].
7. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for loose stools.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: [**12-11**] Tablet, Chewables PO QID (4 times a day) as needed for
heartburn.
11. Outpatient Lab Work
Draw CBC w/diff, BUN/Cr, LFTs, CK on Mondays and Thursdays
Fax results to:
1. Dr [**Last Name (STitle) **] at ([**Telephone/Fax (1) 11708**]
2. Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
14. oxycodone 5 mg/5 mL Solution Sig: Five (5) ml PO every six
(6) hours.
15. heparin lock flush 10 unit/mL Solution Sig: Two (2) ml
Intravenous Q8H and prn line flush per PICC protocol as needed
for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
Cholangitis
Bacteremia - enterococcus x 2, pseudomonas, klebsiella
Liver abscess
Metastatic pancreatic cancer with subcutaneous nodules,
peritoneal mets, pulmonary mets
Pain
Anemia
GI bleeding
GERD
Liver function abnormalities
Acute renal failure and hyperkalemia
Diabetes
Coronary artery disease - h/o complete heart block, s/p pacer
Hypertension
Hypoalbumenemia
Dependent edema
Pleural Effusions
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with nausea, vomiting, confusion, and an
elevated white blood cell count from a severe infection from
your biliary tract (Liver, pancreas, and gallbladder)that is due
to your pancreatic cancer. You had bacteria in your blood from
the infection and developed a liver abscess. You needed an [**Hospital1 **]
to replace the stent in your liver and a drain placed in your
liver abscess. Your infections are being treated with IV
antibiotics. You will need several weeks of treatment and have
had a PICC line placed so you receive antibiotics as an
outpatient. You have also had problems with bleeding in your
stools that has been treated with blood transfusions. It is
likely that this problem is also from your tumor. Because there
are no treatments for your tumor, we do not recommend further
work up for the bleeding but continued symptom [**Hospital1 **] with
blood transfusions as needed. Your pancreatic cancer has
continued to grow and we expect that it will cause you more
symptoms over time. The cancer is not treatable. For this
reason, you have decided (with your son's help) to be DNR/DNI
and NOT to go to an intensive care unit but focus on your
comfort if you become sicker.
.
The following changes have been made to your medications:
STOP Amlodipine
STOP Carvedilol
STOP Insulin
STOP Lactulose
STOP Lisinopril
STOP Oxycontin
STOP Aspirin
STOP Bisacodyl suppository
STOP Glucosamine and Omega 3
START Daptomycin IV antibiotic once daily for 3 weeks
START Cefepime IV antibiotic twice daily for 3 weeks
START Oxycodone 5 ml every 6 hours as a scheduled dose and [**4-19**]
ml every 4 hours as needed for pain
START Mirilax 17 grams daily as needed for constipation
START Calcium carbonate (TUMS) 1-2 tablets as needed for
heartburn
START Senna [**12-11**] twice daily as needed for constipation
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2153-1-3**] at 3:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 90718**], MD
Specialty: Internal Medicine
Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 70526**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
They can call the number listed above.
.
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2153-2-12**] at 7:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
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"157.8",
"197.0",
"041.04",
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"576.1",
"401.9",
"790.7",
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] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"38.93",
"50.91",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
22147, 22212
|
13680, 18264
|
258, 377
|
22654, 22654
|
6098, 10011
|
24638, 25734
|
3557, 3603
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20266, 22124
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22233, 22633
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|
22791, 24615
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3633, 6079
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184, 220
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405, 1926
|
22669, 22767
|
18287, 18756
|
2758, 3140
|
3156, 3541
|
10046, 13657
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,493
| 198,110
|
43781
|
Discharge summary
|
report
|
Admission Date: [**2206-6-9**] Discharge Date: [**2206-6-12**]
Date of Birth: [**2134-3-14**] Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Syncope, nausea and vomiting
Major Surgical or Invasive Procedure:
The pt arrived after a cardiac catheterization at [**Hospital3 **] with an intraaortic balloon pump and a temporary
transvenous pacing wire. These were removed and no new
procedures or invasive procedures were done at [**Hospital1 18**].
History of Present Illness:
Mr. [**Known lastname 94073**] is 72 yo M with h/o CAD s/p CABG in [**2196**] with 4
vessel disease (LIMA-LAD, SVG-D1-OM1, and SVG-RCA), HTN, HLD,
last echo in [**2199**] with EF of 50%, who presented to an OSH with
syncope x 2, upper abdominal pain, found to have an acute IMI
today.
.
According to wife, pt was found unresponsive at home by wife.
She brought him indoors where he syncopyzed, and the pt's wife
immediately called EMS. Of note, he was diaphoretic and
nauseous at the time, but did not complain of chest pressure.
.
EMS gave him 1L of fluid and on EKG, found ST elevations in the
inferior leads. Initial vitals at the OSH ED were: HR: 59, BP:
159/86, RR: 18, 100% on 4L by NC. The pt was sent to cath but
was unable to be stented with a possible downed vein graft to
the RCA. The pt was started on a heparin drip, a dopamine drip
(running at 5), integrillin was started but D/C'ed after the
patient vomited blood. An AIBP was placed to augment coronary
perfusion and a temporary pacing wire was placed via a femoral
sheath. The patient was transfered to [**Hospital1 18**] for further
management.
.
Upon arrival, the pt is awake and responsive and already has an
aortic balloon pump and trans-venous temporary pacing wire in
place. He was transferred to us for continued management of his
infarct and multiple medical issues. Pt has no complaints
except for gas in his abdomen. Denies any CP, N/V, diaphoresis,
SOB.
.
On review of systems, +hematemesis. 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.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2196**] (LIMA-LAD, SVG-D1-OM1, and SVG-RCA)
-PERCUTANEOUS CORONARY INTERVENTIONS: Cath in [**2203**] with stenting
of the SVG to RCA (x4) for NSTEMI
-PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
-GERD
-BPH
-Hiatal Hernia
Social History:
Non-smoker, occasional alcohol, no drugs
owns barber shop
Family History:
Father and CAD after age of 65, Mother died of MI in late 70s.
7 siblings, many with HLD.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
VS: T- 97.2 HR- 80 BP- 119/63 99% on 2L by NC
GENERAL: WDWN [**Male First Name (un) 4746**] 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 noted.
CARDIAC: Irregularly irregular rate, + S1, S2. No m/r/g
appreciated.
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 abdominal bruits.
EXTREMITIES: lower extremities cold to touch with 1+ pulses. 2+
radials. No clubbing/cyanosis/edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS
[**2206-6-9**] 05:58PM BLOOD WBC-12.8* RBC-4.41* Hgb-13.1* Hct-39.7*
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.5 Plt Ct-263
[**2206-6-9**] 05:58PM BLOOD PT-13.5* PTT-109.5* INR(PT)-1.2*
[**2206-6-9**] 05:58PM BLOOD Plt Ct-263
[**2206-6-9**] 05:58PM BLOOD Glucose-117* UreaN-15 Creat-1.3* Na-140
K-4.0 Cl-105 HCO3-25 AnGap-14
[**2206-6-9**] 05:58PM BLOOD ALT-14 AST-26 LD(LDH)-191 CK(CPK)-178
AlkPhos-58 TotBili-0.4
[**2206-6-9**] 05:58PM BLOOD CK-MB-14* MB Indx-7.9* cTropnT-0.13*
[**2206-6-9**] 05:58PM BLOOD Albumin-3.6 Calcium-8.7 Phos-3.4 Mg-2.1
[**2206-6-10**] 03:25AM BLOOD %HbA1c-6.0* eAG-126*
DISCHARGE LABS
[**2206-6-12**] 06:05AM BLOOD WBC-13.0* RBC-3.63* Hgb-10.8* Hct-32.7*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.6 Plt Ct-210
[**2206-6-12**] 06:05AM BLOOD Neuts-65.8 Lymphs-27.6 Monos-6.0 Eos-0.2
Baso-0.3
[**2206-6-12**] 06:05AM BLOOD Plt Ct-210
[**2206-6-12**] 06:05AM BLOOD Glucose-158* UreaN-18 Creat-1.2 Na-137
K-4.1 Cl-102 HCO3-23 AnGap-16
[**2206-6-12**] 06:05AM BLOOD Calcium-8.6 Phos-2.1*# Mg-2.1
ECHOCARDIOGRAM from [**2206-6-10**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal to mid inferior and infero-lateral
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
# STEMI/CORONARIES: Pt has known CAD s/p CABG in [**2196**] (LIMA-LAD,
SVG-D1-OM1, and SVG-RCA), and also cath for NSTEMI in [**2203**] with
stenting of the SVG--> RCA vein with bms x 4. Underwent
unsuccessful PCI at OSH of SVG-RCA STE-IMI. Upon transfer, the
pt had a transvenous pacer as well as an IABP in place. These
were discontinued within 48 hours of hospitalization.
- Continued ASA 325mg PO daily.
- Continue plavix 75 mg PO daily.
- Continue atorvastatin 80 mg PO daily.
.
# Hypotension: Given IMI, pt's BPs were low upon initial
presentation. Pt was maintained on a dopamine drip, however
this was weaned off within 24 hours.
.
# RHYTHM: Pt was on transvenous pacemaker while in house,
however this was pulled within 48 hours as the patient's native
rhythm was wnl. The pt was maintained on tele/monitored bed
throughout this hospitalization.
.
# PUMP: Pt's last echo in our system ([**2200**]) shows an EF of 50%,
so a repeat ECHO was done (results included). An ACE-inhibitor
and a beta-blocker were started
- Repeat echo while here for evaluation of wall motion abnls and
EF
- CHANGED ACEi to a lower dose (lisinopril 5 mg PO daily)
- Started pt on beta-blocker, and is being discharged on
Metoprolol Succinate 25 mg PO daily.
.
# GI Bleed: Uncertain etiology of hematemesis. Per GI, likely
[**1-14**] old gastritis worsened by anticoagulation today. Pt also
has a hiatal hernia. Pt had an NGT placed with NG lavage which
shows active slow ooze. This was D/C'ed after stabilization of
output and Hct. The patient was started on Pantoprazole 40 mg
IV BID, and transitioned to PO.
- Continue pantoprazole 40 mg PO BID.
- Pt was seen by GI--> declined EGD in light of improving status
in house. Will need F/U at [**Location (un) 620**] for GI issues.
- GI requests EGD in [**7-22**] weeks.
Medications on Admission:
LISINOPRIL - 10 mg PO daily
METOPROLOL SUCCINATE 50 mg PO daily
SIMVASTATIN - 20 mg PO daily
ZANTAC - 150MG PO QHS
ASPIRIN - 325 mg PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 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*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual take one tablet as needed for chest pain 5 minutes
apart, do not take any more than 3 tablets total: Call 911 if
you still have chest pain after 3 doses. .
Disp:*25 tablets* Refills:*0*
9. Outpatient Lab Work
Please check CBC and chem-7 on Tuesday [**6-17**] anc call results
to Dr. [**Last Name (STitle) 2539**] at [**Telephone/Fax (1) 49151**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. ST-elevation myocardial infarction (heart attack)
SECONDARY DIAGNOSES
1. Gastrointestinal Bleeding
2. Hypotension (low blood pressure)
3. Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
from [**Hospital6 33**] for continued management of your heart
attack after a cardiac catheterization at [**Hospital3 **] was unable
to open the clogged vessel. We were able to take out the
temporary pacing wire and the aortic balloon pump, and we were
able to stabilize your blood pressure and heart rate. When you
first came to [**Hospital1 18**], you had vomited some blood, however during
the course of your stay, it looks like you have had no further
bleeding. You will need to see the gastroenterology doctors as [**Name5 (PTitle) **] outpatient and an upper endoscopy in [**7-22**] weeks. You will
need a [**Date Range **] test in 1 month, Dr. [**Last Name (STitle) **] can arrange that at
[**Hospital1 **] [**Location (un) 620**].
.
We have changed your medications. Please do the following:
1. Please stop your simvastatin 20 mg daily.
2. START ATORVASTATIN (LIPITOR) 80 mg every night.
3. Stop Zantac, start taking Pantoprazole twice daily to protect
your stomach from bleeding.
4. Continue your aspirin 325 mg daily
5. Decrease your Lisinopril to 5 mg daily from 10 mg
6. Decrease your Toprol to 25 mg daily from 50 mg
7. Start Plavix to help keep your heart arteries open. You will
need to take this medicine every day. Do not skip any doses or
stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you to. This is
extrememtly improtant to prevent another heart attack.
8. Take nitroglycerin under your tongue as needed for chest
pain. Sit down and take 5 minutes apart, no more than 3 tablets
total. Call Dr. [**Last Name (STitle) **] if you have any chest pain for which you
take nitroglycerin.
Followup Instructions:
Primary Care:
Department: DR. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD
When: THURSDAY [**2206-12-18**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 49151**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: DR. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD
When: THURSDAY [**2206-6-19**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 49151**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Cardiology:
Name: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD
Department: Cardiology
When: Wednesday [**7-16**] at 11:45am
Location: [**Hospital1 **] Hospital - [**Location (un) 620**]
Address: [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2206-6-12**]
|
[
"578.0",
"V45.81",
"458.9",
"410.71",
"427.31",
"414.00",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
9369, 9418
|
6108, 7923
|
325, 566
|
9642, 9642
|
3932, 6085
|
11481, 12783
|
2982, 3186
|
8115, 9346
|
9439, 9621
|
7949, 8092
|
9793, 11458
|
3201, 3913
|
2652, 2832
|
257, 287
|
594, 2558
|
9657, 9769
|
2863, 2890
|
2580, 2632
|
2906, 2966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,568
| 105,582
|
53588
|
Discharge summary
|
report
|
Admission Date: [**2124-7-8**] Discharge Date: [**2124-7-24**]
Date of Birth: [**2070-10-22**] Sex: M
Service: MEDICINE
Allergies:
Tegretol / Lasix
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
IABP
Swan ganz x2
Cardiac catheterization
History of Present Illness:
53yo male with history of obesity, OSA, and depression who p/w
increasing SOB x5d. 5d ago he noted DOE while climbing flight of
stairs. It was sudden onset and not a/w nausea, CP, diaphoresis.
SOB persisted throughout day and was worse with lying flat. He
also reports significant bilat lower ex and abd edema and approx
5 lb weight gain in 2d. SOB persisted and was worsened with any
physical activity. He said he could "talk it down" until day of
admit when it worsened. He denies any cough, chills, fevers, or
chest pain. He has no hx of CAD, CHF and no new meds.
.
In the ED, 96.8 102/78 73 16 100% RA. Promptly went into HR of
130s with aflutter and SBP 120s. Exam showed cool extremities
and bibasilar rales. He was given Dilt 20 IV and 30 PO with HR
improvement to 110 and SBP 130 -> 80s. He needed 600 IVF. Neo
given intermittently with no improvement in HR. EKG aflutter
with NA, NI and ventricular rate of 130 w delayed RWP. Labs
showed Trop 0.02, CK 187, MB 10. INR 1.7, WBC 15.8, ARF (Cr 2.4)
and transaminitis (ALT [**2055**] and AST 736). Anion gap 17 and
lactate 3.4. CXR w pulm congestion. CT abd showed cirrhotic
liver with small ascites w small/mod bilateral pleural
effusions. He was given [**Last Name (LF) 94463**], [**First Name3 (LF) **] 325. ECHO in ED showed
mod MR so patient admitted to CCU for cardiogenic shock.
.
Currently, he is thirsty. On full ROS, he denies any dizziness,
HA, LH, nausea, CP, SOB. he reports increasing abdominal girth
and leg swelling over last several days. Denies any fevers,
chills, cough, sputum.
Past Medical History:
1. CARDIAC RISK FACTORS: hx HTN
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: no
3. OTHER PAST MEDICAL HISTORY:
Obesity
OSA
Depression
OCD
Social History:
-Tobacco history: never tobb
-ETOH: none since [**40**] yrs ago. Reports 30 beers/wk x10 yrs in
20s.
-Illicit drugs: prior cocaine, marijuana, halucinogenics but
none in 30 yrs. Never IVDU.
-Lives with wife; has two daughters. Not working.
-No recent travel
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission -
General Appearance: Overweight / Obese, Anxious
Head, Ears, Nose, Throat: Normocephalic, Oropharynx clear
without erythema, MMM
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic), tachycardic, regular, no murmur
appreciated. distant S1 and S2 without split. no heaves
appreciated.
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
No(t) Clear : , Crackles : bilat bases. )
Abdominal: Distended, protuberant, dullness, no shifting
dullness. No organomeg appreciated. No rebound or guarding.
mild tenderness throughout.
Extremities: Right: 4+ pitting edema, Left: 4+ pitting edema,
cool extremities
Skin: No rashes
Neurologic: Attentive, Oriented x 3, Follows simple commands,
Responds to: vocal stimuli, Movement: Purposeful, Tone: Normal,
not increased
Pertinent Results:
==========
Labs
==========
On admission -
[**2124-7-8**] 05:25PM BLOOD WBC-15.8*# RBC-4.62 Hgb-14.3 Hct-41.5
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.7 Plt Ct-268
[**2124-7-8**] 05:25PM BLOOD Neuts-75* Bands-1 Lymphs-14* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2124-7-8**] 05:25PM BLOOD PT-18.5* PTT-25.1 INR(PT)-1.7*
[**2124-7-8**] 05:25PM BLOOD Glucose-121* UreaN-86* Creat-2.4*#
Na-129* K-4.8 Cl-91* HCO3-21* AnGap-22
[**2124-7-8**] 05:25PM BLOOD ALT-[**2055**]* AST-736* CK(CPK)-187*
AlkPhos-178* TotBili-1.2
.
On discharge -
[**2124-7-24**] 06:45AM BLOOD WBC-10.9 RBC-4.22* Hgb-12.7* Hct-37.5*
MCV-89 MCH-30.0 MCHC-33.8 RDW-16.1* Plt Ct-320
[**2124-7-23**] 07:20AM BLOOD WBC-11.2* RBC-4.48* Hgb-13.0* Hct-40.1
MCV-90 MCH-28.9 MCHC-32.3 RDW-15.3 Plt Ct-270
[**2124-7-24**] 06:45AM BLOOD Glucose-85 UreaN-15 Creat-1.1 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-14
[**2124-7-23**] 05:12PM BLOOD Glucose-97 UreaN-19 Creat-1.3* Na-141
K-5.2* Cl-105 HCO3-29 AnGap-12
[**2124-7-14**] 04:07AM BLOOD ALT-412* AST-86* AlkPhos-86 TotBili-1.0
[**2124-7-24**] 06:45AM BLOOD Digoxin-0.7*
==========
Radiology
==========
CT Abd/Pelvis [**2124-7-8**]
1. Findings suggestive of fluid overload, with small-to-moderate
bilateral
pleural effusions, with hilar fullness in the visualized lung
bases.
2. Nodular contour of the liver, which can be seen with
cirrhosis, with a
small amount of ascites.
3. Rounded hypodensities in the right lobe of the liver are
incompletely
characterized without intravenous contrast.
4. Cystic structure inferior to the third portion of the
duodenum. This is
of uncertain etiology with differential diagnostic
considerations including a fluid-filled normal bowel loop,
duplication cyst, and duodenal diverticulum.
.
===========
Cardiology
===========
C. Cath [**2124-7-11**]
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent CAD.
2. An 8Fr 30cc intra-aortic balloon pump was inserted via a
right common
femoral artery with good diastolic augmentation and systolic
unloading.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Cardiogenic shock.
3. Insertion of IABP.
.
TTE [**2124-7-11**]
Mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. LV wall thicknesses normal. LV mildly dilated.
There is severe global left ventricular hypokinesis (LVEF =
20-25 %). Restrictive left ventricular filling pattern
suggestive of severe diastolic dysfunction. RV is dilated with
moderate global free wall hypokinesis. Normal aortic valve. 3 +
MR. [**First Name (Titles) **] [**Last Name (Titles) **] htn.
.
TTE [**2124-7-14**]
On IABP: There is severe global left ventricular hypokinesis
(LVEF = 20 %). RV with moderate global free wall hypokinesis.
Moderate (2+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Off IABP: Overall LV
systolic function remains severely depressed with some subtle
increased systolic thickening of the anterior and lateral LV
segments (LVEF 25-30%). The degree of mitral regurgitation
increased to moderate to severe (3+). Compared with the prior
study (images reviewed) of [**2124-7-11**], overall LV systolic
function appears slightly improved and the degree of MR less
Brief Hospital Course:
# Cardiogenic shock: Patient admitted with cardiogenic shock.
Work up for causes was unremarkable, including Cath revealing
clean coronaries, HIV, Iron studies, RF, [**Doctor First Name **] and TSH. EF is
depressed globally without regional wall motion abnls and
improved on IABP. TTE showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. LV wall thicknesses
normal. LV mildly dilated. There is severe global left
ventricular hypokinesis (LVEF = 20-25 %). Restrictive left
ventricular filling pattern suggestive of severe diastolic
dysfunction. RV is dilated with moderate global free wall
hypokinesis. Normal aortic valve. Mild PA htn. TTE also showed
3+ MR, but it was unknown how much this complicated patient's
Cardiogenic shock picture. A repeat TTE on [**7-14**] showed minimal
improvement in EF on IABP and unchanged MR. In addition, patient
was admitted in A flutter and it was felt that this rhythm
disturbance on top of an already compromised EF caused the
patient to go into cardiogenic shock. Patient was initially
managed on Milrinone and Dopamine, but an IABP was placed during
patient's cardiac catheterization. Milrinone was eventually
weaned off and replaced by afterload reduction by ace
inhibitors, which were slowly titrated up and eventually, the
patient's IABP was able to be removed on [**2124-7-19**]. He was also
re-started on B-blocker therapy given his stable hemodynamics
after removal of the IABP. Given his massive total body volume
overload, the patient was agressively diuresed with a lasix drip
while in the CCU and managed to diurese several liters, however,
after less than 24 hours on the lasix drip the patient developed
a total body pruritic maculopapular rash concerning for a drug
rash. Given that lasix had been recently increased, it was
suspected that lasix was related to the rash and was
discontinued. The patient was switched to oral Ethacrynic acid
instead, as it contains no sulfa moiety in case this was
contributing to the patient's rash. The patient responded well
to oral Ethacrynic acid, and was able to be volume net negative
on 50mg daily.
.
# Coronaries: Cardiac biomarkers were flat when cycled. Cardiac
catheterization revealed clean coronaries. Patient was continued
on [**Date Range **] while in house.
.
# Cardiac Rhythm: On admission, the patient was in atrial
flutter. Per the patient, he had no prior history of AFib or
Flutter. During his hospitalization, he was transiently in
sinus rhythm after cardioversion in the OR on HD #2, but sinus
rhythm was not maintained throughout the hospitalization.
Patient was given a bolus of Amiodarone and eventually started
on Digoxin for rate control. In addition, after recovery from
cardiogenic shock, the patient was placed on a beta-blocker, but
despite this remained in paroxysmal atrial flutter throughout
this hospitalization. The patient was started on
anti-coagulation with coumadin and heparin during this
hospitalization given his paroxysmal AF, and PVD, as below.
.
# PVD: While in the CCU with an IABP the patient was noted to
have bilateral cool lower extremeties that appeared somewhat
cyanotic and mottled appearing. The patient's circulation to
his lower extremeties improved after removal of the IABP.
Vascular surgery was consulted and felt that the patient may
have been showering emboli given his significant PVD, and would
most likely benefit from being on anti-coagulation with coumadin
for at least the next few months.
.
# Respiratory failure: On HD#2, patient was intubated via nasal
airway in the setting of planned cardioversion. He
self-extubated on [**2124-7-13**] and did not require re-intubation with
no further episodes of respiratory distress this
hospitalization.
.
# Acute renal failure: Felt to be due to ATN in the setting of
shock. Cr gradually improved back to 1.1 at time of discharge
while on a stable diuretic regimen.
.
# ID: Patient spiked multiple fevers over the course of his
first week in the hospital. He was initially covered broadly
with vancomycin and zosyn given initial concern for sepsis.
Culture data remained negative and lines were removed without
growth of bacteria. Antibiotics were stopped on [**2124-7-16**] and
patient did not respike a temperature. In the setting of Tube
feeds, patient had some diarrhea but initial C diff toxins were
negative. On [**7-17**] the patient's stool was positive for C Diff and
he was started on a 14 day course of Metronidazole for
treatment.
.
# Rash: The patient developed a total body rash as described
above, felt to be a drug rash with lasix as the likely offending
[**Doctor Last Name 360**]. He recieved Benadryl, Sarna lotion, and topical
hydrocortisone cream with some improvement in his pruritis. The
rash stopped progressing after discontinuation of the lasix and
switching to ethacrynic acid as above.
.
# Depression: The patient's home dose of Seroquel and
Fluvoxamine were continued throughout his hospitalization.
.
# Transaminitis: Suspect most likely due to shock liver in the
setting of cardiogenic shock. The patient's transaminases
improved without intervention. A liver consult was initially
requested in case a heart transplant was necessary, and it was
deemed that the patient does not have cirrhosis advanced enough
to interfere with such a procedure should it become necessary.
Medications on Admission:
1. Provigil 200 daily
2. Seroquel 150 QHS
3. BiPap
4. Fluvoxamine 100mg [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Fluvoxamine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ethacrynic Acid 25 mg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*1*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*1*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
8. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash/ puritis.
Disp:*1 Tube* Refills:*0*
9. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritus.
Disp:*1 bottle* Refills:*0*
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Quetiapine 150 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: cardiogenic shock
Acute Systolic Congestive Heart Failure.
Discharge Condition:
Stable
Discharge Instructions:
You presented to the hospital with shortness of breath. You
were found to have profoud low blood pressure from your heart's
inability to squeeze. You were started on strong medications to
improve your heart's pump function. You transiently required a
balloon pump to help augment your heart's forward flow. Your
balloon pump was removed on [**2124-7-19**] and you are being discharged
on several new medications including: Ethacrynic acid,
Lisinopril and Carvedilol to help improve your heart's squeeze
potential. You are also being sent home on Amiodarone,
Digoxin, and Coumadin for your irregular heart beat.
Metronidazole, an antibiotic, is being prescribed for your
diarrhea, and you should take this for the next 8 days. Please
discuss with Dr. [**Last Name (STitle) 5717**] about setting up lung, liver and thyroid
testing now that you are on the amiodarone.
.
You were started on Coumadin, a powerful blood thinner to
prevent blood clots because of your atrial fibrillation. You
will need to check a coumadin level or INR frequently until the
level is between 2 and 3. You will see Dr. [**Last Name (STitle) 5717**] in 2 days and
can check your INR then at the [**Hospital3 **]. Please
call Dr. [**Last Name (STitle) 5717**] right away if you notice dark or bloody stools, a
nosebleed that won't stop, or vomiting blood.
.
Your home dose of Provigil was discontinued during this
hospitalization due to your critical illness. Please consult
with your primary care physician before restarting this
medication. You should continue taking all your other home
medications as before.
Please seek immediate medical attention if you experience chest
pain, shortness of breath, abdominal pain, nauasea,
palpitations, or any change in your baseline health status.
.
Please weigh yourself daily at home before breakfast. Call Dr.
[**First Name (STitle) 437**] is you have a weight gain or more than 3 pounds in 1 day
or 6 pounds in 3 days.
Please follow a low sodium diet.
Followup Instructions:
PCP/INR Check:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2124-7-26**] 11:10
Cardiology:
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**8-28**] at
9:00.
You will have an ECHO scheduled at ECHOCARDIOGRAM
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-8-28**] 8:00
Dr.[**Name (NI) 3536**] office may call you with an earlier appt.
Vascular Surgery:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2124-8-21**] 11:00 [**Hospital 6752**] Medical Building, [**Last Name (NamePattern1) 8028**].
Completed by:[**2124-7-24**]
|
[
"300.3",
"V10.46",
"693.0",
"424.0",
"428.0",
"E944.4",
"276.4",
"311",
"789.59",
"571.5",
"V45.77",
"785.51",
"278.01",
"570",
"518.81",
"008.45",
"427.32",
"276.1",
"443.9",
"428.21",
"401.9",
"327.23",
"276.0",
"584.5",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"96.6",
"37.22",
"88.56",
"96.04",
"89.64",
"96.71",
"38.93",
"88.72",
"99.61",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
13772, 13830
|
6807, 12143
|
305, 349
|
13942, 13951
|
3580, 5619
|
15974, 16758
|
2429, 2544
|
12283, 13749
|
13851, 13921
|
12169, 12260
|
5636, 6784
|
13975, 15951
|
2559, 3561
|
2006, 2077
|
246, 267
|
377, 1932
|
2108, 2137
|
1954, 1986
|
2153, 2413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,864
| 195,073
|
40443
|
Discharge summary
|
report
|
Admission Date: [**2173-7-17**] Discharge Date: [**2173-7-21**]
Date of Birth: [**2105-4-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Decline in mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 68 year old woman who is well known to the
Neurosurgery service. She originally presented on [**2173-5-16**] 68F who
was camping in [**Location (un) 3844**] when she awoke at 230am with a
severe sudden onset headache and informed her
husband. She was nauseous and diaphoretic at that time but did
not vomit. She was taken to [**Hospital 8641**] Hospital where her mental
status delined and she was intubated. CT head showed a large
left occipital IPH with intraventricular extension. She
developed hypothermia and an enlarging left pupil. She received
mannitol, lasix, and decadron and was transported to [**Hospital1 18**] for
further care.
She underwent a craniotomy and evacuation of the hematoma. She
was eventually extbated but re-intubated for respiratoy
distress. She eventually required a tracheostomy. She could not
have a PEG due to a large gastric ulcer. A gastric biopsy was
positive for invasive zygomycosis. ID was consulted amd
treatement was initiated. She was also treated for seizures
detected on EEG.
On [**6-8**] a bed was offered and she was trasnfered to rehab. She
ahd a recent admission to the MICU for fever and pneumonia. On
[**7-17**] she was admitted to [**Hospital1 18**] for a decline in her neurologic
exam and findings of large Left hemorrhage at her craniectomy
site.
Past Medical History:
s/p Hemorrhagic Stroke [**5-/2173**]
- Large left occipital IPH with intraventricular extension
- s/p left craniectomy and evacuation of hematoma
Gastric Mucormycosis
- s/p several weeks of amphotericin treatment, stopped in
setting of intermittent fevers of unclear etiology
[**2173-5-16**]: Left craniectomy and evacuation of hematoma
[**2173-5-21**]: Trach placement
[**2173-5-25**]: EGD w/ gastric biopsy
- Seasonal allergies
Social History:
Was previously living with husband normally in [**Name (NI) 108**] but camps
each summer in [**Location (un) **] in a trailer which she was prior to
hospitalization for intracranial hemorrhage. No tobacco.
Currently at [**Hospital 100**] Rehab. Sister is HCP.
Family History:
CVA in mother, father, and grandmother.
Physical Exam:
On Admission:
Gen: ventilated on trach, ill appearing
HEENT: Pupils: R NR L reactive EOMs unable to assess
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: unresponsive, not sedated
Cranial Nerves:
I: Not tested
II: Pupils Right 3mm NR, Left 3mm/2.5mm
III-XII: unable to assess
Motor: decorticate posture with LUE and extend with RUE,
sustained clonus BLE
Sensation: unable to assess
Coordination: unable to assess
Pertinent Results:
[**2173-7-17**] CXR
Pulmonary edema and bilateral pleural effusions. Retrocardiac
opacity could represent volume loss or developing infection.
[**2173-7-17**] CT head
Status post left hemicraniectomy with large mixed density
intraparenchymal and intraventricular hemorrhage. Evidence of
rightward shift of the normally midline structures.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the SICU opn [**2173-7-17**] after imaging
revealed a large left sided hemorrhage at her craniectomy site
with diffuse edema. She was on a ventilator. She had minimal eye
opening and was localizing to pain in the LUE. She continued to
receive her nafcillin. Family discussions were held and she was
DNR on [**7-17**]. More family member arrived on [**7-18**]. Her poor
prognoisis for a meaningful recovery was relayed again to family
members and the decision was made to withdraw support except for
comfort measures only. Under comfort measure guidelines with a
palliative care consult she was started on IV morphine and
ativan as needed for comfort and scolpolamine patches were
added; all other medications and tube feeds were held. She was
transfered to the regular floor and family maintained a steady
presence. Social work and the palliative care teams were
available for the family as well.
A hospice bed was available on [**7-21**] and the patient was
transferred to hospice.
Medications on Admission:
From rehab list
- levetiracetam 100 mg/mL Solution [**Month/Year (2) **]: [**2161**] ([**2161**]) mg PO BID
per NG tube.
- metoprolol tartrate 100 mg Tablet TID
- Nafcillin 2mg Q4hours IV - started [**7-10**]
- nystatin 100,000 unit/mL Suspension - 5ml PO TID after meals.
- omeprazole 40mg daily
- posaconazole 200mg QID
- KCL po elixir 20 meq daily
- Vancomcyin 250mg po TID
- quetiapine fumarate 6.25mg daily oral
- quetiapine fumarate 12.5mg QHS
- albuterol/ipratrop inhaler - 6 puffs q4hrs
- chlorhexidine gluconate - 15ml QID swish and spit
- cholestyramine 4grams
- diltiazem 30mg q6 hours per G tube (total 45mg q6hrs)
- diltiazem 15mg q6hrs per G-tube (total 45mg q6hrs)
- furosemide 20mg po (by NG tube)
- lidocaine jelly q6hrs topical
- zinc oxide q8h topical
- prn acetaminophen 650mg q4h
- prn dextrose oral gel
- prn glucagon 1mg IM
- prn ondansetron 4mg Q8h
Discharge Medications:
1. morphine 50 mg/mL Solution [**Month/Year (2) **]: 5-20 mg/hr Injection INFUSION
(continuous infusion) as needed for Comfort.
2. scopolamine base 1.5 mg Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
3. scopolamine base 1.5 mg Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
4. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Year (2) **]: [**12-13**] Injection
Q8H (every 8 hours) as needed for nausea.
5. morphine 5 mg/mL Solution [**Month/Day (2) **]: [**12-13**] Injection Q1H (every
hour) as needed for for comfort.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]Hospice House
Discharge Diagnosis:
Left intraparenchymal hemorrhage
Discharge Condition:
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Comfort Care
Followup Instructions:
none
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2173-7-21**]
|
[
"277.39",
"431",
"V44.0",
"348.4",
"V49.86",
"V66.7",
"V46.11",
"348.5",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5974, 6030
|
3377, 4407
|
297, 304
|
6107, 6189
|
3013, 3354
|
6250, 6381
|
2424, 2466
|
5334, 5951
|
6051, 6086
|
4433, 5311
|
6213, 6227
|
2481, 2481
|
233, 259
|
332, 1669
|
2770, 2994
|
2495, 2712
|
2727, 2754
|
1691, 2129
|
2145, 2408
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,820
| 150,131
|
30309
|
Discharge summary
|
report
|
Admission Date: [**2109-10-3**] Discharge Date: [**2109-10-12**]
Date of Birth: [**2051-9-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Peritoneal dialysis
History of Present Illness:
Mr. [**Known lastname 8014**] is a 58 year old male with history of Hepatitis C
with portal gastropathy, RCC s/p nephrectomy, ESRD on PD, CAD
s/p NSTEMI with RCA BMS stent ([**5-4**]) now off plavix, chronic
LGIB presents with 1 day of non-productive cough and worsening
shortness of breath at rest. At baseline he is able to ambulate
approximately [**Age over 90 **] yards before getting fatigued, however over
the past day he has been increasingly short of breath with
minimal exertion and yesterday morning was short of breath at
rest. He also reports one to two minutes of substernal chest
pressure this afternoon which resolved spontaneously - notes
that this was very different from CP in [**Month (only) 547**]. No radiation or
associated diaphoresis or nausea. In [**Month (only) 547**] he describes more
intense chest pressure with left arm numbness and vomiting. Of
note, he recently travelled to Foxwoods and noted that he did
not take his medications for 2 days (Sunday/Monday) and had many
dietary indiscretions including all-you-can-eat buffets. He did
do his PD manually which is how he normally does PD when he
travels (at home uses a machine).
.
In the ED, the patient's vitals were T 100.0, BP 133/72, HR 94,
RR 28, O2sat 87% on RA, 97% on 6L. Labs notable for elevated
white count at 12.5 and 90% neutrophils, troponin T 1.36, CK
173, CKMB 20, MB index 11.6. Blood cultures were sent. He was
given Levofloxacin for possible PNA and Lasix 80mg IV. CXR read
as likely pulmonary edema, consider atypical infection. ECG
unchanged, first degree AV block. He was given aspirin, beta
blocker. Cards consult in ED felt that elevated troponins were
related to demand ischemia with CHF exacerbation in setting of
dietary indiscretion and medication non-compliance.
.
Review of systems on admission is positive for orthopnea,
dyspnea on exertion, PND, LE edema and occasional chest pain. He
also notes dysuria but is unsure if discomfort with urination
began prior to or following placemtn of the urinary catheter.
Negative for fevers, chills.
Past Medical History:
- renal cell carcinoma s/p R nephrectomy [**2103**]
- ESRD after failing of L kidney, now on peritoneal dialysis,
undergoing renal transplant eval
- HTN
- chronic hep C: found during kidney transplant eval, currently
being followed by Dr. [**Last Name (STitle) 497**] in liver clinic and was being
evaluated for cirrhoisis with liver bx on [**9-12**]
- CAD s/p MI in [**5-4**], bare metal stent to RCA
- hemorrhoids: s/p surgical correction [**8-3**], with subsequent
decrease in BRBPR but still gets on occasion. On surveillence
cscope [**6-3**], noted to have grade 2 internal hemorrhoids
- PVD: chronic symptoms of claudication but yet to undergo
workup
- capsule endoscopy [**2109-8-27**] showed fresh blood in the duodenum
- gastric antral vascular ectasia by EGD, s/p APC coag on [**9-5**]
Social History:
He is married. He has 3 kids. He works as a painter. He has
history of chronic smoking at 1.5 packs for 30 years. He quit 5
years ago. He has history of intravenous drug abuse when he was
in his 20s. His alcohol history before his surgery was two 6
packs per week for about 5-6 years.
Family History:
His father is deceased with cirrhosis. His mother has diabetes.
He has 1 sister who is healthy.
Physical Exam:
VS T 97.6, HR 87, BP137/85, RR28, O2sat 90% 4L NC
Gen: Sitting up in bed, dyspneic with conversation.
HEENT: dry MM
Neck: Elevated JVP to 8cm
CV: Regular rhythm, nl s1 s2, no m/r/g appreciated
Chest: Crackles R>L base, diffuse wheezing.
Abd: Soft, obese, NT, ND, +BS
Ext: 1+ edema at the ankles, warm bilaterally.
Rectal: trace guaiac positive (in ED)
Skin: Multiple excoriations over lower extremities, abdomen.
Pertinent Results:
[**2109-10-3**] 08:20PM LACTATE-1.2
[**2109-10-3**] 08:15PM GLUCOSE-123* UREA N-101* CREAT-15.5*#
SODIUM-140 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-20*
[**2109-10-3**] 08:15PM ALT(SGPT)-24 AST(SGOT)-44* LD(LDH)-527*
CK(CPK)-173 ALK PHOS-50 TOT BILI-0.4
[**2109-10-3**] 08:15PM CK-MB-20* MB INDX-11.6* cTropnT-1.36*
[**2109-10-3**] 08:15PM CALCIUM-8.3* PHOSPHATE-7.5*# MAGNESIUM-1.6
[**2109-10-3**] 08:15PM WBC-12.5* RBC-3.03* HGB-9.8* HCT-28.7* MCV-95
MCH-32.4* MCHC-34.3 RDW-17.5*
[**2109-10-3**] 08:15PM NEUTS-90.2* BANDS-0 LYMPHS-6.1* MONOS-2.4
EOS-1.1 BASOS-0.2
[**2109-10-3**] 08:15PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2109-10-3**] 08:15PM PLT SMR-LOW PLT COUNT-141*
[**2109-10-3**] 08:15PM PT-13.5* PTT-26.6 INR(PT)-1.2*
.
.
[**2109-10-6**] 05:09AM - CPK ISOENZYMES cTropnT-4.54
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2109-10-12**] 06:39AM 9.0 2.85* 9.1* 25.8* 91 31.9 35.2* 16.2*
146*
[**2109-10-11**] 07:56AM PT-12.4 PTT-30.7 INR-1.1
.
MISCELLANEOUS HEMATOLOGY ESR
[**2109-10-12**] 06:39AM 71*
.
[**2109-10-9**] 05:54AM INHIBITORS & ANTICOAGULANTS ACA IgG-6.41 ACA
IgM-10.81
.
[**2109-10-12**] 06:39AM RENAL & GLUCOSE Glucose-85 UreaN-120
Creat-14.9 Na-133 K-4.2 Cl-91 HCO3-22
.
.
Studies:
[**2109-10-4**] Echo: Conclusions:
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 60%). 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
ascending aorta is moderately dilated. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2109-4-29**], the findings are similar.
.
[**2109-10-5**] Echo:
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with focal mid to distal septal hypokinesis (branch
disease?). 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 aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly to moderately
thickened. There is a moderate-sized, mobile echodensity on the
aortic valve (0.7 cm mobile echodensity on the LV side of the
non-coronary cusp) suggestive of a vegetation. There is no
significant valvular aortic stenosis (at most trivial). The
increased transaortic velocity is likely related to increased
stroke volume due to aortic regurgitation. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate to severe mitral annular
calcification (involving the chordal structures). There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2109-10-4**], no
change (aortic valve vegetation was present but not reported.
Mild regional LV hypokinesis was present but not reported).
Reviewing the TTE from [**5-4**], the regional dysfunction and aortic
vegetation are now new.
IMPRESSION: Mild regional LV hypokinesis (overall preserved LVEF
of 55%) c/w CAD. Moderate-sized aortic valve vegetation of
unclear significance. Moderate AI. If clinically indicated, a
TEE may better assess the valvular vegetation.
[**2109-10-8**] TEE:
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. Overall
left
ventricular systolic function is normal (LVEF>55%). Right
ventricular systolic function is normal. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened. There is a moderate-sized (0.8 mm x 0.5
mm) vegetation on the noncoronary cusp of the aortic valve. No
aortic valve abscess is seen. Moderate (2+) aortic regurgitation
is seen. The mitral valve leaflets are severely
thickened/deformed with focal areas of increased thickening. A
possible vegetation is noted on the posterior mitral valve
leaflet. No mitral valve abscess is seen. There is severe mitral
annular calcification without overt mitral stenosis. Mild (1+)
mitral regurgitation is seen. There is no abscess of the
tricuspid valve. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
IMPRESSION: Vegetation on the noncoronary cusp of the aortic
valve with
moderate aortic regurgitation. Possible vegetation on the
posterior leaflet of the mitral valve with mild mitral
regurgitation. Complex atheroma is in the descending aorta. No
definite perivalvular abcess.
Brief Hospital Course:
Mr. [**Known lastname 8014**] is a 58 year old male with multiple medical problems
including ESRD on PD who presents with one day of cough,
shortness of breath due concerning for acute coronary syndrome,
transferred to the MICU and found to have aortic valve
vegetation on TTE as an incidental finding.
.
MICU Course:
He was admitted to the MICU for further care of his shortness of
breath and positive cardiac enzymes. The troponin levels
remained elevated due to poor renal clearance, whereas CK-MB
trended down and was no longer tracked on transfer from MICU.
Cardiology followed the patient closely and decided not to
puruse cath options since the patient is not an anticoagulation
candidate due to history of GI bleeds. Cardiology felt that
ischemia was due to demand in the setting of decompensated CHF.
He had transient episodes of RVR secondary afib, with beta
blockade held once during a transient episode of hypotension on
[**10-8**] (MICU day 6). Otherwise, the patient was hemodynamically
stable for most of his MICU course.
.
The patient was also transiently short of breath, with O2
saturations in the low 90s while on 4LNC. His respiratory
status improved with nebulizers and fluid-balance control with
his peritoneal dialysis. On transfer from the MICU, he saturated
well on room air.
Of note, a TTE ([**2109-10-5**]) was revealing of an aortic valve
vegetation that was not present as seen in an echo from [**2109-4-29**].
A subsequent TEE confirmed the aortic vegetation, and revealed a
possible mitral valvle abnormality. Of note, no abscesses were
found. All blood cultures have been negative to date. A
presumptive diagnosis of culture-negative endocarditis was made
on [**10-8**]. Broad antibiotic coverage was started with IV
vancomycin and levofloxacin. A PICC line was placed on [**10-9**] to
allow proper IV access for treatment. On transfer to the
medicine service, he did not complain of new chest pains or
shortness of breath.
He continued to get peritoneal dialysis throughout his MICU
stay.
His MICU LOS was 7 days.
***
.
# Cardiac:
**Ischemia: On this admission, cardiac enzymes were positive in
the ED and likely due to demand ischemia. An EKG showed 1st
degree AV block, nondiagnostic Q waves in inferior and lateral
leads, and 0.[**Street Address(2) 1755**] depressions in V4-V6. Troponin continued to
remain elevated likely due to poor clearance and less likely
related to ongoing ischemia. The CK-MB was flat.
Anticoagulation was held due to his history of GI bleeding. He
was maintained on beta-blockers, and aspirin. Upon transfer from
the MICU to the medicine floor, he was hemodynamically stable.
On two occasions he complained of chest discomfort that was
responsive to a GI cocktail. On discharge, he no longer had
angina or dyspnea.
**Pump: He had an ejection fraction of 55% on TTE. He was kept
on bete blockers and kept euvolemic for his stay. He had mild
bilateral edema to his ankles that diminished by the day of
discharge.
**Rhythm: In the MICU, he had transient episodes of atrial
fibrillation with rapid ventricular response. On transfer to the
medicine floor, he remained in normal sinus rhythm while being
monitored on telemetry. He did have a borderline prolonged QT
interval of 450 that was closely monitored on serial EKGs in the
setting of levofloxacin which is known to prolong QT intervals.
.
# Aortic valve vegetation: He was treated for culture-negative
endocarditis. On admission, the patient had a low grade
temperature, and elevated white blood cell count with neutrophil
predominance. There were no clear sources of infection, and
urine, blood cultures, and chest x-ray were all negative.
However, the presentation was concerning for endocarditis based
on vegetation on his aortic valve (with a possible vegetation on
the mitral valve as well) on TEE imaging. He also had an
elevated ESR, and CRP. Gentamicin was not started due to poor
renal function and concerns for eigth cranial nerve damage. He
was continued on levofloxacin (PO) and IV vancomycin. Morning
trough levels were used to find an optimal dosing regimen (500
mg every 72 hours). He should continue to complete a 6 week
course of levofloxacin and vancomycin. A PICC was inserted to
allow a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] vancomycin as needed. By
the day of discharge, all cultures and seroligies were negative
or pending.
.
# Hypoxia: On admission he was oxygenating well on 5L NC,
however he became tachypneic in the MICU, and he was tried on
CPAP with some improvement. His chest x-ray on admission showed
volume overload with no signs of infiltrate. Peritoneal dialysis
was initiated at higher concentration to remove fluid. On
transfer to the medicine floor, he oxygenated well on room air
and was given atrovent and albuterol nebulizers as needed.
.
# ESRD on PD/RCC s/p nephrectomy: He was followed by the renal
team throughout his hospitalization. He was given a dose of
lasix 40mg IV x 2 in ED, and responded with only minimal urinary
output. He was continued with PD - 1.5%, 1.5% and 2.5% every 6
hours. His phosphate levels continued to be elevated and he was
started on PhosLo with good effect. Medications were renally
dosed. He was given an outpatient appointment to be followed by
a nephrologist here as well as nutritionist from the transplant
center. Erythropoetin was restarted prior to discharge but no
change in hematcrit was observed.
.
# Chronic LGIB: He has a history of Grade 2 internal
hemorrhoids, and a capsule endoscopy from [**2109-8-27**] showed fresh
blood in the duodenum. An EGD showed gastric antral vascular
ectasia s/p APC coag on [**9-5**]. During this hospitalization, his
hematocrit was stable at 26-28. Anticoagulants were held.
.
Code: DNR/DNI
Medications on Admission:
Aspirin 325mg daily
Lanthanum 500 mg Tablet PO TID W/MEALS
Ferrous Sulfate 325 mg Tablet [**Hospital1 **]
B-Complex with Vitamin PO daily
Nitroglycerin 0.3 mg Tablet, Sublingual PRN chest pain
Cinacalcet 60 mg PO daily
Simvastatin 40 mg Tablet daily
Docusate Sodium 100 mg Capsule PO BID
Metoprolol Tartrate 25 mg Tablet PO BID
Pantoprazole 40 mg Tablet, Delayed Release PO Q12H
Quinine Sulfate 260 mg Tablet PO at bedtime
Epoetin Alfa 10,000 unit/mL Solution MWF
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
7. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
10. Maalox 1,000 mg Tablet, Chewable Sig: One (1) ML PO TID (3
times a day) as needed.
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*0*
14. B Complex Tablet Sig: One (1) Tablet PO once a day.
15. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*100 Capsule(s)* Refills:*0*
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 32 days.
Disp:*16 Tablet(s)* Refills:*0*
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day as needed.
Disp:*2 inhaler* Refills:*0*
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
19. Vancomycin 500 mg Recon Soln Sig: One (1) Intravenous every
seventy-two (72) hours for 35 days: Please follow up with the
outpatient Infectious Disease clinic to have your vancomycin
level checked. .
Disp:*12 * Refills:*0*
20. Outpatient Lab Work
CBC, Na, K, Cl, BUN, Cr, AST, ALT, alkaline phosphatase,
bilirubin, vancomycin trough on [**10-19**].
Please fax results to Dr. [**Last Name (STitle) 12070**] at [**Telephone/Fax (1) 31117**]
21. Outpatient Lab Work
CBC, Na, K, Cl, BUN, Cr, AST, ALT, alkaline phosphatase,
bilirubin, vancomycin trough on [**10-26**].
Please fax results to Dr. [**Last Name (STitle) 12070**] at [**Telephone/Fax (1) 31117**]
22. PICC line care
Please perform PICC line care per CCS protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Endocarditis
Primary: End-stage renal disease
Primary: Myocardial ischemia
Secondary: Atrial fibrillation
Secondary: Shortness of breath
Discharge Condition:
Afebrile, hemodynamically stable, normal vital signs, chest-pain
free, on peritoneal dialysis
Discharge Instructions:
You have been admitted for shortness of breath and chest
discomfort. On this admission, an incidental finding of
endocarditis (bacterial infection of your heart valves) was
found. You are being discharged with antibiotics that you should
continue to take as instructed for approximately the next 5
weeks.
.
You should take all medications as instructed.
.
You will need a weekly CBC, electrolytes, BUN, Creatinine, LFTs,
and vancomycin trough drawn by your PCP. [**Name10 (NameIs) 357**] make sure to
have these labs drawn.
.
You should continue with the peritoneal dialysis schedule that
you have been given.
.
If you begin to experience symptoms of worsening chest pains,
shortness of breath, loss of consiousness, high fevers, blood in
your stools, sudden increased weight gains, worsening swelling
in your feet, pain or swelling around your peritoneal dialysis
line, high fevers, or any other concerning signs, please contact
a physician [**Name Initial (PRE) 2227**].
.
Please follow up with all appointments that have been made for
you.
Followup Instructions:
Please follow up with your PCP to have weekly CBC, electrolytes,
BUN, Creatinine, Liver function tests, and vancomycin trough
drawn. We have given you a prescription for this labwork to be
done on [**10-19**] and [**10-26**]. These results can be faxed to her office
at [**Telephone/Fax (1) 31117**].
.
Several follow-up appointments have been made for you:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12070**] MD, [**10-21**], 3PM
Provider: [**Name10 (NameIs) **] [**First Name (STitle) 805**] MD, [**2113-10-22**] AM, [**State 72151**]. Phone: [**Telephone/Fax (1) 5972**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2109-10-28**]
9:30
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2109-11-19**] 10:00
*** Please Call [**Hospital1 18**] Transplant Center to make an appointment
with Nutritionist [**First Name4 (NamePattern1) 1370**] [**Last Name (NamePattern1) 30084**]. Ph#[**Telephone/Fax (1) 673**]
|
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icd9cm
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[
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[]
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[
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3229, 3516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,092
| 166,390
|
41053
|
Discharge summary
|
report
|
Admission Date: [**2177-4-27**] Discharge Date: [**2177-5-8**]
Date of Birth: [**2114-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
lower extremity weakness, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 y/o F newly diagnosed rectal mass who presents with lower
extremity weakness, numbness and acute urinary retention. Prior
to her aortofemoral bypass ([**2177-3-6**]) she had progressively
worsening weakness of the bilateral lower extremities and
ascending numbness (L > R) which somewhat improved following
bypass but did not completely resolve. 1-2 weeks ago patient
began to experience worsening weakness and numbness and today
she had difficulty walking which prompted her to present to
[**Hospital3 **]. Due to concern of urinary retention patient
transfered to [**Hospital1 18**] for evaluation where she was evaluated by
several services.
.
Neurology, Neurosurgery and Radiology felt most likely her
neurological symptoms were due to lumbosacral plexus invasion of
tumor. Based on exam and imaging available (MRI unable to be
completed) they did not feel she was suffering from cauda equina
or cord compression. No saddle anesthesia on exam. Patient later
denied above urinary retention and described difficulty
urinating due to preference of foley instead of bed pan. They
did not recommend steroids or surgical involvement. Vascular
service saw patient and found no acute vascular issues (palpable
femoral and DP pulses B/L, normal CT aortic graft, no acute
vascular issues). Colorectal surgery also consulted.
.
VS on presentation to ED T 98.2, BP 147/74, HR 84, RR 18, 99%
RA. Patient received Valium 20 mg IV (for MRI), Fentanyl 100mcg
and Ciprofloxacin in the ED. Following valium doses patient BP
dropped to 68-75/43-60 and improved to SBP 90s following 4 L NS.
Vitals on transfer HR 101, 90/64, 16, 99%RA. Patient mentated
and with good urine output with low BPs. She was admitted to the
ICU due to hypotension and concern she would trigger on the
floor. On arrival to the ICU her VS BP 131/56 and HR 105.
Past Medical History:
- Aortofemoral bypass [**2177-3-6**] for actute aortic thrombus
- Rectal CA, discovered at time of surgery in [**March 2177**], not yet
staged, not treated
- Diabetes on insulin
- Left humerus fracture [**2177-2-4**] secondary to LE weakness
- CAD s/p MI 8 years ago (no intervention)
- Chronic pain
- Hypercholesterolemia
- HTN
- Bed bound due to L. humerus fracture
PSH:
aortobifemoral in [**Month (only) 958**], R SCV port placement.
Social History:
Lives with partenr of 25 years, here with her. Smoked 1ppd x 50
years - quit in [**Month (only) 958**]. Three children. Denies ETOH use. Denies
current drug use.
Family History:
Mother 83 - CVA
Father 39 - MI
No family history of colon, breast or ovarian cancer
Physical Exam:
GEN: thin, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact.
Lower extremity: Left [**3-8**], Right [**4-8**]. Gross sensation intact.
Upper extremity: Left [**3-8**], right [**4-8**]. Gross sensation intact.
Reflexes: patella 0 b/l. toes downgoing.
RECTAL: Per ED and patient rectal tone intact.
.
On Discharge:
VS - Tm/c: 99.0/97.1, BP 146/80 (132-156/60-80), HR 86 (86-80),
RR 20, sats 98% on RA,
GEN: NAD, cachectic, lying in bed, comfortable
HEENT: PERRL, EOMI, frontal, Oral mucosa pink not OP lesions,
not LAD, no increased JVP
Axilla: 1cm lymph node palpated bilaterally
CV: Tachycardic, s1s2 no S3S4, no m/r/g
LUNGS: fine crackles at the bases bilaterally, no wheezes,
rales, rhonchi
ABD: large midline surgical scar, +BS, Soft NT, ND, No HSM
EXT: 2+ peripheral pulses, calf and thigh muscle wasting
bilaterally
NEURO: A&Ox3, CN II-XII intact,
RUE: elbow flexion/extension [**5-8**], wrist flexion/extension [**5-8**],
deltoid [**5-8**]
LUE: deltoid [**4-8**], elbow extension [**4-8**], elbow flexion [**4-8**], wrist
flexion/extension [**4-8**]
RLE: hip flexor [**4-8**], knee extension [**3-8**], knee flexion [**4-8**], ankle
flexion/dorsiflexion [**5-8**]
LLE: hip flexor [**3-8**], knee extension [**3-8**], knee flexion [**3-8**], ankle
flexion/dorsiflexion [**5-8**]
Reflexes:
Patellar - no reflexes elicited bilaterally
Achilles - no reflexes bilaterally
Down going toes bilaterally
Sensation intact throughout
Pertinent Results:
[**2177-4-27**] 12:45PM BLOOD WBC-8.5 RBC-4.08* Hgb-13.3 Hct-37.9
MCV-93 MCH-32.5* MCHC-34.9 RDW-14.3 Plt Ct-285#
[**2177-4-28**] 03:50AM BLOOD WBC-16.9*# RBC-3.90* Hgb-12.4 Hct-37.1
MCV-95 MCH-31.7 MCHC-33.4 RDW-14.3 Plt Ct-302
[**2177-4-27**] 12:45PM BLOOD Neuts-58.1 Lymphs-31.0 Monos-4.6 Eos-5.5*
Baso-0.8
[**2177-4-27**] 12:45PM BLOOD Glucose-160* UreaN-15 Creat-0.6 Na-138
K-3.4 Cl-101 HCO3-26 AnGap-14
[**2177-4-28**] 03:50AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.5*
[**2177-4-27**] 09:37PM BLOOD Lactate-1.7
.
MICRO:
[**2177-4-27**] MRSA SCREEN Negative
[**2177-4-27**] BLOOD CULTURE Pending
[**2177-4-27**] BLOOD CULTURE Pending
[**2177-4-27**] URINE Negative
.
IMAGING:
[**2177-4-27**] CTA ABD:
IMPRESSION:
1. Large locally invasive rectal mass with increased pelvic
lymphadenopathy.
2. Patent aortobifemoral graft with a right groin collection
most likely
seroma, although an abscess cannot be excluded.
3. Nodular adrenal glands with adjacent prominent lymph nodes.
Given known
history of a rectal mass, this may represent distal nodal and
adrenal
metastases.
.
[**2177-4-27**] MRI T&L SPINE:
IMPRESSION:
1. No evidence of spinal canal narrowing is demonstrated
involving the
thoracic or lumbar spine.
2. There is a wedge compression deformity of the superior
endplate of L2.
Chronicity of this is inconclusive given no prior exams for
comparison and no STIR sequence (the patient refused completion
of the study) to evaluate for acute edema. The posterior wall of
the L2 vertebral body is intact without retropulsion. If
clinically warrented, a second attempt at acquiring the STIR
sequence can be attempted.
3. With the above limitations in mind, remainder of the study
does not show
acute abnormality to explain the patient's symptoms.
.
[**2177-4-27**] CXR:
IMPRESSION: No acute intrathoracic process
.
[**2177-4-27**] Gallbladder/liver U/S:
IMPRESSION:
1. Mixed hyper- and hypoechoic lesion at the borders of segment
VII and VIII, corresponding to the approximately 2 cm lesion
noted on CT, which displays more CT features of a hemangioma.
The other presumed probable flash-filling cavernous hemangioma
within segment VI could not be identified son[**Name (NI) 5326**]
despite extensive scanning through this region in multiple
positions and is likely isoechoic to the surrounding parenchyma.
Again, CT features are most suggestive of hemangiomas and lesion
would be highly atypical for rectal metastases.
If further confirmation is needed, a dedicated MRI would be the
best
examination (patient may benefit from being scanned on large
bore magnet on
[**Hospital Ward Name **] due to claustrophobia). Alternatively multiphasic CT
could also
be performed (less desirable given multiple prior CT's) or this
could be
followed on subsequent imaging.
2. Enlarged right adrenal gland may reflect underlying
hyperplasia and is
stable from prior CTs dating back to [**2177-3-5**]. This could
also be
evaluated at time of MRI.
Brief Hospital Course:
62yo F w/ newly diagnosed rectal adenocarcinoma with lower
extremity weakness and intitial concern for cord compression
which was ruled out and determined to be related to lumbosacral
compression from tumor burden. She was started on
chemo/radiation therapy and transferred to [**Hospital1 **] to complete her treatment
.
# Hypotension: On arrival to the hospital, patient was
normotensive, in the emergency department, she was given valium
and fentanly for sedation prior to MRI and became hypotensive to
60/40, she was bolused 4 L NS in the ED and admitted to the
MICU. However, by the time she arrived in the ICU SBP 130s and
MAP > 65. Patient was mentating with good urine output.
Hypotension is of unclear etiology likely hypovolemia versus
medication side effect (occured following valium and fentanyl).
No evidence of infection to suggest septic shock. No evidence of
decompensated heart failure on exam or by history. No increased
O2 requirement to suggest massive PE or chest pain to suggest
ACS. Pt denied being on BP meds. Her pressures remained within
the 90's to 120's during the first few days and then the day
prior to admission, the patient was hypertensive with SBP in the
130-150 range. She was transferred to the oncology service for
work up of lower extremity weakness. She was discharged OFF her
home Metoprolol, which was not restarted.
.
# Lower extremity weakness and numbness: On admission there was
concern that this could represent cord compression or cauda
equina syndrome. Originally reported urinary retention but on
further history actually did not want to use a bed pan and
preferred a foley. MRI of the T- and L-spine were done and was
not complete due to patient's anxiety but were reviewed by
radiology and neurology and neurosurgery and felt to be
sufficient to rule out cord compression. Patient also examined
by Neurology and Neurosourgery and exam was not consistent with
cord compression or cauda equina. Neurology and radiology felt
symptoms due to lumbosacral plexus invasion of tumor. No
further imaging was done as the patient was claustrophobic and
does not tolerate sedating medications well. Her Foley was
discontinued when she arrived to the floor and was urinating
without issues. She was also seen by colorectal surgery,
radiation oncology and medical oncology. There was some initial
concern that there was metastasis in the liver, but after
further review, it was decided that they were more likely
hemangiomas. Her case was discussed during GI rounds and it was
decided to start neo-adjuvant chemo/radiation therapy. 5FU and
radiation therapy was started [**2177-5-7**], the plan is for her to
continue radiation for 30 treatments and 5-Fluorouracil for 6
weeks however duration of therapy will be guided by outpatient
oncologist. She was seen by physical therapy and because of her
lower extremity weakness she was discharged to Rehab.
.
.
# Rectal cancer: Per patient this is a new diagnosis. Per OMR
patient worked up at [**Hospital3 **] - felt to be rectal cancer
stage T2N1Mx. Port appears to be placed for chemo but patient
was unclear of plan. [**Hospital3 **] was contact[**Name (NI) **] for medical
records and Onc and Rad Onc were consulted. Pain control with
tylenol, prn oxycodone. Please see course and plan for
treatment as above.
.
# UTI: on [**5-8**] patient had dysuria and grossly positive UA, she
was treated with ciprofloxacin and will need to continue for a
total of 7 days.
.
# Diabetes: Insulin sliding scale. Finger sticks were well
controlled.
.
# Aortofemoral bypass [**2177-3-6**] for actute aortic thrombus:
Vascular evaluated in ED felt no vascular issues. This was not
an active issue during her hospital stay.
.
# CAD s/p MI 8 years ago (no intervention): No chest pain.
Aspirin was continued once it was decided there would be no
further procedures.
.
# Chronic pain: Diffuse also with l humerus fracture and rectal
cancer. Was on standing tylenol, gabapentin, lidocaine patch,
oxycodone prn. Her pain was well controlled during the course
of her stay.
.
# Hypercholesterolemia: Continued statin.
.
Transitional Issues:
- Patient is to receive neo-adjuvant chemotherapy/radiation
therapy
- Monitor for improvement in neuro exam. If no improvement in
symptoms with treatment, shrinking of tumor then may need neuro
exam for possible EMG.
Medications on Admission:
Medications at Home:
Aspirin 81mg PO daily
.
MEDICATIONS at time of transfer:
ciprofloxacin 500mg PO Q12 (d1 = [**4-28**])
heparin 5000u SC TID
gabapentin 300mg PO daily
acetaminophen 1000mg PO Q6
lidocaine patch 5% patch TD daily
miralax 17gm PO daily
senna 1 tab PO BID
colace 100mg PO BID
simvastatin 20mg PO daily
ISS
thiamine 100mg PO daily
MVI 1 tab PO daily
.
Discharge Medications:
1. 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.
2. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
3. 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.
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. fluorouracil 500 mg/10 mL Solution Sig: Three [**Age over 90 1230**]y
(350) mg Intravenous ONCE as directed by oncologist for 5 days:
Fluorouracil 350 mg IV Days 1, 2, 3, 4 and 5. ([**2177-5-7**],
[**2177-5-8**], [**2177-5-9**], [**2177-5-10**] and [**2177-5-11**])
(225 mg/m2)
(Wednesday [**2177-5-7**] through Sunday [**2177-5-11**]) .
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Lorazepam 0.5 mg IV Q4H:PRN anxiety or nausea
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. Prochlorperazine 10 mg IV Q6H:PRN nausea
17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
18. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
19. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
20. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): Please see attached sheet for
sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
Lower extremity weakness
Rectal adenocarcinoma
Urinary tract infection
Secondary Diagnosis:
Type II diabetes
Hypertension
Hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms [**Known lastname **],
It was a pleasure caring for you in your hospital stay at
[**Hospital1 18**]. You were transferred from [**Hospital 8125**] Hospital to [**Hospital1 18**] for
weakness in your legs. You were evaluated by the Neurosurgery
and Neurology specialists and an MRI showed that the spread of
your rectal cancer is compressing the nerves that go to your
legs which explains your symptoms. You started chemotherapy in
this hospital stay with 5-Fluorouracil and also started external
beam radiation therapy. You will continue both the chemotherapy
and the radiation treatments as an outpatient.
While in the hospital, you were also found to have a urinary
tract infection and you were started on a course of antibiotics
as an outpatient which will be continued on discharge as
instructed below.
We have made the following changes to your medications:
- 5-Fluorouracil was STARTED for chemotherapy
- Ciprofloxacin was STARTED, to be taken until [**2177-5-14**]
- Gabapentin was STARTED
- Oxycodone was STARTED
- Tylenol was STARTED
- Lidocaine patches were STARTED
- Insulin was STARTED
- Lorazepam was STARTED
- Ondansetron was STARTED
- Prochlorperazine was STARTED
- Thiamine was STARTED
- Docusate, Polyethylene Glycol, and Senna were STARTED
- Multivitamin was STARTED
- Metoprolol was STOPPED
- Levemir was STOPPED but your Humalog sliding scale was
continued
- You will be taking Aspirin 81mg daily
Followup Instructions:
Please keep the following appointments:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2177-5-14**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2177-5-14**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 8129**]
Department: Primary Care Physician
[**Name Initial (PRE) 2897**]: Tuesday, [**5-20**] 9:30am
Department: VASCULAR SURGERY
When: FRIDAY [**2177-6-13**] at 10:00 AM
With: VASCULAR LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"799.4",
"458.29",
"V54.19",
"272.0",
"228.04",
"250.00",
"414.01",
"154.1",
"198.89",
"V85.1",
"412",
"300.4",
"728.87",
"V58.67",
"728.2",
"285.22",
"E935.2",
"V45.89",
"599.0",
"E939.4",
"338.3",
"V15.51",
"338.29",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
14602, 14673
|
7627, 11728
|
341, 347
|
14880, 14880
|
4664, 7604
|
16512, 17688
|
2858, 2944
|
12385, 14579
|
14694, 14694
|
11994, 11994
|
15063, 15903
|
12015, 12362
|
2959, 3514
|
3528, 4645
|
11749, 11968
|
15932, 16489
|
264, 303
|
375, 2199
|
14806, 14859
|
14713, 14785
|
14895, 15039
|
2221, 2662
|
2678, 2842
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,740
| 143,301
|
35115+57977
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-10-25**] Discharge Date: [**2175-10-30**]
Date of Birth: [**2129-5-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Epilepsy
Major Surgical or Invasive Procedure:
[**2175-10-25**]: s/p left temporal lobectomy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
History of Present Illness:
46 yo right handed man with intractable epilepsy secondary to
traumatic brain injury. Multiple failed medication trials. On
[**2175-8-30**] he had depth electrodes and grid placement for seizure
foci mapping.
Past Medical History:
Epilepsy
Social History:
Married, lives with wife.
Family History:
Non-contributory
Physical Exam:
On Admission:
AOx3, neurologically intact.
At Discharge:
The patient had swelling at the craniotomy site with some
subgaleal swelling. Visual field deficits were hard to confirm
due to the associated eyelid swelling post-operatively. There
were no focal neurological deficits upon discharge.
Pertinent Results:
[**2175-10-26**] 01:31AM BLOOD WBC-11.3*# RBC-4.09* Hgb-13.0* Hct-38.4*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.6 Plt Ct-227
[**2175-10-26**] 01:31AM BLOOD Glucose-134* UreaN-14 Creat-0.9 Na-145
K-4.5 Cl-107 HCO3-29 AnGap-14
[**2175-10-26**] 01:31AM BLOOD Calcium-9.2 Phos-5.4*# Mg-1.7
[**2175-10-26**] 01:31AM BLOOD Phenyto-13.3
Brief Hospital Course:
[**Known firstname **] [**Known lastname 1169**] is a 46 yo male electively admitted for left
temporal lobectomy with Dr. [**Last Name (STitle) **] for intractable Epilepsy.
Post-operatively, he remained in the ICU for close monitoring.
He had post op CT that showed some blood in operative bed, but
this was stable on repeat CT 12 hrs later. His exam remained
intact. He complained of incisional pain/headache. He was
transferred to the floor POD#1. His diet and activity were
advanced. He was on steroids that were tapered. His dilanatin
(name brand only) was continued. On POD#2 he was not taking a
full diet and was somewhat uncomfortable there was a question of
a seizure versus dizziness from ambulating. On day of discharge
he was tolerating a regular diet and voiding without difficulty
Medications on Admission:
Dilanin 200mg Qam, 300mg Qpm
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
2. 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*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*40 Capsule(s)* Refills:*0*
4. Dexamethasone 2 mg Tablet Sig: 1.5 tabs [**Hospital1 **] X3 days, 1 tab
[**Hospital1 **] x2 days 1 tab qdX2 days then stop Tablets PO see does.
Disp:*20 Tablet(s)* Refills:*0*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QPM (once a day (in the evening)).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QAM (once a day (in the morning)).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
6 days.
Disp:*6 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, please
refrain from taking until your follow-up appointment.
??????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.
Please continue your seizure medications per your Neurologist.
Please call Dr.[**Name (NI) 12757**] office with any questions or concerns
at [**Telephone/Fax (1) 3231**]
Followup Instructions:
You will need you sutures to be removed on [**11-3**] please call for
an appointment to [**Telephone/Fax (1) 3231**]
You will need to follow-up with Dr [**Last Name (STitle) 11294**] 4 weeks
post-operatively with a Head CT w/o contrast. Please call for an
appointment appointment.
Name: [**Known lastname 1937**],[**Known firstname 126**] Unit No: [**Numeric Identifier 12892**]
Admission Date: [**2175-10-25**] Discharge Date: [**2175-10-30**]
Date of Birth: [**2129-5-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 3656**]
Addendum:
Patient was to be discharged on [**10-29**], but pain management was an
issue and he was kept inpatient for pain management.
Chief Complaint:
Epilepsy
Major Surgical or Invasive Procedure:
[**2175-10-25**]: s/p left temporal lobectomy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1703**]
History of Present Illness:
46 yo right handed man with intractable epilepsy secondary to
traumatic brain injury. Multiple failed medication trials. On
[**2175-8-30**] he had depth electrodes and grid placement for seizure
foci mapping.
Past Medical History:
Epilepsy secondary to trauma
Social History:
Married, lives with wife.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
On Admission:
AOx3, neurologically intact.
At Discharge:
The patient had swelling at the craniotomy site with some
subgaleal swelling. Visual field deficits were hard to confirm
due to the associated eyelid swelling post-operatively. There
were no focal neurological deficits upon discharge.
Pertinent Results:
[**2175-10-26**] 01:31AM BLOOD WBC-11.3*# RBC-4.09* Hgb-13.0* Hct-38.4*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.6 Plt Ct-227
[**2175-10-26**] 01:31AM BLOOD Glucose-134* UreaN-14 Creat-0.9 Na-145
K-4.5 Cl-107 HCO3-29 AnGap-14
[**2175-10-26**] 01:31AM BLOOD Calcium-9.2 Phos-5.4*# Mg-1.7
[**2175-10-26**] 01:31AM BLOOD Phenyto-13.3
MRI Brain [**2175-10-25**]:
IMPRESSION:
1. Redemonstration of the post-surgical changes in the left
frontal region
and left frontal lobe and increased FLAIR hyperintense signal in
the left
temporal lobe anteriorly and medially for surgical planning.
2. Increased signal related to mucosal thickening in the right
maxillary in the bilateral mastoid air cells.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 46 yo male electively admitted for left
temporal lobectomy with Dr. [**Last Name (STitle) 1703**] for intractable Epilepsy.
Post-operatively, he remained in the ICU for close monitoring.
He had post op CT that showed some blood in operative bed, but
this was stable on repeat CT 12 hrs later. His exam remained
intact. He complained of incisional pain/headache. He was
transferred to the floor POD#1. His diet and activity were
advanced. He was on steroids that were tapered. His dilanatin
(name brand only) was continued. On POD#2 he was not taking a
full diet and was somewhat uncomfortable there was a question of
a seizure versus dizziness from ambulating. On [**10-29**], discharge
home was planned but pain management was an issue and he was
kept inpatient for pain management. On [**10-30**] Oxycontin 30mg [**Hospital1 **]
was initiated with Dilaudid 2-4mg PO Q3 for break through pain.
Pain was well managed and on [**10-30**] was discharged home.
Medications on Admission:
Dilantin 200 mg every morning
Dilantin 300 mg every evening
(Brand Name Only)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QPM (once a day (in the evening)).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QAM (once a day (in the morning)).
4. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) for 7
days.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Breakthrough Pain.
Disp:*80 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day.
8. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, please
refrain from taking until your follow-up appointment.
??????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.
Please continue your seizure medications per your Neurologist.
Please call Dr.[**Name (NI) 4957**] office with any questions or concerns
at [**Telephone/Fax (1) 4958**]
Followup Instructions:
Your sutures will need to be discontinued on [**2175-11-6**] with the
nurse practitioner, please call [**Location (un) 4956**] at [**Telephone/Fax (1) 4958**] to make
this appointment.
You will need to follow-up with your neurosurgeon 4 weeks
post-operatively with a Head CT w/o contrast. Please call for an
appointment [**Telephone/Fax (1) 4958**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**]
Completed by:[**2175-10-30**]
|
[
"E929.8",
"338.18",
"345.41",
"907.0",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.53"
] |
icd9pcs
|
[
[
[]
]
] |
9168, 9174
|
7174, 8187
|
5624, 5751
|
9227, 9227
|
6466, 7151
|
10728, 11239
|
6102, 6120
|
8315, 9145
|
9195, 9206
|
8213, 8292
|
9372, 10705
|
6150, 6150
|
6208, 6447
|
5576, 5586
|
5779, 5990
|
6164, 6194
|
9241, 9348
|
6012, 6042
|
6058, 6086
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,694
| 127,447
|
54554
|
Discharge summary
|
report
|
Admission Date: [**2110-12-7**] Discharge Date: [**2110-12-12**]
Date of Birth: [**2062-1-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Tetracycline / Penicillins / Sulfa (Sulfonamide Antibiotics) /
Clindamycin / Cephalosporins / Macrolide Antibiotics / Lactulose
/ cefuroxime / ciprofloxacin / Levaquin / Erythromycin Base
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
"right face pain"
Major Surgical or Invasive Procedure:
right craniectomy and washout of epidural empyema [**2110-12-7**]
History of Present Illness:
This is a 48 year female with a past medical history
significant for multiple craniotomies for aneurysm in [**2103**]. She
presented to the Emergency Department on [**2110-12-7**] with right
facial pain
[**10-27**], headache, and skin sensitivity with low grade fevers
(99-100) for the week prior to admission. The patient denied
weakness, numbness
or tingling sensation, bowel or bladder dysfunction. The patient
had baseline decreased hearing in the right ear since her
hospital admission for meningitis in [**2108**] and baseline reported
decreased peripheral vision in the right eye since [**2103**] at the
time of her surgery at [**Hospital6 13753**].
Past Medical History:
Brain aneurysm s/p coiling (vs. surgery?) at [**Hospital1 112**], 1st
surgery [**2103-4-30**] followed by a 2nd surgery [**2103-9-3**].
Tubal Ligation DMII- (patient states that she does not have
diabetes but this is listed in her chart in multiple
places)/Polycystic ovarian syndrome. admission for
meningitis [**2108**]
Social History:
non contributory
Family History:
Non contributory
Physical Exam:
PHYSICAL EXAM:
O: T:99.6 BP: 98/50 HR:87 R:18
Gen: comfortable, NAD.
HEENT: Pupils: [**4-20**] EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-20**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: 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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-22**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On the day of discharge [**2110-12-12**]:
The patient is oriented to person place and time, full strength
and sensation in all 4 extremities. The incision is clean dry
and intact- 4 staples were removed today- the surgical incision
is closed with disolvable sutures. The patient reports increased
right ear hearing deficit since pre-op(baseline right ear
hearing deficit since [**2108**]) and will follow up with ENT for this
as an outpatient. The patient reports a right peripheral vision
deficit at baseline since her surgery in [**2103**] which is not noted
on bedside exam.pupils are equal and reactive, bilateral lateral
nystagmus present, otherwise EOMs intact, No pronator drift.
face is symetric. temporal muscle is slightly protruding under
the skin on right and this is the patient's baseline since her
prior surgery [**2103**].pt tolerates regular diet. ambulates
independently with steady gait. voids without difficulty.
the patient is wearing her Helet when out of bed at all times.
Pertinent Results:
CT HEAD W/ CONTRAST Study Date of [**2110-12-7**] 4:32 AM Radiology
READ IMPression:
1. No acute intracranial abnormality, status post aneurysm
clipping.
2. Status post right middle cranial fossa craniectomies,
complicated by
chronic mastoiditis and otitis media, with increased bony
erosion.
3. New right facial and external auditory canal inflammatory
changes, with
probable superficial masseter abscess.
CT ORBITS, SELLA & IAC W/ CONTRAST Study Date of [**2110-12-7**] 4:33
AM Radiology Read:
IMPRESSION:
1. Status post right MCF craniectomies, complicated by chronic
otomastoiditis. There has been progressive erosion of the
mastoid septae,
tegmen tympani, and petrous apex, without destruction of the
ossicular chain or scutum. Patient remains at risk for
intracranial extension and/or CSF leak.
2. Right facial and external auditory canal inflammation.
Rim-enhancing
fluid collection superficial to right masseter muscle, highly
suspicious for abscess, which may be amenable to percutaneous
drainage.
MRI/MRA/MRV BRAIN W/O CONTRAST Study Date of [**2110-12-7**] 10:05 AM
Radiology Read
IMPRESSION:
1. Peripherally enhancing fluid collection along the right
temporal bone flap with mild epidural fluid component and
extensive dural thickening and
enhancement. These findings raise the suspicion of temporal soft
tissue
abcess, bone flap osteomyelitis and extra-axial empyema.
2. Diffuse likely reactive edema and enhancement involving the
right
infratemporal and retromaxillary zygomatic fossa as well as the
masticator
space.
3. No evidence of intra-axial involvement.
CT Head [**2110-12-7**]
IMPRESSION:
1. Status post right craniectomy with expected post-surgical
changes
including residual blood products and air locules in the
vicinity of surgery.
2. Chronic mastoiditis.
3. Previously noted masseter abscess is not well appreciated on
today's
examination.
Pathology Report Tissue: Plates and screws. Study Date of
[**2110-12-7**]
Report not finalized.
Assigned Pathologist [**Last Name (LF) 2336**],[**First Name3 (LF) **] E.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-1/4923**]
Plates and screws.
Cardiology Report ECG Study Date of [**2110-12-7**] 12:57:44 PM
Sinus rhythm. Poor R wave progression, probably a normal
variant. Compared to the previous tracing of [**2108-12-21**] there is no
significant diagnostic change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 178 78 344/386 51 9 34
CHEST (PORTABLE AP) Study Date of [**2110-12-7**] 1:14 PM FINDINGS: As
compared to the previous radiograph, the lung volumes are
normal. Normal size of the cardiac silhouette. Minimally
increased vascular diameters, consistent with minimal fluid
overload. No focal parenchymal opacity suggesting pneumonia. No
pleural effusions. No pneumothorax.
CT HEAD W/O CONTRAST Study Date of [**2110-12-7**] 8:17 PM Radiology
Read
IMPRESSION:
1. Status post right craniectomy with expected post-surgical
changes
including residual blood products and air locules in the
vicinity of surgery.
2. Chronic mastoiditis.
3. Previously noted masseter abscess is not well appreciated on
today's
examination.
CHEST PORT. LINE PLACEMENT Study Date of [**2110-12-9**] 9:45 AM
IMPRESSION:
1. New right PICC terminating approximately 3.5 cm below the
cavoatrial
junction.
2. Slightly improved aeration and stable mild pulmonary vascular
congestion.
[**2110-12-7**] 03:37AM GLUCOSE-107* LACTATE-1.2 K+-3.9
[**2110-12-7**] 03:43AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2110-12-7**] 03:43AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2110-12-7**] 03:43AM PLT COUNT-316
[**2110-12-7**] 03:43AM NEUTS-80.2* LYMPHS-14.9* MONOS-3.3 EOS-1.3
BASOS-0.3
[**2110-12-7**] 03:43AM WBC-16.7* RBC-4.59 HGB-13.6 HCT-40.5 MCV-88
MCH-29.8 MCHC-33.7 RDW-13.2
[**2110-12-7**] 03:43AM URINE GR HOLD-HOLD
[**2110-12-7**] 03:43AM URINE UCG-NEGATIVE
[**2110-12-7**] 03:43AM GLUCOSE-107* UREA N-5* CREAT-0.7 SODIUM-138
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-31 ANION GAP-14
[**2110-12-7**] 01:01PM PT-13.1 PTT-30.5 INR(PT)-1.1
[**2110-12-7**] 03:46PM freeCa-1.07*
[**2110-12-7**] 03:46PM HGB-11.0* calcHCT-33
[**2110-12-7**] 03:46PM GLUCOSE-111* LACTATE-0.7 NA+-136 K+-3.9
CL--100
[**2110-12-7**] 03:46PM TYPE-ART PO2-91 PCO2-42 PH-7.44 TOTAL CO2-29
BASE XS-3
[**2110-12-7**] 05:10PM freeCa-1.11*
[**2110-12-7**] 05:10PM HGB-12.3 calcHCT-37
[**2110-12-7**] 05:10PM GLUCOSE-137* LACTATE-0.8 NA+-139 K+-4.1
CL--101
[**2110-12-7**] 05:10PM TYPE-ART PO2-176* PCO2-43 PH-7.43 TOTAL
CO2-29 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2110-12-7**] 08:29PM PT-13.9* PTT-27.1 INR(PT)-1.2*
[**2110-12-7**] 08:29PM PLT COUNT-299
[**2110-12-7**] 08:29PM WBC-13.0* RBC-3.72* HGB-11.1* HCT-32.7*
MCV-88 MCH-29.7 MCHC-33.8 RDW-13.4
[**2110-12-7**] 08:29PM CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2110-12-7**] 08:29PM GLUCOSE-176* UREA N-5* CREAT-0.7 SODIUM-143
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-29 ANION GAP-12
[**2110-12-12**] 01:32PM BLOOD WBC-9.4 RBC-3.77* Hgb-11.0* Hct-33.0*
MCV-87 MCH-29.2 MCHC-33.4 RDW-13.6 Plt Ct-408
[**2110-12-9**] 05:30AM BLOOD Neuts-72.2* Lymphs-21.7 Monos-4.0 Eos-1.9
Baso-0.3
[**2110-12-12**] 01:32PM BLOOD PT-13.6* PTT-27.9 INR(PT)-1.2*
[**2110-12-12**] 01:32PM BLOOD Glucose-151* UreaN-5* Creat-0.6 Na-143
K-3.7 Cl-111* HCO3-26 AnGap-10
[**2110-12-12**] 01:32PM BLOOD Calcium-8.1* Phos-2.6* Mg-2.2
[**2110-12-12**] 08:59AM BLOOD Vanco-22.5*
[**2110-12-10**] 03:45PM BLOOD Vanco-7.5*
[**2110-12-8**] 04:00PM BLOOD Vanco-11.7
Brief Hospital Course:
This is a 48 year old female with past medical history
significant for multiple craniotomies presents with R facial
pain and low grade temperatures. MRI revealed right temporal
fluid collection with dural enhancement suspicious for empyema,
possible osteomyelitis. She was admitted to the neurosurgery
service for further management. She was taken to the OR
emergently on [**12-7**] for craniectomy and evacuation of right
epidural empyema and a right epidural drain placement x2 .
Post operatively, patient was nonfocal on examination. She had
complaints of baseline decreased hearing in the right ear (since
[**2108**]) and impaired right visual field deficit (since [**2103**])she
was taken to the ICU for further monitoring. Infectious Disease
was consulted and patient started on antibiotic triple therapy
with vancomycin, cefepime and flagyl. A helmet was ordered to be
worn at all times while the patient is out of bed to protect the
craniectomy site.The ENT service was consulted while the patient
was inhouse for the risk of mastoiditis as a source for
infection and they agreed with the plan for IV antibiotics. Dr.
[**Last Name (STitle) 111610**] would like to see the patient after her course of IV
antibiotics is complete for formal audiogram and assesment for
residual infection.
On POD1 the subgaleal drains were removed and the patient was
transferred to the regular floor. The patient recieved the
[**Location (un) **]. Vancomycin troughs were followed throughout her hospital
stay and her dose was adjusted to maintain a goal vanco level of
15-20 as recommended by ID.
On [**12-9**] cefepime was discontinued as organism appeared to be
gram stain positive.The vancomycin was increased to 1250 mg
every 8 hours.A PICC line was placed in anticipation of long
term home IV antibiotics.
On [**12-10**],The vancomycine was increased to 1500mg every 8 hours.
physical therapy cleared the patient for home and occupational
therapy cleared the patient to go home with occupational
therapy.
On [**12-11**], the patient Neurontin was increased per the patients
request to her home dose of 1200 mg po TID.
On [**12-12**], Infectious Disease saw the patient and recommended
that the flagy be discontinued which is was. The vancomycin
trough elevated (39.7)and not thought to be a true trough. This
was reordered and was 22. The infectious disease
recommendations were to change the Vancomycin dosing to 1250 mg
TID with plan for trough level to be drawn prior to the 4th
dose. The patient will call for an appointment for follow up
with infectious disease on Monday. Lab work will be drawn at
the patient home and faxed to the [**Hospital **] clinic which will include
CBC with diff, chem 7, LFTs, BNP, vancomycin trough. Serum
magnesium and potassium levels were low and repleated. The
patient was found to have white pustules in her mouth all over
the oral pharynx and was started started nystatin for thrush.
There was 4 staples that were removed from the old drain sites.
The patient complained of worsening decreased hearing on the
right since the time of surgery. The ENT service was called to
evaluate the patient prior to her disposition home. There was
no formal audiogram testing available, but bedside evaluation
was consistent with worsening sensory neural hearing loss on the
right. The patient was initiated on a Prednisone taper over 12
days and recommedation for follow up in [**1-19**] weeks for audiogram
as outpatient was made. The patient will call for this
appointment on Friday.The patient is documented to have type II
diabetes meilitis but denies this diagnosis. She states that
she has a blood glucose moniotr at home and feels capable and
comfortable taking her blood sugar at home prior to meals and
prior to bed. If her blood sugar is over 200 then she will call
her primary care physician for [**Name9 (PRE) 444**]. The patient will be
dispo to home with occupational therapy, a home safety
evaluation, and home infusion therapy. The exam on the day of
discharge is outlined above.
Medications on Admission:
Tylenol with Codien 1 tab po PRN, trazadone75mg q HS, Cymbalta
120 mg 1 cap po q am, oxycodone 10 mg TID PRN, gabapentin 300 mg
TID
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime):
as taken at home- please see your PCP for continued scripts.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): as taken at
home please see your PCP for continued scripts.
6. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day): home medication - please see your PCP for
continued scripts for this medication.
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for headache: do not drive while taking this
medication-hold for lethargy.
Disp:*30 Tablet(s)* Refills:*0*
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 10 days.
Disp:*200 ML(s)* Refills:*0*
9. vancomycin 500 mg Recon Soln Sig: 02.5 Recon Solns
Intravenous Q 8H (Every 8 Hours): total of 6 weeks start date
[**12-7**] at night- DOSE:1250 mg every 8 hours IV for a total of 6
weeks.trough on [**12-13**] before 4th dose.
Disp:*qs Recon Soln(s)* Refills:*0*
10. Outpatient Occupational Therapy
Occupational therapy at home
-
Pt to wear Hemult at all times when OUT of BED- no skull bone on
right side of head
11. Outpatient Lab Work
for OPAT Please obtain weekly CBC with Diff,chem 7, LFTs BMP,
vanc trough and fax results per instructions below
all lab results should be faxed to ID RN at [**Telephone/Fax (1) 1419**]
(all questions regarding outpatient antibiotics should be
directed to infectious disease RNs at [**Telephone/Fax (1) 57729**]
12. Outpatient Lab Work
for OPAT Please obtain:vanc trough prior to 4th dose and fax
results per instructions below
all lab results should be faxed to ID RN at [**Telephone/Fax (1) 1419**]
(all questions regarding outpatient antibiotics should be
directed to infectious disease RNs at [**Telephone/Fax (1) 57729**]
13. prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day
for 7 days: prednisone taper:
60 mg po qd x 7 days
then, 50 mg po qd x 1 day.
then, 40 mg po qd x 1 day, then 30 mg po qd x 1 day, then 20 mg
po qd x 1 day, then 10 mg po qd x 1 day then you may discontinue
use of this medication.
Disp:*87 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
right temporal epidural empyema
worsening sensory neural hearing loss, right ear
Discharge Condition:
stable, oriented to person place and time, full strength and
sensation in all 4 extremities. The incision is clean dry and
intact- 4 staples were removed today- the surgical incision is
closed with disolvable sutures. The patient reports increased
right ear hearing deficit since pre-op and will follow up with
ENT for this as an outpatient. The patient reports a right
peripheral vision deficit at baseline since her surgery in [**2103**]
which is not noted on bedside exam.pupils are equal and
reactive, bilateral lateral nystagmus present, otherwise EOMs
intact, No pronator drift. face is symetric. temproal muscle is
slightly protruding under the skin on right and this is the
patients baseline since her prior surgery [**2103**].pt tolerates
regular diet. ambulates independently with steady gait. voids
without difficulty.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You have dissolvable sutures. You must keep that area dry for
10 days (The date of your surgery was [**12-7**].
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You were NOT on any medications such as Coumadin (Warfarin),
or Plavix (clopidogrel), or Aspirin. Do not begin taking any of
these medications until cleared by Dr [**Last Name (STitle) **]
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
You will be Taking a medication called Vancomycin IV for a TOTAL
of 6 weeks. The VNA nurses will be drawing lab work and your
vancomycin level will be followed. The goal trough level is 20.
Your dosing was changed on the day of discharge and your level
will be drawn prior to your 4th dose of vancomycin at home.
This should be faxed to the infectious disease nurses at
[**Telephone/Fax (1) 1419**].
Weekly labs will be drawn which will included CBC with
differential,LFTs, Chemistry 7, BMP,vancomycin trough This
should be faxed to the infectious disease nurses at
[**Telephone/Fax (1) 1419**].
The ENT surgeon saw you today and noted that you have worseing
sensory neural hearing loss on exam and recommended that you
begin two week course of Steroids (prednisone). You will be
sent home on this. While on this medication please check your
blood sugars with your glucometer prior to each meal and prior
to bed. if your Finger stick glucose level is 200 or higher
please call your primary care physician for management.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-27**] days(from your date of
surgery [**2110-12-7**] for a wound check). This appointment can be
made with the Nurse Practitioner. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need an MRI of the brain with and without gadolinium
contrast.
?????? Please call [**Telephone/Fax (1) 457**] for a follow up appointment
with Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 977**],in the Infectious Disease Clinic. If
you need to change this appointment, please call them at
[**Telephone/Fax (1) 457**].
?????? You need to have the following labs drawn weekly: CBC
with diff,BMP, Chem7, Lfts, Vancomycin trough. All labortory
The results should be faxed to the [**Hospital **] clinic at [**Telephone/Fax (1) 1419**].
all questions regarding outpatient antibiotics should be
directed to the infectious disease RN at [**Telephone/Fax (1) 57729**]
?????? You need to make an appointment with Dr. [**Last Name (STitle) 3878**] (ENT)
in [**1-19**] weeks for follow up and an outpatient audiogram. Please
call [**Telephone/Fax (1) 2349**] to make this appointment.
You already had the following appointment in the system
scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Known firstname 2477**], MD Phone:[**Telephone/Fax (1) 31444**] Date/Time:[**2110-12-15**]
2:30
Completed by:[**2110-12-12**]
|
[
"389.15",
"324.0",
"V45.89",
"112.0",
"383.00",
"V12.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
16424, 16482
|
9634, 13675
|
471, 539
|
16607, 17441
|
3892, 9611
|
20055, 21776
|
1624, 1642
|
13858, 16401
|
16503, 16586
|
13701, 13835
|
17465, 20032
|
1672, 1830
|
413, 433
|
567, 1227
|
2123, 3873
|
1845, 2107
|
1249, 1574
|
1590, 1608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,068
| 167,971
|
12817+56407
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-10-18**] Discharge Date: [**2174-11-18**]
Date of Birth: [**2106-6-2**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Ivp Dye, Iodine Containing / Morphine
Attending:[**First Name3 (LF) 20846**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
small bowel resection
History of Present Illness:
The patient is a 68-year-old female with a complicated course
beginnging in [**2174-8-10**] when she presented to an OSH ED
complaining of abdominal pain. A subsequent colonoscopy found
two polyps, an adenocarcinoma in the right colon in [**Month (only) **]
[**2173**] at the hepatic flexure. This colonoscopy was followed
by a segmental colon resection on [**2174-9-26**] at
[**Hospital 882**] Hospital. All lymph nodes were
negative.Postoperatively, the patient had a pleural
effusion,bilateral pneumonia and pulmonary edema due to
diastolic
dysfunction. There was no prolonged intubation. She
wasdischarged to rehab three days prior to her admission here
[**Hospital 39478**] [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **], and currently presents
from rehab. At rehab today, the patient was noted to have
rectal bleeding, dull abdominal pain, and a low grade fever.
Past Medical History:
diastolic dysfunction
hypertension
breast cancer dx 7 years prior to admission treated with
chemotherapy, lumpectomy and radiation
colon adenocarcinoma s/p right colectomy
vaginal bleeding associated with tamoxifen treatment
Social History:
[**Last Name (Titles) **] only speaking woman with two grown children
Family History:
deferred
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97, heart
rate 74, blood pressure 92/44, 19 respirations/minute, and
satting 94 percent on 5 liters. In general, she was in
moderate distress. Cardiovascular: She had regular rate and
rhythm. Lungs: She had decreased breath sounds on the
right. Abdomen: Firm, moderately distended. There was no
rebound or guarding. She was tender to palpation in the left
upper quadrant. Extremities: She had a [**1-11**] plus edema
bilaterally. Rectal exam: She was guaiac positive. There
was stool in the vault. There was normal tone.
Pertinent Results:
INITIAL LABORATORIES: White count 13.6, hematocrit 29.4,
442,000 platelets. Panel 7: Sodium 133, potassium 5.5,
chloride 99, bicarbonate 23, BUN 51, creatinine 1.4, glucose
191. ALT 32, AST 46, T-bili 0.6, albumin 2.3, amylase 34,
lipase 16, alk phos 264, PT 13.1, PTT 25.6, INR 1.1, lactate
4.5. Chest x-ray showed a right pleural effusion,
atelectasis in the right lower lobe.
Brief Hospital Course:
The following is a brief summary of the [**Hospital 228**] hospital
course from a system's perspective. The patient spent 23 days in
the intensive care unit, before being transferred to the floor
on [**2174-11-9**].
1) Gastrointestinal: On the day of admission ([**2174-10-18**]) a CT scan
revealed a large fluid collection with free air, most likely
consistent with a anastomtotic leak. The patient went to the
operating room where peritonitis and a small bowel perforation
were found during exploratory laparotomy. A small bowel
resection with primary anastamosis, lysis of adhesions, and
gastrostomy were performed. Ostomy site opened on hospital day
number 4. On [**2174-10-29**], a CT scan showed large extravasation of
contrast (likely from anastamosis leak) and purulent fluid
collection. CT guided drain was placed with immediate return of
1L of feculent material. Wound opened to fascia at the bedside
and noted to be draining stool on hopstial day number on
[**2174-10-30**]. A vacuum dressing was applied to this wound. On
[**2174-11-5**] a repeat CT scan deomnstrated peristent fluid
collections and two additional pigtail drains were placed. One
drain was removed on the final day of admission. At the time of
discharge, the abddominal wound continued to heal with q3day vac
dressing changes. The patient's abdomen was soft non-tender and
non-distened at discharge. There was probably continued leakeage
from the small bowel.
2) Respiratory: Patient met ARDS criteria was intubated
postoperatively for a prolonged period. A tracheostomy was
placed on [**2174-11-1**]. Trach collar trials began on [**2174-11-4**]. At
the time of discharge, patient had oxygen staruation in the high
90% range on 40-50% oxygen via trach mask. She was able to talk
easily with passy muir valve.
3) Fluid/Electrolyte/Nutrion: TPN begun on [**10-21**] and then
discontinued on [**10-27**] as tube feeds began to be advanced to
goal. However tube feeds were subseqently discontinued and TPN
resatred on [**2174-10-30**].
4) Gynecology: Vaginal bleeding noted on hospital day number 4
and again noted on [**2174-11-15**] and [**2174-11-16**]. A very limited pelvic
ultrasound was consistent with a fibroid uterus. The patient
was evaluated by the gynecology service who believed the
bleeding was chonic in nature and secondary to fibroids or
possibly enodetrial cancer. Surgical intervention and further
work up wer not recommended. Patient should follow-up with Dr.
[**Last Name (STitle) **] as outpateint.
5) ID: The patient was treated with broad spectrum antibiotics
including fluconazole, vancomycin, levofloxacin, zosyn,
ceftriaxone, linezolid and flagyl throughout her hospital
course. Coverage was finally narrowed, however, on [**2174-11-6**] to
linezolid and fluconzaole for methicillin resistant staph
aureus, multiple yeast species, highly resistant E. coli, and
vancomycin resistant enterococcus all of which grew from
mutliple peritoneal fluid and swab cultures.
6) Tube/Lines/Drains: Patient has a gastrostomy tube, two
pigtail abdominal drains (intially three, one was removed), a
vacuum dressing on her abdomen, a right upper extremity double
lumen PICC line placed on [**2174-11-15**] (previous left upper extremity
discontinued n [**2174-11-15**]). Left upper extremity ultrasound
demonstrated on thrombus.
Medications on Admission:
nifedipine, paxil, lorazepam
Discharge Medications:
1. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
2. Enalaprilat 0.625 mg IV Q6H
3. Linezolid 600 mg IV Q12H (complete 10 days following
discharge)
4. Hydralazine HCl 10 mg IV Q2-3H:PRN SBP>180
5. Hydromorphone 0.5 mg IV Q3-4H:PRN extreme brekathrough pain;
monitor for sedation
6. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) patch Transdermal
every seventy-two (72) hours.
Disp:*qs * Refills:*2*
7. Fluconazole in Normal Saline 200 mg/100 mL Piggyback Sig: Two
Hundred (200) mg Intravenous once a day for 10 days.
Disp:*QS * Refills:*0*
8. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Twenty (20) mg
Intravenous every six (6) hours.
Disp:*qs * Refills:*2*
9. Insulin Regular Human 300 unit/3 mL Syringe Sig: sliding
scael Subcutaneous four times a day.
Disp:*qs * Refills:*2*
10. Miconazole Nitrate 2 % Powder Sig: One (1) appl Topical
four times a day as needed.
Disp:*qs * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
perforated ileum
small bowel leak
wound breakdown
vaginal bleeding
Discharge Condition:
fair
Discharge Instructions:
Please flush two abdominal drains with 10-20 mL of sterile
normal saline every shift.
Please flush gastric tube every shift with 30 mL of nromal
saline.
Please give patient total parenteral nutrtion every day and
check TPN labs every day. Please adjust electrolytes
accordingly. Patient is to remain NPO until cleared by Dr. [**Last Name (STitle) **]
to eat.
Please change vacuum dressing once every three days and
abdominal wet to dry dressing TID.
Please continue IV antibiotic Linezolid and antifugnal
fluconazole for ten days following discharge.
Followup Instructions:
Please follow-up with general surgeon Dr. [**Last Name (STitle) **] 10-14 days
following discharge. Call ([**Telephone/Fax (1) 26761**] for appointment and
directions.
Please also follow-up with gynecologist Dr. [**Last Name (STitle) **] when health
status is improved. An endometrial sampling may be indicated
when patient's health is improved. Call ([**Telephone/Fax (1) 39479**] for
appointment. Doctor [**First Name (Titles) **] [**Last Name (Titles) 595**] speaking.
Name: [**Known lastname 7131**],[**Known firstname 1731**] Unit No: [**Numeric Identifier 7132**]
Admission Date: [**2174-10-18**] Discharge Date: [**2174-11-18**]
Date of Birth: [**2106-6-2**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Ivp Dye, Iodine Containing / Morphine
Attending:[**First Name3 (LF) 7133**]
Addendum:
On [**2174-11-17**] patient self discontinued her tracheostomy. Oxygen
saturation remained excellent on 2L of oxygen via nasal canula.
Patient actually appeared more comfortable and was better able
to cough and clear her secretions follwoing removal of the
tracheostomy.
Patient was also noted to have a low potassium of 3.0 on the
morning of dishcarge and this was repleted with IV potassium
chloride.
Pertinent Results:
[**2174-11-17**] 09:40AM BLOOD WBC-9.5 RBC-3.60* Hgb-10.3* Hct-31.9*
MCV-89 MCH-28.6 MCHC-32.3 RDW-17.6* Plt Ct-207
[**2174-11-17**] 09:40AM BLOOD Plt Ct-207
[**2174-11-18**] 06:00AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.2
[**2174-11-18**] 06:00AM BLOOD Glucose-106* UreaN-27* Creat-0.4 Na-137
K-3.0* Cl-102 HCO3-28 AnGap-10
Most recent blood, sputum, and urine cultures from 12/3/4 were
negative.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**] MD [**MD Number(1) 2750**]
Completed by:[**2174-11-18**]
|
[
"568.0",
"997.4",
"V10.3",
"998.59",
"038.9",
"623.8",
"518.5",
"567.2",
"998.2",
"E870.0",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"38.91",
"31.1",
"38.93",
"54.59",
"54.91",
"43.19",
"00.14",
"99.15",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
9644, 9875
|
2679, 6016
|
338, 362
|
7319, 7325
|
9226, 9621
|
7929, 9207
|
1640, 1650
|
6095, 7115
|
7229, 7298
|
6042, 6072
|
7349, 7906
|
1665, 1686
|
283, 300
|
390, 1289
|
1701, 2251
|
1311, 1537
|
1553, 1624
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,326
| 119,304
|
24984
|
Discharge summary
|
report
|
Admission Date: [**2171-10-3**] Discharge Date: [**2171-10-9**]
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Zoloft / Celexa / Trazodone
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
SOB, palpitations
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is an 81 y/o f with nsclc s/p lul lobectomy, RCC s/p
nephrectomy, htn, cad (MI [**2168**]), afib, cva who presented to
[**Hospital6 **] with two to three days of increasing
palpitations and shortness of breath. She also noticed
concurrent hand discomfort bilaterally. She denies any f/c,
chest pain, n/v/d, abdominal pain, or dysuria, but she does note
a chronic "smoker's" cough. The shortness of breath occurs at
rest but is most noticeable with exertion; she is unable to walk
more than a few stairs at a time before becoming dyspneic. She
went to MVH and was found to be in rapid afib, and her troponin
I was minimally elevated at 0.26.
Past Medical History:
PMH:
1.)Non-small cell lung cancer s/p LUL lobectomy
2.)Renal cell cancer s/p right nephrectomy
3.)Coronary artery disease with MI in [**2168**]
4.)Paroxysmal atrial fibrillation
5.)CVA -- In past few months, with residual balance deficit
6.)Left sided blindess [**3-13**] to retinal artery thrombus
7.)Diverticulosis
8.)Arthritis
9.)Depression
.
PSH:
1.)LUL lobectomy
2.)Right nephrectomy
3.)CCY
4.) AAA repair with aortic stent
Social History:
Pt lives by herself on [**Hospital3 4298**]. Her niece, a former
EMT, lives behind her and is her hcp. She is currently smoking
and has a 65pack yr hx. Stopped drinking etoh during the past
few months.
Family History:
NC
Physical Exam:
t 99.3, bp 140/90, hr 93, rr 18, spo2 95%ra
gen- chronically but not acutely-ill appearing f, looks her age,
nad
neck- no jvd, no lad
cv- irreg irreg, no m/r/g
pul- moves air mod well, prolonged expr phase, no w/r/r
abd- soft, nt, nabs
extrm- no cyanosis/edema, warm/dry
nails- mild clubbing, no pitting/color changes/indentations
neuro- a&ox3
Pertinent Results:
[**2171-10-8**] 04:58AM BLOOD WBC-25.0* RBC-3.44* Hgb-9.2* Hct-28.7*
MCV-83 MCH-26.7* MCHC-32.0 RDW-13.9 Plt Ct-297
[**2171-10-7**] 07:36AM BLOOD WBC-31.2*# RBC-3.55* Hgb-9.6* Hct-29.3*
MCV-83# MCH-27.0 MCHC-32.7 RDW-13.5 Plt Ct-280#
[**2171-10-7**] 05:40AM BLOOD WBC-15.3*# RBC-3.72* Hgb-11.1* Hct-33.9*
MCV-91# MCH-29.7 MCHC-32.6 RDW-13.4 Plt Ct-165
[**2171-10-7**] 05:22AM BLOOD WBC-32.6* RBC-3.42* Hgb-9.6* Hct-28.6*
MCV-83 MCH-28.0 MCHC-33.6 RDW-13.8 Plt Ct-288
[**2171-10-5**] 02:52AM BLOOD WBC-19.3* RBC-4.25 Hgb-11.7* Hct-35.2*
MCV-83 MCH-27.4 MCHC-33.1 RDW-13.1 Plt Ct-291
[**2171-10-8**] 04:58AM BLOOD Neuts-91.5* Bands-0 Lymphs-5.1* Monos-3.2
Eos-0.1 Baso-0
[**2171-10-7**] 07:36AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+
[**2171-10-8**] 04:58AM BLOOD Plt Smr-NORMAL Plt Ct-297
[**2171-10-8**] 04:58AM BLOOD PT-14.8* PTT-98.6* INR(PT)-1.4
[**2171-10-7**] 07:36AM BLOOD Plt Ct-280#
[**2171-10-8**] 04:58AM BLOOD Glucose-184* UreaN-48* Creat-1.2* Na-144
K-4.6 Cl-112* HCO3-18* AnGap-19
[**2171-10-7**] 07:36AM BLOOD Glucose-125* UreaN-40* Creat-1.2*# Na-140
K-3.7 Cl-107 HCO3-21* AnGap-16
[**2171-10-7**] 05:40AM BLOOD Glucose-168* UreaN-70* Creat-2.6*# Na-138
K-4.7 Cl-107 HCO3-22 AnGap-14
[**2171-10-7**] 05:22AM BLOOD Glucose-130* UreaN-39* Creat-1.2* Na-139
K-3.6 Cl-107 HCO3-20* AnGap-16
[**2171-10-7**] 05:40AM BLOOD CK(CPK)-178*
[**2171-10-7**] 05:22AM BLOOD CK(CPK)-441*
[**2171-10-5**] 12:20PM BLOOD CK(CPK)-[**2094**]*
[**2171-10-7**] 05:40AM BLOOD CK-MB-6
[**2171-10-7**] 05:22AM BLOOD CK-MB-28* MB Indx-6.3* cTropnT-3.67*
[**2171-10-8**] 04:58AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.5
[**2171-10-7**] 07:36AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.4
[**2171-10-7**] 12:02PM BLOOD Type-ART Temp-38.0 pO2-56* pCO2-37
pH-7.37 calHCO3-22 Base XS--3
[**2171-10-7**] 09:26AM BLOOD pO2-52* pCO2-33* pH-7.39 calHCO3-21 Base
XS--3
[**2171-10-6**] 06:18PM BLOOD Type-ART pO2-79* pCO2-31* pH-7.46*
calHCO3-23 Base XS-0
[**2171-10-4**] 04:22PM BLOOD O2 Sat-98
[**2171-10-7**] 12:02PM BLOOD Lactate-2.1*
[**2171-10-7**] 09:26AM BLOOD Lactate-1.9
[**2171-10-6**] 06:18PM BLOOD Lactate-1.7
[**2171-10-7**] 09:26AM BLOOD freeCa-1.16
.
Cardiology Report ECG Study Date of [**2171-10-8**] 8:22:10 AM
Atrial fibrillation
Low limb lead QRS voltages - is nonspecific
Diffuse ST-T wave abnormalities - cannot exclude in part
ischemia - clinical
correlation is suggested
.
[**10-8**] CXR IMPRESSION:
1. No pneumothorax.
2. Mild pulmonary edema, likely reflecting CHF.
3. Interval increase in left retrocardiac opacity, which could
be atelectasis dependent edema, or developing pneumonia, alone
or in combination.
.
[**10-7**] Echo
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated. The right
atrium is moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%). Resting regional wall motion abnormalities include
basal inferior
and basal and mid inferolateral akinesis. The other walls are
hyperdynamic.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Moderate to
severe (3+)
mitral regurgitation is seen.
6.There is no pericardial effusion.
.
Brief Hospital Course:
81 y/o f with nsclc, rcc, HTN, cad, afib, s/p nephrectomy [**3-13**]
renal cell CA, and cva presents to osh with palpitations and sob
and found to be in rapid afib with a slight troponin leak now
s/p cardiac catheterization revealing 2 VD with unsuccessful
passage of wire across [**Month/Day (2) 8714**] lesion, hypotension, decreased RR and
runs of VT, intubated and sedated on levophed and lidocaine with
variable improvement requiring pressors who decided to become
[**Month/Day (2) 3225**].
# CAD: Pt was transferred to [**Hospital1 18**] for catheterization. RHC
showed relatively normal filling pressures (PCWP 11). When dye
was injected to do left heart cath she developed an acute drop
in BP, chest pain, bradycardia with ST depressions in V2-V5 and
mental status changes. She has decreased respiratory rate and
anesthesia was called to intubate her. She was given atropine
and was started on dopamine, but became tachycardic and had a
runs of VT with a stable blood pressure. She was started on
lidocaine drip and given 150 mg of amiodarone. She was weaned
off of the dopamine and then was started on levophed. Multiple
attempts were amde to cross the [**Hospital1 8714**] lesion, but were
unsuccessful.Echo in the lab showed LVEF 55% with hypokinesis of
the inferior wall and severe MR. She was transferred to the CCU
, intubatred and sedated on levophed and lidocaine drip.
Initially unclear if [**Name (NI) 8714**] lesion was acutely active or chronic
with some demand ischemia. As Cardiac enzymes continued to rise,
seems that an acute coronary event occurred. CT surgery
reviewed films and felt that patient was not a surgical
candidate. We continued to trend enzymes and recheck EKGs.
Continued [**Last Name (LF) **], [**First Name3 (LF) **], plavix did not having surgery,
continued statin, heparin gtt. On [**10-9**], a decision was made to
make the pt [**Name (NI) 3225**] per pt and family. We discussed this with Dr.
[**Last Name (STitle) **] who agreed with plan. Pt decided to have comfort measures
only and to discontinue pressors and other non pain relieving
medications. We discontinued antibiotics since patient was no
longer responsive to stimuli off pressors and she expired on
[**10-9**] appearing quite comfortable.
.
# Hypotension: Possibly secondary to active ischemia in cath lab
and VT (see above, pt required pressors, then weaned off- then
unable to tolerate her own BP and placed on again.
.
# A-fib -- Pt has long standing paroxysmal a-fib, likely related
to cad, la enlargement, or age-related conduction abnormalities.
She remained in continuous a fib most likely [**3-13**] ischemia and
remained on heparin drip.
.
# VT - Most likely secondary to ischemia.
.
# CRI -- Pt had a cr cl of around 30-35, probably [**3-13**] to
nephrectomy, htn, vascular disease. As such, we renally dosed
meds, provided with n-acetylcysteine pre/post-cath and gave
pre-cath bicarb. Avoided nephrotoxins.
.
#CVA -- Most likely embolic related to her afib. Restarted
warfarin in house
.
#Ppx -- heparin gtt, PPI
Medications on Admission:
1.)Metoprolol XL 25mg twice daily
2.)Imdur 20mg twice daily
3.)Digoxin 0.25mg daily
4.)Furosemide 10mg daily
5.)[**Month/Day (2) **] 81mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"518.5",
"V10.11",
"410.71",
"401.9",
"414.01",
"V10.53",
"997.1",
"593.9",
"496",
"427.89",
"578.0",
"V12.59",
"427.31",
"443.9",
"427.1",
"412",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"37.23",
"38.93",
"96.04",
"00.17",
"96.71",
"36.01",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8755, 8764
|
5485, 8528
|
282, 294
|
8815, 8824
|
2040, 5462
|
8880, 8890
|
1656, 1660
|
8723, 8732
|
8785, 8794
|
8554, 8700
|
8848, 8857
|
1675, 2021
|
225, 244
|
322, 967
|
989, 1421
|
1437, 1640
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,185
| 196,508
|
26456
|
Discharge summary
|
report
|
Admission Date: [**2187-12-14**] Discharge Date: [**2187-12-19**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo female s/p fall; she reports sitting on edge of chair and
fell asleep landing on floor head first. She was unable to get
up and subsequently crawled to another room where she was able
to activiate her Lifeline for help. She was transferred from a
referring facility to [**Hospital1 18**] for trauma care.
Past Medical History:
ESRD on peritoneal dialysis
Hypertension
Hypothyroidism; s/p thyroidectomy
Osteoathritis, s/p Bilat THR
Social History:
Lives alone in [**Hospital3 **] facility.
Widowed.
Has 3 daughters and 2 sons
Family History:
Noncontributory
Physical Exam:
VS upon admission:
96 165/88 90 20 95% room air sats
Gen: lying in bed, wearing c-[**Last Name (un) **]
HEENT: abrasion on forehead; PERRL 4->2
Neck: collar, supple
Chest: CTA bilat.
Cor: RRR, no M/R/G
Abd: soft NT/ND
EXT: No C/C/E
Neuro: Alert and oriented x3. Speech fluent. Follows commands
Pertinent Results:
[**2187-12-14**] 12:15AM GLUCOSE-133* UREA N-29* CREAT-7.0* SODIUM-137
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-21*
[**2187-12-14**] 12:15AM ALT(SGPT)-20 AST(SGOT)-30 ALK PHOS-234*
AMYLASE-97 TOT BILI-0.4
[**2187-12-14**] 12:15AM PLT COUNT-224
[**2187-12-14**] 12:15AM PT-12.0 PTT-24.0 INR(PT)-1.0
CT HEAD W/O CONTRAST [**2187-12-14**] 12:18 AM
CT HEAD W/O CONTRAST
Reason: please eval for bleed
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with fall, BL SDH, type 2 dens fx per OSH,
right shoulder pain
REASON FOR THIS EXAMINATION:
please eval for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 84-year-old female status post fall.
COMPARISON: None.
TECHNIQUE: Routine non-contrast head CT.
FINDINGS: There is a small right-sided subdural hematoma
measuring no more than 3 mm in diameter. A tiny, 2-mm subdural
hematoma is also seen along the right falx cerebri. A moderate
left-sided subdural hematoma extends along the left frontal
bone, along the falx cerebri, and down along the left tentorium
cerebelli. At greatest dimension adjacent to the left falx
cerebri, this measures 6 mm. The septum pellucidum is slightly
shifted to the right by 3 mm. There is no evidence of
herniation. There is no loss of [**Doctor Last Name 352**]-white matter
differentiation. Low attenuation within the periventricular
white matter is consistent with small vessel ischemic disease.
The surrounding soft tissue and osseous structures demonstrate a
dens fracture. The paranasal sinuses and mastoid air cells are
appropriately aerated. No additional fractures are identified
within the skull.
IMPRESSION: Bilateral acute subdural hemorrhages, left greater
than right as described above. 3-mm shift of normal midline
structures to the right.
CT C-SPINE W/O CONTRAST [**2187-12-14**] 12:19 AM
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: please eval for fx
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with fall, BL SDH, type 2 dens fx per OSH,
right shoulder pain
REASON FOR THIS EXAMINATION:
please eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 84-year-old female status post fall. Evaluate.
COMPARISON: None.
TECHNIQUE: MDCT imaging of the cervical spine was performed
without intravenous contrast. Coronal and sagittal reformatted
images were obtained.
FINDINGS:
The normal cervical spinal alignment is maintained. There is a
type II odontoid fracture. No additional fractures are seen
within the cervical spine. Degenerative changes are seen
primarily along the facet joints. There is no loss of vertebral
body height. Mild narrowing of the intervertebral disk space is
seen at C6/7. CT is not as sensitive as MR in defining
intrathecal detail. The visualized outline of the thecal sac is
unremarkable.
IMPRESSION: Type II odontoid fracture.
CT UP EXT W/O C [**2187-12-14**] 10:53 AM
CT UP EXT W/O C; CT RECONSTRUCTION
Reason: S/P FALL, EVAL HUMERUS FX
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman s/p fall with right proximal humerus fx
REASON FOR THIS EXAMINATION:
please do CT of right shoulder, patient has humerus fx on plain
film
CONTRAINDICATIONS for IV CONTRAST: None.
CT EXAMINATION OF THE RIGHT SHOULDER:
DATE OF EXAM: [**2187-12-14**].
INDICATION: 84-year-old female status post fall with right
proximal humeral fracture.
TECHNIQUE: Contiguous 2.5 mm axial images were obtained through
the right glenohumeral joint without the administration of
contrast. Images were reformatted in oblique, coronal, and
sagittal planes.
FINDINGS: Comparison with plain film examination dated [**12-14**], [**2187**]. There is a minimally displaced and partially rotated
fracture through the greater tuberosity. The surgical neck and
lesser tuberosity are intact without fracture. The glenohumeral
joint articulation is unremarkable, without subluxation or
dislocation. There is a moderate glenohumeral joint effusion,
with a 2 cm oval shaped more hyperintense fluid collection
within the subcoracoid or subscapular recess, compatible with
hemarthrosis. Remainder of the soft tissues is unremarkable. The
biceps tendon is appropriately seated within the bicipital
groove.
There is vascular calcification involving the axillary artery.
No displaced rib fractures are seen in the area imaged. There is
pleural thickening within the left lung apex, as well as a focal
pleural-based calcification. Coronary vessel calcification is
also identified.
The acromioclavicular joint is intact.
IMPRESSION: Minimally displaced and rotated fracture of the
greater tuberosity. No other fractures identified.
SHOULDER 1 VIEW BILAT [**2187-12-14**] 12:33 AM
SHOULDER 1 VIEW BILAT
Reason: please eval for fx/dislocation
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with fall, BL SDH, type 2 dens fx per OSH,
right shoulder pain
REASON FOR THIS EXAMINATION:
please eval for fx/dislocation
EXAM ORDER: Bilateral shoulders.
HISTORY: Trauma.
A single AP view of the left shoulder show 2-part surgical neck
fracture of the proximal left humerus. There is no apposition of
the humeral shaft and head fragments. The humeral shaft is
anteriorly displaced with relation to humeral head. Since there
is only one view of the left shoulder, evaluation of lesser and
greater tuberosities is limited for an associated fracture.
Right shoulder, a single AP view shows mildly displaced greater
tuberosity fracture. No other fracture is seen on this single
view.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedics; Spine
Service and Neurosurgery were immediately consulted. Her humeral
fracture was treated non surgically; she is being treated with
sling and will need to follow up in [**Hospital 1957**] clinic in 2 weeks for
repeat films. Spine service has recommended hard cervical collar
immobilization for the next 6 weeks and follow up in the Ortho
Spine clinic in [**5-2**] weeks. Neurosurgery has recommended Dilantin
for a total of 7 days; her last dose will be on [**12-22**]. Renal was
also consulted because of her ESRD; she will need to follow up
with her primary nephrologist after her discharge. Geriatrics
service was consulted because of patient's mechanism of injury
and have made several recommendations; patient has been started
on Calcium and Vit D and will need bone densitometry when in
rehab.
Medications on Admission:
Synthroid
Epo
Neurontin
Lipitor
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
for HR less than 60 and SBP less than 100 mmHg.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8 ().
5. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day) for 3 days: Discontinue after
last dose on [**12-21**].
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
12. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
s/p Fall
Bilateral Subdural Hematoma
C2 Odontoid fracture
Right Humeral fracture
Discharge Condition:
Stable
Discharge Instructions:
Follow up in [**Hospital 4695**] Clinic in [**5-2**] weeks
Follow up in [**Hospital **] clinic in 2 weeks
You must continue to wear your neck collar for next 6 weeks
Continue with your Dilantin to prevent seizures until [**12-22**]
Followup Instructions:
1.Call [**Telephone/Fax (1) 1669**] for an appointment with [**Hospital 4695**] Clinic
after your discharge from rehab. You will need to call for an
appointment.
3.Bone Densitometry while in rehab will need to be scheduled
4.Follow up in [**Hospital **] Clinic in 2 weeks with Dr. [**Last Name (STitle) 1005**];
call [**Telephone/Fax (1) 1228**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2187-12-19**]
|
[
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icd9cm
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[
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[
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24,465
| 185,111
|
5805
|
Discharge summary
|
report
|
Admission Date: [**2123-10-8**] Discharge Date: [**2123-10-18**]
Date of Birth: [**2050-8-26**] Sex: M
Service: MEDICINE
Allergies:
Methyldopa / Shellfish
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy C4-C5.
2. Anterior cervical arthrodesis C4-C5.
3. Structural allograft.
4. Anterior plating C4-C5.
5. PEG tube placement
History of Present Illness:
Patient is a 73 year old male with atrial fibrillation, ESRD on
HD, DM type 2, prior CVA, who presents to the ED after falling
in his bathroom at home. His wife reports she heard a thump, and
found the patient on the floor with a large laceration on his
head, awake.
.
He remembers walking to the bathroom and falling over his walker
into the tub. He does not think that he lost consciousness, but
according to his wife he did for about one minute. He remembers
lying in the tub and not being able to move his legs. His wife
called 911.
.
He denies any prodrome before the fall, including
lightheadedness, palpitations, chest pain, SOB.
.
In [**Hospital1 18**] ED, he was noted to have no strength in his lower
bilateral extremities, and poor strength in his upper
extremities. His cranial nerves were intact, and his vitals
remained stable. He had imaging of his neck, which showed an
acute C3 fracture, as well as C4/C5 osteophyte with cord
compression. Neurosurgery was consulted, as well as trauma
surgery. They recommended no surgical treatment at this time,
but decadron and close monitoring. CT chest showed a
non-calcified nodule, and there was a renal mass seen on CT abd.
He was admitted to ICU for monitoring of neuro status, and to
medicine due to multiple co-morbidities.
.
ROS: He recently has been feeling well.
Past Medical History:
CAD s/p CABG '[**20**]
CHF (LVEF 30-35%)
DM II
Hyperlipidemia
HTN
CKD V due to diabetic nephropathy on HD since [**3-/2122**]
moderate pulm HTN
AF on coumadin, history of stroke (by report) with mild residual
R-sided weakness
PVD s/p L SFA to PT bypass for nonhealing ulcer
tachy-brady s/p PM '[**16**]
Social History:
lives at home with wife, + hx smoking quit 30 yrs ago after 10
yrs of smoking [**1-2**] ppd, very rare etoh.
Family History:
M: DM2, HTN; F: DM2; MGM: DM2; MGF: DM2.
"Everyone with HTN."
Physical Exam:
T 96.5
BP 136/62
HR 64
RR 20
Oxygen 98% ra
GENERAL: Elderly male lying flat with hard cervical collar,
speaking with garbled voice
HEENT: MMM, large echymsois and significant swelling of left
periorbital area. Large sutured laceration of left anterior
head. Pupils 3mm and reactive. Poor dentition.
NECK: In hard collar.
CARDIAC: Regular, no appreciated murmur or rub.
LUNGS: Coarse BS bilaterally, diminished at left base.
ABDOMEN: soft, flat, NT, ND, pos BS.
EXTREMITIES: no c/c. R 1+ edema. L no edema. Right arm fistula.
SKIN: laceration on head and knees.
NEURO: AAO x 3. Cranial nerve exam normal. Garbled speech. [**3-4**]
strength in left deltoid and forearm. 4-/5 in right arm deltoid,
[**2-1**] in forearm. Able to lift left leg against gravity, Unable to
move right leg, though does flex as a reflex at times. Equivocal
toes. Could not elicit LE DTR.
PSYCH: Appropriate.
Pertinent Results:
[**2123-10-8**] 01:21PM WBC-5.4 RBC-3.17* HGB-10.6* HCT-33.0*
MCV-104* MCH-33.4* MCHC-32.1 RDW-14.5
[**2123-10-8**] 01:21PM NEUTS-74.5* LYMPHS-14.0* MONOS-5.8 EOS-5.7*
BASOS-0.1
[**2123-10-8**] 01:21PM PLT COUNT-159
[**2123-10-8**] 01:21PM PT-30.9* PTT-36.1* INR(PT)-3.3*
[**2123-10-8**] 01:21PM GLUCOSE-205* UREA N-20 CREAT-3.6* SODIUM-133
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-31 ANION GAP-14
[**2123-10-8**] 01:21PM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.8
[**2123-10-18**] 06:11AM BLOOD WBC-9.2# RBC-2.97* Hgb-9.8* Hct-30.8*
MCV-104* MCH-32.9* MCHC-31.7 RDW-16.1* Plt Ct-184
[**2123-10-18**] 06:11AM BLOOD PT-12.0 PTT-24.4 INR(PT)-1.0
[**2123-10-18**] 06:11AM BLOOD Glucose-169* UreaN-67* Creat-4.7* Na-143
K-4.4 Cl-100 HCO3-31 AnGap-16
[**2123-10-18**] 06:11AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.3
[**2123-10-13**] 07:30AM BLOOD Carbamz-1.4*
[**2123-10-17**] 05:07AM BLOOD Carbamz-3.9*
.
[**2123-10-8**] 01:21PM CK(CPK)-47
[**2123-10-8**] 01:21PM CK-MB-NotDone
[**2123-10-8**] 01:21PM cTropnT-0.20*
[**2123-10-9**] 02:31PM BLOOD CK(CPK)-101
[**2123-10-9**] 02:31PM BLOOD CK-MB-6 cTropnT-0.16*
[**2123-10-9**] 12:05AM BLOOD CK(CPK)-128
[**2123-10-9**] 12:05AM BLOOD CK-MB-6 cTropnT-0.19*
[**2123-10-8**] 01:21PM BLOOD CK(CPK)-47
[**2123-10-8**] 01:21PM BLOOD cTropnT-0.20*
.
[**2123-10-8**] 09:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2123-10-8**] 09:13PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2123-10-14**] 07:59PM BLOOD Type-ART Rates-/12 FiO2-36 pO2-159*
pCO2-40 pH-7.42 calTCO2-27 Base XS-1 Intubat-INTUBATED
Vent-CONTROLLED
[**2123-10-14**] 06:55PM BLOOD pO2-160* pCO2-48* pH-7.35 calTCO2-28 Base
XS-0
[**2123-10-14**] 04:04PM BLOOD Type-ART pO2-310* pCO2-41 pH-7.41
calTCO2-27 Base XS-1 Intubat-NOT INTUBA
[**2123-10-14**] 07:59PM BLOOD Glucose-147* Lactate-1.3 Na-139 K-4.1
Cl-103
[**2123-10-14**] 06:55PM BLOOD Glucose-165* Lactate-1.3 Na-139 K-4.6
Cl-100
[**2123-10-14**] 04:04PM BLOOD Glucose-147* Lactate-0.9 Na-139 K-4.5
Cl-101
[**2123-10-14**] 07:59PM BLOOD freeCa-1.12
[**2123-10-8**] 1:21 pm BLOOD CULTURE **FINAL REPORT [**2123-10-14**]**
AEROBIC BOTTLE (Final [**2123-10-14**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2123-10-14**]): NO GROWTH.
[**2123-10-10**] 12:21 am URINE Source: CVS.
**FINAL REPORT [**2123-10-12**]**
URINE CULTURE (Final [**2123-10-12**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ 16 R
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
[**2123-10-8**] CT C spine
1. Apparent blockage of the intrathecal contrast especially
ventrally at the C4/5 level due to a large disc osteophyte
complex which appears to be causing severe canal stenosis.
2. At C3/4, there is a disc osteophyte complex which appears to
be causing moderate canal stenosis. At C6/7, there is a disc
osteophyte complex which is causing mild canal stenosis.
3. No high-grade canal stenosis of the thoracic or lumbar spine
although evaluation of the lumbar spine is somewhat limited by
suboptimal filling of the thecal sac by contrast.
4. Again seen is a nondisplaced fracture of the anteroinferior
corner of C3.
5. Multilevel degenerative changes as described above.
Please refer to CT of the abdomen and pelvis for full
description of other significant findings.
[**2123-10-8**] CT Chest/Abdomen/Pelvis
1) Non-calcified 4 mm lung nodules require CT follow up within
six to 12 months. Slightly larger area of ground-glass opacity
in the left upper lobe may represent contusion. Follow up is
advised.
2) Bilateral renal hyperdense and hypodense lesions, which may
represent simple and hemorrhagic cysts though evaluation is
incomplete on this noncontrast study. Further evaluation with
multiphasic CT or MRI is recommended. Cystic structure inferior
to left kidney may represent exophytic cyst.
3) Significantly enlarged prostate measuring approximately 5.5
cm.
4) Extensive calcifications of the aorta and its branches.
5) Degenerative changes with large posterior osteophytes of the
spine as described above.
[**2123-10-8**] CT Head
1. Extensive left frontal scalp and left periorbital and
preseptal soft tissue swelling and hematoma. Within the context
of this severely limited scan, there does not appear to be an
intracranial hemorrhage or acute fracture.
[**2123-10-8**] ECG - Ventricular paced rhythm. Compared to prior
tracing of [**2123-8-4**] atrial pacing is no longer clearly seen.
[**10-14**] intraoperative c-spine 2 views
Two intraoperative portable radiographs of the cervical spine
are submitted for interpretation. The first radiograph
demonstrates a probe positioned at the C4-5 disc space. The
second radiograph demonstrates an anterior fusion plate with
screws at C4 and C5 with an interbody fusion device at the C4-5
disc space. The patient is intubated. There are very large
anterior osteophytes at C5-6. There is diffuse disc space
narrowing at all levels. There is a bridging osteophyte at C6-7.
[**10-15**] CT C-spine w/out contrast: Comparison is made to the
preoperative studies from [**2123-10-8**].
There is a new anterior fixation plate with two screws through
the bodies of C4 and C5. An intervertebral bone graft is seen
within the disc space as well as small bubbles of air. There is
no evidence of hardware breaks. The screws are well placed
within the vertebral bodies. The anterior plate is well apposed
to the vertebral bodies.
There has been partial resection of the posterior corners of the
vertebral bodies adjacent to the C4/5 disc. The previously seen
posterior osteophytes have been largely resected with some
minimal osteophytes remaining at the uncovertebral joints
bilaterally.
The evaluation of the intraspinal contents is somewhat limited
due to streak artifacts from the orthopedic hardware. Bilateral
foraminal stenoses are again seen at this level.
Again seen is a non-displaced corner fracture of the
anteroinferior corner of C3.
Multilevel degenerative changes are again seen as before.
There is new soft tissue emphysema of the anterior neck,
especially extending along the right side of the neck and along
the esophagus.
The visualized lung apices are clear.
IMPRESSION:
1. Since [**2123-10-8**], new ACDF of C4 and C5 with no evidence of
hardware breaks. The previously seen posterior disc osteophyte
complex has been resected with residual osteophytes of the
uncovertebral joints bilaterally remaining.
2. Again visible is a non-displaced fracture of the
anteroinferior corner of C3.
3. Multilevel degenerative changes as previously described.
CHEST (PORTABLE AP) [**2123-10-18**] 9:00 AM
In comparison with the study of [**10-14**], there is no interval
change. Specifically, no evidence of new pneumonia.
Brief Hospital Course:
73 year old male with multiple medical problems including
coronary artery disease, diabetes mellitus, and ESRD on HD, who
presents after mechanical fall with C3 fracture and cord
compression.
.
1. Fall
Patient was admitted after a fall at home when he was found down
by his wife. According to his wife, she heard a thump and found
him in the bathroom. He reports however that he tripped forward
over his walker and hyperreflexed his neck against the edge of
his bathtub. He denies any complaints of chest pain,
palpitations, and seizure activity. Given that the fall was
unwitnessed, patient underwent a syncope evaluation. Regarding
arrhythmias, EP evaluated the patient and interrogated his
pacer. No events were found. Regarding cardiac ischemia, MI was
ruled out with three sets of negative enzymes. Regarding
structural heart disease, patient has had an echocardiogram on
[**11-4**] which had no evidence of aortic stenosis or other
structural defect. Regarding neurological event, seizure
remained on the differential given his history. EP consulted,
pacer functioning normally. No evidence of ischemia/MI, CE's
stable. ECHO [**11-4**] no evidence of AS or other structural defect
that could explain syncope. Infection appeared unlikely given
that patient remained afebrile and no history to suggset
infection. CT showed no evidence of bleed to suggest hemorrhagic
stroke. Cannot get MRI to r/o acute embolic stroke, though pt
was supratherapeutic so less likely. Patient's blood culture was
negative. This was thought to be most likely a mechanical fall.
.
2. Acute fracture of C3 and cord compromise.
Patient was found to have an acute C3 fracture with evidence of
cord compromise. He was evaluated by neurosurgery who
recommended initial treatment with dexamethasone and then
patient went to the OR on [**2123-10-14**]. His procedure was
uncomplicated and he has follow-up imaging and neurosurgery
appointments on [**2123-11-3**]. He has been using standing tylenol and
prn morphine for pain control. He should continue on the hard
collar until he follows up with Dr. [**Last Name (STitle) 548**]. He will need
intensive physical and occupational therapy.
.
3. Coronary Artery Disease
Patient's cardiac enzymes were negative and his ECG remained
unremarkable. Regarding his medication regimen, aspirin was held
during his initial perioperative state but was restarted within
2-3 days of his procedure. His ACEI and beta blocker were
initially held due to the need to maintain an SBP > 120 in the
perioperative state. His ACEI was restarted and his beta blocker
will need to be added back on within his first 3-4 days at rehab
with goal to maintain SBP>90 per neurosurgery. His statin was
continued.
.
4 CHF:
Patient has a history of a depressed ef (~30%) and he remained
stable from that standpoint during his admission. His fluid
status was maintained with HD. His ACEI and beta blocker were
initially held as discussed in #3 CAD. His ACEI was restarted
and his beta blocker will need to be restarted. His fluid status
can continue to be monitored with HD.
.
5. ESRD:
Patient is followed by Dr. [**Last Name (STitle) 118**]. He is normally on a TuThSa HD
regimen. During the [**Holiday 1451**] week, he was dialyzed on Monday
[**10-18**] and will need dialysis on Wednesday [**10-20**] and then return
to his usual schedule on Saturday [**10-23**]. New renal mass in L
kidney. [**Month (only) 116**] need w/u as outpt. Patient was continued on epo and
nephrocaps.
.
6. HTN:
Goal SBP is > 90 to maintain spinal perfusion. He was restarted
on lisinopril and should be restarted on his beta blocker as his
SBP tolerates.
.
7. Atrial Fibrillation
Patient's coumadin was held perioperatively. He was restarted on
[**10-17**]. His INR and coumadin dose will need to be monitored
daily.
.
# Anemia:
He has anemia associated with CKD and receives EPO.
.
# PPX: pneumoboots, aspiration and fall precautions, bowel
regimen, ppi for steroids
# Code: full.
# Contact: Wife [**Name (NI) 3508**] [**Name (NI) **] [**Name (NI) 23054**] [**Telephone/Fax (1) 23057**]
Medications on Admission:
EC Aspirin 81mg daily
Folic acid 1mg daily
Glyburide 2.5mg qd
Lipitor 80mg daily
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
Nephrocaps 1 daily
Tegretol XR 200mg [**Hospital1 **]
Tums 500mg [**Hospital1 **]
Vitamin B12 500mcg daily
Vitamin B6 50mg daily
Warfarin 5mg TUES/FRI, 6mg M/W/TH/Sat/Sun, last dose [**2123-7-31**]
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Carbamazepine 100 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day).
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
9. Insulin Regular Human 100 unit/mL Solution Sig: Three (3)
Injection ASDIR (AS DIRECTED): Please continue according to the
attached sliding scale. .
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Please continue a dexamethasone taper according to the
following schedule: 4mg on [**10-18**] and [**10-19**]; 3mg on [**10-20**] and
[**10-21**]; 2mg on [**10-22**] and [**10-23**]; 1mg on [**10-24**] and [**10-25**].
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Epo Sig: 4000 (4000) unit Hemodialysis once a week.
16. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO twice a day.
17. Coumadin 1 mg Tablet Sig: 5-6 Tablets PO at bedtime: Patient
takes 5-6mg of coumadin normally. Please monitor INR daily and
titrate coumadin dosage accordingly. .
18. Morphine 4 mg/mL Syringe Sig: 2-4 mg Injection every four
(4) hours as needed for pain.
19. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. C3 fracture
2. Spinal Cord Compression C4-5; C6-7
3. Urinary Tract Infection
4. End Stage Renal Disease on hemodialysis
5. Diabetes Mellitus
6. Difficulty Swallowing
.
SECONDARY DIAGNOSIS:
1) End stage renal disease on hemodialysis TUES/THURS/SAT at
[**Location (un) 1468**]
Dialysis under the care of Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] (right arm AV
fistula)
2) Hyperlipidemia
3) Hypertension
4) Possible seizure disorder, none in 15 years
5) Diabetes Type II complicated by retinopathy and neuropathy
6) Atrial fibrillation
7) [**4-4**]: Stroke: (Left MCA embolic stroke) with possible
residual right sided weakness, on chronic anticoagulation
8) [**12-5**]: Hip fracture
9) Depressed Left Ventricular Function, Ejection Fraction 30-35%
[**11-4**], Moderate mitral regurgitation, Coronary Artery Disease
status post silent Myocardial Infarction [**2109**], CABG [**2120**] with
LIMA to LAD, SVG to OM2, SVG to PDA
10) s/p pacemaker placement for tachybrady syndrome in [**2116**] with
generator change [**3-6**]. Considered for ICD upgrade but EP study
negative for inducible VT
11) [**2121**]: Peripheral [**Year (4 digits) **] Disease status post left SFA to PT
bypass
12) Intracranial abscess, treated 50+ years ago with surgery
(patient
reports that he never had an intracranial hemorrhage as noted in
prior records in CCC)
13) History of urinary retention
14) Cataracts, s/p surgery bilaterally
15) Recent thrombocytopenia which has since improved. HIT screen
neg
16) Moderate pulmonary hypertension
.
Discharge Condition:
Stable - Patient continues to be NPO due to poor swallowing
function. He also has limited ability to move his lower
extremities and is able to move his upper extremities (L>R) with
4+/5 strength bilaterally but limited finger extension and
flexion. Patient is alert and oriented to person, place, and
time.
Discharge Instructions:
You were admitted to the hospital for evaluation after your
fall. You were found to have fractured a bone in your neck and
that small fragments of bone were compressing your spinal cord.
You had a procedure called an anterior cervical diskectomy,
arthrodesis, and plating of your C4-C5.
.
While you were hospitalized, you were also found to have a
urinary tract infection and were treated with an antibiotic
called vancomycin for a five day course.
.
Given the difficulty of wearing your collar and your recent
procedure, you are unable to swallow food. We have instead
placed a PEG tube (feeding tube) into your stomach so that you
can continue to receive nutrition and medications. You will need
to have a speech and swallow evaluation repeated during your
stay at rehab.
.
We also held your coumadin in the setting of your recent injury
and surgery. Your neurosurgery team felt comfortable restarting
your coumadin on [**2123-10-17**]. You will need to have your INR and
coumadin dose monitored daily until you are again therapeutic
with an INR between [**1-2**]. Your tegretol was also held for a few
days while you were unable to eat. We have restarted this and
you will need to monitor your tegretol levels every 3 days until
it is considered therapeutic.
.
We continued you on all of your previous medications and
continued your dialysis according to your previous schedule. You
normally receive dialysis on Tuesday - Thursday - Saturday;
however due to the [**Holiday 1451**] holiday, you received dialysis
on Monday [**10-18**], are scheduled to get dialysis on
Wednesday [**10-20**], and then resume your normal schedule
with dialysis on Saturday [**10-23**].
.
Please continue to take all of your medications as prescribed.
Please go to all of your follow up appointments. If you have
fevers, chills, night sweats, abdominal pain, diarrhea, nausea,
vomiting, headache, please seek immediate medical attention.
.
We have made the following changes to your medication list since
your admission:
- dexamethasone - you were added on this medication to improve
swelling around your spinal cord after your fall. We will slowly
decrease your dose of steroids over the next 7-8 days.
- Senna and bisacodyl - we added these medications to maintain
regular bowel movements.
- Tylenol - We added scheduled tylenol to treat post-operative
pain.
- Morphine - We added morphine as needed for pain breakthrough
- Pantoprazole - We added pantoprazole to prevent stress induced
esophagitis or ulcers.
Followup Instructions:
Please follow-up with your primary care doctor Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] within 1-2 weeks of your discharge from rehab. Dr. [**Name (NI) 23058**] office phone number is [**Telephone/Fax (1) 250**].
.
Please also follow-up with your neurosurgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]
on [**11-3**] at 1:15pm in the [**Hospital **] Medical Building [**Location (un) 3202**] on [**Last Name (NamePattern1) 439**]. You will also need a CT scan of
your neck. Your radiology appointment for your CT scan will be
on [**11-3**] at 11:45am on the [**Hospital Ward Name 517**] on the Clinical
Center [**Location (un) **]. If you need to reschedule, please call his
office at [**Telephone/Fax (1) 1669**] for your appointment time.
.
You also have an appointment with your podiatrist [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**],
DPM on [**2123-10-28**] 3:30. If you need to cancel or reschedule your
appointment, please call his office at [**Telephone/Fax (1) 543**].
.
You also have a PACEMAKER CALL appointment on [**2123-10-19**] 10:45. If
you need to reschedule, please call them at [**Telephone/Fax (1) 59**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
Completed by:[**2123-10-18**]
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icd9pcs
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[]
]
] |
16673, 16745
|
10293, 14361
|
289, 444
|
18363, 18672
|
3252, 10270
|
21216, 22593
|
2270, 2333
|
14746, 16650
|
16766, 16766
|
14387, 14723
|
18696, 21193
|
2348, 3233
|
245, 251
|
472, 1801
|
16977, 18342
|
16785, 16956
|
1823, 2127
|
2143, 2254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,940
| 131,669
|
45168+58792
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-5-29**] Discharge Date: [**2124-6-12**]
Date of Birth: [**2048-10-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Upper GI Bleed
.
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
Ultrasound-guided liver biopsy
.
History of Present Illness:
75 M with hx of PUD, PVD s/p fem-fem bypass on coumadin,
emphysema, who originally presented to [**Hospital1 18**]-[**Location (un) 620**] with one
week of nausea and vomiting, diffuse abd pain, decreased PO
intake, and decreased urination. No fever, chills, diarrhea, or
melena. Patient was found to be hypotensive to the 80's
systolic. He was found to have a UTI and received a dose of
levaquin. He looked sufficicently ill that he was intubated,
had a R triple lumen placed, and an NG lavage showed 1.2 L of
[**Location (un) **] blood return. His INR was discovered to be 7, Hct 10.2,
lactic acid 12.5, creatinine 2.6, INR 7.3. so he received 4
units of NS, 2 units PRBC and one unit of FFP, as well as 5 mg
IV vitamin K and 5 mg Sub-q. He was started on ocreotide and
nexium and transferred here for further work-up and management.
.
In the ED, patient remained hypotensive to 80's. He was started
on vasopressin as a single [**Doctor Last Name 360**] for concern about possible
esophageal varices. He was given a dose of flagyl for concern
about possible bacterial translocation and GI was paged. He had
labs drawn and is getting 2 units of emergency release blood
while waiting for his type and screen to be completed. He
received a dose of versed for comfort.
He is being admitted to the MICU for close monitoring and
possible endoscopy.
Past Medical History:
Hypertension
Hyperlipidemia
PVD, s/p LLE bypass at [**Hospital1 2025**] in [**2115**] with revision in [**2116-3-11**]
[**2118**] s/p left deep femoral artery->peroneal bypass by Dr.
[**Last Name (STitle) **], left fifth ray amputation for osteomyelitis
[**6-17**]: left common iliac stenting, left external iliac artery
stenting
[**2123-7-10**]: fem-fem bypass, right femoral to popliteal bypass
PUD (per records in CCC- patient denies)
Emphysema
Sclerosing cholangitis
Cholecystectomy
Appendectomy
[**4-16**]: spontaneous pneumothorax ([**Hospital3 **])
Alcohol use- 3-4 beers per day
Social History:
Patient is divorced and lives alone. He has four
children.
His daughters are very involved in his care. Kerrin [**Hospital3 **]:
[**Telephone/Fax (1) 96541**]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96542**] [**Telephone/Fax (1) 96543**].
Family History:
N/C
Physical Exam:
VS: T: 96 BP: 96/51 P: 79 RR: 18 O2 sat: 100% on vent
GEN: intubated, sedated, NAD
HEENT: AT, NC, pupils constricted, minimally reactive, no
conjuctival injection, anicteric, MM dry, ETT and NGT in place,
NGT is draining dark maroon colored fluid
CV: heart sounds very distant, regular
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, NT, ND, + BS
EXT: warm, dry, lower extremities covered in flaking skin
NEURO: intubated, sedated, does not respond to voice
Pertinent Results:
ADMISSION LABS
[**2124-5-29**] 02:30AM WBC-15.3*# RBC-2.75*# HGB-5.6* HCT-20.2*#
MCV-73*# MCH-20.5*# MCHC-27.9* RDW-22.7*
[**2124-5-29**] 02:30AM GLUCOSE-100 UREA N-74* CREAT-1.9* SODIUM-144
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-15* ANION GAP-29*
[**2124-5-29**] 02:31AM HGB-5.7* calcHCT-17
[**2124-5-29**] 04:52AM WBC-14.7* RBC-3.63*# HGB-8.7*# HCT-27.3*#
MCV-75* MCH-23.9*# MCHC-31.8# RDW-20.9*
[**2124-5-29**] 04:52AM ALT(SGPT)-269* AST(SGOT)-495* LD(LDH)-1065*
ALK PHOS-113 AMYLASE-100 TOT BILI-1.6*
[**2124-5-29**] 09:43AM LACTATE-1.7
[**2124-5-29**] 11:20PM CALCIUM-8.5
[**2124-5-29**] 11:20PM HCT-38.8*
.
CXR [**2124-5-28**]: FINDINGS: Endotracheal tube is seen with tip
approximately 7 cm above the carina. Nasogastric tube is seen
with tip coiled in the stomach. Right-sided central venous line
with tip overlying the mid SVC. Cardiac and mediastinal contours
are unremarkable. Pulmonary vascularity appears within normal
limits. Nodular densities overlying the right upper and mid
lungs again seen, the lower of which possibly represents nipple
shadow. This is not significantly changed from prior. No
definite focal consolidation identified, although the right
costophrenic angle is excluded from the image. IMPRESSION:
1. Endotracheal tube with tip approximately 7 cm above the
carina. 2. Unchanged nodular densities within the lungs. Right
upper lobe nodule concerning for possible malignancy, and
further evaluation with CT recommended.
.
from [**Hospital1 4086**] -CT ABDOMEN AND PELVIS: Examination is a little
limited by the lack of oral and intravenous contrast. Within
the liver, multiple discrete hypodense lesions are seen which
are most consistent with metastatic disease. There is no
obvious intra- or extrahepatic biliary dilatation seen. The
gallbladder is not clearly identified. The spleen is normal.
There is some dilatation of the stomach, the cause of which is
not readily apparent. The duodenal sweep appears unremarkable.
No [**Hospital1 **] evidence of wall thickening is seen. No real adjacent
lymphadenopathy of note.
.
Upper Endoscopy [**5-29**]: Giant duodenal ulcer, nonbleeding, white
base. No visible vessel. Severe esophagitis.
.
Colonoscopy [**6-2**]:
Diverticulosis of the sigmoid colon and distal descending colon
Mass in the mid-transverse colon (injection, biopsy)
Small, yellow, plaque-like lesions on an erythematous base were
noted just poximal to the mass. (biopsy)
Ulcers in the sigmoid colon and descending colon
Edematous and hyperemic in the all visualized portions
Otherwise normal colonoscopy to mid-transverse colon
.
.
Transverse Colon biopsy [**6-2**]:
A. Colon (transverse), mucosal biopsy: Colonic mucosa with
regenerative changes and fragments of fibrinopurulent exudate,
consistent with ulceration.
B. Colon (transverse mass), mucosal biopsy: Fragments of
adenoma. No submucosa is present to evaluate for invasion.
Multiple levels examined. .
.
Bilateral ABI [**6-7**]: Doppler waveform analysis reveals a biphasic
waveform at the right common femoral and popliteal arteries with
monophasic waveforms at the dorsalis pedis and posterior tibial.
The tibial vessels were non-compressible and an ABI could not be
obtained. On the left there are monophasic waveforms at the
common femoral and popliteal with absent DP and PT signals.
Pulse volume recordings reveal mild blunting at the thigh on the
right, there is dampening at the level of the calf and again at
the ankle on the right. On the left there is a severely dampened
waveform at the common femoral level with a further severe
dampening at the calf and a essentially flat trace at the ankle
and metatarsal.
IMPRESSION: Significant left aortoiliac and bilateral SFA and
tibial disease.
.
Brief Hospital Course:
75M with hx of PUD, PVD s/p fem-[**Doctor Last Name **] bypass on coumadin,
emphysema, transferred from [**Hospital1 18**]-[**Location (un) 620**] to our MICU with
severe blood loss anemia, elevated INR, UTI, and sepsis s/p
intubation. Now stable for transfer to the floor with stable
Hct, BP, and breathing on 2L NC O2. Now found to have mass in
transverse colon suspicious for malignancy with mets to liver
and awaiting surgery recs and biopsy results.
.
# s/p UGI bleed: Patient with giant duodenal ulcer which was
likely cause for severe anemia and Hct of 10 upon arrival at
OSH. Received 8U PRBCs in MICU. EGD showing no active bleeding
so blood loss was likely chronic. Patient's Hct has been stable,
is 40 on admission. Patient's supratherpeutic INR (thought to be
[**2-12**] shock liver in setting of sepsis and possible infiltrative
disease) also reversed with FFP. Now INR is normalized. Patient
weaned off continuous PPI. Now on protonix PO BID.
.
# transverse colon/liver lesions concerning for malignancy:
Colonoscopy on [**2124-6-2**] showing 4cm mass in transverse colon
suspicious for malignancy. Given high CEA, normal AFP, and
appearance of liver lesions more consistent with metastasis on
CT scan, most likely this is GI primary with liver metastasis.
Biopsies taken, is partial obstruction. Patient able to pass
stool, no abdominal pain. Hct stable but slightly trending
downwards. No acute bleed. Patient and family made aware of
preliminary results and they know that this is most likely
cancer. Colorectal surgery was consulted. Biopsy of the
transverse colon mass from the colonoscopy was inconclusive. It
revealed tissue consistent with an adenoma however the tissue
sample was superficial and likely inadequate to provide evidence
of invasion. Oncology recommended a biopsy of his liver lesions
to obtain a more definitive tissue diagnosis. He had ultrasound
guided liver biopsy on [**6-9**] and results are pending at the time
of discharge. He will follow up with Dr. [**Last Name (STitle) 3274**] in oncology as
an outpatient to further discuss the treatment plan.
.
# Respiratory: The patient was intubated at the OSH for unclear
indications, possibly hematemesis, and post endoscopy, was
successfully extubated on [**2124-5-29**]. Patient with history of
emphysema, large smoking history. If patient with respiratory
difficulty, could be due to emphysema/copd, possible pleural
thickening, bleb which is concerning for malignancy in this
patient with weight loss/smoking history, or fluid overload.
Currently patient breathing comfortably on 2L NC O2 but with
course breath sounds. Pt had speech/swallow eval on [**5-30**] but if
patient with difficulty with current diet, can reeval by video
swallow for aspiration
.
# Hypotension: Resolved. BP stable. He was started on a low dose
of lisinopril.
.
# Transaminitis: Shock liver with sepsis/septic shock in MICU
with infiltrative with liver lesions concerning for malignancy.
Currently LFTs trending down. Abdominal US showed no biliary
tree abnormalities.
.
# Ecoli UTI: Patient finished 7 day course of cipro for ecoli
UTI. Foley discontinued and patient voiding well on own.
.
# ARF: Prerenal and resolved with IVF resuscitation.
.
# PVD: s/p fem fem bypass with lower extremity ulcers on feet
bilaterally, no sign of infection. He was evaluated by vascular
surgery while in house. Has dry gangrene of the 2nd left toe. No
indication for surgical intervention currently, per vascular. He
will follow-up with vascular as an outpatient. Coumadin was held
in the setting of GI bleed.
.
# Sacral decub ulcer: patient seen by wound care nurse on [**5-29**].
Will follow recs per wound care nurse, have reevaluation if
necessary
.
# Nutrition: Pt appeared cachectic and had low albumin.
Nutrition was consulted. He was also evaluated by speech and
swallow. By discharge, he was cleared for a diet of thin
liquids and soft solids.
.
#DISPOSITION: Patient was discharged to rehab. Plan was for him
to follow up with Dr. [**Last Name (STitle) 3274**] in oncology for results of his
liver biopsy and to discuss the treatment plan for his likely
metastatic malignancy.
.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
PRN (as needed).
5. Hydrochlorothiazide 12.5 mg Capsule One PO DAILY
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime.
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP<100.
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
.
Discharge Disposition:
Extended Care
Facility:
Palm [**Hospital 731**] Nursing Home
Discharge Diagnosis:
Final diagnosis
Colonic mass suspicious for malignancy
Upper gastrointestinal bleed
.
Discharge Condition:
Stable
.
Discharge Instructions:
You were admitted for a low blood count and admitted to the
intensive care unit. You received blood transfusions and workup
for the bleed. You had a CT scan which showed a mass in your
colon and also lesions in your liver consistent with cancer.
.
Take all medications as prescribed.
.
If you develop bleeding, lightheadedness or dizziness, chest
pain, shortness of breath, or fevers > 101, you should call your
doctor or return to the emergency room.
.
Followup Instructions:
An appointment has been scheduled for you with Dr. [**Last Name (STitle) 3274**] of
oncology. Monday [**6-19**] at 1pm. Arrive 15 minutes early and go
to registration prior to your appointment. Telephone number is
([**Telephone/Fax (1) 51002**].
.
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in the next 2 weeks.
Telephone [**Telephone/Fax (1) 4775**].
.
Scheduled Appointments :
Provider VASCULAR [**Apartment Address(1) 871**] ([**Doctor First Name **]) VASCULAR LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2124-7-6**] 2:00
.
Provider [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2124-7-6**] 3:00
.
Name: [**Known lastname 15324**],[**Known firstname 2636**] Unit No: [**Numeric Identifier 15325**]
Admission Date: [**2124-5-29**] Discharge Date: [**2124-6-12**]
Date of Birth: [**2048-10-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 161**]
Addendum:
.
Regarding the patient's peripheral vascular disease, coumadin
and aspirin were held in the setting of GI bleed. Coumadin
should be held indefinitely given his colon mass. Would
recommend starting aspirin 81mg daily in 2 weeks. This can be
discussed at his follow-up appointment with Dr. [**Last Name (STitle) **] of
vascular surgery on [**7-6**].
.
Discharge Disposition:
Extended Care
Facility:
Palm [**Hospital **] Nursing Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]
Completed by:[**2124-6-12**]
|
[
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"197.7",
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"599.0",
"530.19",
"707.14",
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"492.8",
"799.4",
"272.4",
"153.1",
"570",
"560.9",
"428.0",
"707.03",
"428.31",
"038.9",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"50.11",
"45.13",
"96.71",
"99.04",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
14080, 14295
|
6912, 11058
|
288, 350
|
12102, 12113
|
3157, 6889
|
12615, 14057
|
2641, 2646
|
11551, 11886
|
11993, 12081
|
11084, 11528
|
12137, 12592
|
2661, 3138
|
232, 250
|
378, 1733
|
1755, 2344
|
2360, 2625
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,495
| 157,357
|
44174
|
Discharge summary
|
report
|
Admission Date: [**2109-4-23**] Discharge Date: [**2109-4-29**]
Service: ICU
CHIEF COMPLAINT: An 82-year-old female with hypotension.
HISTORY OF PRESENT ILLNESS: The patient was admitted on
[**2109-4-23**] with a complaint of chest pain that woke her
from sleep.
The patient went to dialysis where she experienced chest pain
again. It was thought at this time that it might be
secondary to a pericarditis. The patient also had an episode
of bradycardia while on dialysis and was noted to have a left
fistula clotted.
The patient was previously admitted with atrial fibrillation
and treated with diltiazem and propafenone. The patient had
a CT angiogram which was negative for aortic dissection and
significant for a stable pericardial effusion. The patient
also ruled out for a myocardial infarction with negative
creatine kinases and troponins.
The patient had thrombolysis of her fistula on [**4-24**]. The
patient was also evaluated by Endocrinology for a low
thyroid-stimulating hormone, low free T4, and low T3. It was
thought at this time the patient was suffering from Secu
thyroid syndrome.
On [**2109-4-27**], dialysis was stopped for hypotension. An
echocardiogram on [**4-29**] showed an ejection fraction of
greater than 55%, moderate-to-large pericardial effusion. No
tamponade. Medical Intensive Care Unit was called to
evaluate the patient with systolic blood pressure in the low
70s. Blood pressure had been trending downward since
[**2109-4-26**]; and at baseline, the patient had a systolic
blood pressure range of greater than 130.
The patient currently denied abdominal pain or chest pain.
The patient did note some shortness of breath. No nausea or
vomiting, and reportedly was lightheaded when attempting to
sit up. The patient did not have any evidence of bleeding
from the gastrointestinal tract, and currently was not making
any urine. The patient was started on vancomycin and
levofloxacin empirically and a bolus of 750 cc of normal
saline. The patient was then admitted to the [**Hospital Ward Name 332**]
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. End-stage renal disease.
2. Chronic obstructive pulmonary disease with an FEV1
of 0.55, FEV1:FVC ratio of 75% or predicted.
3. Gastroesophageal reflux disease.
4. Hypertension.
5. Known pericardial effusion.
6. Status post cholecystectomy.
7. Atrial fibrillation.
ALLERGIES: PENICILLIN and SULFA (which cause a rash).
MEDICATIONS ON ADMISSION: Medications in the hospital were
heparin subcutaneous, Zantac 150 mg intravenously q.d.,
Nephrocaps one tablet p.o. q.d., Sevelamer 2400 mg p.o.
t.i.d., aspirin 81 mg p.o. q.d., lisinopril 5 mg p.o. q.d.,
salmeterol 1 to 2 puffs p.o. b.i.d., propafenone 150 mg p.o.
t.i.d., ipratropium 2 puffs q.i.d., APAP 325/150 mg p.o.
q.d., albuterol and Atrovent nebulizers as needed.
FAMILY HISTORY: Father with [**Name2 (NI) 499**] cancer. Family history of
renal disease.
SOCIAL HISTORY: She lives with her husband. A 65-pack-year
history. Occasional ethanol.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was 97, heart rate was 87, blood pressure
was 74/palp, respiratory rate was 16, 95% on 1 liters. In
general, the patient was a pleasant/elderly female in no
apparent distress. Head, eyes, ears, nose, and throat
revealed mucous membranes were dry. Neck revealed no jugular
venous distention appreciated. Cardiovascular with an
irregularly irregular heart rate. No murmurs, rubs or
gallops. Pulmonary revealed diffuse wheezes bilaterally at
the bases. The abdomen was soft, nontender, and
nondistended. Extremities revealed no clubbing, cyanosis or
edema. Neurologically, alert and oriented times three.
Cranial nerves II through XII were intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Data revealed
white blood cell count was 13.3 (increased from 9.2),
hematocrit was 31.2, platelets were 364. PT was 59.6.
Chemistry-7 was remarkable for creatinine of 4.3, blood urea
nitrogen was 28, sodium was 144, bicarbonate was 25. Calcium
was 10.1, magnesium was 5.2, phosphate was 2.1. Arterial
blood gas revealed 7.32/47/82, lactate of 1.4. Blood
cultures were pending times two.
RADIOLOGY/IMAGING: Electrocardiogram revealed atrial
fibrillation at 91 beats per minute, left axis deviation. No
ST-T wave changes.
ASSESSMENT AND PLAN: In summary, this was an 82-year-old
female with a history of end-stage renal disease, pericardial
effusion (without tamponade physiology), and chronic
obstructive pulmonary disease, who presented with
hypotension.
HOSPITAL COURSE: It was thought at this time the etiology
was most likely multifactorial; however, given an increase in
white blood cell count, concern for sepsis was high, and the
patient was given empiric antibiotic coverage. It was also
thought that the patient should have a repeat echocardiogram
to assess for tamponade; however, it was less likely that
tamponade was causing hypotension secondary to lack of
tamponade physiology.
The patient was maintained with aggressive fluid hydration
and multiple intravenous fluid boluses. On the morning of
[**4-29**], the patient was found unresponsive, and there was a
question if initial neurologic examination showed a left
hemineglect. A heparin drip had been started the day
previous for atrial fibrillation. The patient was emergently
intubated and was minimally responsive. The patient appeared
to be in a junctional rhythm at 60 beats per minute on
telemetry. After dopamine and bicarbonate were given, the
patient reverted back to a normal sinus rhythm at 60 beats
per minute. On examination, it was noted that the patient's
extremities were cold and clammy.
The patient had an arterial blood gas which showed worsening
acidemia with a pH of 7.2, PCO2 of 242, and PO2 of 415 on
100%, lactate had increased to 3.9. The patient also had a
blood urea nitrogen of 36 and a creatinine which had
increased to 5.1.
It was thought at this time that the patient's heart rhythm
was most likely secondary to a major metabolic insult. It
was still debated as to whether tamponade was contributing to
hypotension. There was also concern that the patient was on
a heparin drip and demonstrated possible left hemineglect.
The heparin was discontinued, and the patient was scheduled
to have a CT scan of her head to rule out bleed. However,
the patient was never hemodynamically stable enough to be
sent to the CT scanner. The patient was continued on a
dopamine drip and propafenone was also continued at this
time.
On [**2109-4-29**] (at 9:45 p.m.), the patient became
bradycardic and hypotensive again. She was noted to have a
blood pressure of 39/palp, and a heart rate of 45. The
patient was given 1 mg of atropine, and 1 mg of epinephrine,
and intravenous fluids. The patient's rhythm then changed to
asystolic cardiac arrest.
Chest compressions were initiated. The patient was given 2 mg
more of atropine and epinephrine and 1 ampule of bicarbonate.
The chest compressions continued, and rhythm changed to
coarse ventricular fibrillation. The patient was shocked in
succession times three without rhythm. Cardiopulmonary
resuscitation was then re-initiated. Examination revealed
bilateral breath sounds. The patient was given another
milligram of atropine. Epinephrine, bicarbonate, dopamine,
and Levophed were wide opened; and intravenous fluids were
placed wide open.
The patient was thought to be hyperkalemic and given calcium
carbonate, D-50 saline; repeat potassium was 4.4. The
patient returned from a normal sinus rhythm to ventricular
tachycardia for approximately 15 minutes, and blood pressure
increased. Pressors were weaned. An emergent Cardiology
consultation for a repeat echocardiogram was called.
The patient's rhythm changed again asystole, and pressors
were restarted, and atropine was given. Emergent
pericardiocentesis with 50 cc to 60 cc of venous blood,
not clotted, returned without hemodynamic response. The
patient remainder in asystole, and the patient was pronounced
dead at 9:25 p.m.
CONDITION AT DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. End-stage renal failure.
2. Possible sepsis complicated by profound hypotension.
3. Pericardial effusion.
4. Lactic acidosis.
5. Hyperkalemia.
6. Atrial fibrillation.
7. Asystolic cardiac arrest.
8. Respiratory failure.
9. Mental status changes.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2109-9-2**] 17:09
T: [**2109-9-9**] 02:01
JOB#: [**Job Number 94789**]
|
[
"423.8",
"403.91",
"276.4",
"518.81",
"276.7",
"996.73",
"427.31",
"496",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"96.71",
"38.93",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2860, 2936
|
8116, 8662
|
2468, 2843
|
4584, 8070
|
8085, 8095
|
105, 146
|
175, 2088
|
2110, 2441
|
2953, 4566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,638
| 142,506
|
23600
|
Discharge summary
|
report
|
Admission Date: [**2163-4-11**] Discharge Date: [**2163-4-16**]
Date of Birth: [**2127-2-22**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 55946**]
Chief Complaint:
Increasing abdominal girth; lower extremity edema
Major Surgical or Invasive Procedure:
Exploratory laparotomy, bilateral salpingo-oophorectomy, removal
of 7.5 liters abdominal ascites, cul-de-sac biopsy
History of Present Illness:
36 y.o. G0 referred to triage for evaluation of increasing
abdominal girth, lower extremity edema. Interview conducted in
Mandarin, so somewhat limited. Pt reports ~2 months of
sensation
of "something there", i.e. palpable abdominal masses
bilaterally.
She was seen at [**Hospital3 **] for evaluation, and had a
transabdominal ultrasound [**1-3**] (pt refused transvaginal u/s)
which showed 2 large fundal pedunculated fibroids. Neither
ovary
was visualized transabdominally at that time. The pt was
originally scheduled for OR w/ Dr. [**Last Name (STitle) **] next week, but was
referred for evaluation presently given rapidly progressing
physical findings.
The pt reports that over the past month, she has had increasing
abdominal girth and distention - no pain, fevers, bleeding,
changes in urination, nausea/vomiting, or any weight changes
beyond abdominal girth. Has had light vaginal spotting x 2
days,
but is due for her period.
Past Medical History:
PGynHx:
- LMP: [**2163-3-16**], for past few years, has had irregular menses and
increasing dysmenorrhea; no menorrhagia
- No known h/o STD's, abnormal paps
- Last Pap: [**11-3**] Negative for intraepithelial lesion/malignancy
POBHx: G0
PMedHx:
- Anemia
PSurgHx:
- ear surgery
Social History:
Denies use of tobacco/etoh/drugs. Moved to U.S. from [**Country 651**] [**11-2**]
Family History:
Denies any family h/o malignancies or other significant medical
conditions
Physical Exam:
PE: chronically ill looking patient, walking around relatively
easy despite grossly distended abdomen
VS: normal and stable
Gen: AAOx3, mild distress
HEENT: PERRL, EOMI, sclera normal, no jaundice
Heart: RRR, no murmurs or gallop
Lungs: CTAB, with decreased breath sounds over the bases
Abdomen: severly distended and tight w/ ascitis, non-tender,
normal bowel sounds, dull to percussion in the bilateral pelvic
area
Extremities: 2+ pitting edema
Skin: normal
Neuro: intact
Pertinent Results:
[**2163-4-11**] 12:38PM GLUCOSE-105 UREA N-9 CREAT-0.9 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-23 ANION GAP-15
[**2163-4-11**] 12:38PM ALT(SGPT)-22 AST(SGOT)-47* LD(LDH)-272* ALK
PHOS-33* AMYLASE-60 TOT BILI-0.5
[**2163-4-11**] 12:38PM LIPASE-31
[**2163-4-11**] 12:38PM ALBUMIN-2.9* CALCIUM-8.1* PHOSPHATE-4.0
MAGNESIUM-1.8
[**2163-4-11**] 12:38PM HCG-<5
[**2163-4-11**] 12:38PM CEA-36* CA125-630*
[**2163-4-11**] 12:38PM WBC-7.7 RBC-4.73 HGB-14.7# HCT-42.6# MCV-90#
MCH-31.1# MCHC-34.5# RDW-13.4
[**2163-4-11**] 12:38PM PLT COUNT-494*
[**2163-4-11**] 12:38PM PT-13.3* PTT-29.7 INR(PT)-1.2*
Brief Hospital Course:
Upon presentation, the pt had a CT scan of her abdomen and
pelvis to help delineate the etiology of her abdominal girth.
The CT demonstrated two dominant and large pelvic masses, the
right measuring 11.7 x 18.5 x 22.0 cm in size. The left was
slightly smaller at 8.8 x 6.8 x 10.6 cm; both lesions had cystic
components. The uterus was unremarkable but there was a massive
amount of abdominal and pelvic free fluid noted. Additionally,
there was a question of a focus of soft tissue thickening along
the anterior/inferior aspect of the body of the stomach. These
findings were concerning for either ovarian cancer or bilateral
Krukenberg tumors. Bilateral lower extremity dopplers were also
obtained to rule out DVT given the pt's lower extremity edema
which were negative.
The pt was admitted to the gyn oncology service. Given the
question of stomach-thickening on CT scan, GI was consulted to
rule out a GI primary prior to proceeding w/ an exploratory
laparotomy. The pt underwent an EGD on HD#2 at which point an
ulcerated, fungating and infiltrative mass w/ malignant
appearance was noted in the stomach body and cardia. Biopsies
were taken which ultimately demonstrated adenocarcinoma,
predominantly signet ring cell type.
The heme/onc service was also consulted regarding the pt's
condition and, conjointly, the decision was made to take the pt
to the OR for a debulking procedure both for symptomatic relief
for the pt as well as to decrease her tumor burden for possible
chemotherapy and ascertain more definitively the extent of
peritoneal disease. Also, it was felt that if the ovarian
metastases were the only areas of extensive disease, then a
gastrectomy performed in the near-future may be able to render
the pt w/ no evidence of disease. On [**2163-4-13**], the pt was taken
to the OR and an exploratory laparotomy, bilateral
salpingo-oophorectomy, and peritoneal biopsy were performed.
Approximately 8 liters of ascites were additionally drained
intraoperatively. Please see operative report for full detail
regarding the procedure.
The pt's postoperative course was complicated initially by
decreased O2 sats. The pt did receive a large amount of IV
fluids intraoperatively, and a CXR obtained in the PACU
demonstrated moderate-sized bilateral pleural effusions. It was
felt that the pt's O2 requirement was secondary to volume
overload and she was given 10 mg of lasix in the PACU to help
reverse this. The pt was temporarily monitored in the [**Hospital Unit Name 153**]
overnight on POD#0/1 given her O2 requirement but diuresed well
and was transferred out on POD#1. The pt continued to diurese
well without any further diuretics necessary and was weaned from
O2 completely on POD#3.
The pt's postoperative course was otherwise uncomplicated. She
was tolerating a full diet, her pain was well controlled w/ oral
medications, and she was ambulating and voiding without
difficulty on POD#3. Thus, she was discharged to home on POD#3
in stable condition. She has an appointment to follow-up with
the hematology/oncology team on [**4-25**] at 9:30 am to discuss
chemotherapy options.
Medications on Admission:
none
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*50 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic signet ring adenocarcinoma of the stomach
Discharge Condition:
Good
Discharge Instructions:
- Please call Dr. [**First Name (STitle) 1022**] if you experience fever > 100.5, chills,
nausea and vomiting, worsening or severe abdominal pain, or if
you have any other questions or concerns. Please call if you
have redness and warmth around your incision, if your incision
drains pus, or if your incision reopens.
- No driving for 2 weeks after surgery AND no driving while
taking percocet as it can make you drowsy.
- No heavy lifting or exercise for 6 weeks to allow your
incision to heal fully.
- Please keep your follow-up appointments as outlined below.
Followup Instructions:
The following appointments have been scheduled for you:
1) Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**] MD/[**Last Name (LF) 8848**], [**Name8 (MD) **] MD
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-4-25**] 9:30 ;
HEMATOLOGY/ONCOLOGY-CC9
2) Please call Dr.[**Name (NI) 2989**] office at [**Telephone/Fax (1) 5777**] to schedule a
postoperative appointment within 4 weeks of discharge.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 55947**] MD, [**MD Number(3) 55948**]
|
[
"151.4",
"198.6",
"789.5",
"198.82",
"197.6",
"518.0",
"511.9",
"276.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"70.23",
"65.61",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
6725, 6731
|
3117, 6242
|
379, 497
|
6828, 6835
|
2476, 3094
|
7447, 8015
|
1888, 1966
|
6297, 6702
|
6752, 6807
|
6268, 6274
|
6859, 7424
|
1981, 2457
|
290, 341
|
525, 1469
|
1491, 1772
|
1788, 1872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,266
| 111,581
|
1195
|
Discharge summary
|
report
|
Admission Date: [**2100-12-1**] Discharge Date: [**2100-12-9**]
Date of Birth: [**2027-1-21**] Sex: M
Service: MEDICINE
Allergies:
Lidocaine / Morphine / Ambien
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
transfered from OSH for medical management of AMI and other
multiple medical problems.
Major Surgical or Invasive Procedure:
right knee incision and drainage (bursa washout)
History of Present Illness:
Patient is a poor historian. The following history is taken from
the notes and from the patient.
.
Mr. [**Known lastname **] is a 73 yo M who is transferred from an OSH s/p fall
at home. He was brought by EMS to the OSH. He was found awake
and alert but on the ground complaining of weakness and fatigue.
Per patient, he just couldn't get up. No LOC or hitting his
head. No loss of bowel or bladder function. He was brought to
the OSH and was found to have an elevated WBC, Cr 4.8, and
slightly elevated troponin I on admission. Subsequent troponins
continued to rise with a max of 4.7 and he was started on a
heparin gtt. He was also found to be fluid overloaded and with
ascities. He received a paracentesis with removal of 5L and
dialysis (per his home schedule on T, TH, Sa). During the course
of his hospitalization, he developed what was thought to be a
gout flare in his right knee. He has received most of his
medical care at [**Hospital1 18**] in the past and was transferred here for
further medical management.
.
On ROS he denies current SOB, CP, n/v, f/c, diarrhea. He makes
very little urine on his own. He describes pain in his right
knee which has improved slightly from yesterday. He denies any
current lightheadedness, HA, changes in vision, cough,
palpitations, or abdominal pain.
Past Medical History:
1. Coronary artery disease status post coronary artery bypass
graft in [**2077**]
2. Right ventricular dysplasia with atrial and ventricular
tachycardia, status post ablation
3. Multiple arrhythmias status post ablation
4. DDD pacemaker secondary to sick sinus syndrome with
paroxysmal atrial fibrillation (h/o 4 pacemakers)
5. Congestive heart failure requiring multiple hospital
admissions
6. ESRD, now hemodialysis dependent, recent placement of
AV-Fistula ([**2099-6-16**]). Removal of 3L three times a week.
7. Passive liver congestion syndrome requiring 2x week
paracentesis for volumes of [**3-24**] L.
7. Type II diabetes mellitus
8. Gout s/p left great toe amputation
9. Degenerative joint disease of knees and back
10. Obstructive sleep apnea
11. Allergic rhinitis
12. History of peripheral vascular disease, right greater than
left. Status post right lower extremity angiography with three
stents with maximum diameter of 8 mm and now status post
angiography and atherectomy to the left lower extremity in [**Month (only) 958**]
of [**2097**]
13. Cardiomyopathy EF>55% with TR and hypokinesis of the R V per
echo in [**2097**]
14. Obstructive sleep apnea
15. Appendectomy
16. h/o GI Bleed from AVMs with chronic need for iron
replacement.
17. hypothyroidsm
18. hyperparathyroidism of renal disease
Social History:
Patient lives in [**Location **], MA, with wife. [**Name (NI) **] 2 children.
Patient is a retired printer.
-No alcohol history
-Quit smoking in [**2077**] after 2 ppd x 20 year smoking history
(40pack-year)
- Denies illicit drug use
Family History:
Cardiac disease, DM, Prostate ca, cirrhosis. Son also has RV
dysplasia .
Physical Exam:
T 96.0, BP 104/60, HR 60, RR 22, O2sat 95% on 3L, FS 216
General: Pleasant obese male lying in bed in NAD
Skin: several open sores on arms with dirty fingernails. PVD
skin changes with bilateral lower extremities
HEENT: NCAT, anicteral sclera, injected conjunctiva bilaterally,
left pupil reactive to light. Right pupil less reactive- pt says
he had recent cataract surgery in that eye. Could not assess JVD
given body habitus, no cervical LAD appreciated.
CV: distant heart sounds, but RRR with 2/6 systolic murmur heard
best at LUSB without radiation.
Lungs: bibasilar crackles; distant breath sounds at the right
base. No wheezes, rales, or rhonchi
Abdomen: distended but still soft. +BS, non-tender to palpation.
+ascities.
Extremities: very trace edema on left lower extremity.
peripheral vascular disease skin changes with erythema
bilaterally. Right knee with suprapatellar 3+ edema and beefy
red erythema extending past patella. Warm and mildly tender to
touch. ROM not fully tested secondary to discomfort.
Pertinent Results:
Labs on transfer from OSH: WBC 6.9 with 93.5%PMNs, 22% bands,
6%metamyelocytes, 1 nucleated RBC, Hgb 12.7, Plts 101, PTT 67 on
heparin gtt of 600 units, sodium 134, potassium 4, chloride 99,
CO2 18. BUN 38, Cr. 4.7, BS 117. Ammonia level elevated at 61,
BNP 1242, vanco level [**2100-12-1**] was 5
.
Trends: CK CK MB Trop I
94 6.4 0.71
133 14.2 2.96
144 13.5 3.61
-- --- 4.7
.
Studies from OSH:
[**2100-11-29**]: CXR 2 views: no pneumonia. Cardiomegaly. Pacemaker
inplace. no evidence of CHF. Small pleural effusion on lateral
view.
.
[**2100-11-30**]: U/S guided paracentesis: removal of 5100 mL fluid with
270 WBC, with 14%PMNs, 24% L, 60% monocytes, 10,000 RBC
.
[**2100-11-30**] VQ scan: low probability of PE
.
ECHO (per d/c summary from OSH- no actually report with transfer
papers) showed poor LV function with an EF of 30-35%.
Labs from [**Hospital1 18**]:
Micro: staph aurea from prepatellar bursa x3
Brief Hospital Course:
70 yo M with multiple medical problems including RV dysplasia
leading to right heart failure and chronic hepatic congestion,
ESRD requiring dialysis, DM2 and an AMI.
.
#AMI: patient was asymptomatic but was found to have largely
elevated troponins at the OSH. He does have ESRD which
obviously affects the troponin clearence in the blood. He was
continued on a heparin gtt originially on admission. This is
was stopped secondary to bleeding. Unsure about appropriate
medical regimen given his extensive history and RV dysplasia.
Has tried BB in past but had symptomatic hypotension from it.
Likely no statin given his liver function. Not on an ACEI
currently. Has h/o GI bleed- so careful with anticoagulation.
Probably reason he is not on ASA. While in the hospital an ASA
was started.
.
#h/o multiple arrhythmias: s/p multiple ablations. pacer in
place. EP consult in AM to evaluate pacer and found it to be
functioning well.
.
#PAF: Continued his home amiodarone and was monitored on
telemetry. The issue of anticoagulation is discussed above.
.
#DM2: patient not on medications on transfer. Will start with
humalog sliding scale and add standing insulin based on 24 hour
usage. His fingersticks were monitored and found to always be
within the 100-150 range qAC. He was placed on an insulin SS
with humalog but did not require any use of insulin.
.
#ESRD: requires dialysis T, TH, SA. The renal fellow was
notified and made recommendations regarding his nephrocaps and
phoslo and calcitriol. He underwent dialysis as schedule.
.
#Chronic hepatic congestion: requires paracentesis twice a week.
He was monitored closely and a therapeutic paracentesis was
performed on [**2100-12-6**].
.
#Right-sided and left-sided heart failure: from RV dysplasia.
He was placed on a 1L fluid restriction and a CXR on admission
showed no evidence of fluid overload. As above, he was
monitored for ascites build up.
.
#erythematous right knee: considered gout flare at OSH given
this is a recurrent site for him. Given WBC and diff with bands
and metamyl, concern for cellulitis. Patient received vancomycin
at OSH. Continued allopurinol and stopped colchicine secondary
renal insufficiency. Rheumatology was consulted and tapped his
pre-patellar bursa three times to remove fluid. It grew out
Staph aureas which was MSSA. Vancomycin was changed to
nafcillin. Ortho was consulted for concern over a septic joint.
Despite pain in his knee, the patient was able to ambulate on
the joint and it was believed the infection was not in the joint
itself. Ortho did decided to take him to surgery for a wash out
procedure. During the procedure he developed hypotension which
continued in the PACU. He was transferred to the CCU. He never
recovered from the procedure and expired in the CCU. His family
wanted an autopsy performed.
.
#hypothyroidism: continue levothyroxine. TFTs were WNL.
.
#Code status: Full code
Medications on Admission:
Meds on transfer:
heparin gtt
aminodarone 200mg daily
allopurinol 100mg [**Hospital1 **]
lovxyl 0.175mg daily
calcitrol 0.25mg daily
atarax 10mg TID
zoloft 100mg daily
nephrocaps PO TID
phoslo 2tabs QAC
lovenox SC 40mg qAM
protonix 40mg daily---had not received
procrit 1300mg ----had not received
digoxin 0.25mg [**Hospital1 **] given on [**11-29**]
colchicine 0.5mg IV q6 x2 on [**11-30**]
vancomycin 1g IV given [**11-30**] and [**12-1**]
NTG 0.4mg SL prn
acetaminophen 650mg PO/PR q4 prn
dulcolax PR qAM prn
reglan 10mg PO/IV q6 prn
vicodin 1 tab q3-4hrs prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
primary diagonsis:
cardiopulmonary arrest leading to death
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2101-1-12**]
|
[
"244.9",
"458.8",
"250.00",
"711.06",
"V09.0",
"995.92",
"427.31",
"585.6",
"715.16",
"038.9",
"721.90",
"427.5",
"428.0",
"V45.01",
"V45.81",
"327.23",
"573.0",
"425.4",
"410.90",
"414.00",
"041.11",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"83.5"
] |
icd9pcs
|
[
[
[]
]
] |
8979, 8988
|
5421, 8336
|
377, 427
|
9090, 9099
|
4484, 5398
|
9152, 9319
|
3357, 3432
|
8950, 8956
|
9009, 9069
|
8362, 8362
|
9123, 9129
|
3447, 4465
|
251, 339
|
455, 1756
|
1778, 3089
|
3105, 3341
|
8380, 8927
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,843
| 116,190
|
50376
|
Discharge summary
|
report
|
Admission Date: [**2119-9-29**] Discharge Date: [**2119-10-6**]
Date of Birth: [**2060-9-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
subclavian central venous catheter placement
endotracheal intubation and extubation
peripherally inserted central venous catheter
History of Present Illness:
59 yo M with advanced MS, hx of MRSA/VRE, neurogenic bladder,
g-tube/colostomy, psych disorders, hypothyroidism presents from
NH with hypoxia. Patient noted to be shortness of breath,
tachypnea, tachycardia, diaphoretic starting [**2119-9-27**]. Patient
dx with LLL PNA at [**Hospital 100**] rehab on [**9-27**] started on Augmentin
and Nebs. NH VS Tmax 100.2 HR 120-130s, BP 110/60's, RR 40 O2
sat 80's on 4 L NC. ABG was 7.56/26/83. Patient transfered to
[**Hospital1 18**] for ongoing management.
.
In the ED VS: 98.0 125 100/60 20's-40 99% NRB. CXR showing
possible aspiration, CTA protocol r/out PE c/w multilobar PNA.
Started Vanco, levo, Flagyl for aspiration PNA. Total 3 L fluid
bolus for BP 80->90s via right subclavian line placed in ED.
.
Upon arrival to the ICU, VSS, BP 110's, still very tachypneic RR
~40 however does not appear in distress, O2 sat 99% NRB, desats
to upper 70's when pulls off mask.
Past Medical History:
- Multiple sclerosis.
- Neurogenic bladder.
- Swallowing disorder.
- Schizoaffective disorder/Depression.
- Hypothyroidism.
- s/p colectomy with mucous fistula in [**2106**] secondary to C.diff
colitis, course complicated by abscess, has G-tube
- h/o aspiration pneumonia
- h/o MRSA/VRE in urine [**2107**]
- GERD
- anxiety
Social History:
The patient is a [**Hospital 100**] Rehab resident. No
ETOH, no tobacco, no IV drug use. has legal guardian
Physical Exam:
Upon arrival to the ICU:
VS: 97.3 BP 112/73 HR 121 97% NRB-->78% RA
Gen: middle aged male, contracted on left side, non verbal, NAD,
not using accessory muscles of respiration.
Neck: supple, JVD above clavicle at 45 degrees
Heent: slightly pale, MMM, PERRL, anicteric, sunken eyes
Skin: pale, no rashes, moist, few LE excoriations
Chest: rhonchi diffusely, good air entry, no rales
CVS: nl S1 S2, tachy, regular, no m/r/g appreciated
Abd: soft, colostomy draining soft brown stool, NT/ND, BS+
Ext: atrophy, no edema, +excoriations, warm, 2+ dp pulses b/l,
right arm/hand contracted
Neuro: PERRL, 2mm pupils, does not follow commands, moans, able
to use left hand
.
Pertinent Results:
Admission Labs:
[**2119-9-29**] 12:40AM WBC-10.7 RBC-3.11*# HGB-9.0*# HCT-27.1*#
MCV-87 MCH-28.9 MCHC-33.2 RDW-16.7*
[**2119-9-29**] 12:40AM PLT COUNT-156
[**2119-9-29**] 12:40AM NEUTS-84.4* LYMPHS-8.4* MONOS-5.1 EOS-1.7
BASOS-0.3
[**2119-9-29**] 12:40AM GLUCOSE-109* UREA N-31* CREAT-1.2 SODIUM-135
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
[**2119-9-29**] 12:55AM LACTATE-2.1*
[**2119-9-29**] 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-9-29**] CXR: There is a consolidation at the left lower lobe
with air bronchograms. There is diffuse opacification of both
lung fields. There is mild re-distribution of pulmonary
vasculature, but no septal lines and no frank evidence for
pulmonary edema. The heart and great vessels of the mediastinum
are stable. Severe thoracolumbar scoliosis is again noted.
IMPRESSION: Left lower lobe pneumonia with more diffuse
pneumonia or mild pulmonary edema.
.
[**2119-9-29**] CTA chest:
Brief Hospital Course:
A/P: 59 yo patient with advanced MS presents with multilobar
PNA.
.
1.) Multilobar Pneumonia/Respiratory Failure: The patient had a
fever, cough, and chest xray finding s consistent with
pneumonia. He developed progressive respiratory distress and
was electively intubated and placed on mechanical ventilation.
He underwent a bronchoscopy which on lavage releaved staph
aureas (methicillin resistant) and a moderate amount of
hemorrhage. He was treated initially with broad spectrum
antibiotics which were later tailored once antibiotic
sensitivities were available. He will complete a 14 day course
of vancomycin (7 days of which after discharge). Of note, he
did develop a self-limited mild eosinophilia while on zosyn. He
did not develop a rash or clinically worsen. This should not be
thought of as an absolute contra-indication for future zosyn
therapy should this antibiotic be clinically indicated. He was
gradually weaned from the venilator as he was diuresed with
furosemide and acetazolamide. He was successfully extubated and
upon discharge he had stable oxygenation with supplemental
oxygen by face mask. A PICC line was placed for antibiotics.
His vancomycin on the day of discharge was held for a high
trough level. His goal vancomycin trough should be [**10-6**]. He
will be discharged on 1 gram of vancomycin every day which can
be adjusted per vancomycin trough. He received nebulized
bronchodilators.
.
2.) Hypotension: The patient did develop hypotension to sbp ~90
during his admission. This was thought likely to be from
sepsis. He was fluid resusitated and received brief period of
vasopressors. He had an appropriate response on [**Last Name (un) 104**]-stim
testing and did not require steroid replacement. Upon discharge
he was normotensive with maintenance of adequate urine output
and stable creatinine.
.
3.) Anemia. Hct 27 (baseline low 40's). Guiac positive ostomy
output per ED. The hematocrit drop was thought secondary to the
pulmonary hemorrhage with subsequent blood being swallowed into
the stomach. His hematocrit stabilized. He did not require
blood transfusions.
.
4.) Hypothyroid: no acute issues during this hospitalization and
he continued on his home dose of synthroid.
.
5.) GERD. PPI, elevate head of bed.
.
6.) Psych. H/o schizoaffective disorder, anxiety. The patient
is non-verbal and minimally responsive at baseline and it was
difficult to assess mood or thought disorders. A psychiatry
consult was obtained to make recommendations on use of the
patient's despiramine during this acute illness. A despramine
level was checked and found to not be toxically elevated. He
was continued on this medication. He received versed and
fentanyl while intubated then low dose ativan as needed for
anxiety and agitation post-extubation.
.
7.) Multiple Sclerosis: The patient has advance multiple
sclerosis. He has a neurogenic bladder and chronically foley
dependent. Urine output was monitored with foley catheter in
place
.
8.) PPx. PPI, Heparin SC, hold bowel reg/has colostomy
.
9.) FEN. He recieved tube feeds via his gastrostomy tube. His
electrolytes were repleted as necessary.
.
10.) Thrombocytosis: The patient had an elevated platelet count
which was thought to be a reactive process secondary to his
resolving pneumonia exacerbated by the diuresis that was
required to resolve the pulmonary edema. This lab value should
be follow-up to insure resolution.
.
11.) Full Code. Confirmed in NH records and with sister who is
legal guardian.
.
12.) Dispo: The patient was monitored in the intensive care unit
while in the hospital. He was transferred back the the MAC unit
where he was a resident.
.
13.) Access: He had a subclavian central venous catheter placed
for volume resusitation. He was discharge with PICC line for
the IV antibiotics.
.
14.) Comm: Sister [**Name (NI) **] [**Name (NI) 1726**] [**Telephone/Fax (1) 104993**], [**Telephone/Fax (1) 104994**];
Brother [**Name (NI) 4036**] [**Name (NI) 104995**] [**Telephone/Fax (1) 104996**]
PCP [**Name Initial (PRE) **] [**Telephone/Fax (1) 608**]
Medications on Admission:
- Augmentin 500 mg q12 started [**9-28**]
- Ativan 0.5 prn
- Synthroid 50 mcg daily
- Pepcid 20 mg daily
- MVI daily
- Desipramine 75 mg daily
- G-tube Jevity 1.2 cal
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Pneumonia
Sepsis
.
Secondary:
Multiple sclerosis
schizoaffective disorder
neurogenic bladder
hypothyroidism
Anemia
c. dif colitis s/p colectomy with mucous fistula
Discharge Condition:
stable. afebrile. stable vital signs. tolerating tube feeds at
goal.
Discharge Instructions:
You have been evaluated and treated for pneumonia. You will
continue to receive antibiotics for the next 7 days according to
the prescriptions.
Followup Instructions:
Per extended care facility routine
|
[
"596.54",
"340",
"280.0",
"428.0",
"507.0",
"786.3",
"530.81",
"482.41",
"518.81",
"244.9",
"288.3",
"038.9",
"V09.0",
"295.70",
"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.04",
"96.04",
"33.23",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7925, 7991
|
3624, 7707
|
323, 455
|
8208, 8279
|
2576, 2576
|
8472, 8510
|
8012, 8187
|
7733, 7902
|
8303, 8449
|
1890, 2557
|
276, 285
|
483, 1400
|
2593, 3601
|
1422, 1748
|
1764, 1875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,329
| 132,291
|
49958
|
Discharge summary
|
report
|
Admission Date: [**2121-12-6**] Discharge Date: [**2121-12-10**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypertensive urgency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
This is a 42 yo man with DM I, ESRD on HD, CAD, CHF, HTN
presenting with substernal chest pain being transferred to MICU
for hypertensive urgency requiring nitro gtt. Pt awoke this AM
with sharp stabbing non-radiating SSCP associated with some
shortness of breath. On presentation to ED with SBP>220 and
respiratory rate in 30's on NRB. Recieved ASA 325, Morphine,
Anzememt, and Lopressor. Given persistent HTN started on NTG gtt
and sent for [**First Name3 (LF) 1988**] hemodialysis. Underwent HD in K+ bath
which he tolerated well without difficulty and remained chest
pain free [-4.5L]. Given NTG gtt for reasons other than CP, not
suitable for floor admission. Pt transferred to MICU for further
management.
.
Upon arrival to ICU: Pt c/o severe throbbing frontal HA and some
nausea. Pt denies SOB or CP. Confirms ED story. Further
describes never having pain like this in past. Pt has [**Last Name (un) 6550**] doing
well otherwise. Underwent HD on Thursday without event. Pt
denies any recent changes in medications or missed doses. Wt
stable. No dietary changes. remaining ROS negative for F/C/S,
change in bowel habits, abd pain or persistent nausea/vomitting.
.
Currently patient complains of headache, but no chest pain,
shortness of breath, abdominal pain. Does report some nausea.
No fevers or chills.
Past Medical History:
1. DM type I x 17 years
2. End stage renal disease- dialyzed T, Th, Sat at [**Location (un) **]
Dialysis.
3. Hypertension, poorly controlled
4. Right foot operation - bone excision
5. Right foot ulcer
6. Depression, h/o prior SA and psych hospitalizations.
7. Esophagitis on EGD [**10-21**] H.Pylori negative
8. History of L flank pain as above
Social History:
Lives with mother in subsidized housing. Has four children.
Former floor tech. No smoking, EtOH, drugs.
Family History:
Diabetes in multiple relatives
Physical Exam:
VS: T:99.4 P:84 BP:112/53 RR:10 O2Sat:97% on 2L
GENERAL: hispanic man resting in bed, uncomfortable
HEENT: PERRL, EOMI, OP clear, MMM
NECK: supple, no JVD
CARDIOVASCULAR: RRR, S4, no m/r/g appreciated
LUNGS: CTAB, no W/R/R
ABDOMEN: soft, ND, NT, no HSM, no other masses
EXTREMITIES: no edema, +thrill and bruit over left arm HD
fistula
NEURO: AO3, CNs [**Month/Year (2) 5235**], appropriate, flat affect
Pertinent Results:
Labs on admission: WBC 10.2 (80% neutrophils, 12.7% lymphs), Hgb
10.4, Hct 32.6, Plt 215
Normal coags
Chem 10 remarkable for K 7, Cr 9.2, phos 5.6
.
CK 232 --> 100 --> 67
CK MB 6 --> 4
Troponin T 0.25 --> 0.3 --> 0.3
.
CTA ([**12-6**]): 1. No evidence of aortic dissection. 2. Lung
findings consistent with fluid overload. 3. Small fluid density
pericardial effusion..
.
CT head ([**12-6**]): No acute intracranial hemorrhage or mass
effect.
.
CXR ([**12-6**]): Moderate hydrostatic edema, wide differential
diagnosis given the presence of normal sized heart. Given
history of end-stage renal disease as obtained from earlier
radiographic study reports, uremia is top diagnostic
consideration.
.
Several EKGs done [**2037-12-5**], see OMR for details
.
Labs at discharge: WBC 4, Hgb 9.3, Hct 29.4, Plt 190
Chem 7 BUN 22, creatinine 6.1
Phos 4.3
Brief Hospital Course:
Mr. [**Known lastname 104318**] is a 42 year old man with DM I, ESRD on HD, CAD, CHF
and HTN who presented with chest pain requiring ICU care for
hypertensive urgency, with blood pressures steadily better
controlled.
.
# Hypertension: As per previous notes, Mr. [**Known lastname 104319**] baseline SBP
is 150-170. The exacerbating factor for this episode is unclear,
but his blood pressures were better post hemodialysis and after
being on a nitroglycerin drip in the MICU. The patient did not
have any signs of end organ damage.
- In the hospital the patient received nifedipine 90mg PO daily,
Metoprolol XL 150 mg PO DAILY, Lisinopril 40 mg PO DAILY. We
added a second dose of toprol XL 150 mg at night so that he was
discharged on toprol 150 mg [**Hospital1 **].
- We did consider increasing his lisinopril dose, but at the
time of discharge, his blood pressure was in the 130s systolic.
- On the floor, the patient remained without headache or chest
pain.
- He was instructed to follow up with his primary care physician
within one week upon discharge.
.
# ESRD c/b hyperkalemia: Once he arrived on the floor, his
electrolytes were stable. He received hemodialysis and was able
to return to his usual schedule (Tuesday/Thursday/Saturday). The
Renal team did follow along with us during his hospitalization.
- The patient was continued on his home Calcium Acetate 667 mg
PO TID W/MEALS and Calcium Carbonate 500 mg PO TID.
- The patient does have a left fistula, which was functioning
appropriately.
.
# Chest pain: Mr. [**Known lastname 104318**] did have chest pain in the setting of
HTN but remained free of chest pain on the floor. He did
complain of headache with the nitroglycerin drip. It was
determined that his ECG and clinical picture were not consistent
with ACS. He does have an elevated troponin T presumably
secondary to his poor renal function which was near his
baseline. His CKMB was not elevated. A recent pMIBI with
negative stress and imaging showing fixed inferior wall defect
and no reversible defects.
- We continued the patient's Lisinopril, Metoprolol, and ASA.
- We did consider statin as outpatient but most recent LDL 73 in
[**2121-9-16**].
.
# Vitreous hemorrhage - The patient was seen by ophthalmology
while in the MICU. He was [**Year (4 digits) 1988**] for an appointment in their
triage clinic for the day of discharge, and Dr. [**Last Name (STitle) **] was
notified of this. The patient did complain of "wavy" vision out
of the left eye, consistent with his hemorrhage. Further
management of this will be per Dr. [**Last Name (STitle) **] and his team.
.
# HA: The patient's headache was likely secondary to the
nitroglycerin drip. His head CT was without abnormality and he
had a non-focal neurologic exam.
.
# DMI: The patient was given his home dose of NPH with HISS as
per his home schedule. The NPH dose was reduced from 14 U at
night to 12 U at night due to low blood sugars (in the 50s) in
the early morning for two mornings in a row.
.
# GI: The patient was continued on his home regimen of
hyoscyamine, glycopyrrolate (anticholinergic agents),
metoclopramide, dolasetron, clonazepam (anti-emetics) and
simethicone.
.
# Depression: As per records, Mr. [**Known lastname 104318**] has a history of prior
SA and psych hospitalizations. Throughout his hospitalization,
he was without HI/SI. It is noted that the patient often has
undergoes hospitalization during times of increased social
stressors. He is also more comfortable about discussing these
matters when spoken with in Spanish.
- He was continued on his home dose of citalopram 20mg daily.
.
# FEN: He tolerated a cardiac, diabetic, renal diet while
hospitalized.
.
# Prophylaxis: He received subcutaneous heparin and protonix.
.
# Code status: FULL
Medications on Admission:
1. Metoclopramide 10 mg PO QIDACHS
2. Calcium Carbonate 500 mg PO TID WITH MEALS
3. Lisinopril 20 mg PO DAILY
4. Nifedipine 60 mg Sustained Release PO DAILY
5. Docusate Sodium 100mg PO
6. Pantoprazole 40 mg Delayed Release (E.C) PO
7. Simethicone 80 mg PO QID
8. Citalopram 20 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. Gabapentin 300 mg PO Q24H
11. Clonazepam 0.5 mg PO TID
12. Aspirin 81 mg PO DAILY
13. Hyoscyamine Sulfate 0.125 mg Sublingual QID PRN
14. Calcium Acetate 667 mg PO TID
15. Metoprolol Succinate Oral
16. Metoprolol Succinate 50 mg Sustained Release 24HR PO DAILY
17. Doxepin 10 mg PO HS
18. Glycopyrrolate 1 mg PO TID
19. Dextromethorphan-Guaifenesin 10-100 mg/5 mL 5 ML PO Q6H
20. Cepacol 2 mg PRN
21. Nafcillin in D2.4W 2 g/100 mL IV Q6H
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO twice a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
11. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
16. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
18. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) UNITS Subcutaneous QAM.
Disp:*QS one month UNITS* Refills:*2*
19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twelve
(12) UNITS Subcutaneous at bedtime.
20. INSULIN
Continue your NPH insulin twice per day, taking 20 units in the
morning and 12 units at night.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Secondary: Diabetes mellitus
End stage renal disease on hemodialysis
Discharge Condition:
Hemodynamically stable and comfortable on room air
Discharge Instructions:
Please take all medications as prescribed. Please call your
doctor or return to the emergency room should you develop any of
the following symptoms: headache, nausea or vomiting with
inability to keep down liquids or medications, changes in vision
or loss of vision, weakness or numbness of either arm or leg,
facial droop, fever > 100.5, chills, or any other concerns.
Followup Instructions:
You should continue your usual dialysis schedule on Tuesdays,
Thursdays, and Saturdays. You should follow up with your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within one week. At that time, you
should have your blood pressure checked. Call [**Telephone/Fax (1) 65441**] for
an appointment.
You have an appointment with the eye specialists this afternoon
at 2:45 pm in the [**Hospital Ward Name 23**] Center on the [**Location (un) 442**]. The clinic
phone number is [**Telephone/Fax (1) 253**]. You will see Dr. [**Last Name (STitle) **] during
this visit.
Please keep these other already-[**Last Name (STitle) 1988**] appointments:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **] SOCIAL WORK
Date/Time:[**2121-12-15**] 10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-12-29**]
8:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-12-29**] 9:30
Completed by:[**2121-12-11**]
|
[
"585.6",
"733.90",
"414.01",
"275.3",
"E942.4",
"250.51",
"403.01",
"311",
"428.0",
"362.01",
"784.0",
"379.23",
"786.59",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10042, 10048
|
3543, 7304
|
336, 351
|
10183, 10236
|
2673, 2678
|
10654, 11859
|
2202, 2234
|
8112, 10019
|
10069, 10162
|
7330, 8089
|
10260, 10631
|
2249, 2654
|
276, 298
|
3445, 3520
|
379, 1696
|
2692, 3426
|
1718, 2065
|
2081, 2186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,800
| 182,113
|
46356
|
Discharge summary
|
report
|
Admission Date: [**2160-1-28**] Discharge Date: [**2160-2-8**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation [**2160-1-27**]
Self-extubation [**2160-1-30**]
Intubation [**2160-1-31**]
Extubation [**2160-2-4**]
Intubation/mechanical ventilation
History of Present Illness:
63 y/o man with a PMHx of COPD on home O2(1.5-2L) &
schizophrenia who was presented to the ED with complaint of
cough, shortness of breath for 2 days. Additional history is
unclear, as the patient was noted to be a poor historian, but
according to the medical records, the pt was recently
hospitalized for COPD exacerbation (discharged on [**12-24**] and
again on [**1-3**]). He has recently been treated with azithromycin,
levoquin and completed a prednisone taper on [**1-14**]. He was last
seen by his PCP [**Last Name (NamePattern4) **] [**1-13**], at which time he appeared to be doing
well and without complaints.
.
In the ED this evening, vitals were initially BP 121/61, HR 111,
RR 34, sating 81% on Room air. He recieved Solumedrol,
vancomycin and levoquin. He was noted to have worsening
respiratory status and was placed on a non-rebreather. He
subsequently was noted to be more lethargic, placed on bi-pap
and then intubated. His BP dropped following intubation and the
patient was given 4L NS and was started on levophed at .03 and
transferred to the [**Hospital Unit Name 153**].
.
Here, the patient is intubated, sedated, non-arousable on
fentanyl and versed. Additional history was unobtainable.
Past Medical History:
1) COPD: FEV/FVC 60% in [**2150**] (no recent PFTs available), on
home 1.5-2L O2 at night only
2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
3) Schizophrenia
4) Hx GI bleeding
5) Mental Retardation
Social History:
Lives in [**Location **] with brother and brother-in-law. On
disability since [**2149**] for mental health issues. Visiting nurse
twice daily. Ongoing tobacco use, in the past as much as 4
packs/day. Denies ongoing EtOH or drug use.
Family History:
Non-contributory
Physical Exam:
VSS, Sat >90% on 2L nasal canula
GEN: NAD, well developed middle aged male, poor eye contact
[**Name (NI) 4459**]: anicteric, reactive
NECK: Supple, no lymphadenopathy, no thyromegaly
PULM: very poor air movement, but clear bilaterally
CARD: Distant heart sounds, rrr by pulse, no M/R/G appreciated
ABD: BS+, soft, mildly distended
EXT: 2+ radial and pedal pulses. No clubbing, cyanosis or edema,
shin bruising on left leg
SKIN: hairless legs, vericose veins bilateral shins, extensive
nail thickening bilateral toes.
NEURO/PSYCH: poor eye contact, rambling speech but will answer
direct questions appropriately
Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2160-1-27**]:
SINGLE AP SUPINE BEDSIDE CHEST RADIOGRAPH: ET tube is in
satisfactory position, approximately 6 cm above the carina and
at the level of the lower border of the clavicles. NG tube
descends below the diaphragm with tip not visualized. There is
worsening aeration, with increasing patchy consolidation in the
right, middle, and lower lobes, which may represent an infection
or aspiration. The left lung remains clear. No pneumothorax.
IMPRESSION: ET tube in satisfactory position. Worsening right
middle and lower lung zone infiltrates, which could represent
infection or aspiration.
CHEST (PORTABLE AP) Study Date of [**2160-1-30**]:
PORTABLE AP CHEST RADIOGRAPH: NG tube follows appropriate
course. ET tube tip terminates 74 mm above the carina.
Right-sided central line with tip terminating in mid SVC.
Worsening of opacities in both lung bases, that could represent
area of aspiration pneumonia. Cardiomediastinal silhouette is
unremarkable.
CHEST (PORTABLE AP) Study Date of [**2160-2-4**]:
FINDINGS: Endotracheal tube terminates about 5.7 cm above the
carina. Other indwelling devices remain in standard positions.
Cardiomediastinal contours are within normal limits. Multifocal
patchy parenchymal opacities in the right mid and both lower
lungs appear slightly improved. Findings may be due to provided
history of pneumonia. Differential diagnosis includes
asymmetrical pattern of pulmonary edema in the setting of COPD.
ADMISSION LABORATORY RESULTS:
[**2160-1-27**] 08:30PM BLOOD WBC-17.0* RBC-4.86 Hgb-15.3 Hct-44.5
MCV-92 MCH-31.5 MCHC-34.4 RDW-12.7 Plt Ct-368
[**2160-1-27**] 08:30PM BLOOD Neuts-89.5* Lymphs-7.4* Monos-2.9 Eos-0.1
Baso-0.1
[**2160-1-27**] 08:30PM BLOOD PT-14.2* PTT-34.2 INR(PT)-1.2*
[**2160-1-27**] 08:30PM BLOOD Glucose-135* UreaN-20 Creat-1.2 Na-138
K-4.5 Cl-98 HCO3-30 AnGap-15
[**2160-1-27**] 08:30PM BLOOD Calcium-9.1 Phos-4.1 Mg-1.7
[**2160-1-27**] 09:58PM BLOOD Type-ART Temp-37.5 Rates-/30 pO2-323*
pCO2-79* pH-7.17* calTCO2-30 Base XS--1
DISCHARGE LABORATORY RESULTS:
[**2160-2-5**] 4:24 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2160-2-6**]**
MRSA SCREEN (Final [**2160-2-6**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
BLOOD GAS RESULTS:
[**2160-1-27**] 09:58PM BLOOD Type-ART Temp-37.5 Rates-/30 pO2-323*
pCO2-79* pH-7.17* calTCO2-30 Base XS--1
[**2160-2-4**] 08:31AM BLOOD Type-ART Rates-[**11-7**] Tidal V-500 PEEP-5
FiO2-30 pO2-76* pCO2-60* pH-7.35 calTCO2-35* Base XS-4
-ASSIST/CON Intubat-INTUBATED
[**2160-2-4**] 03:21PM BLOOD Type-ART Temp-36.7 Rates-/22 Tidal V-350
PEEP-5 FiO2-30 pO2-82* pCO2-53* pH-7.38 calTCO2-33* Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2160-2-4**] 06:35PM BLOOD Type-ART Temp-36.7 Rates-/30 FiO2-35
pO2-92 pCO2-51* pH-7.40 calTCO2-33* Base XS-4 Intubat-NOT INTUBA
MICROBIOLOGY:
[**2160-2-2**] URINE URINE CULTURE-FINAL (NO GROWTH)
[**2160-1-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{MRSA}
[**2160-1-29**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
[**2160-1-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}; LEGIONELLA CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY
{YEAST, PENICILLIUM SPECIES}
[**2160-1-28**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2160-1-28**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2160-1-28**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
[**2160-1-28**] URINE URINE CULTURE-FINAL (NO GROWTH)
[**2160-1-27**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2160-1-27**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
Brief Hospital Course:
# Hypercarbic Respiratory distress/tachypnea:
Pt with a history of COPD and recent hospitalizations for
exacerbation/pneumonia. Given this history and his CT findings,
it is likely that his initial presentation of dyspnea, cough,
leukocytosis were similar to his previous complaints. His rapid
respiratory decline upon presentation, however, is possibly due
to increased supplemental O2 and a subsequent deminished
respiratory drive. PCO2 has been in the 50's at basline per
previous ABGs. Patient was initiated on vancomycin,
levofloxacin, and IV solumedrol at presentation. Throughout the
MICU course, the patient was switched from IV solumedrol to oral
prednisone on [**2160-1-31**] and a taper was begun. The dose of
prednisone was 10 mg [**Hospital1 **] starting on [**2160-2-4**] prior to
transfer out of the intensive care unit. Patient remained
intubated from admission until self-extubation on [**2160-1-30**]. He
showed signs of hypercarbia on his arterial blood gas and was
put on BiPAP; however, he evetually required intubation again
early in morning of [**2160-1-31**]. He was then diuresed with > 2L
negative fluid balance on [**2160-2-4**] prior to extubation. His
sedation was lightened and he was extubated on afternoon of
[**2160-2-4**] with blood gas of 7.40/51/92 on face mask with 35%
FiO2 several hours after extubation. Later in the evening of
[**2160-2-4**] he had ABG on room air was 7.42/49/74.
The patient's repiratory status continued to improve throughout
his hospitalization and he was discharged to pulmonary rehab.
His prednisone can continue to be tapered as an outpatient, with
20 mg po qday until [**2160-2-9**], then 10 mg po qday thru [**2160-2-13**] and
then discontinue.
.
# Hypotension/Hypertension:
Patient required levophed for SBPs in the 80's s/p intubation on
[**2160-1-27**]. Hypotension was not fluid responsive and was likely
induced by sedation required for intubation. Alternatively, may
have been hypovolemic due to recent illness or septic like
picture in the setting of his pulmonary infection. Patient was
liberated from support with levophed on morning of [**2160-1-29**].
He then had hypertension starting on [**2160-2-1**] that required
PRNs of IV hydralazine and furosemide IV. These episode of
hypertension tended to correlate with sedation being lightened
while patient was intubated. Concern was raised that his
hypertension to the 200s systolic prior to extubation on
[**2160-2-4**] would lead to flash pulmonary edema, thus he was
transiently on a nitro drip on [**2160-2-4**] following extubation.
After extubation, he continued to be mildly hypertensive
150's-160's. PO hydralazine was started and titrated up.
On the medical floor, the patient's hydralazine was discontinued
and his blood pressures remained within an acceptable range.
.
# Leukocytosis: The patient had a persistent and increasing
leukocytosis during his hospital admission. At 22K on [**2159-2-6**],
further infectious work-up was performed and unremarkable. WBC
back down to 15K on discharge.
.
# Hyperglycemia:
No history of diabetes, though had some hyperglycemia thought to
be due to steroids and was started on NPH [**Hospital1 **] while in the MICU.
As his steroid dosing was tapered off, he began having several
FSBG values that were in the 50s and 60s, his insulin was
discontinued and FSBG values were measured for one additional
day.
.
# Schizophrenia/MR:
Pt apparently well functioning despite disability. Per report of
case manager, he is the most functional person in his household
and takes care of the bills. No active issues with schizophrenia
during this hospitalization. We continued Zyprexa 5 mg QD.
Medications on Admission:
ALBUTEROL SULFATE 2 puffs q 4 hrs prn
FLUTICASONE-SALMETEROL 1 puff [**Hospital1 **]
ATROVENT 2 puffs four times a day
OLANZAPINE [ZYPREXA] 5 mg QD
OMEPRAZOLE - 20 mg QD
SPIRIVA 1 capsule QD
ASPIRIN - 81 mg Tablet QD
HOME OXYGEN 2 LITERS NASAL CANULA AT BEDTIME.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): until [**2160-2-13**], then decrease to 10 mg po qday x 4 days
then discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD Exacerbation, acute
Hypercarbic hypoxemic respiratory failure
MRSA Pneumonia
Leukocytosis, resolved
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Hospitalized for respiratory failure secondary to severe COPD
and pneumonia. Discharged to [**Hospital3 7**] for pulmonary
rehabilitation.
Return to ED if having significant SOB, high fevers, confusion,
chills, rigors or increasing shortness of breath.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2160-2-19**] 9:40
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2160-2-26**] 9:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2160-2-26**] 10:00
|
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[
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1987, 2221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,539
| 100,035
|
41331
|
Discharge summary
|
report
|
Admission Date: [**2115-2-22**] Discharge Date: [**2115-3-19**]
Date of Birth: [**2078-8-9**] Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Post-cardiac arrest, asthma exacerbation
Major Surgical or Invasive Procedure:
Intubation
Removal of chest tubes placed at an outside hospital
R CVL placement
History of Present Illness:
Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant
with dilated cardiomyopathy s/p AICD, asthma, and HTN admitted
to an OSH with dyspnea now admitted to the MICU after PEA arrest
x2. The patient initially presented to LGH ED with hypoxemic
respiratory distress. While at the OSH, he received CTX,
azithromycin, SC epinephrine, and solumedrol. While at the OSH,
he became confused and subsequently had an episode of PEA arrest
and was intubated. He received epinephrine, atropine, magnesium,
and bicarb. In addition, he had bilateral needle thoracostomies
with report of air return on the left, and he subsequently had
bilateral chest tubes placed. After approximately 15-20 minutes
of rescucitation, he had ROSC. He received vecuronium and was
started on an epi gtt for asthma and a cooling protocol, and was
then transferred to [**Hospital1 18**] for further evaluation. Of note, the
patient was admitted to LGH in [**1-4**] for dyspnea, and was
subsequently diagnosed with a CAP and asthma treated with CTX
and azithromycin. Per his family, he has also had multiple
admissions this winter for asthma exacerbations.
.
In the [**Hospital1 18**] ED, 35.3 102 133/58 100%AC 500x20, 5, 1.0 with an
ABG 7.16/66/162. He had a CTH which was unremarkable. He then
had a CTA chest, afterwhich he went into PEA arrest.
Rescucitation last approximately 10-15 minutes with multiple
rounds of epi and bicarb, with ROSC. He was then admitted to the
MICU for further management.
.
Currently, the patient is intubated, sedated, and parlyzed.
Past Medical History:
Asthma
Dilated cardiomyopathy
Multiple admissions for dyspnea this winter ([**1-26**]).
Anxiety/depression
CKD
HLD
Obesity
HTN
Social History:
Unknown
Family History:
Unknown
Physical Exam:
ADMISSION:
VS: 35.9 124 129/67 99% AC 480x24, 5, 1.0
Gen: ETT in place, intubated, sedated.
HEENT: ETT in place.
CV: Tachy S1+S2
Pulm: Poor air movement bilaterally. Diffuse wheezes
bilaterally.
Abd: S/D hypoactive BS
Ext: 1+ edema bilaterally
Neuro: Unresponsive.
.
Discharge: 98.5 102/65 76 20 95-98% RA
In cage bed to prevent patient from falling out of bed.
Occasionally calling out. Lungs clear without wheezes.
Pertinent Results:
Labs on Admission:
[**2115-2-22**] 08:50AM BLOOD WBC-19.5* RBC-4.76 Hgb-14.9 Hct-44.3
MCV-93 MCH-31.4 MCHC-33.7 RDW-12.9 Plt Ct-201
[**2115-2-22**] 08:50AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2*
[**2115-2-22**] 08:50AM BLOOD Glucose-306* UreaN-21* Creat-1.2 Na-144
K-4.1 Cl-111* HCO3-28 AnGap-9
[**2115-2-22**] 08:50AM BLOOD Albumin-3.4* Calcium-6.2* Phos-5.5*
Mg-2.2
[**2115-2-22**] 09:32AM BLOOD calTIBC-320 Ferritn-1129* TRF-246
[**2115-2-22**] 07:17AM BLOOD Type-ART pO2-162* pCO2-66* pH-7.16*
calTCO2-25 Base XS--6 Intubat-INTUBATED
.
Labs on Discharge
[**2115-3-18**] 11:34AM BLOOD Type-ART pO2-95 pCO2-33* pH-7.54*
calTCO2-29 Base XS-5 Intubat-NOT INTUBA
[**2115-3-5**] 05:35AM BLOOD ALT-49* AST-23 AlkPhos-53 TotBili-0.9
[**2115-3-19**] 04:45AM BLOOD Glucose-73 UreaN-25* Creat-1.4* Na-133
K-4.1 Cl-95* HCO3-21* AnGap-21*
[**2115-3-19**] 04:45AM BLOOD WBC-12.4* RBC-4.47* Hgb-14.3 Hct-41.3
MCV-93 MCH-32.0 MCHC-34.6 RDW-13.3 Plt Ct-352
[**2115-3-19**] 04:45AM BLOOD Neuts-56 Bands-0 Lymphs-38 Monos-3 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
.
CXR (in MICU): Mr read - cardiomegaly, RIJ in SVC, ETT 4.5 cm
above carina. Blunting of costophrenic angles bilaterally with
low lung volumes. Loss of retrocardiac diagphragm and bilateral
opacities (L>R)
.
CXR:
1. NG tube at 7.2 cm above the carina. [**Month (only) 116**] consider advancing
for optimal placement.
2. Severe cardiomegaly with globular shape. In the absence of
prior
comparison, the differential is broad, including moderate
pericardial
effusion, mediastinal hemorrhage, or acute cardiac failure.
Recommend
clinical correlation.
.
CTH: My read, no acute bleed
.
CTA Chest:
1. No evidence of pulmonary embolism, although evaluation of
subsegmental branches is limited.
2. Moderate cardiomegaly without pericardial effusion.
3. Bilateral dependent atelectasis.
4. Multiple nondisplaced rib fractures on the right, some of
which are subacute. Also possible subtle nondisplaced fractures
of the left ribs.
5. Nondisplaced acute sternal fracture in addition to a subacute
nondisplaced sternal fracture.
.
TTE: The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated. LV
systolic function appears depressed (ejection fraction ? 30
percent) with regional variation. There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. 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.
.
ECG (post-arrest): Sinus with 1:1 conduction. LAA. LAD, RBBB,
LAFB. STD in V4-V6.
.
ECG (pre-arrest): Sinus with 1:1 conduction. LAD, bifascicular
block. No lateral STD.
.
ECG (OSH, unclear pre/post arrest): Sinus with 1:1 conduction.
Bifascicular (RBBB, LAFB) block. STD in V5-6.
.
EEG [**2-27**]
IMPRESSION: This is an abnormal video EEG telemetry due to the
slow and
disorganized background of 6.5 Hz with bursts of generalized
slowing
that showed no clear reactivity. These findings indicate a
severe
encephalopathy. This may be consistent with the patient's
history of
anoxia; however, toxic/metabolic disturbances, infection, and
medication
effects are also among the most frequent causes of
encephalopathy. No
clear epileptiform discharges or seizures were seen.
LUMBAR SPINE [**2115-3-11**]
CLINICAL INFORMATION: Evidence of fracture, seizure, fall, low
back pain.
FINDINGS:
Three views of the lumbar spine demonstrate mild narrowing of
the left
femoroacetabular joint. There is mild scoliosis of the
thoracolumbar spine. The ventricular lead of a pacemaker is
identified. No fracture of L2 through L5 is identified. However,
there is a compression fracture of L1, with compression of the
superior endplate, and a sclerotic fracture line. Given the
mechanism of fall, if there is acute pain referable to L1, then
this would be considered an acute finding. There is no apparent
retropulsion of the posterior margin of L1 into the spinal
canal. No other fractures are identified at this time. Facet
joints are aligned. There is early calcification of the aorta.
IMPRESSION: Compression fracture of L1 with anterior wedge
deformity, likely an acute finding. No other fractures
identified.
EKG: Normal sinus rhythm. Complete right bundle-branch block
with left anterior fascicular block. Diffuse ST-T wave changes
laterally.
CT Head:
COMPARISON: [**2115-2-22**].
TECHNIQUE: Non-contrast axial images were obtained through the
brain.
FINDINGS: There is no intracranial hemorrhage, edema, or loss of
[**Doctor Last Name 352**]/white matter differentiation. Ventricles and sulci are
normal in size and configuration. The basilar cisterns are not
compressed. Paranasal sinuses demonstrate fluid in the sphenoid
air cells and right posterior ethmoid air cell, likely related
to prolonged hospitalization. Mastoid air cells are well
aerated.
IMPRESSION: No evidence of acute intracranial abnormalities.
Brief Hospital Course:
Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant
with dilated cardiomyopathy s/p AICD, PE not on anticoagulation,
asthma, and HTN admitted to an OSH with dyspnea now the
transferred to [**Hospital1 18**] MICU after PEA arrest x2.
# PEA arrest and subsequent anoxic brain injury.: Suspect that
original OSH PEA arrest due to hypoxemia or acidosis, with [**Hospital1 18**]
ED PEA arrest due to acidosis with admission pH 7.16 on arrival.
TTE with evidence of RV failure to suggest PE. LVEF 30% with
known dilated cardiomyopathy. He was cooled per protocol.
Initially, his EEG was concerning without evident brain
activity. On hospital day 3, there was only comatose activity
and his prognosis was guarded. However, the patient was able to
be weaned off the vent and over the course of the next three
days his mental status improved. He was alert, oriented to
place and day of the week and moving all 4 extremities. He
became more interactive on transfer to the floor, was initially
speaking in spanish and English and not always making sense but
then started responding more appropiately and following
commands. On hospital day 11 he had a witnessed grand mal
seizure and was given ativan and started on Keppra with
neurology consult. His mental status was worse for 24 hours
after the seizure but then he slowly returned to his recent
baseline. He was somewhat aggitated so his Keppra was switched
to Topiramate. He had a subsequent seizure on [**3-18**] with LUE
tonic clonic activity and impaired consciousness but this
resolved spontaneously after 1-2 minutes. He was contineud on
topamax per neuro recommendations. OT and PT were consulted and
worked with the patient as he will likely require a long
rehabilitation course. At the time of discharge the patient was
alert, oriented (though not always to date), following commands
but impulsive with poor motor planning leading to several falls.
Neurology notes indicate the patient has the potential
toimprove from a neurologic standpoint. He also may have
recurrent seizures which should be treated with ativan IV or IM
and do not neccessarily indicate patient needs to return to
hospital unless they continue for greater than 5 minutes or he
has multiple recurrent seizures or complications such as
aspiration.
-patient will be on Topiramate 25mg PO BID until [**3-22**] PM then
increase to 50mg po BID for seven days then increase to 75mg [**Hospital1 **]
ongoing.
-patient will follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in his s/p
arrest neurology clinic
-patient will require intensive PT and OT in an anoxic brain
injury unit.
.
# Respiratory failure: Believed to be due to status asthmaticus,
although inciting event unclear. [**Name2 (NI) 227**] multiple cardiac arrests,
also a concern for development of ARDS. The patient was
initially treated broadly with vancomycin, cefepime, flagyl,
cipro, and oseltamavir. He was treated with IV soludemedrol and
albuterol MDI. He was ventialted according to ARDS-Net protocol.
On admission, he had two chest tubes placed for pneumothoraces.
They were removed on hospital day 1. In his first several days,
his respiratory status was comprimised by lobar collapse, first
of the RUL and then of the RML. His extubation was initially
limited both by agitation requiring sedation and by requirements
for high PEEP to maintain oxygenation. His oxygenation was
improved with diuresis and agitation was better controlled with
seroquel. He was extubated on [**3-1**] and respiratory status was
stable. His Asthma was treated with standing and PRN albuterol
and ipratriopium and a slow prednisone taper which he l
completed on [**2115-3-18**] and he was restarted on Advair
-patient may require additional nebs on top of his standing
advair though his respiratory status has been very stable,
without wheezing for the last week.
- would like benefit from outpatient PFTs and is scheduled to
see a pulmonologist in follow up.
.
# Ventilator associated pneumonia: Patient developed a fever on
[**2-27**] with new infiltrates on chest xray while intubated. He was
initially covered with vanc/cefepime and cipro. Cipro was
eventually discontinued. He did not grow any organisms other
than yeast in his sputum. He completed an 8 day course of
Vanco/Cefepime.
.
# Myoclonus: when mental status improved, was noted to have
myoclonic jerks. per neurology, likely [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Syndrome
which is anoxic injury to the purkinje cells. These jerks
continued for about one week and then became rare.
.
# dilated [**Last Name (LF) 89982**], [**First Name3 (LF) **] 30%. s/p ICD. Patient was
diuresed with IV lasix in the ED and then transitioned to PO
lasix, home dose, on the floor. His respiratory status remained
stable. Also continued on home dose of carvedilol and Lisinopril
but ACE downtitrated from 40 to 20 when had elevated Cr 1.9 on
[**3-18**] and slightly low BPs high 90s/60s. BP improved to 100s/60s.
.
#Hypertension: Patient's home regimen was continued on the
floor, but his SBP dipped into the high 80s and low 90s so
lisinopril was decreased to 20mg po daily and his SBP remained
100-130.
.
# L1 compression fracture: After the patient fell, he was
complaining of low back pain so a L-spine Xray was performed and
showed L1 compressin fracture with No cord impingement on
imaging. The patient had no localizing deficits on serial neuro
exam. He was treated with pain medication including low dose
ultram, standing tylenol and a lidocaine patch. Calcitonin was
tried for pain with compression fracture but this did not seem
to help with symptoms so was discontinued.
.
# Leukocytosis: WBC >20 persistently in the MICU even after
being treated for infection. Since no new infection was found
this was presumed [**12-26**] steroids and the leukocytosis improved
with prednisone taper. WBC 12 on day of discharge
.
# Hyperglycemia: Patient is not known to be a diabetic and was
felt [**12-26**] steroids, his sugars were controlled on sliding scale
insulin in the hospital but he no longer had insulin
requirements as his prednisone was tapered.
.
#. [**Last Name (un) **]: Cr 1.9 on [**3-18**] from 1.2 which improved to 1.4 on [**3-19**]
with decreasing ACE and 500cc bolus. He should have repeat
creatinine and labs on [**3-22**] to ensure stability.
# Guardianship: Guardianship paperwork was started in the
hospital.
Medications on Admission:
Carvedilol 25 [**Hospital1 **]
Lasix 80 mg po bid
Xanax 0.25 mg 1-2 tabs prn
albuterol MDI
Ibuprofen prn
Benadryl prn
Advair diskus
Lsinopril 40 daily
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. 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 pain/fever.
4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**11-25**] Tablet, Rapid
Dissolves PO QHS (once a day (at bedtime)) as needed for sleep.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain/fever.
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on and 12 hours off every 24 hour period.
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
16. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 3 days: 1 [**Hospital1 **] until [**3-22**] PM then increase to 2
tablets [**Hospital1 **] for 7 days then 3 tablets [**Hospital1 **] ongoing.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
18. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
19. lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection twice a day
as needed for seizure that last longer than 5 minutes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Anoxic Brain Injury s/p PEA arrest x2
Status Asthmaticus
Ventilator Associated Pneumonia
Chronic Systolic Heart Failure
L1 compression fracture
Seizures after hypoxic brain injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) because he has poor motor planning
Discharge Instructions:
You came to the hospital after having a cardiac arrest and an
asthma exacerbation. You had another cardiac arrest in our
hospital and were admitted to the MICU. You required intubation
but were able to wean off the machine and breathe on your own.
We treated you for pneumonia and asthma. Your mental status
slowly improved, though you did have 2 seizures, last on [**3-18**].
You were started ons eizure medications for this.
.
Please take your medications as prescribed and follow up with
your doctors [**Name5 (PTitle) 7928**].
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2115-4-3**] at 1:10 PM
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
When: WEDNESDAY [**2115-4-3**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2115-4-11**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"493.90",
"V45.02",
"E879.8",
"349.82",
"428.0",
"584.9",
"348.1",
"997.31",
"249.00",
"276.0",
"345.10",
"427.5",
"276.2",
"518.81",
"780.01",
"278.00",
"805.4",
"428.22",
"E888.9",
"518.0",
"493.91",
"E932.0",
"425.4",
"403.90",
"585.9",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"33.24",
"33.29"
] |
icd9pcs
|
[
[
[]
]
] |
16931, 17003
|
8130, 14579
|
308, 390
|
17227, 17227
|
2629, 2634
|
18004, 18938
|
2167, 2176
|
14780, 16908
|
17024, 17206
|
14605, 14757
|
17446, 17981
|
2191, 2610
|
228, 270
|
418, 1976
|
7541, 8107
|
2648, 7532
|
17242, 17422
|
1998, 2126
|
2142, 2151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,064
| 116,717
|
39743
|
Discharge summary
|
report
|
Admission Date: [**2175-6-29**] Discharge Date: [**2175-7-4**]
Date of Birth: [**2112-4-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 yo M with DMI on an insulin pump admitted with hyperglycemia
and in diabetic ketoacidosis. Patient was admitted to [**Hospital1 2025**] in
[**2175-5-5**] with trauma (fall from ladder) resulting in
intracranial hemorrhage, SAH, C3 and C4 fractures and L2/L3
fractures. Wife does not know if EtOH was involved in the fall.
He was discharged to [**Hospital3 **] and while he was there, he
was maintained on RISS without the pump. He had episodes of
orthostatic hypotension at the time which required re-admission
to [**Hospital1 2025**] for work-up. He was discharged on [**2175-6-23**] home with Lantus
20 U QHS and Lispro insulin sliding scale. Since then, the
patient's wife reports hyperglycemia at home with FS ranging
from 200s to 600s. She does not know his pump settings but
stated that his carbohydrate ratio was 10:1. He also had
increased increased nocturia (increased from some baseline
difficulty with urinary retention due to traumatic foley
placement at rehab), anorexia, and 20 lb weight loss. No
polyphagia or polydipsia. Denied any chest pain, fevers, cough,
shortness of breath, abdominal pain, diarrhea. No illicit
ingestions. His wife states that even after the brain injury,
his mental status was stable (AOx3, requiring some help with
ADLs, but enough concentration to possibly operate his pump.) on
discharge from rehab. However, the day of presentation, she
noted he was more confused and not responding appropriately to
questions. His primary endocrinologist is Dr.[**Name (NI) 4849**] at the
[**Last Name (un) **]. He presented to the [**Last Name (un) **] today out of concern for
these symptoms, and was sent to the ED by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32886**] for
treatment of DKA.
.
In the ED, initial vs were: T 97.3 125 92/51 20 92% on RA.
Patient appeared pale in triage, confused, and smelled of
ketones. FS was 703. Lab sig for Na of 126, K of 6.9, Cre of
1.3, and anion gap of 35. VBG 7.08/35/48/11. U/A with ketones
and glucose. EKG without any ischemic changes or peaked T-waves.
He received Zofran 4 mg IV x2, Morphine 2 mg IV x1 for a
headache, 4 L of normal saline, and insulin gtt at 5 U/hr. Prior
to transfer, his VS were 97.6 92 108/72 16 98% on RA. FS was
432. No chemistries ordered prior to transfer.
.
On the floor, the patient appeared AOx1 to name only, and unable
to concentrate on answering questions, saying only 'insulin'. He
continued to be fluid resuscitated with ~1400 ccs of NS, 1 L of
20 meQ KCL and NS, and 6 U/hr insulin gtt. His FS decreased from
351 to 279 and anion gap closed from 20 to 15. His gtt was
decreased to 2 U/hr and fluids changed to D5 1/2 NS until
patient would be alert enough to eat.
.
Review of systems: (per wife)
(+) 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:
Type I Diabetes Mellitus
- complicated by neuropathy, retinopathy
- on insulin pump since [**2154**]
- s/p laser treatment
Hypertension
Hypercholesterolemia
Depression
Peripheral Vascular Disease- s/p L fem [**Doctor Last Name **] in [**2154**]
due to heel infection. iliac stent.
Carpal Tunnel Syndrome
PTSD
GERD
.
Past Surgical History:
s/p appendectomy
Bilateral Shoulder surgery
Social History:
lives with wife [**Name (NI) **]. disabled plumber. smoker (50 ppy hx) quit
2 months ago. no illicits. Possible EtOH dependence (wife is not
able to quantify how much patient drinks but is concerned he
drinks more than she knows)
Family History:
father died of lung cancer. No cardiac dz.
Physical Exam:
Vitals: 98.1 109 147/63 84 19 98% on RA
General: AOx3 (could not name hospital name); comfortable, in
NAD
HEENT: Sclera anicteric, MMdry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Mild wheezing left lower lobe, no rales/rhonchi, good air
entry
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds minimal,
no rebound tenderness or guarding, no organomegaly
skin: poor skin turgor
Ext: cold LEs (L>R), 1+ pulses, no edema
Neurologic exam: cn intact, no gross motor deficits, decreased
sensation to LT in LE b/l, gait not assessed
Pertinent Results:
[**2175-6-29**] 06:00PM BLOOD WBC-10.3 RBC-4.45* Hgb-13.7* Hct-45.1
MCV-102* MCH-30.9 MCHC-30.5* RDW-13.9 Plt Ct-380
[**2175-6-29**] 06:00PM BLOOD Neuts-91.1* Lymphs-6.7* Monos-1.5*
Eos-0.1 Baso-0.5
[**2175-6-29**] 06:00PM BLOOD Plt Ct-380
[**2175-7-2**] 02:00AM BLOOD PT-12.0 PTT-26.4 INR(PT)-1.0
[**2175-6-29**] 06:00PM BLOOD Glucose-730* UreaN-36* Creat-1.3* Na-126*
K-6.2* Cl-81* HCO3-10* AnGap-41*
[**2175-7-2**] 02:00AM BLOOD Glucose-177* UreaN-4* Creat-0.6 Na-137
K-4.2 Cl-102 HCO3-25 AnGap-14
[**2175-6-30**] 01:12AM BLOOD CK(CPK)-344*
[**2175-6-30**] 07:20AM BLOOD Lipase-53
[**2175-6-30**] 01:12AM BLOOD CK-MB-34* MB Indx-9.9* cTropnT-0.88*
[**2175-6-30**] 05:28AM BLOOD CK-MB-39* MB Indx-10.7* cTropnT-1.19*
[**2175-6-30**] 12:30PM BLOOD CK-MB-37* MB Indx-11.6* cTropnT-1.42*
[**2175-6-30**] 08:26PM BLOOD CK-MB-22* MB Indx-9.9* cTropnT-1.10*
[**2175-6-29**] 11:27PM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8
[**2175-6-30**] 07:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-6-29**] 08:16PM BLOOD pO2-48* pCO2-35 pH-7.08* calTCO2-11* Base
XS--20 Comment-GREEN TOP
[**2175-6-29**] 08:16PM BLOOD Glucose-GREATER TH Lactate-3.4* Na-134*
K-5.4* Cl-99*
[**2175-6-29**] 11:33PM BLOOD Glucose-303* Lactate-1.8
[**2175-6-29**] 11:33PM BLOOD freeCa-1.17
.......................
[**2175-6-29**] ECG: Sinus tachycardia. Right axis deviation. Right
bundle-branch block. Non-specific ST-T wave abnormalities.
Cannot rule out anterolateral ischemia. Suggest clinical
correlation and repeat tracing. No previous tracing available
for comparison.
.
[**2175-6-29**] CXR: 1. No consolidation or acute abnormality. 2. Vague
nodular opacity projecting over the right mid lung. Nonemergent
chest CT can be obtained for further evaluation.
.
[**2175-6-30**] CT Head W/Out Contrast: 1. No acute intracranial
abnormality.
2. Hypodensity in the left frontal lobe, likely due to
encephalomalacia.
Brief Hospital Course:
63 yo M with IDDMI presenting with hyperglycemia, anorexia, and
weight loss, admitted to the MICU with diabetic ketoacidosis.
.
MICU [**Location (un) **] Course: The patient was in DKA on admission with
altered mental statu, polyuria, and weight loss. Labs notable
for FS in the 700s, metabolic acidosis, ketones in urine. Likely
in setting of decreased insulin administration compared to his
usual pump settings. No evidence of infection (U/A negative, no
consolidation on CXR). He was made NPO, aggressively
resuscitated with IVF, and placed on an insulin drip with
frequent finget sticks. He was successfully transitioned to
subcutaneous insulin and his diet was advanced. His symptoms
resolved. [**Last Name (un) **] was consulted.
He was also found to have an NSTEMI. He was placed on full
dose ASA, a statin, beta-blocker, and ACE-I. A TTE showed mild
regional left ventricular systolic dysfunction with lateral
hypokinesis. Cardiology was consulted and recommended
outpatient follow-up.
Altered Mental Status: Patient with delirium likely in setting
of DKA. However, given known ICH, he had a CT scan of the head
to rule out further intracranial processes which was negative.
With lowering of his blood sugar, his mental status returned to
baseline.
Abnormal CXR: The pt needs a f/u Ct in 6 months to ensure
stability of pulmonary nodules.
Medications on Admission:
ASA 325 mg PO daily
Captopril 25 mg PO BID
Finasteride 5 mg PO daily
Lantus 20 U SQ QHS
Lispro RISS TID
Metformin 1000 mg PO BID
Nicotine Patch 21 mg/24 hr TD daily
Crestor 20 mg PO daily
Effexor XR 150 mg PO daily
Trazodone 50 mg PO daily
Reglan 5 mg PO TID before meals
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care
Discharge Diagnosis:
Primary: Diabetic keto-acidosis, Non-ST Elevation MI
Secondary: DM Type 1, HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Discharge Instructions:
You were admitted to the [**Hospital1 18**] on [**6-29**] for symptoms of diabetic
keto-acidosis (confusion, dizziness). You were also found to
have had a non-ST elevation myocardial infarction (heart attack)
when you presented to the emergency department on [**6-29**]. For
your diabetic keto-acidosis, we gave you regular IV insulin and
IV fluids to bring your blood sugars down. For your heart
attack, we continued you on your home medications (aspirin,
statin, and captopril) and we started you on a new medication-
metoprolol. We also obtained an ECHO of your heart to see how
it was pumping on [**6-30**]- the study showed some irregularity in
the heart's ability to contract in one particular area. We
re-started you on your insulin pump and you have follow-up apts.
scheduled at [**Hospital **] Medical Center on [**2175-7-20**] and [**2175-8-4**]. We
are also suggesting that you follow-up with a cardiologist as an
out-patient regarding your recent heart attack. Physical
therapy will be necessary for you to have at home. However it
is important that you do not over exert yourself for the next
month. And you are now able to urinate w/out the need of a
catheter.
Please stop taking the following medications:
Finasteride
Metformin
Lantus
Lispro
Please start taking the following medications:
Metoprolol 25mg three times daily
[**Last Name (un) **] recommends the following settings for your insulin pump:
Basal: 12am-9am 1.1 U/hr,
Basal: 9am-12am 1.4 U/hr
Ins:Carb - B 1:10, L 1:8, D 1:10
[**Last Name (un) **] F - 1:30 correct to 120
You will be following up with Dr.[**Doctor Last Name 4849**] on [**7-20**] and you will
meet with the pump nurse on [**8-4**]. You should ask to sign up for
a pump class when you are there.
You should follow with your PCP within one week. Please talk to
your PCP about obtaining [**Name Initial (PRE) **] stress test to evaluate your heart
function.
Your cardiology appt is next month.
Followup Instructions:
Name: [**Last Name (LF) 12203**],[**First Name3 (LF) **] P.
Location: [**Hospital1 **] PRIMARY CARE
Address: [**Street Address(2) **]., 1ST FL, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 31010**]
Appointment: Tuesday [**2175-7-18**] 11:15am
[**2175-7-20**] at 12:30 pm: apt. w/ Dr.[**Name (NI) **] ([**Last Name (un) **] Diabetes Center)
ph: ([**Telephone/Fax (1) 17484**]
[**2175-8-4**] at 2:30 pm: apt. w/ insulin pump educator ([**Last Name (un) **]
Diabetes Center) ph: ([**Telephone/Fax (1) 17484**]
Department: CARDIAC SERVICES
When: MONDAY [**2175-8-14**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2175-7-5**]
|
[
"250.13",
"783.0",
"V58.67",
"357.2",
"250.63",
"362.01",
"401.9",
"788.29",
"410.71",
"530.81",
"250.53",
"443.9",
"309.81",
"311",
"272.0",
"354.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8526, 8587
|
6840, 7855
|
317, 323
|
8711, 8711
|
4898, 6817
|
10857, 11758
|
4203, 4247
|
8608, 8690
|
8229, 8503
|
8884, 10834
|
3894, 3940
|
4262, 4769
|
3074, 3533
|
274, 279
|
351, 3055
|
8726, 8860
|
4786, 4879
|
3555, 3871
|
3956, 4187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,618
| 153,677
|
54999
|
Discharge summary
|
report
|
Admission Date: [**2151-7-27**] Discharge Date: [**2151-7-31**]
Date of Birth: [**2085-7-18**] Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
1.) Transthoracic lung biopsy - interventional radiology
History of Present Illness:
Ms. [**Known lastname 112303**] is a 66yoF with a history of hypertension and
hyperlipidemia who is being transferred from the neurosurgery
service for further evaluation of multiple brain metastases and
a lung mass seen on imaging studies. She was in her usual state
of health through [**2151-7-25**] when she developed a frontal headache
that was unresponsive to NSAIDs. She had also described
unsteadiness on her feet for a few days. She presented to
[**Hospital1 2436**] ED where a head CT revealed a left frontal mass and
multiple cerebellar lesions with effacement of 4th ventricle.
She was thereafter transferred to [**Hospital1 18**].
She was admitted to the neurosurgery SICU due to concern for
mass effect and risk for hydrocephalus, though her vital signs
were stable. Her examination revealed left dysmetria, imbalance.
Though she was fully oriented, she was somewhat tired and
mentally "slow." MRI confirmed the presence of the masses seen
on CT with infra and supratentorial brain lesion suggestive of
metastasis. CT torso done for detection of primary lesion
showed a large LUL lesion with satellite lesions in both lungs
and hilar/mediastinal lymphadenopathy. She was started on
dexamethasone and phenytoin for seizure prophylaxis.
Neuro-oncology was consulted, and recommended diagnostic biopsy
of a lung lesion, with likely whole-brain radiation therapy for
her brain metastases. Interventional pulmonology was consulted
and recommended avoidance of transbronchial biopsy approach, as
intubation could increase her intracranial pressure. A
transthoracic, CT-guided approach was recommended via IR, who
are not yet involved in her care.
On arrival to the oncology floor, her vitals were:
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
PMHx: HTN, CHOL, left upper tooth extraction [**7-22**]. She had a
cavity and high likelihood that a root canal would be needed so
the tooth was extracted and implant was used.
Social History:
Social Hx: She is a right handed billing manager at [**Hospital3 18242**]. She smoke 1 pack per day for two years and this was
over 25 years ago. Social ETOH.
Family History:
Family Hx: Her mother had lung CA and her father had lymphoma
Physical Exam:
[]ADMISSION PHYSICAL EXAM:
O: 97.7 86 141/88 16 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5-2.0 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
No infection/drainage noted at tooth extraction site
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2.5 to 2.0
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: 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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-8**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Coordination: normal rapid alternating
movements, heel to shin. Left dysmetria
Handedness Right
[]DISCHARGE PHYSICAL EXAM:
O: T 98.2, HR 75,BP 141/88,RR 16, 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: PERRLA, EOMs intact
Extrem: Warm and well-perfused.
Chest: CTAB, good air exchange, no w/r/r
CV: RRR, no m/g/r, s1, s2
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light. Visual fields
are full to confrontation.
III, IV, VI: 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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-8**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Coordination: normal rapid alternating
movements, heel to shin. Left dysmetria
Handedness Right
Pertinent Results:
#ADMISSION LABS:
[**2151-7-27**] 05:16AM GLUCOSE-91 UREA N-26* CREAT-0.6 SODIUM-142
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2151-7-27**] 05:16AM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2151-7-27**] 05:16AM WBC-6.1 RBC-4.28 HGB-13.2 HCT-38.5 MCV-90
MCH-30.9 MCHC-34.3 RDW-13.2
[**2151-7-27**] 05:16AM PLT COUNT-257
[**2151-7-27**] 05:16AM PT-9.8 PTT-30.2 INR(PT)-0.9
[**2151-7-27**] 03:45AM GLUCOSE-99 UREA N-27* CREAT-0.6 SODIUM-143
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-30 ANION GAP-11
[**2151-7-27**] 03:45AM estGFR-Using this
[**2151-7-27**] 03:45AM WBC-6.2 RBC-4.37 HGB-13.3 HCT-38.9 MCV-89
MCH-30.4 MCHC-34.1 RDW-13.2
[**2151-7-27**] 03:45AM NEUTS-74.9* LYMPHS-18.5 MONOS-4.4 EOS-0.8
BASOS-1.4
[**2151-7-27**] 03:45AM PLT COUNT-247
[**2151-7-27**] 03:45AM PT-10.3 PTT-29.9 INR(PT)-0.9
#PERTINENT LABS:
[**2151-7-28**] 02:02AM BLOOD WBC-7.0 RBC-4.36 Hgb-13.4 Hct-38.6 MCV-89
MCH-30.8 MCHC-34.8 RDW-12.9 Plt Ct-257
[**2151-7-29**] 06:15AM BLOOD WBC-9.9 RBC-4.47 Hgb-13.2 Hct-39.1 MCV-87
MCH-29.6 MCHC-33.8 RDW-13.7 Plt Ct-285
[**2151-7-30**] 06:25AM BLOOD WBC-9.5 RBC-4.69 Hgb-14.0 Hct-41.4 MCV-88
MCH-29.9 MCHC-33.8 RDW-13.8 Plt Ct-304
[**2151-7-31**] 07:10AM BLOOD WBC-12.8* RBC-4.68 Hgb-13.9 Hct-41.0
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.0 Plt Ct-289
[**2151-7-27**] 03:45AM BLOOD Neuts-74.9* Lymphs-18.5 Monos-4.4 Eos-0.8
Baso-1.4
[**2151-7-31**] 07:10AM BLOOD Plt Ct-289
[**2151-7-30**] 06:25AM BLOOD Plt Ct-304
[**2151-7-30**] 06:25AM BLOOD PT-10.1 PTT-28.1 INR(PT)-0.9
[**2151-7-29**] 06:15AM BLOOD Plt Ct-285
[**2151-7-29**] 06:15AM BLOOD PT-10.4 PTT-26.3 INR(PT)-1.0
[**2151-7-28**] 02:02AM BLOOD Plt Ct-257
[**2151-7-28**] 02:02AM BLOOD PT-10.3 PTT-27.3 INR(PT)-0.9
[**2151-7-27**] 05:16AM BLOOD Plt Ct-257
[**2151-7-27**] 05:16AM BLOOD PT-9.8 PTT-30.2 INR(PT)-0.9
[**2151-7-27**] 03:45AM BLOOD Plt Ct-247
[**2151-7-27**] 03:45AM BLOOD PT-10.3 PTT-29.9 INR(PT)-0.9
[**2151-7-31**] 07:10AM BLOOD Glucose-78 UreaN-19 Creat-0.6 Na-139
K-3.3 Cl-96 HCO3-34* AnGap-12
[**2151-7-30**] 06:25AM BLOOD Glucose-95 UreaN-24* Creat-0.7 Na-140
K-4.1 Cl-102 HCO3-34* AnGap-8
[**2151-7-29**] 06:15AM BLOOD Glucose-96 UreaN-20 Creat-0.6 Na-140
K-3.8 Cl-101 HCO3-33* AnGap-10
[**2151-7-28**] 02:02AM BLOOD Glucose-115* UreaN-15 Creat-0.5 Na-138
K-3.8 Cl-101 HCO3-26 AnGap-15
[**2151-7-29**] 06:15AM BLOOD ALT-36 AST-22 LD(LDH)-223 AlkPhos-61
TotBili-0.4
[**2151-7-31**] 07:10AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9
[**2151-7-30**] 06:25AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.9
[**2151-7-29**] 06:15AM BLOOD Albumin-3.9 Calcium-9.2 Phos-2.9 Mg-1.9
UricAcd-3.8
[**2151-7-28**] 02:02AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.8
[**2151-7-29**] 06:15AM BLOOD CEA-3.6
#MICROBIOLOGY:
[][**2151-7-27**] 5:16 am BLOOD CULTURE
Blood Culture, Routine (Pending):
[][**2151-7-27**] 5:16 am MRSA SCREEN NASAL SWAB.
**FINAL REPORT [**2151-7-29**]**
MRSA SCREEN (Final [**2151-7-29**]): No MRSA isolated
[][**2151-7-28**] 2:02 am BLOOD CULTURE
Blood Culture, Routine (Pending):
[][] Tissue: LUL XTP (1 JAR). Procedure Date of [**2151-7-30**]
Report not finalized.
Assigned Pathologist [**Last Name (LF) 1431**],[**First Name8 (NamePattern2) 1432**] [**Doctor First Name 1433**]
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-1/3338**]
LUL XTP (1 JAR).
#RADIOLOGY:
[]MR HEAD W/ CONTRAST Study Date of [**2151-7-27**] 5:52 AM
IMPRESSION: Numerous supra- and infratentorial enhancing
lesions, with the largest lesions in the left cerebellar
hemisphere and left frontal lobe as above. Considerations
favour multifocal intracranial metastatic disease.
[]CT ABD & PELVIS AND CHEST W & W/O CONTRAST, ADDL SECTIONS
Study Date of [**2151-7-27**] 10:20 AM
IMPRESSION:
1. Findings are consistent with lung cancer originating in the
left upper lobe with bilateral hilar and mediastinal
lymphadenopathy.
2. Multiple pulmonary nodules throughout both lungs are
concerning for
metastatic disease.
3. Normal examination of the abdomen and pelvis. No evidence
for liver or adrenal metastases.
[]CHEST (PORTABLE AP) Study Date of [**2151-7-30**] 3:07 PM
IMPRESSION: Multiple pulmonary nodules as well as a dominant
nodule within
the left hilar region compatible with the patient's known
metastatic neoplasm,
with likely a lung primary. Status post biopsy, there is no
evidence of
pneumothorax.
Brief Hospital Course:
[]BRIEF CLINICAL HISTORY:
66yoF with a history of hypertension and hyperlipidemia who was
transferred from the neurosurgery service for further evaluation
of multiple brain metastases and a lung mass seen on imaging
studies, c/f lung primary.
[]ACTIVE ISSUES:
#.Brain and lung masses: Patient presented with headaches,
dizziness, and unsteady gait. After brain and body imaging
revealed a lung mass with lesions in the brain, she was admitted
to the neurosurgery SICU due to concern for mass effect and risk
for hydrocephalus, though her vital signs were stable. Her
examination revealed left dysmetria, imbalance. Though she was
fully oriented, she was somewhat tired and mentally "slow." MRI
confirmed the presence of the masses seen on CT with infra and
supratentorial brain lesion suggestive of metastasis. CT torso
done for detection of primary lesion showed a large LUL lesion
with satellite lesions in both lungs and hilar/mediastinal
lymphadenopathy. She was started on dexamethasone and phenytoin
for seizure prophylaxis.
Neuro-oncology was consulted, and recommended diagnostic biopsy
of a lung lesion, with likely whole-brain radiation therapy for
her brain metastases. Interventional pulmonology was consulted
and recommended avoidance of transbronchial biopsy approach, as
intubation could increase her intracranial pressure. A
transthoracic, CT-guided approach was recommended via IR.
Patient has h/o GI polyp but otherwise no other onc history. She
has a remote history of smoking over 25 years prior. Based on
imaging studies, likely lung primary with mets to brain. The
patient was seen by neurosurgery and neuro-oncology. The plan
is to consult interventional radiology to perform a CT guided
transthoracic biopsy of the lung mass for tissue diagnosis. In
the event that IR considered this procedure to be too
challenging, interventional pulmonology consented the patient
for a bronch to obtain tissue diagnosis. Neuro oncology had
preliminary plan for whole brain radiation and possible
decompression of cerebellar lesion. The patient was seen by
radiation oncolog during her hospitalization with the plan to
begin simulation and treatment as an outpatient. Patient went
to interventional radiology on [**2151-7-30**] for a transthoracic lung
mass biopsy, pathology pending. Follow up CXR showed no evidence
of a pneumothorax. She will continue taking the dexamethasone
4mg Q6H as an outpatient, along with the phenytoin for seizure
prophylaxis 100mg TID.
#.Dizziness and Nausea: secondary to brain lesions, the most
prominent of which is in the cerebellum which accounts for her
dizziness and unsteadiness. These symptoms resolved by day two
of admission and she required no zofran in the 48 hours leading
up to discharge. She had no emesis and no falls during this
hospitalization. She was seen by physical therapy on the day of
discharge and was cleared to go home with a cane for gait
stabilization.
#.HTN: Well controlled as an outpatient. Will continue home
regimen. In order to control intracranial pressure, the patient
was placed on HydrALAzine 10 mg IV Q6H:PRN SBP>140. During her
hospitalization, her BPs remained well below the threshold for
hydralazine. At the time of discharge, the patient was sent
home on her normal outpatient regimen of HCTZ 50mg daily and
lisinopril 20mg daily.
[]TRANSITIONAL ISSUES:
1.) patient to follow up with Dr. [**Last Name (STitle) **] as an outpatient
2.) final pathology report pending from transthoracic biopsy.
High likelihood lung primary with mets to brain.
3.) patient to follow up with radiation oncology on Tuesday,
[**8-3**] or Wednesday, [**8-4**]. Radiation oncology will
call patient on [**Month (only) 766**], [**8-2**] to confirm.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 20 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp/ha
max 4g/24 hrs
4. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 6 hours Disp
#*120 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*60
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Phenytoin Sodium Extended 100 mg PO TID
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth three
times a day Disp #*90 Capsule Refills:*0
9. Senna 1 TAB PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lung mass with Multiple brain lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 112303**],
It was a pleasure treating you.
You were admitted to the [**Hospital1 69**]
for dizziness and gait instability. You had a brain and body
imaging study that revealed masses in your lungs and brain. You
were seen by the neurosurgery service and neuro oncology. You
had a biopsy done and the results are pending. You will be seen
as an outpatient by the radiation oncology service and by an
oncologist, Dr. [**Last Name (STitle) **], who will be in charge of your managment
as an outpatient. We wish you and your family the best:
Please continue taking all of your outpatient medications as
prescribed, EXCEPT:
ADD dexamethasone
ADD Oxycodone
ADD Pantoprazole
ADD phenytoin
ADD docusate (you can purchase this over the counter for
constipation)
ADD senna (you can purchase this over the counter for
constipation)
ADD Tylenol (you can purchase this over the counter)
Followup Instructions:
*You will be contact[**Name (NI) **] on [**Name (NI) 766**], [**8-2**] regarding follow up
with Radiation Oncology. You will be scheduled for either
Tuesday, [**8-3**], or Wednesday [**8-4**].
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2151-8-10**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"787.02",
"401.9",
"198.3",
"781.3",
"780.4",
"162.3",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.26"
] |
icd9pcs
|
[
[
[]
]
] |
14898, 14904
|
10086, 10332
|
279, 338
|
14986, 14986
|
5660, 5661
|
16072, 16547
|
3090, 3154
|
14046, 14875
|
14925, 14965
|
13851, 14023
|
15137, 16049
|
3196, 3328
|
8689, 10063
|
13453, 13825
|
2100, 2696
|
231, 241
|
10347, 13432
|
366, 2081
|
4893, 5641
|
5677, 6492
|
15001, 15113
|
6508, 8399
|
2718, 2897
|
2913, 3074
|
4438, 4642
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,347
| 105,159
|
6225
|
Discharge summary
|
report
|
Admission Date: [**2121-9-22**] Discharge Date: [**2121-9-27**]
Date of Birth: [**2037-1-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
PICC line placed
History of Present Illness:
The patient is an 84 year old Russian speaking female with
diastolic CHF and several recent admissions for heart failure
exacerbations, who presented to the ED today with pre-syncope.
She was discharged home yesterday, [**2121-9-21**], after being
effectively diuresed with a lasix drip. This morning her VNA
nurse came to the house. As she got up to open the door, the
patient fainted and the VNA nurse caught her. She was put in a
chair and immediately awoke. She did not have any chest pain,
nausea, vomiting, or diaphoresis. The VNA nurse took the
patient's blood pressure, which was reportedly very low, and she
was brought to the ED in an ambulance.
.
During her last admission, in addition to treatment for a heart
failure exacerbation, she was also worked up for restricitve
cardiomyopathy. She had monoclonal bands in her unrine and her
serum, and a bone marrow biopsy was performed as part of the
workup for restrictive cardiomyopathy. An oncology consult was
obtained. The other working diagnosis had been aymloidosis, but
the bone marrow biopsy results were going to be analyzed before
investigating amyloid disease.
.
While VNA was at her home, the patient stood up this morning and
her blood pressure decreased dramatically to 60/palpation,
resulting in near syncope. She was brought to the [**Hospital1 18**] ED for
this reason.
.
In the ED her blood pressure was 92/65, HR 74, RR 18, saturating
98% on 4L NC. She recieved 500cc of iv fluids. She looked dry on
exam. Her hematocrit was 36, up from 31. She is being admitted
to [**Hospital1 1516**] for observation.
.
When she came to the floor, she did not have any dizziness and
she was hemodynamically stable.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
Diastolic Congestive Heart Failure, thought to be restrictive
cardiomyopathy (multiple myeloma versus cardiac amyloid)
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Hiatal Hernia
- GERD
- Syncopal episode in remote past
Social History:
Lives at home alone, but has VNA services 3x/wk. Has home health
aide and homemaker to help with household chores. States can
only walk 10 ft and do minimal cooking for self [**12-17**] SOB. Denies
any falls at home.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
No family history of CHF, sudden cardiac death
Physical Exam:
Admission Exam
VS: T=96.3 BP=100/66 HR=70 RR=20 O2 sat=98 2L
GENERAL: Cachectic female.
HEENT: NCAT. Sclera anicteric. Mucous membranes dry.
NECK: Supple with JVD to the jaw line
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, Distant heart sounds. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. 2+ pitting edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] to
level of thigh.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+
Left: Carotid 2+ Radial 2+
Pertinent Results:
[**2121-9-22**] 12:45PM CK-MB-10 MB INDX-6.5* proBNP-[**Numeric Identifier 24248**]*
[**2121-9-22**] 12:45PM cTropnT-0.41*
[**2121-9-22**] 12:45PM CK(CPK)-154
Brief Hospital Course:
HYPOTENSION/CHF: JVD, distant heart sounds, low voltage on EKG,
enlarged RA and LA, lower extremity edema, pulm edema on CXR,
suggest congestive heart failure, possibly restrictive in
nature. Pt's bone marrow path results returned positive for MM
and CLL. Amyloidosis also of consideration in this patient with
renal failure, monoclonal spike, anemia, possible restrictive
HF. The patient's pre-syncopal episode was likely due to
orthostatic hypotension. Pt was given gentle fluid boluses
initially. Pt had brief episode of hypotension on the floor and
was briefly started on Levophed. She was transfered to the CCU
for close monitoring. In the CCU, Levophed was d/c-ed, and pt
stabalized with lasix gtt. Over the next few days, several
liters of fluid was removed. She appeared significantly more
euvolemic on exam. Pt's "air hunger" and SOB was treated
symptomatically with lasix and morphine.
.
# Multiple Myeloma/CLL: Bone marrow biopsy report returned
positive for MM and CLL. It did not reveal amyloidosis but that
does not conclusively rule out the diagnosis. Oncology team
notified patient and family and did not reccomend any
therapeutic treatment given her poor performance status,
multi-organ failure. Palliative care was consulted and met with
family and patient to discuss goals of care. Decision was made
to make patient DNR/DNI and to focus on goals of comfort.
Patient was given morphine for air-hunger and continued on lasix
drip for symptoms of heart failure.
.
# CORONARIES: No EKG changes consistent with acute ischemia. No
chest pain. Troponin leak likely due to combination of demand
ischemia and chronic kidney disease resulting in decreased
troponin clearance. Troponin steady since admission. Continued
ASA, atorvastatin. Atorvastatin was discontinued on [**9-24**] after
palliative care family meeting.
.
# RHYTHM: Pt with first degree AV nodal block on EKG on
admission. EKG during hypotensive episode was bradycardic.
Patient had short runs of unsustained VT (5-10 beats) few times
daily. Metoprolol tartrate was started at 6.25mg TID, but was
frequently held due to low BP. Transitioned to toprol 12.5mg.
.
# CKD: Cr. baseline 1.0 in [**6-/2121**], 1.4-1.5 in [**7-/2121**], now
1.8-1.9. On this admission creatinine is 2.1-2.2 range. Cr has
been gradually trending up over the last few months. Bence [**Doctor Last Name 49**]
proteins found in urine on prior admission. Patient likely has
pre-renal azotemia from heart failure complicated with
underlying renal insuficiency from MM/Amyloid.
.
# Hyperlipidemia- Continued home atorvastatin.
.
# GERD- Continued home PPI.
.
# Goals of Care: Heme/Onc did not feel that there were any
therapeutic options for patient's MM/CLL/Possible amyloid.
Palliative care was consulted and helped family make decisions
about end of life care. Patient was made DNR/DNI with a focus on
comfort. She was given morphine 0.5mg-2mg for SOB and air-hunger
symptoms. Patient eventually passed with her daughter at the
bedside.
Medications on Admission:
atorvastatin 10 mg daily
omeprazole 20 mg daily
aspirin 81 mg daily
torsemide 20 mg daily
metolazone 5 mg daily
metoprolol succinate 25 mg daily
spironolactone 25 mg daily
potassium chloride 10 mEq [**Hospital1 **]
nitroglycerin 0.3 mg Tablet SL as needed
alendronate 35 mg qSaturday
Senna Daily
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Heart Failure
Multiple Myeloma
CLL
Renal Failure
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
deceased
|
[
"530.81",
"428.33",
"584.9",
"203.00",
"277.39",
"272.4",
"403.90",
"780.2",
"585.9",
"553.3",
"428.0",
"458.9",
"425.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7185, 7194
|
3812, 6797
|
316, 335
|
7287, 7297
|
3623, 3789
|
7354, 7365
|
2739, 2787
|
7144, 7162
|
7215, 7266
|
6823, 7121
|
7321, 7331
|
2802, 3604
|
2150, 2342
|
265, 278
|
363, 2042
|
2373, 2432
|
2064, 2130
|
2448, 2723
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,922
| 149,467
|
10201
|
Discharge summary
|
report
|
Admission Date: [**2149-5-30**] Discharge Date: [**2149-6-4**]
Date of Birth: [**2104-8-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
loss of consciousness/melenic stools
Major Surgical or Invasive Procedure:
ercp
History of Present Illness:
HPI: Mr. [**Known lastname 4972**] is a 44 year old male with a history of HCV/EtOH
cirrhosis s/p OLT [**2149-1-13**]. He was brought to the ED following a
syncopal episode. He reports that he has been having black,
tarry stools for the last 3 days that became heavy today. There
is no bright red blood. He has been nauseous since last night,
but has not vomited. He has become progressively more fatigued
and weak over the past few days. This morning, he was too tired
to walk to the bathroom. He stood to use his urinal, became
dizzy, fainted, and fell to the ground. He landed on his left
wrist and ankle, which are painful now. He is also complaining
of headache, but it is unknown if he hit his head as the fall
was
not witnessed. He does not have abdominal pain. He underwent
EGD
in [**1-8**], which demonstrated mild portal gastropathy and grade 1
nonbleeding varices.
Past Medical History:
- transjugular liver biopsy in [**2144-8-2**]
- H/o SBP -> on prophylaxis
- H/o encephalopathy
- H/o ascites
- jaundice starting in [**2148-6-1**]
- ? no EtOH since [**Month (only) 958**] to [**2148-7-2**], h/o cocaine in [**2141**]
-OLT [**2149-1-13**] c/b HA stenosis, stented
-[**11-6**] admit to [**Hospital **] Hospital for rehab/?depression
-[**5-8**] candidiasis
-[**5-8**] syncopal episode attributed to UGI bleeding
Social History:
lives with mother in [**Name (NI) 86**]. Denies etoh, drugs
disabled chem engineer
Family History:
NC
Physical Exam:
T98 BP100/61 HR105 RR17
Gen: pale, appears tired, speaking slowly
HEENT: no icterus, dry mucous membranes
Pulm: clear to auscultation bilaterally
CVS: tachycardic, regular rhythm, no murmurs/rubs/gallops
Abd: soft, nontender, nondistended, +bowel sounds, well-healed
subcostal incisions, guiaic positive as per ED, NG lavage not
grossly bloody
Ext: no edema, no clubbing, no cyanosis
Pertinent Results:
[**2149-5-30**] 12:20PM WBC-5.5 RBC-2.07*# HGB-6.7*# HCT-19.6*#
MCV-95 MCH-32.5* MCHC-34.3 RDW-20.0*
[**2149-5-30**] 12:20PM ALT(SGPT)-60* AST(SGOT)-38 ALK PHOS-75
AMYLASE-13 TOT BILI-0.2
[**2149-5-30**] 12:20PM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-4.9*
MAGNESIUM-1.4*
[**2149-5-30**] 12:20PM LIPASE-7
[**2149-5-30**] 12:20PM PLT COUNT-160
[**2149-5-30**] 12:20PM PT-11.5 PTT-23.4 INR(PT)-1.0
[**2149-6-4**] 06:25AM BLOOD WBC-3.8* RBC-3.27* Hgb-10.7* Hct-30.8*
MCV-94 MCH-32.6* MCHC-34.7 RDW-19.5* Plt Ct-89*
[**2149-6-4**] 06:25AM BLOOD Plt Ct-89*
[**2149-6-4**] 06:25AM BLOOD Glucose-117* UreaN-26* Creat-1.3* Na-144
K-4.8 Cl-111* HCO3-26 AnGap-12
[**2149-6-4**] 06:25AM BLOOD ALT-42* AST-30 AlkPhos-62 TotBili-0.3
[**2149-6-1**] 03:37AM BLOOD FK506->30.0
[**2149-6-2**] 05:45AM BLOOD FK506-30.0*
[**2149-6-3**] 06:10AM BLOOD FK506-19.9
[**2149-6-4**] 06:25AM BLOOD FK506-10.2
Brief Hospital Course:
An NG was placed while in the ED for lavage. No blood was
detected. He received 2 units of PRBC while in the ED for a Hct
of 19.6. Hct increased to 23.6. An EGD was performed with no
active bleeding noted. Serial hematocrits were done. He was
transferred to the SICU for management until [**6-1**]. Another 2
units of PRBC were given with hct increase to 31.8. A CT without
contrast revealed gaseous distention of the small and large
bowel consistent with recent EGD procedure. No evidence of
perforation or free fluid collections within the abdominal
cavity. Submillimeter nonobstructive right renal calculi or
vascular calcification was noted.
ASA and plavix (for hepatic artery stent) were held.
On [**6-1**] potassium was 6.7. Repeat K+ was 5.7. IV lasix, saline,
insulin and bicarb were given. K+_decreased to 4.8.
A CT of the head showed no acute intracranial pathology. EKG was
normal. A CT of the left ankle and left wrist were negative for
fractures. Ortho was consulted for persistent left foot pain. PT
was consulted and recommended crutches for foot pain limiting
ambulation.
IV protonix was started [**Hospital1 **]. Fluconazole was started for
esophageal candidiasis. Consequently, prograf levels increased
to 30. Prograf was held for elevated levels since fluconazole
was started on [**2149-6-3**].
On [**2149-6-4**], his FK level was 10.2. He was discharged on FK of
3mg Q 12 hours with strict instructions to follow up on [**2149-6-5**]
and have an FK level drawn, as well as a CBC and chem-7.
Of note, a CT scan from [**2149-6-3**] was negative for any source of GI
bleeding, such as pseudoaneurysm.
Medications on Admission:
colace 100", prednisone 12.5', plavix 75', ASA 325', Gemfibrozil
600", Bactrim, MMF 500", Valcyte 900', protonix 40', Prograf 6",
insulin sliding scale, NPH 10U qAM
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
UGI bleeding
L foot synovial injury
Discharge Condition:
good
Discharge Instructions:
Please call the transplant office [**Telephone/Fax (1) 673**] if you experience
fevers, chills, nausea, vomiting, black or bloody stools,
abdominal pain, jaundice, too low or too high glucoses,
dizziness or any concerns.
Completed by:[**2149-6-4**]
|
[
"112.84",
"303.91",
"V42.7",
"571.2",
"578.1",
"280.0",
"780.2",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5012, 5070
|
3172, 4797
|
350, 356
|
5150, 5157
|
2260, 3149
|
1836, 1840
|
5091, 5129
|
4823, 4989
|
5181, 5432
|
1855, 2241
|
274, 312
|
384, 1271
|
1293, 1719
|
1735, 1820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,698
| 140,666
|
45763
|
Discharge summary
|
report
|
Admission Date: [**2166-9-23**] Discharge Date: [**2166-9-26**]
Date of Birth: [**2084-10-17**] Sex: F
Service: MEDICINE
Allergies:
Protamine / Lovenox
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
The patient is an 81 year old female with past medical history
of coronary artery disease, aortic stenosis status post Aortic
valve repair, diastolic congestive heart failure, End stage
renal disease on hemodialysis (MWF [**Location (un) **]), diabetes , and
hypertension who presented to the ED with left thigh pain after
a fall [**9-22**] in the afternoon. The patient states she went to the
refrigerator using her walker when her knee gave out and she
fell on her butt. Her legs were twisted under her. She denies
LOC or head injury. She was unable to weight bear on her left
leg and after one of pain day decided to come to the ED.
Past Medical History:
1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation
in ICU (at time of colectomy) - removed
5. Severe AS s/p mechanical AVR, [**Hospital3 **], goal INR [**2-11**]
6. Hypertension
7. Elevated cholesterol
8. Diabetes type 2
9. End-stage renal disease on HD MWF (via LUE AVF)
10. Bilateral total knee replacment
11. Multiple skin lesions removed by general and plastic surgery
12. Hypothyroidism
13. Presumptive history of atrial fibrillation; on amiodarone
14. revision of LUE AVF [**2165-11-21**] -->functioning and started HD
[**12-20**]
Social History:
Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager Her son [**Name (NI) **] lives her on the [**Location (un) 19201**] of their two family home.
Family History:
She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn.
Physical Exam:
VS: Afebrile BP 115/46 HR 52 100% on 2L NC
GEN: African American female in NAD, sitting up in bed
HEENT: EOMI, PERRL, oropharynx clear
NECK: Supple, no [**Doctor First Name **]
CHEST: CTABL, no w/r/r
CV: Bradycardic, S1S2, no m/r/g
ABD: Soft/NT/ND; colostomy with associated herniation at site
EXT: no c/c/e
SKIN: no rashes
NEURO: AAOx 3; no focal deficits; gait deferred; answers
questions appropriately
.
Pertinent Results:
Admission labs-
[**2166-9-22**] 10:44PM BLOOD WBC-3.7* RBC-3.90* Hgb-12.4 Hct-37.7#
MCV-97 MCH-31.7 MCHC-32.8 RDW-15.1 Plt Ct-169
[**2166-9-22**] 10:44PM BLOOD Neuts-59.4 Lymphs-31.0 Monos-5.8 Eos-3.2
Baso-0.6
[**2166-9-22**] 10:44PM BLOOD PT-26.5* PTT-30.9 INR(PT)-2.6*
[**2166-9-22**] 10:44PM BLOOD Glucose-86 UreaN-44* Creat-6.3*# Na-139
K-4.5 Cl-99 HCO3-29 AnGap-16
[**2166-9-24**] 06:15AM BLOOD Calcium-6.9* Phos-5.7*# Mg-1.9
Images-
xray
RIGHT FEMUR: Diffuse osteopenia. Suboptimal radiograph for
evaluation of a
fracture. No definite fracture or dislocation seen; however
subtle fracture could be missed. On one of the images, there is
overlapping hand with ring, which is limiting the evaluation of
that area.
RIGHT KNEE: Status post total knee arthroplasty. No evidence of
lucency at
the total hip prosthesis. No evidence of fracture or
dislocation. Vascular
calcifications are seen. There is a large calcified fibroid.
IMPRESSION
1. Suboptimal radiograph; however, no definite fracture or
dislocation seen. 2. Vascular calcifications.
3. Calcified fibroid.
CT pelvis
IMPRESSION:
No evidence of free fluid or hematoma.
CT lower ext
PRELIMINARY READ-
non displaced fracture of the left lesser trochanter. No
hematoma.
Brief Hospital Course:
The patient is an 81 year old female with past medical history
of coronary artery disease, aortic stenosis status post Aortic
valve repair, diastolic congestive heart failure, End stage
renal disease on hemodialysis (MWF [**Location (un) **]), diabetes , and
hypertension who presents with left hip pain.
In the ED, VS were : T98.4 BP 104/48 HR 58 RR18 100%RA. She
received tramadol and toradol for pain but was still unable to
ambulate given severe pain. The next morning in the ED her blood
pressure was found to be in the 84/31 -> 78/32. She also had a
Hct drop from 37 to 31 and there was concern that she was
bleeding. She was given 2L NS while in the ED with some
improvement in pressure and her AM BP meds were held. Hip films
showed osteopenia but no fractures. CT abdomen and CT thigh
were done to further evaluate her hypotension and the CT thigh
showed nondisplaced fracture of her left lesser trochanter.
Ortho was consulted and felt she did not need surgery and
recommended PT consult and partial weight bearing as tolerated.
She was transferred to the ICU for further management of her
hypotension.
# Hypotension: Her BP improved with 2L of fluid bolus. The
hypotension was thought to be realated to fluid depletion
initially. Her BP meds were stopped. She had several low BPs
into the 80s while asleep, and was given small fluid boluses
without great effect. She went for HD the day after admisison,
she was 7kg above her dry wt, had 1.5 liters removed and BP
actually improved. Therefore, she was likely not fluid depleted,
but more likely was fluid overloaded. Her hct was stable and a
CT of the extremity and abd/pelvis showed no evidence of
bleeding as an explaination. Her amiodarone was restarted but
her metoprolol and hydralazine were held. When she was
transfered to the medicine floor, her BP meds continued to be
held and her blood pressure remained in the low 100s. She
should continue to not take her metoprolol as long as her blood
pressures remains low, but this medication can be restarted as
an outpatient if her BP increases.
# Trochanteric fracture: She had a new stable, non-displaced
fracture. Pt was seen by ortho who recommended partial weight
bearing as tolerated and PT, and surgical repair was not needed
at this time. She was treated for her pain with tylenol and IV
morphine with her turning. She continued to improve and did well
on tylenol alone.
# ESRD: Continued on HD M/W/F. Continued on nephrocaps and
sevelamir. Renal followed the pt while admited. She should be
discharged on a new medication: Sevelamer Carbonate 2400 mg
three times a day with meals.
# Anemia of chronic disease: Iron studdies showed ferretin 1295,
TIBC 161, trasnferin 124. Pt received EPO at hemodialysis.
# Hypothyroidism: stable. Continued on levothyroxine. TSH = 3.5
# Atrial fibrillation: She was in sinus rhythm and her
metoprolol was initially was held due to low BP. She was
continued on her amiodarone. She was continued on
anticoagulation.
# Hyperlipidemia: She was continued on her statin
Medications on Admission:
Nexium 40mg PO daily
Fluticasone/salmeterol 250/50mcg 1 INH [**Hospital1 **]
Senna
Aranes
ASA 81mg PO daily
Hydralazine 25mg PO q6hours (hold on dialysis days)
Simvastatin 20mg PO daily
Amiodarone 200mg PO daily
Ambien 5mg qHS PRN
Metoprolol 50mg PO bid.(hold on dialysis days)
Lactulose PRN
Colace 50mg PRN
Levthyroxine 88mcg tab PO daily
Warfarin
Nephrocaps 1mg PO daily
Sevelamer 2400 mg PO TID W/MEALS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Lactulose 10 gram/15 mL Solution Oral
8. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for fever/pain.
Disp:*60 Tablet(s)* Refills:*0*
13. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*qs Tablet(s)* Refills:*2*
14. Aranesp (Polysorbate) Injection
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary diagnosis:
Trochanteric fracture
Hypotension
End stage renal disease
Secondary diagnosis:
hypothyroidism
atrial fibrillation
anemia of chronic disease
Discharge Condition:
Good. Afebrile, hemodynamically stable. Pain well controlled.
Discharge Instructions:
You came to the hospital because you fell and hurt your leg.
You had a CT scan which showed you have a nondisplaced fracture
of your thigh bone and the orthopedic surgeons thought that you
did not need surgery. They said that you can bear weight on
your leg as tollerated. You were transfered to the ICU because
you were found to have low blood pressure. There you received
IV fluids and pain medications. You did well and were
transfered back to the medicine floor. During your
hospitalization you continued to have your hemodialysis. You
tollerated this well. You were also evaluated by the physical
therapists who recommended that you go to rehab until your leg
heals a little more.
The following changes have been made to your medications:
Start: Sevelamer Carbonate 2400 mg three times a day with meals
Stop: metoprolol
Stop: hydralazine
Please go to all follow up appointments (see below)
Please call your doctor or return to the hosptial if you have
fever above 103, chest pain, shortness of breath, increased
weight gain over 5 lbs, increased pain in your leg, or any other
symptoms of concern.
Followup Instructions:
Please go to the following appointments:
You have an appointment in Orthopedics with [**Name6 (MD) 2191**] [**Name8 (MD) 97510**], NP on [**10-9**] at 9:20 am. The phone number is
[**Telephone/Fax (1) 1228**]
You will need to go the [**Location (un) 1773**] of the [**Hospital Ward Name **] building at
9 am the day of your appointment ([**2166-10-9**]) so that you can have
an x ray done
You should also make an appointment with your nurse
practitioner, [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 10686**]. Her phone number is ([**Telephone/Fax (1) 30577**].
She has asked that you call her as soon as you are discharged
from rehab so that she can make a house call to check on you.
Provider [**Name9 (PRE) **],[**Name9 (PRE) **] AV CARE AV CARE [**Location (un) **] (NHB)
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2166-12-8**] 8:00
|
[
"V43.64",
"244.9",
"428.32",
"V45.11",
"V12.04",
"V09.0",
"V44.3",
"428.0",
"458.9",
"272.0",
"733.90",
"V45.72",
"585.6",
"820.20",
"403.91",
"V43.3",
"E885.9",
"250.00",
"285.21",
"V43.65",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8526, 8581
|
3823, 6860
|
289, 299
|
8785, 8849
|
2566, 3800
|
10010, 10881
|
2016, 2123
|
7316, 8503
|
8602, 8602
|
6886, 7293
|
8873, 9987
|
2138, 2547
|
241, 251
|
327, 967
|
8701, 8764
|
8621, 8680
|
989, 1724
|
1740, 2000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,835
| 143,977
|
9156
|
Discharge summary
|
report
|
Admission Date: [**2177-10-27**] Discharge Date: [**2177-11-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
Chest pain, melena
Major Surgical or Invasive Procedure:
EGD
colonoscopy
capsule endoscopy
L.buttock skin biopsy
History of Present Illness:
HPI: 89 yo man with hx of CAD, atrial fibrillation on coumadin,
duodenal ulcer [**10-14**] who presents to ED with chest tightness,
weakness, and black stool. He complained of 4d of chest
"stiffness" with exertion. Day of admit, daughter noted pt to be
pale and "confused". He did not have any SOB, palpitations,
nausea, vomiting.
.
In the ED: VS stable with SBP 140s. He was AAOx3, pale, soft
abdomen. EKG showed a.fib, rate= 50, ST depressions V2-V6 c/w
[**10-14**] but new from [**4-13**]. NG lavage negative but some nasal
trauma per ED res so left in. Guaiac pos black stool. Labs: Hct
21.9, INR 5, Trop 0.05, CK 103, MB 6, Cr 1.8. He was given 2u
FFP, vitamin K 10 IV x1, and ordered 2u pRBCs. 2 18g PIVs
placed, PPI given. GI was notified who recommended admit to ICU
and scope in the am. Head CT en route to floor given his initial
confusion-"no acute intracranial pathology"
.
MICU course: s/p FFP, vit K, 5 units PRBC's. EGD on
[**10-28**]-normal. Colonoscopy [**10-29**]: grade 1 hemorrhoids,
diverticulosis in whole colon, otherwise normal to cecum. Pt had
5 sets of cardiac enzymes. Troponin 0.05x4. EKG shows RBBB with
non-specific ST/T changes.
.
Currently pt is denying fever/chills, URI symptoms, visual
changes, SOB, CP, palpitations, abd pain/n/v/d/constipation,
dark stools, bloody stools, dysuria/hematuria,
paresthesias/weakness, h/a, LH
Past Medical History:
1. Atrial fibrillation: history of slow ventricular response, on
Coumadin
2. Hypertension
3. CAD: [**1-10**] stress-MIBI showing ischemic EKG changes in
inferior and lateral leads and MIBI showing a mild reversible
inferior wall defect, medical management only
4. CHF: ischemic cardiomyopathy (mildly depressed EF 50-55%)
5. ?COPD: documented in notes but no PFTs
6. Melanoma: s/p excision [**4-11**] & [**2174-10-3**] R posterior
auricular region, + radiation treatments (last in [**12-13**]),
concern for recurrence in [**3-13**] but pt refused further w/u
7. Basal cell carcinoma: s/p excision on [**12-11**] & [**4-11**]
8. Diverticulosis
9. Glaucoma
10. Venous insufficiency
11. Hearing impairment
12. Irritable bowel syndrome
13. Macular degeneration
Social History:
PER OMR
from [**Country 4754**], lives with granddaughters who assist with [**Name (NI) 4461**]
and meds, daughter also involved in care, able to ambulate
around apt freely prior to admit; + tob- 10cig/d x 20y, quit
years ago; denies
EtOH and drugs
Family History:
mx family members with CAD
Physical Exam:
VS: T 96 BP 130/60 HR 53, RR 20, 96%2L
Gen: NAD, cooperative
Neuro:
- alert to person, place-"different place in the hospital", date
- CN ii-xii intact
- motor: [**4-12**] bilat upper, lower ex
- [**Last Name (un) 36**] to gross touch
Heent: PERRLA, EOMI, no JVD
Cards: s1s2 2/6 systolic murmur loudest in aortic area, no R/G
Lungs: B/L air entry, bibasilar crackles, decreased breath
sounds R.base
Abd: BS+, soft, NT/ND, no guarding or rebound
ext: no C/C/E 2+ pulses
Pertinent Results:
[**2177-10-27**] 09:58PM CK(CPK)-75
[**2177-10-27**] 09:58PM CK-MB-NotDone cTropnT-0.05*
[**2177-10-27**] 09:58PM HCT-22.1*
[**2177-10-27**] 09:58PM PT-17.4* PTT-31.3 INR(PT)-1.6*
[**2177-10-27**] 08:02PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2177-10-27**] 08:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2177-10-27**] 02:20PM URINE HOURS-RANDOM
[**2177-10-27**] 02:20PM URINE GR HOLD-HOLD
[**2177-10-27**] 02:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2177-10-27**] 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2177-10-27**] 01:50PM GLUCOSE-147* UREA N-86* CREAT-1.8* SODIUM-139
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2177-10-27**] 01:50PM estGFR-Using this
[**2177-10-27**] 01:50PM CK(CPK)-103
[**2177-10-27**] 01:50PM cTropnT-0.05*
[**2177-10-27**] 01:50PM CK-MB-6
[**2177-10-27**] 01:50PM DIGOXIN-<0.2*
[**2177-10-27**] 01:50PM WBC-7.6 RBC-2.21*# HGB-7.4*# HCT-21.9*#
MCV-99* MCH-33.4* MCHC-33.6 RDW-15.6*
[**2177-10-27**] 01:50PM NEUTS-81.8* LYMPHS-11.9* MONOS-5.0 EOS-1.0
BASOS-0.3
[**2177-10-27**] 01:50PM PLT COUNT-217
[**2177-10-27**] 01:50PM PT-44.5* PTT-38.0* INR(PT)-5.0*
.
Ct head:IMPRESSION: No acute intracranial pathology.
.
Cxr: [**10-27**]:Stable lingular opacity compared with one year ago,
though new from [**2174**]. Given the nonresolution of this opacity
compared with multiple prior radiographs, CT is recommended to
further evaluate. This followup recommendation was made via the
critical results communication dashboard on [**2177-10-28**].
No evidence of pneumonia or CHF. Stable cardiomegaly.
.
EKG [**10-27**]:
Atrial fibrillation. Right bundle-branch block. Downsloping ST
segment
depressions in leads V3-V6 with primary T wave changes in leads
V2-V3.
Cannot exclude ischemia. Compared to tracing of [**2176-10-17**] the ST
segment
depressions are slightly less pronounced.
.
CXR:IMPRESSION: [**10-29**]:New right mid and lower zone opacities
consistent with aspiration/pneumonia. Findings communicated to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by telephone at the time of review.
.
EGD-normal
colonoscopy-grade 1 hemorrhoids, diverticulosis of the whole
colon
Brief Hospital Course:
A/P: 89 y/o man with hx of duodenal ulcer, h pylori [**10-14**], CAD,
Afib, p/w CP and found to have melanotic stools, hct 21, INR
5.0. s/p FFP, vitamin K, PRBC's. EGD normal, colonoscopy shows
diverticulosis without active bleeding.
.
# GIB: Pt was given FFP, vitamin K, PRBCs for goal HCT >30 given
demand ischemia. Pt's anticoagulation was stopped. He had PIV's
placed. Serial HCT's and INR were followed and remained stable.
GI was consulted and performed and EGD which was normal.
Colonoscopy showed grade 1 hemorrhoids and diverticulosis. PT
was placed on a PPI. Pt underwent a capsule endoscopy for which
the results will be followed up as an outpatient. Additionally,
pt was found to have +h.pylori in [**2175**] for which he was not
treated secondary to elevated creatinine. Spoke to GI regarding
this matter who feels that after patient's clinical condition
improves, pneumonia resolves, and is off current antibiotics,
can consider H.pylori treatment as EGD was normal.
.
# Chest pain: Likely demand ischemia in the setting of known CAD
and anemia. Currently chest pain-free. EKG showed changes c/w
prior GIB when he had demand ischemia. No current pain. Aspirin
and coumadin initially held [**1-10**] GIB. ASA eventually restarted.
Repeated sets of cardiac enzymes were flat. Serial EKG's
unchanged. Pt was continued on his home dose statin and Imdur.
However, lasix and ACEI were held [**1-10**] bleed and transiently
elevated creatinine. Small dose lisinopril was restarted. Goal
HCT was >30 and he was transfused accordingly.
.
# Cards rhythm: afib on coumadin. He received FFP and Vitamin K
in the ED. Coumadin and ASA were held [**1-10**] bleed. Scope results
as above. ASA restarted. PT placed on telemetry for monitoring.
.
# CHF: hx of mild systolic CHF thought [**1-10**] CAD (Given his stress
report). Pt appeared clinically euvolemic and transiently
hypovolemic given hypernatremia and elevated creatinine. IVF
were given. Diuretics and ACEI originally held given bleed. Low
dose ACEI restarted. Can consider to increase ACEI to 5mg Qam
and 10mg Qpm and lasix 40mg daily after discharge upon
discussion with the PCP.
.
# SOB: [**10-30**] am, required 5L O2, Pt given Lasix and diuresed.
Placed on O2. Repeat CXR showed evidence of aspiration pneumonia
for which pt was placed on levoflox and flagyl. Sputum culture
was consistent with oropharyngeal flora. PT will be treated with
antibiotics for a total of 10 days. Last dose on [**11-7**]. Pt has
some low grade temperatures 99's. IF temperature is >99.5, get
rectal temperature. If rectal >100.5 perform blood culturesx2.
Pt should get a repeat CXR for temperature spike. He should have
a repeat CXR in [**3-14**] weeks. Pt should receive nebulizer
treatments at rehab around the clock for 4-5 days after
discharge.
.
#hyperglycemia: Pt found to be hyperglycemic with no known
history of diabetes. HE was started on a RISS and AIC
checked-5.9. HE was placed on a DM diet and given diabetic
teaching. Pt was started on low dose oral hypoglycemic,
glypizide 2.5mg daily. He should follow up with PCP for further
management.
.
# Confusion: Pt is currently orientedx3. I suspect his altered
ms was in setting of anemia, hypoperfusion, demand ischemia.
Head CT negative, UCx, Bcx negative. Sedating medications were
minimized.
.
# Renal function: Baseline Cr 1.3 - 1.5. Worsened function
likely prerenal azotemia. FENA was 0.3%. PT's creatinine and
sodium improved with IVF. Diuretics held. Creatinine was
trended. PT initially had a foley upon arrival to the floor. It
was eventually removed and he was able to void without
difficulty for several days. However, on [**11-4**] pt was having
some difficulty voiding. Bladder scan revealed ~700cc of urine
and foley was replaced.
.
# urinary retention:PT has no known history of BPH or prostate
problem. However, he experienced some urinary retention on [**11-4**]
and foley was replaced. He should have the foley in place upon
discharge and undergo a voiding trial at rehab.
.
# sacral area wound. 1inch area with some small area of blood
oozing. Wound care was consulted who recommended a dermatology
consult. Dermatology felt the lesion to be unusual but
suspicious for neoplasm. They performed 3 punch biopsies on
[**2177-11-4**] and closed the wound with sutures. Pt will need the
sutures removed in [**9-21**] days. Dermatology will contact the
PCP/family with biopsy results.
.
# Communication:
- [**Doctor First Name **]: daughter: HCP: [**Telephone/Fax (5) 31508**]
- Daughters [**Name (NI) **] and [**Name2 (NI) 698**]: [**Telephone/Fax (3) 31509**]
.
# Disposition - ?home with VNA and PT
Medications on Admission:
Lisinopril 5qam, 10qpm
Lasix 40 qam
ASA 325
Imdur 30 daily
Coumadin 4x5d and 2x3d
lipitor 10 daily
[**Doctor First Name 130**] daily
iron gluc
omeprazole 20 daily
vitamin d 1000
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Green Nursing Home
Discharge Diagnosis:
gastrointestinal bleed
angina
diverticulosis
CAD
atrial fibrillation
hyperglycemia
urinary retention
Discharge Condition:
good, stable
Discharge Instructions:
You were admitted for chest pain and decreased hematocrit/dark
stools. You underwent a work up for the etiology of chest pain
and it was thought to be due to your anemia. You underwent an
endoscopy which was normal and a colonoscopy that showed some
hemorrhoids and diverticulosis. You also underwent a capsule
endoscopy. The results will take about a week to return and your
PCP will be notified of them by the gastroenterologist. In the
past, you had a positive test for H.pylori (a bacteria that can
live in your gastrointestinal tract and lead to ulcers). You
should discuss with your PCP [**Name Initial (PRE) **]/or gastrointestinal doctor
about possible treatment for this. Your coumadin was stopped
secondary to bleeding. We restarted you on a baby aspirin but
you should discuss with your PCP when and if to resume your
coumadin.
.
Additionally, you were found to have elevated blood sugars. You
were started on an oral medication to lower your blood sugar,
placed on a diabetic diet, and given teaching regarding testing
your blood sugar at home. You will discuss with your PCP further
treatment.
.
IF you develop fever, chills, chest pain, difficulty breathing,
abdominal pain, nausea, vomiting, diarrhea, dark or bloody
stools please contact your doctor or go to the emergency room.
.
Please take your medications as prescribed and follow up with
your appointments below.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**]. Please contact your pcp to
schedule [**Name Initial (PRE) **] follow up appointment.
Patient needs a CT chest to followup lingular opacity.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2177-11-7**] 9:00
.
Gastroenterology: Please call [**Telephone/Fax (1) 463**] or 2136 to schedule a
follow up appointment in the next 2-3 weeks to follow up the
results of your capsule endoscopy. You were seen by Dr. [**First Name4 (NamePattern1) 2795**]
[**Last Name (NamePattern1) 2314**].
.
Please follow up with dermatology, Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1971**]
for the results of your skin biopsy.
|
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"459.81",
"V10.82",
"564.1",
"788.20",
"414.8",
"232.5",
"V58.61",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"86.11",
"99.07",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
10582, 10651
|
5732, 10353
|
282, 340
|
10796, 10811
|
3331, 4671
|
12243, 13116
|
2796, 2824
|
10672, 10775
|
10379, 10559
|
10835, 12220
|
2839, 3312
|
224, 244
|
368, 1730
|
4679, 5709
|
1752, 2513
|
2529, 2780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,336
| 138,082
|
53497+59536
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-2-6**] Discharge Date: [**2159-2-19**]
Date of Birth: [**2077-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Coronary Artery Disease
Major Surgical or Invasive Procedure:
Left Heart Catheterization
History of Present Illness:
81 yo male with history of HTN, HL, COPD and OSA who recently
had an annual physical and an EKG which was notable for Q waves
and suggestive of an old MI. Recent stress echo showed baseline
anterior hypokinesis which becomes
akinetic at peak stress and extensive ST-T wasve depression,
also notable for possible nontransmural MI and anterior
ischemia. Pt is asymptomatic. Pt presents today for cardiac
catheterization to further evaluate.
.
Cath on [**2-6**] by Dr. [**Last Name (STitle) **] showed occluded LAD and heavily
calcified coronaries and sequential disease. The operators were
not able to engage a balloon so patient's procedure was ended
and patient was sent to the floor to be evaluated by CT Surgery.
During the procedure there was concern for a possible small
dissection in the distal right coronary artery that still had
good flow by report.
.
On arrival to the floor, patient was comfortable with no pain at
the Cath site, breathing normally and had been made aware of the
need for CABG.
.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-CAD prior MI on EKG
-Hypertension
-Dyslipidemia
-PVD: right carotid artery blockage 70-80%
-COPD/ asthma
-OSA (uses CPAP)
-GERD
-Osteoarthritis
-Colon polyps
-Prostate nodule
-Skin CA (melanoma/ basal cell)
Social History:
-Tobacco history: 1 ppd smoker for 65 years having quit 3 years
ago
-ETOH: rare
-Illicit drugs: none
worked as a breaksman for the rail roads as well as loading
trucks for budweiser. he is a veteran of the korean war, lives
in [**Location **] with his wife and at baseline walks 1 mile a day
with his dog without getting short of breath.
Family History:
Mother died of MI at age 87.
Physical Exam:
ADMISSION EXAM:
VS: T=98.7 BP=110/60 HR=74 RR=18 O2 sat=95% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of at clavical
CARDIAC: Distant heart sounds though PMI located in 5th
intercostal space, midclavicular line. RR, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Anterior exam only
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
[**2159-2-6**] 09:55PM BLOOD Plt Ct-160
[**2159-2-6**] 09:55PM BLOOD Na-139 K-4.5 Cl-103
[**2159-2-6**] 09:55PM BLOOD CK-MB-4
.
DISCHARGE LABS:
[**2159-2-17**] WBC-9.3 RBC-2.73* Hgb-9.1* Hct-27.5* MCV-101* MCH-33.3*
MCHC-33.0 RDW-12.8 Plt Ct-205
[**2159-2-17**] Glucose-97 UreaN-24* Creat-0.8 Na-138 K-4.0 Cl-99
HCO3-31
[**2159-2-17**] INR(PT)-1.9* Coumadin 2.5 mg
[**2159-2-16**] INR(PT)-1.3* Coumadin 2.5 mg
[**2159-2-15**] INR(PT)-1.2* Coumadin 2.5 mg
[**2159-2-16**] Mg-2.5
[**2159-2-17**] Digoxin-0.7*
CATH [**2159-2-6**]:
1. Selective coronary angiography in this right dominant system
demonstrated severe 2 vessel coronary artery disease. The LMCA
had mild
disease. The LAD had a proximal 100% stenosis with collateral
filling
through the RCA. The LCX had minimal disease. The RCA had a
99% mid
vessel lesion, and 99% distal lesion at the bifurcation of the
RPL and
RPDA.
2. Limited resting hemodynamics revealed normal left and right
sided
filling pressures with LVEDP 11mm Hg and RVEDP 8mm Hg. Cardiac
index
was preserved at 3.16 L/min/m2. Normal PA pressure with mean PA
18mmHg
and PASP 32 mm Hg. Normal central arterial pressure at
121/58mmHg.
FINAL DIAGNOSIS:
1. Severe 2 vessel coronary artery disease.
2. Normal left & right sided filling pressures.
3. Normal cardiac output.
Chest CT [**2159-2-7**]: IMPRESSION:
1. Normal caliber thoracic aorta with atherosclerotic
calcifications as
detailed above.
2. A total of three right apical and middle lobe lung nodules,
ranging up to 8 mm. If prior imaging is available, we are happy
to compare. Otherwise, followup is recommended in three months.
3. Moderate centrilobular emphysema.
4. Asbestos related pleural plaques. No evidence of asbestosis
or
mesothelioma.
Renal US: [**2159-2-7**]
Both kidneys are visualized and normal in size and echogenicity.
The right measures 12.5 cm while the left measures 12.0 cm in
the sagittal
dimension. There is mild fullness in the collecting systems of
the kidneys
bilaterally, more prominent on the left than on the right.
Within the left
kidney at there is a 2.6 x 2.4 x 2.7 cm simple cyst. No
perinephric fluid
collections identified on either side. The bladder is somewhat
distended measuring 10.6 x 11.8 x 11.1 cm but is otherwise
unremarkable.
IMPRESSION: Mild pelviectasis within the kidneys without
evidence of
caliectasis. Distended bladder.
.
ECHO: [**2159-2-12**]
Overall left ventricular systolic function is severely depressed
(LVEF= 25-30 %). Right ventricular chamber size and free wall
motion are normal. There are complex (>4mm) atheroma in the
aortic root. There are complex (>4mm) atheroma in the ascending
aorta. 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 leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Anterior /anteroseptal walls are akinetic and thinned with ?
Aneurysm @the apical portion the anterior wall
Post Bypass
The patient is s/p CABGX2
The patient is on a Norepinephrine drip @ 0.05 mcg/kg/min
The LVEF is 30-35%
There is persistent Akinesis of the Anterior /Anteroseptal wall
with a dyskinetic apex
The Mitral regurgitation is similar to prebypass
All other valves are similar to prebypass on examination
CXR: [**2159-2-14**]: The heart is mildly enlarged. There is continued
central pulmonary vascular congestion, but no overt edema. The
patient has been extubated, and multiple lines, including a
Swan-Ganz catheter, a left thoracostomy tube, mediastinal
drains, and orogastric tube have been removed. There is a new
small right pleural effusion. The lung volumes are low. There is
no pneumothorax.
IMPRESSION:
1. Interval removal of multiple support lines.
2. New small right pleural effusion.
3. No pneumothorax.
[**2159-2-19**] 04:30AM BLOOD WBC-10.5 RBC-3.14* Hgb-9.9* Hct-31.8*
MCV-101* MCH-31.6 MCHC-31.3 RDW-13.7 Plt Ct-256
[**2159-2-19**] 04:30AM BLOOD Plt Ct-256
[**2159-2-19**] 04:30AM BLOOD PT-33.9* PTT-33.9 INR(PT)-3.3*
[**2159-2-18**] 07:55AM BLOOD PT-28.5* INR(PT)-2.7*
[**2159-2-17**] 07:45AM BLOOD PT-20.5* PTT-28.6 INR(PT)-1.9*
[**2159-2-16**] 05:33AM BLOOD PT-13.5* INR(PT)-1.3*
[**2159-2-19**] 04:30AM BLOOD Glucose-118* UreaN-23* Creat-0.8 Na-140
K-4.4 Cl-101 HCO3-30 AnGap-13
[**2-18**] PA&Lat
effusion is less prominent. However, this may merely reflect the
upright
position with the fluid gravitating into the lower portions of
the lung.
There is a small effusion on the left.
Continued enlargement of the cardiac silhouette with mild
elevation of
pulmonary venous pressure. There is poor definition of the right
heart border
with a streak of opacification running obliquely in the anterior
portion on
the lateral view. This raises the question of some volume loss
in the middle
lobe.
Brief Hospital Course:
The patient was brought to the operating room on [**2159-2-12**] where
the patient underwent Coronary artery bypass grafting x2 with
the left internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery. 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. His home CPAP was continued. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Developed rapid atrial
fibrillation. Amiodarone drip was started and transitioned to
PO. He was still poorly rate controlled. Low dose beta-blockers
were initiated but was changed to digoxin and coreg due to
hypotension. The patient was transferred to the telemetry floor
for further recovery. Chest tubes and pacing wires were
discontinued without complication. Anticoagulation; Coumadin
was started [**2-15**] without heparin bridge. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.
By the time of discharge on POD 7 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital 100**] rehab in good
condition with appropriate follow up instructions. Of note a
non-contrast chest CT was obtained for preoperative evaluation
and incidental note was made of several suspicious appearing
lung nodules. There were no previous chest images for
comparison. Therefore it was recommended by radiology that hte
patient undergo repeat chest imaging in 3 months, but absolutely
no later than 6 months. A call was placed to the patient's
[**Hospital 3390**](Dr. [**Last Name (STitle) **]) and a message left with his office regarding
this finding and scheduling follow up. Thorasics was consulted
and did not feel that this was a barrier to CABG.
Medications on Admission:
FLUTICASONE 50 mcg Spray, once a day
IPRATROPIUM BROMIDE [ATROVENT HFA] - (Prescribed by Other
Provider) - Dosage uncertain
LISINOPRIL - 20 mg Tablet once a day in am
MONTELUKAST 10 mg at bedtime
SIMVASTATIN - 40 mg Tablet at bedtime
TRAZODONE - 50 mg Table at bedtime
.
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet
-
two Tablet(s) by mouth once a day in am
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - one Tablet(s) by mouth once a day in am
MULTIVITAMIN WITH IRON -
Discharge Medications:
1. aspirin 325 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*
2. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
chem-10
please send results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital6 17390**]
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: Please give for 7 days, then decrease to 200
mg PO BID, stop on [**2-25**].
Disp:*28 Tablet(s)* Refills:*0*
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: Please start on [**2-25**], then on [**3-4**] cahnage to 200 mg
PO BID x 7 days.
Disp:*14 Tablet(s)* Refills:*0*
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Untill follow up with your [**Month/Year (2) 3390**]. [**Name10 (NameIs) 3390**] may stop.
Disp:*30 Tablet(s)* Refills:*2*
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
17. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 1
weeks.
18. warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM.
19. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
20. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day) for 7 days: then transition to po lasix.
23. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
24. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
increase to pre-op dose once off amiodarone.
25. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY:
-Coronary artery disease with occulsion of the left anterior
decending artery and 99% stenosis of the right coronary artery
-Acute renal insufficency
SECONDARY:
-Hypercholesterolemia
-Hypertension
-Asthma
-Obstructive Sleep Apnea on home CPAP
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Follow-up appointments
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2159-3-22**] 1:00 in
the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2159-5-17**] 2:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2159-5-17**] 1:00 on
the [**Hospital Ward Name 516**] [**Location (un) 861**] Radiology.
NOTHING TO EAT OR DRINK 3 hours before your CT SCAN
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**2159-3-8**] 1:30 Please call for a
follow-up appointment
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 19751**] [**Telephone/Fax (1) 19752**]
**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 for atrial fibrillation
Goal INR 2.0-2.5
First draw: [**2159-2-20**]
Coumadin management following discharge from rehab should be
with your [**Year/Month/Day 3390**] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 19751**]
Completed by:[**2159-2-19**] Name: [**Known lastname 18049**],[**Known firstname **] Unit No: [**Numeric Identifier 18050**]
Admission Date: [**2159-2-6**] Discharge Date: [**2159-2-19**]
Date of Birth: [**2077-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 135**]
Addendum:
lopressor [**Hospital **] rehab notified and spoke with [**Name6 (MD) **] the RN
Medications on Admission:
lopressor discontinued
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2159-2-19**]
|
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icd9cm
|
[
[
[]
]
] |
[
"36.11",
"37.21",
"88.56",
"36.15",
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icd9pcs
|
[
[
[]
]
] |
17264, 17507
|
8454, 10500
|
334, 362
|
14287, 14287
|
3551, 3551
|
15165, 17191
|
2556, 2586
|
11096, 13901
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14011, 14266
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|
4747, 8431
|
14348, 15142
|
3711, 4730
|
2601, 3515
|
3532, 3532
|
271, 296
|
390, 1950
|
3567, 3695
|
14302, 14324
|
1972, 2181
|
2197, 2540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,188
| 159,980
|
41461
|
Discharge summary
|
report
|
Admission Date: [**2166-4-22**] Discharge Date: [**2166-4-28**]
Date of Birth: [**2108-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / yellow jackets
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2166-4-22**] - Mitral Valve Replacement (St. [**Male First Name (un) 923**] Mechanical Valve)
History of Present Illness:
57 yo male who was found to have heart murmur. Subsequent TTE
revealed MR/MS [**First Name (Titles) 151**] [**Last Name (Titles) **]. HTN, and a possible vegetation seen on
anterior MV [**Last Name (Titles) **]. TEE then done. Cath did not show CAD. He
does heavy physical labor and walks one mile daily with mild
DOE.
Past Medical History:
Past Medical History:
mitral regurgitation
mitral stenosis
hyperlipidemia
benign brain tumor ( resect. [**2156**])
pneumothorax ( age 23)
prior pneumonia
tobacco abuse
colon polyps
hemorrhoids
Past Surgical History:
resect. brain tumor [**2156**]
R ing. herniorrhaphy (childhood)
Social History:
Last Dental Exam: 1 yr ago
Lives with:alone (has a son)
Occupation:physical laborer
Tobacco:smokes one ppd currently x 30 yrs
ETOH:sober 5 years
Family History:
non-contrib.; mother had CABG and CVA at 85
Physical Exam:
Pulse:58 97% O2 sat
B/P 116/75
Height: 6'3" Weight: 178
General:tall, thin, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- 2/6 SEM radiates
throughout
chest to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x];no HSM
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact;MAE [**5-8**] strengths, 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: murmur radiates bilat.carotids
Pertinent Results:
[**2166-4-22**] ECHO
PREBYPASS: The left atrium is moderately dilated. 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 ascending, transverse and
descending thoracic aorta are normal in diameter and free of
significant atherosclerotic plaque. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good [**Month/Day/Year **]
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are severely thickened/deformed. The
mitral valve shows characteristic rheumatic deformity. There is
no pericardial effusion. Mean mitral valve gradient was 13mm Hg
with MVA of 1.2 by PHT. Severe MR is present. Normal LV Function
with LVEF > 55%
POSTBYPASS: Normal functioning mechanical [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] bileaflet
dilting disc valve. No significant MR. [**First Name (Titles) **] [**Last Name (Titles) **] motion. No
stenosis (gradient = 3 mmHg). Normal LV systolic function with
LVEF > 55% and no significant wall motion abnormalities.
[**2166-4-26**] 06:45AM BLOOD WBC-7.1 RBC-3.19* Hgb-10.3* Hct-29.4*
MCV-92 MCH-32.3* MCHC-35.0 RDW-13.6 Plt Ct-258
[**2166-4-25**] 06:00AM BLOOD WBC-8.5 RBC-3.05* Hgb-10.1* Hct-28.0*
MCV-92 MCH-33.2* MCHC-36.1* RDW-13.7 Plt Ct-175
[**2166-4-28**] 04:27AM BLOOD PT-32.2* INR(PT)-3.2*
[**2166-4-27**] 01:17PM BLOOD PT-26.0* INR(PT)-2.5*
[**2166-4-27**] 03:19AM BLOOD PT-24.2* PTT-36.4* INR(PT)-2.3*
[**2166-4-26**] 06:45AM BLOOD PT-19.7* PTT-29.6 INR(PT)-1.8*
[**2166-4-25**] 06:00AM BLOOD PT-15.9* INR(PT)-1.4*
[**2166-4-24**] 04:09AM BLOOD PT-14.1* PTT-27.9 INR(PT)-1.2*
[**2166-4-23**] 02:37AM BLOOD PT-13.3 PTT-27.6 INR(PT)-1.1
[**2166-4-22**] 11:45AM BLOOD PT-14.2* PTT-27.1 INR(PT)-1.2*
[**2166-4-22**] 10:50AM BLOOD PT-14.7* PTT-26.7 INR(PT)-1.3*
[**2166-4-28**] 04:27AM BLOOD UreaN-22* Creat-1.1 Na-134 K-4.6 Cl-101
[**2166-4-27**] 03:19AM BLOOD UreaN-17 Creat-1.0 Na-137 K-4.5 Cl-100
[**2166-4-26**] 06:45AM BLOOD Glucose-102* UreaN-20 Creat-1.1 Na-137
K-4.8 Cl-98 HCO3-33* AnGap-11
[**2166-4-28**] 04:27AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 90205**] was admitted to the [**Hospital1 18**] on [**2166-4-22**] for surgical
management of his mitral valve disease. He was taken to the
operating room where he underwent a mitral valve replacement
using a St. [**Male First Name (un) 923**] mechanical valve. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next several hours, he awoke
neurologically intact and extubated. He was started on beta
blockade and amiodarone for atrial fibrillation. A heparin drip
was started as a bridge to Coumadin for his mechanical valve
with a goal INR of 2.5-3.5. Heparin was discontinued when his
INR was therapuetic. He was in sinus rhythm on discharge. Chest
tubes and pacing wires were discontinued without complication.
He was evaluated by physical therapy for strength and
conditioning. He was slow to wean from oxygen therapy, but was
stable on room air by discharge. On postoperative day 6 he was
discharged to [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House in [**Location (un) 86**].
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): MD
to dose daily for goal INR 2.5-3.5 for mechanical mitral valve.
Disp:*60 Tablet(s)* Refills:*2*
7. 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 until further instructed.
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] house
Discharge Diagnosis:
Past Medical History:
mitral regurgitation
mitral stenosis
hyperlipidemia
benign brain tumor ( resect. [**2156**])
pneumothorax ( age 23)
prior pneumonia
tobacco abuse
colon polyps
hemorrhoids
Past Surgical History:
resect. brain tumor [**2156**]
Ring herniorrhaphy (childhood)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
No 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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2166-5-22**] at 9am at [**Hospital3 **]
Cardiologist: Dr. [**Last Name (STitle) 31888**] on [**2166-6-5**] at 1pm.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] [**Telephone/Fax (1) 90206**] in [**4-8**] 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**
Labs: PT/INR for Coumadin ?????? indication is mechanical mitral
valve
Goal INR 2.5-3.5
First draw [**2166-4-29**], then daily until INR consistently within
stable range.
Will need coumadin follow up upon discharge from rehab.
Completed by:[**2166-4-28**]
|
[
"394.2",
"V15.82",
"427.31",
"V12.41",
"E878.1",
"285.1",
"272.4",
"997.1",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6535, 6633
|
4314, 5422
|
315, 414
|
6955, 7122
|
2067, 4291
|
8011, 8824
|
1245, 1291
|
5477, 6512
|
6654, 6654
|
5448, 5454
|
7146, 7988
|
6870, 6934
|
1306, 2048
|
256, 277
|
442, 762
|
6676, 6847
|
1082, 1229
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,668
| 125,994
|
29894
|
Discharge summary
|
report
|
Admission Date: [**2157-2-9**] Discharge Date: [**2157-2-19**]
Date of Birth: [**2098-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
58 F with h/o DM and HTN presents after 2 episodes syncope, most
recent today while waiting for an elevator at work. She felt
dizzy prior to falling but denies CP, SOB. She lost
consciousness and hit her forehead. After waking up she was not
confused and could recount her history and SS#. She did not
have bowel or bladder incontinence. The episode yesterday
occured while waiting for the bus; the patient again lost
consciousness but did not hit her head at that time. She denies
chest pain, SOB, fever, chills, headache, cough, abdominal pain
or dysuria. She does admit to 1 month of DOE, specifically when
climbing up one flight of stairs to her apartment.
.
In ED she was hypertensive, 184/117, HR 96, RR 24, and 95% RA.
Troponin was 0.34. She was given IV metoprolol 10mg, ASA 325,
and metoprolol 25mg PO. CT head negative for bleed. She was
started on a heparin drip for ACS.
Past Medical History:
Diabetes-II
HTN
Social History:
Pt is from Barbados and immigrated to US 18 years ago. Lives
with her children (2 daughters, 1 son). Never smoked, denies
alcohol or drug use. She works at an [**Hospital3 **] facility
caring for elderly adults.
Family History:
Brother with DM. Mother died during childbirth. Father died of
stomach cancer. Aunt with Breast cancer. Sister with [**Name2 (NI) **]
cancer. No h/o cardiac disease.
Physical Exam:
T 99.1 BP 153/94 HR 76 R 20 97% RA
Gen- obese female, speaking in full sentences
HEENT- perrl, R sclera injected in medical aspect. MMM, OP
clear
Neck- no JVD but difficult to assess due to supple neck. No LAD
Heart- distant HS, RRR S1S2, no M/R/G
Lungs- CTAB
Abd- +BS, soft, ND/NT
Ext- trace LE edema, 2+ pp b/l
Pertinent Results:
[**2157-2-9**] 10:00AM PLT COUNT-289
[**2157-2-9**] 10:00AM NEUTS-76.1* LYMPHS-19.4 MONOS-2.7 EOS-0.6
BASOS-1.2
[**2157-2-9**] 10:00AM WBC-8.2 RBC-4.45 HGB-14.0 HCT-38.2 MCV-86
MCH-31.4 MCHC-36.6* RDW-14.5
[**2157-2-9**] 10:00AM CALCIUM-9.8 PHOSPHATE-1.9* MAGNESIUM-1.8
[**2157-2-9**] 10:00AM CK-MB-11* MB INDX-6.3*
[**2157-2-9**] 10:00AM cTropnT-0.34*
[**2157-2-9**] 10:00AM CK(CPK)-175*
[**2157-2-9**] 10:00AM UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-3.6
CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
[**2157-2-9**] 10:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2157-2-9**] 10:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2157-2-9**] 10:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2157-2-9**] 12:50PM ALBUMIN-4.1
[**2157-2-9**] 12:50PM cTropnT-0.33*
[**2157-2-9**] 12:50PM ALT(SGPT)-20 AST(SGOT)-28 ALK PHOS-66
.
CT head [**2-9**]:
1. No evidence for hemorrhage. Left frontal bone soft tissue
swelling.
2. Punctate calcifications in the left cerebellar hemisphere
may relate to old, healed neurocysticercosis.
.
ECG: Sinus @ 78. Q waves in III, aVF. TWI in V2-V5
Brief Hospital Course:
A/P 58 yo with DM, HTN, p/w syncope and found to have massive B
pulmonary emboli
.
1. Pulmonary embolus:
The patient's likely source of her clot was her long plane ride.
She had calf pain and it is questionable if she had a DVT which
led to the embolus. Her malignancy screen is up to date for her
age. She has no history of dvt, no ocp use and does not smoke.
Her hypercoaguability workup is pending (Protein C Antigen;
Protein S Antigen; Anti-Cardiolipin Antibody; Prothrombin
Mutation Analysis; Homocysteine). Her Leni's were negative. A CT
of her abdomen and pelvis did not reveal evidence of IVC clot.
She was maintained on a heparin drip until she therapeutic on
coumadin.
She will need close follow up with her PCP (for INR monitoring)
and [**Month/Year (2) 1978**]. She also has a follow up appointment with the
pulmonology clinic scheduled.
.
# Diabetes:
Ms. [**Known lastname 71455**] is a type II diabetic. She was initially controlled
with sliding scale insulin protocols but was transitioned back
to her home regimen in anticipation of discharge. Her blood
sugars were somewhat elevated throughout her hospitalization and
she should likely have a repeat A1c and medication eval by per
primary care provider after discharge.
.
# Hypertension: Ms. [**Known lastname 71455**] was hypertensive on floor and was
maintained on her home regimen of diltiazem. Her lisinopril was
up titrated to attempt to improve her BP control. We will
discharge her on the new regimen and she should follow up with
her primary care provider for repeat hypertension evaluation.
.
# Cardiac
a) Ischemia: The patient had EKG changes (related to PE), and
Tropoinin elevation (likely from RV strain). Given the RV strain
noted on Echo once this resolves the troponin will likely
resolve as well. She did not have any other indication of
ischemic cardiac disease. She was maintained on daily aspirin,
ACE inhibitor, and lipitor. She should have a repeat EKG in the
future to eval for resolution of her strain changes.
.
b) Pump: RV strain with severe free-wall hypokinesis secondary
to PE seen on ECHO. Preload reduction was avoided. The patient
remained asymptomatic in hospital. She should have a repeat ECHO
in a few months to re-evaluate.
.
c) Rhythm: She was in normal sinus rhythm throughout her
hospitalization.
#). Ms. [**Known lastname 71455**] is FULL CODE.
Medications on Admission:
Lisinopril 40mg qAm, 20mg qPM
Diltiazem XR 360mg daily
Metformin 1000mg [**Hospital1 **]
HCTZ 25mg daily
Glipizide XL 10mg [**Hospital1 **]
Clonidine 0.2mg - 2 tabs [**Hospital1 **]
Omeprazole 20mg daily
Avandia 2mg [**Hospital1 **]
Aspririn 81mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Emboli.
Gout.
Discharge Condition:
Stable.
Discharge Instructions:
You were hospitalized after a syncopal episode and diagnosed
with blood clots in your lungs, known as pulmonary emboli. You
were treated with blood thinning medications to prevent
progression of the clots. Upon discharge from the hospital, you
will need to continue to take these medication to prevent
formation of further clots. This medication needs to have
frequent monitoring of blood levels by your primary care
provider. [**Name10 (NameIs) **] will need to be diligent about follow up in the
coming months.
If you have any recurrent shortness of breath, chest pain,
dizziness, lightheadedness, loss of consciousness or any
concerning or new symptoms, call your doctor immediately or
return to the emergency department.
Take all of your medications as prescribed. If you have
questions about your medications, be sure to contact your doctor
or discuss them with your pharmacist.
Keep all of your scheduled follow up appointments.
Followup Instructions:
1. PCP ([**Last Name (LF) **], [**First Name3 (LF) **]) f/u appt scheduled: [**2-22**] at 6:40 pm.
2. [**Month/Year (2) **] f/u appt scheduled: [**2157-3-11**] at 10 am with Dr.
[**Last Name (STitle) **] for anticoagulation.
3. Pulmonology f/u appt scheduled: Thursday [**2-24**] at 4pm with
Dr. [**Last Name (STitle) **] and NP [**Location (un) 2174**], [**Location (un) 436**] [**Hospital Ward Name 23**]. You will need to
arrive 30 minutes before your appointment time for testing.
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] RN Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2157-2-24**] 4:00
Provider: [**Name10 (NameIs) 7801**],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2157-3-11**] 10:00
|
[
"274.9",
"780.2",
"401.9",
"250.00",
"415.19",
"920",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6683, 6689
|
3294, 5652
|
322, 330
|
6757, 6767
|
2065, 3271
|
7753, 8613
|
1539, 1711
|
5955, 6660
|
6710, 6736
|
5678, 5932
|
6791, 7730
|
1726, 2046
|
275, 284
|
358, 1252
|
1274, 1291
|
1307, 1523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,373
| 197,574
|
44712
|
Discharge summary
|
report
|
Admission Date: [**2182-11-24**] Discharge Date: [**2182-11-28**]
Date of Birth: [**2137-6-3**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
decreased po intake/emesis/constipation
Major Surgical or Invasive Procedure:
upper endoscopy
History of Present Illness:
: 45 yo M resident of [**Hospital1 **] with h/o depression and recent
suicide attempt (cut throat) presents with 6 days of poor po
intake, several episodes of emesis (non-bilious, no blood or
coffee grounds), constipation and dark stools. He reported
feeling lightheaded 2 days ago while walking to the bathroom,
and falling in the bathroom with possible LOC. He informed the
staff at [**Hospital1 **] who reportedly told him he was dehydrated
and should take in more fluids. Patient reports that
concurrently he had been having black tarry stools, which he
first noticed 1-2 weeks ago. He had some constipation and every
time he took a laxative he noticed that his stools were black,
no frank blood. Of note, he had been taking 800 mg ibuprofen TID
for shoulder pain. At [**Hospital1 **], BP noted to be 96/60, HR 88, T
99.8, and he was sent to [**Hospital1 18**] ED.
.
In ED he was found to have orthostatic hypotension and an
elevated Creat of 2.8 (baseline unknown). Hct 30 with unknown
baseline, dropping to 22 on repeat after 3 L NS. Rectal exam
revealed black stool. An NG lavage was negative for blood.
.
On arrival to the [**Hospital Unit Name 153**], VS were 119/60, 110, 100% RA. Patient
was transfused two units of PRBCs and underwent endsocopy. Two
duodenal ulcers with evidence of recent bleeding (not actively
bleeding) were identified. Patient was started on a PPI [**Hospital1 **]. His
HCT was monitored and has been stable x 24 hours.
.
At present, pt is feeling much better. He no longer feels dizzy
when sitting or standing; he has been able to get up and use the
commode without difficulty. His appetite is recovering slowly,
but he has been able to eat. No further emesis. He denies
abdmonial pain. He has not had a bowel movmement since
admission. No chest pain or shortness of breath. His L shoulder
pain is signiifcantly improved.
.
Of note, he has no recollection of how his throat was cut. He
denies SI or HI. He does not feel his mood is depressed. He
states that he was due to be discharged from [**Hospital1 **] this
week.
Past Medical History:
- major depression with recent suicide attempt (cut throat)
- HTN
- h/o left shoulder pain
Social History:
Has been at [**Hospital1 **] for 2 weeks. Originally from [**Country 15800**], came
to the US in the early [**2084**]. Lives by himself. Divorced, but
remains close to his step-daughters. [**Name (NI) 1403**] in "human services."
Drinks EtOH 1-2 drinks/night. + Tobacco use - unclear how much.
No other drug use, no hx of IVDU.
Family History:
NC.
Physical Exam:
AF, 110, 119/60, 100% RA
Gen: Slim AA male appearing well, conversant.
HENNT: Dry MM, anicteric.
CV: RR, nl S1S2, normal rate, No M/R/G
Lungs: CTAB
Abd: soft, NT/ND, +BS, No HSM
Ext: no c/c/edema, strong DP/PT pulses bilaterally
Neuro: A&Ox3
Pertinent Results:
[**2182-11-28**] 07:15AM BLOOD WBC-12.4*
[**2182-11-26**] 06:30AM BLOOD WBC-9.2
[**2182-11-25**] 12:24PM BLOOD Hct-25.3*
[**2182-11-25**] 06:06AM BLOOD Hct-24.4*
[**2182-11-24**] 06:30PM HCT-26.8*#
[**2182-11-24**] 09:57AM HCT-20.7*
.
[**2182-11-24**]
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2182-11-24**] -
GLUCOSE-129* UREA N-83* CREAT-2.1* SODIUM-138 POTASSIUM-4.0
CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
.
WBC-15.2* RBC-2.55*# HGB-8.1* HCT-22.9* PLT COUNT-257 MCV-90
MCH-31.9 MCHC-35.5* RDW-13.4
NEUTS-85.4* BANDS-0 LYMPHS-10.5* MONOS-3.4 EOS-0.3 BASOS-0.3
.
PT-12.2 PTT-24.7 INR(PT)-1.0
.
[**2182-11-24**]
GLUCOSE-132* UREA N-80* CREAT-2.8* SODIUM-133 POTASSIUM-4.9
CHLORIDE-99 TOTAL CO2-24 ANION GAP-15
.
ALT(SGPT)-20 AST(SGOT)-28 ALK PHOS-48 AMYLASE-157* TOT BILI-0.3
.
LIPASE-40 ALBUMIN-3.7
.LITHIUM-1.5
.
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CHEST (PA & LAT) [**2182-11-24**] 7:51 AM
.
IMPRESSION: No evidence for acute cardiopulmonary process.
_
_
_
_
_
_
_
_
_
________________________________________________________________
EGD Report [**Hospital1 **]
Date: [**Last Name (LF) 1017**], [**2182-11-24**] Endoscopist(s): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 61753**],
MD
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (fellow)
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Excavated Lesions Two cratered ulcers was found in the
bulb. There were stigmata of recent bleeding. Adherent clots
were flushed off with clean bases seen.
Impression: Ulcer in the bulb
.
[**2182-11-27**] 06:30AM BLOOD Glucose-90 UreaN-12 Creat-0.9 Na-138
K-3.0* Cl-101 HCO3-27 AnGap-13
[**2182-11-28**] 07:15AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-137
K-3.2* Cl-101 HCO3-26 AnGap-13
[**2182-11-27**] 06:30AM BLOOD VitB12-840 Folate-4.0
[**2182-11-27**] 06:30AM BLOOD TSH-1.4
[**2182-11-27**] 06:30AM BLOOD Lithium-0.7
Brief Hospital Course:
#) UGIB: Upper endoscopy showed proximal duodenal ulcers with
clean bases. [**Month (only) 116**] have been [**12-26**] NSAID use as patient was on
motrin 800 TID for shoulder pain. Received 2 units of PRBCs w/
appropriate response. Then, he had 1 large melenotic BM w/
subsequent 4 point drop in Hct. He received another 2U PRBC,
and his Hct stablized at 30 for >24 hours. He had no further
episodes of bleeding or guaiac + stools; vitals stable during
his admission. Would continue protonix 40mg [**Hospital1 **] for next 2
months and avoid all NSAIDs.
.
#) Major Depression with recent suicide attempt: Pt did not
exhibit any behavior suggestive of psychosis or depression
during this admission; had 1:1 sitter at all times. Seen by
in-house psychiatrist Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 14936**]. She noted that he
may have depression with elements of psychosis, and
significantly, that he has no insight regarding this event.
Lithium was initially held [**12-26**] to renal failure but restarted
after this issue resolved. RPR was negative for ?syphillis, and
pt was continued on celexa and abilify. Pt will follow up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95664**] at [**Hospital6 1597**]. He will need to
have his Lithium levels checked by that time - within range at
0.8 prior to discharge.
.
#) s/p falls: Fell twice at [**Hospital1 **], reports hitting his
head. ?LOC. Head Ct negative. X-ray of face/orbits were
negative. Also complains of left shoulder pain, which is more
chronic - X-ray negative. Pain controlled w/ prn tylenol;
avoiding NSAIDs.
.
#) Renal Failure: Cr 2.9 on admission - baseline unknown -
therefore unclear duration, however, most likely related to
hypovolemia. Resolved with hydration.
.
#) Leukocytosis: Pt's WBC elevated to 17 initially, but he was
afebrile and had no obvious source of infection. White count
likely elevated due to stress response from GIB. Resolved after
receiving PRBC transfusions; slowly rising again to 12 on day of
discharge, but he had no evidence of further bleeding was
hemodynamically stable.
.
#) HTN. Anti-hypertensives initally held given orthostatic
hypotension and GI bleed. Restarted HCTZ for elevated blood
pressure. Lisinopril not given currently for BP range of
112-146/64-86. Could restart if BP elevated >140/90.
.
#) Constipation: Appears to be chronic. Had multiple BM since
admission w/ help of colace and prn senna.
.
#) FEN: Regular diet
.
#) PPX: ambulation, colace
.
#) Code: Full
.
#) dispo - home w/ close psychiatric follow-up
Medications on Admission:
- seroquel 50 mg q 6hrs prn
- Multivitamins 1 CAP PO DAILY
- Lithium Carbonate 450 mg PO BID
- Docusate Sodium 100 mg PO BID
- Citalopram Hydrobromide 20 mg PO DAILY
- Aripiprazole 15 mg PO QHS
- motrin 800 tid
- ultram 50 mg q6 hrs
- hctz 50 mg po daily
- lisinopril 10 mg daily
- Tylenol 650 prn
- MOM prn constipation
- Nicotine Gum 2 mg q 1hr prn (no more then 16 peices per 24 hr)
- Mylanta prn
- trazadone 50 mg qhs prn
- diphenhydramine 50 mg q 4 hrs prn
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
3. Lithium Carbonate 450 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
4. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*60 Cap(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed. Tablet(s)
11. Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour)
as needed.
Disp:*60 Gum(s)* Refills:*0*
12. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed.
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
upper GI bleed
s/p falls
acute renal failure
major depression w/ recent suicide attempt
hypertension
.
Secondary
constipation
Discharge Condition:
good
Discharge Instructions:
Please return for further care if you have bloody or black
stool, blood in your sputum, dizziness, fainting, shortness of
breath, chest pain, fevers, chills, or seizures.
.
Also, be aware of signs of depression - sleeping too much or not
being able to sleep, decreased appetite, fatigue, decreased
sense of pleasure, or any thoughts of suicide.
.
Make sure to take all your medications as directed.
.
Try to eat more bananas as your potassium levels have been low.
Also, it is important for you to drink up to 6 glasses of water
or other fluids per day to prevent dehydration. Do NOT drink
alcohol.
.
Please keep the appointments scheduled for you. The details are
listed below.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95664**] at [**Hospital6 1597**]
on [**12-10**] at 1:30pm. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] 330 [**Hospital3 **] St. in [**Hospital1 8**].
[**Telephone/Fax (1) 27779**].
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12070**] on [**12-4**] at 9:30am at the above address.
[**Telephone/Fax (1) 12071**]
Completed by:[**2182-11-28**]
|
[
"532.40",
"276.52",
"296.24",
"E935.9",
"584.9",
"285.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9923, 9938
|
5372, 7968
|
309, 326
|
10117, 10124
|
3169, 5349
|
10852, 11328
|
2886, 2891
|
8482, 9900
|
9959, 10096
|
7994, 8459
|
10148, 10829
|
2906, 3150
|
230, 271
|
355, 2409
|
2431, 2524
|
2540, 2869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,844
| 102,527
|
34680
|
Discharge summary
|
report
|
Admission Date: [**2188-10-24**] Discharge Date: [**2188-10-30**]
Date of Birth: [**2109-3-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Oxycontin / Penicillins / Prednisone / Codeine /
Advair Diskus
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
pulmonary embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 79 yo woman with hx of non-small cell lung
cancer who was transfered from OSH with bilateral PEs. For full
HPI please see admission note. Briefly, she had last received
taxol, carboplatin, on [**2188-10-20**].She had rcvd avastin as well on
prior cycles but held due to poorly controlled BP. The patient
was at home when she noted acute worsening of chronic dyspnea
and came to [**Hospital1 18**] [**Location (un) 620**] where she was diagnosed with bilateral
PEs. She was started on heparin gtt and bedside ECHO showed RV
strain, but patient remained hemodynamically stable while in
ICU. She was transitioned to lovenox and called out to the
floor.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Adapted from Dr.[**Name (NI) 3279**] notes:
This patient is a former heavy smoker, although quit over 20
years ago. Developed left arm pain down in [**State 108**] late in the
spring of [**2186**]. She was evaluated for this, which included a CT
scan of the chest, which indicated a right middle lobe lung
lesion. She came back to [**Location (un) 86**] and underwent a right middle
lobectomy at [**Hospital6 **] by Dr. [**First Name (STitle) **].
She had a stage I T1 N0 2.6-cm moderately differentiated
adenocarcinoma resected by right middle lobectomy at [**Hospital 2082**] [**2186-7-11**] by Dr. [**First Name (STitle) **]. There was no vascular
lymphatic invasion. Margins were negative. Multiple lymph nodes
were sampled and were negative. She also had a mediastinoscopy
preoperatively with multiple N2 and N3 lymph nodes that were
negative. Over the next year, she had an increasing right lower
lung nodule. She underwent a CT-guided needle biopsy on [**2187-7-31**].
This was a 1.2-cm right lower lobe nodule. The report was
positive for malignancy changes consistent with non-small cell
carcinoma, favor adenocarcinoma. Finally, she did have an MRI of
her brain done at [**Hospital6 **] on [**2188-6-26**]. This
showed some mild chronic
microvascular changes but no evidence of tumor.
PAST MEDICAL HISTORY:
====================
- Non- small cell Lung cancer, adenocarcinoma as above.
- Allergic rhinitis.
- Hypertension.
- Hyperlipidemia.
- Gastroesophaeal reflux disease.
- Esophageal stricture, status post-dilation.
- Status post-total hip replacements and one knee replacement
for osteoarthritis.
Social History:
Per Dr.[**Name (NI) 79529**] note:
She is married and lives with her husband. They winter in
[**State 108**] and they live up here the rest of the time. She does not
work anymore, but used to work as an assistant to a thoracic
surgeon at the [**Location 1268**] VA. She does not drink any alcohol.
She smoked one pack a day for 30-years, but quit in [**2162**].
Family History:
There is no family history of any lung disease. Her brother had
some type of cancer, which was either a thyroid cancer or throat
cancer, the patient is not sure.
Physical Exam:
Vitals - T: 96.3 BP: 126/83 HR: 83 RR: 16 02 sat: 100% on 1L
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, Pale conjunctiva,
patent nares, MMM, dentures,
NECK: no LAD, no JVD
CARDIAC: RRR, S1/S2, Soft 1/6 SEM and LUSB
LUNG: Decreased breath sounds throughout, but no
Wheezes/Rales/Rhonchi.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
[**2188-10-24**] WBC-2.3*# Hgb-10.8* Hct-31.8* Plt Ct-131*#
[**2188-10-25**] WBC-2.0* Hgb-9.7* Hct-27.8* Plt Ct-111*
[**2188-10-25**] WBC-2.0* Hgb-9.6* Hct-27.3* Plt Ct-109*
[**2188-10-26**] WBC-1.7* Hgb-9.5* Hct-27.6* Plt Ct-103*
[**2188-10-27**] WBC-1.6* Hgb-8.3* Hct-23.7* Plt Ct-74*
[**2188-10-28**] WBC-1.3* Hgb-8.1* Hct-23.6* Plt Ct-81*
[**2188-10-29**] WBC-1.4* Hgb-10.6*# Hct-30.8*# Plt Ct-109*
[**2188-10-30**] WBC-2.4*# Hgb-10.4* Hct-30.9* Plt Ct-96*
.
[**2188-10-24**] Neuts-74.5*
[**2188-10-28**] Neuts-28*
[**2188-10-29**] Neuts-9*
[**2188-10-30**] Neuts-7*
.
[**2188-10-24**] UreaN-20 Creat-1.0 Na-129* K-3.4 Cl-90* HCO3-27
AnGap-15
[**2188-10-25**] UreaN-19 Creat-0.9 Na-130* K-2.9* Cl-92* HCO3-28
AnGap-13
[**2188-10-25**] UreaN-20 Creat-1.0 Na-130* K-3.8 Cl-95* HCO3-25
AnGap-14
[**2188-10-26**] UreaN-27* Creat-1.2* Na-131* K-3.7 Cl-95* HCO3-24
AnGap-16
[**2188-10-27**] UreaN-23* Creat-1.1 Na-134 K-4.2 Cl-100 HCO3-29
AnGap-9
[**2188-10-28**] UreaN-16 Creat-0.9 Na-134 K-4.2 Cl-102 HCO3-27
AnGap-9
[**2188-10-29**] UreaN-12 Creat-1.0 Na-136 K-4.5 Cl-102 HCO3-26
AnGap-13
[**2188-10-30**] UreaN-12 Creat-1.0 Na-136 K-4.6 Cl-100 HCO3-28
AnGap-13
.
[**2188-10-25**] 12:00AM BLOOD CK-MB-6 cTropnT-0.31*
[**2188-10-25**] 10:49AM BLOOD CK-MB-4 cTropnT-0.18*
[**2188-10-25**] BLOOD Type-ART Temp-36.1 pO2-112* pCO2-37 pH-7.48*
calTCO2-28 Base XS-4
.
Images:
[**10-24**] TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic valve is
not well seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular systolic function.
Moderately dilated right ventricle with moderate to severe right
ventricular dysfunction. Moderate pulmonary hypertension is
noted.
.
CT chest ([**10-24**]):
1) EXTENSIVE BILATERAL PULMONARY EMBOLISM.
2) UNCHANGED MODERATE RIGHT PLEURAL EFFUSION WITH A POSTERIORLY
LOCULATED COMPONENT.
3) QUESTIONABLE SLIGHT DECREASE IN THE RIGHT APICAL
PLEURAL-BASED
LESION AND IN THE LEFT ANTERIOR UPPER LOBE LESION. OTHER
PULMONARY
LESIONS ARE UNCHANGED.
4) UNCHANGED MEDIASTINAL AND RIGHT HILAR LYMPH NODES, UP TO 1
CM.
Brief Hospital Course:
79 yo woman with hx of non-small cell lung cancer who was
transfered from OSH with bilateral PEs.
.
# Pulmonary emboli: Patient with dyspnea much improved
throughout hospitalization. Discharged on lovenox. .
# Hypertension: patient was intermittinely hypotensive in ICU
but assymptomatic. Recieved fluid boluses with response. Home
medications were held initially. They were restarted gradually
as patient returned to baseline blood pressure. She was
discharge on a decreased dose of atenolol and no chlorthalidone
with instructions to follow with her PCP.
.
# NSCLCa with liver mets: S/p 4 weeks of chemo with taxol,
carboplatin, Avastin, on [**2188-10-20**]. Plan per primary oncologist.
.
# Pancytopenia: Secondary to chemo. Stabilized prior to
discharge and patient remained afebrile.
.
# H/o Intermittent Atrial Tachycardia: On atenolol 75mg twice
daily at home. Discharged on 50mg twice daily.
Medications on Admission:
Atenolol 75 mg [**Hospital1 **]
Atorvastatin 20 mg daily
Irbesartan-HCTZ 150/12.5 mg daily
Rabeprazole 20 mg daily
Tiotroprium 1 Cap daily
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
every twelve (12) hours.
Disp:*3 syringes* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every other day.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Irbesartan-Hydrochlorothiazide 150-12.5 mg Tablet Sig: one
half Tablet PO once a day.
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for itching.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for oral sores: before meals if
needed.
Disp:*100 ML(s)* Refills:*2*
11. Formoterol Fumarate 20 mcg/2 mL Solution for Nebulization
Sig: One (1) solution Inhalation twice a day as needed for
shortness of breath or wheezing.
Disp:*60 solutions* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: pulmonary embolism
Secondary: lung cancer, hypertension
Discharge Condition:
Good
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted because you had a blood clot that traveled to
your lungs. We started you on medication to prevent clot
formation called Lovenox.
The following changes were made to your medications:
START Lovenox 90mg (0.9cc) inject subcutaneously twice daily
START Perforomist nebulizer twice daily
STOP Chlorthalidone
Please continue all other medications as prescribed.
You should see Dr. [**Last Name (STitle) 3274**] in the next two weeks in his office
in [**Location (un) 620**].
Please call your doctor or 911 if you have chest pain, worsened
shortness of breath or for any other concern.
Followup Instructions:
Please call to make an appointment with Dr. [**Last Name (STitle) 3274**] within two
weeks.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2188-11-27**] 3:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2188-11-27**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2188-11-27**] 4:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"496",
"V10.11",
"272.4",
"284.1",
"401.9",
"197.7",
"V43.65",
"V43.64",
"E933.1",
"415.19",
"276.1",
"530.81",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8866, 8924
|
6523, 7424
|
355, 362
|
9033, 9040
|
3964, 6500
|
9723, 10362
|
3150, 3313
|
7613, 8843
|
8945, 9012
|
7450, 7590
|
9064, 9700
|
3328, 3945
|
297, 317
|
390, 1072
|
2459, 2754
|
2770, 3134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,954
| 127,834
|
6633
|
Discharge summary
|
report
|
Admission Date: [**2171-10-15**] Discharge Date: [**2171-10-24**]
Date of Birth: [**2125-1-14**] Sex: F
Service: MEDICINE
Allergies:
Darvon
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
right upper quadrant pain, nausea, vomiting, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 year old female status post living-related donor renal
transplant (6 yrs ago), IDDM since age 11 with triopathy,
hypertension, and recent total vaginal hysterectomy with left
oopherectomy, presented with acute onset right upper quadrant
pain, nausea/vomiting, and fevers for a few hours. She was
febrile to 101 on admission, hypertensive, wbc 19 (90% polys, 6%
bands), and creatinine elevated to 2.9 (baseline low 2's).
Urinalysis revealed >50 wbcs and positive nitrite and leukocyte
esterase. She was started on renal dose levaquin for
pyelonephritis x one dose (250 mg IV)in the ED.
Past Medical History:
GYN HISTORY:
LMP: [**2170-7-17**] CURRENT CONTRACEPTION: None
DATE OF LAST PAP SMEAR: [**2168-9-14**] PLACE: [**Hospital1 18**] RESULT: WNL
OB HISTORY:
G: 2 P: 2 LIVE CHILDREN: 2
PAST MEDICAL/SURGICAL HISTORY:
-Type I DM (age 11) - neuropathy, retinopathy, nephropathy
-S/P living, related donor renal transplant (sister) [**2164**], on
stable immunosuppression (rapamune, cellcept) since that time,
no recent changes, denies any known rejection, followed closely
by [**Last Name (un) **]/transplant/renal teams. ESRD [**1-14**] IDDM. baseline
creatinine in the mid 2's.
-Anemia, on procrit/fe, occasional prbc's
-Hypertension
-Hyperlipidemia
-2+ MR, EF >55%, mild LVH
-Peripheral vascular disease s/p femoral-popliteal bypass x 2
-Cerebrovascular Accidents x 2-aphasia, no residual deficits
-Total vaginal hysterectomy on [**2171-8-20**] [**1-14**] menorrhagia, left
oopherectomy for large ovarian cyst; right cyst noted on u/s but
nothing seen in OR so right ovary still in place. Uncomplicated
post op course
-Right breast cyst removal
-Laser eye surgery
-C-section X 2
-Left labial abscess s/p drainage [**4-13**]
-?Septic L ankle joint [**7-17**] s/p tap, irrigation, contaminated
cultures but 62K wbc, >90% polys, no crystals
Allergies: NKDA
Social History:
divorced with 2 children. 20 pack year smoking history. denied
alcohol or illicit drug use. social pertinents: no HIV risk
factors (recent blood transfusions), trip to [**Location (un) **] this
summer but no other travel, sick contact on day prior to
admission w/ friend who was recovering from pna hospitalization
Family History:
non-contributory
Physical Exam:
T 97.9 BP 136/66 HR 78 RR 20 O2 96% RA
Gen - Alert, awake, in NAD
HEENT - extraocular motions intact, anicteric, mucous membranes
moist
Neck - supple, no jugular venous distention
Chest - bibasilar minimally coarse BS
CV - Normal S1/S2, regular rate and rhythm, + murmur (not new),
no rubs or gallops, 2+ pulses throughout
Abd - soft, nondistended, normoactive bowel sounds, no masses,
nontender, no rebound or guarding
Extr - warm, no clubbing, cyanosis, or edema
Neuro - AOx3, CN2-12 intact, ambulating well, denies loss of
sensation, face symmetric, tongue non-deviated, no dysarthria
Pertinent Results:
[**2171-10-24**] 06:50AM BLOOD WBC-9.2 RBC-2.97* Hgb-7.6* Hct-24.3*
MCV-82 MCH-25.7* MCHC-31.4 RDW-16.5* Plt Ct-700*
[**2171-10-23**] 07:00AM BLOOD WBC-8.6 RBC-2.72* Hgb-7.1* Hct-22.5*
MCV-83 MCH-26.3* MCHC-31.6 RDW-17.0* Plt Ct-624*
[**2171-10-21**] 06:30AM BLOOD WBC-12.9* RBC-3.10* Hgb-8.0* Hct-26.0*
MCV-84 MCH-25.8* MCHC-30.8* RDW-16.1* Plt Ct-649*
[**2171-10-20**] 04:51AM BLOOD WBC-12.4* RBC-3.26* Hgb-8.3* Hct-26.9*
MCV-83 MCH-25.5* MCHC-31.0 RDW-16.0* Plt Ct-626*
[**2171-10-19**] 05:57AM BLOOD WBC-13.8* RBC-3.22* Hgb-8.3* Hct-27.0*
MCV-84 MCH-25.7* MCHC-30.7* RDW-15.9* Plt Ct-557*
[**2171-10-18**] 07:10AM BLOOD WBC-18.8* RBC-3.39* Hgb-8.8* Hct-27.8*
MCV-82 MCH-26.1* MCHC-31.8 RDW-16.6* Plt Ct-519*
[**2171-10-17**] 03:59PM BLOOD WBC-19.1* RBC-3.70* Hgb-9.7* Hct-30.0*
MCV-81* MCH-26.2* MCHC-32.4 RDW-16.2* Plt Ct-555*
[**2171-10-17**] 06:55AM BLOOD WBC-16.7* RBC-3.28* Hgb-8.7* Hct-26.5*
MCV-81* MCH-26.4* MCHC-32.6 RDW-16.1* Plt Ct-507*
[**2171-10-16**] 09:00AM BLOOD WBC-19.9* RBC-3.83* Hgb-10.1*# Hct-31.8*
MCV-83 MCH-26.5* MCHC-31.9 RDW-15.4 Plt Ct-539*
[**2171-10-15**] 01:35PM BLOOD WBC-17.7* RBC-3.25* Hgb-8.0* Hct-27.4*
MCV-84 MCH-24.6* MCHC-29.2* RDW-16.1* Plt Ct-648*
[**2171-10-14**] 09:10PM BLOOD WBC-18.5* RBC-3.52* Hgb-8.9* Hct-27.8*
MCV-79*# MCH-25.4* MCHC-32.1 RDW-15.8* Plt Ct-649*
[**2171-10-24**] 06:50AM BLOOD Neuts-78.7* Lymphs-13.6* Monos-5.0
Eos-2.1 Baso-0.6
[**2171-10-22**] 07:05AM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-10-16**] 09:00AM BLOOD Neuts-87* Bands-6* Lymphs-1* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2171-10-15**] 01:35PM BLOOD Neuts-81* Bands-6* Lymphs-6* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-10-14**] 09:10PM BLOOD Neuts-89* Bands-6* Lymphs-2* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-10-24**] 06:50AM BLOOD Glucose-86 UreaN-32* Creat-2.7* Na-138
K-3.8 Cl-106 HCO3-19*
[**2171-10-23**] 07:00AM BLOOD Glucose-170*UreaN-36*Creat-3.0* Na-142
K-4.0 Cl-109* HCO3-19*
[**2171-10-22**] 03:55PM BLOOD Glucose-93 UreaN-38* Creat-3.1* Na-141
K-3.3 Cl-107 HCO3-17*
[**2171-10-22**] 07:05AM BLOOD Glucose-161*UreaN-39*Creat-3.4* Na-140
K-4.0 Cl-106 HCO3-18*
[**2171-10-21**] 06:30AM BLOOD Glucose-183*UreaN-37* Creat-2.8* Na-140
K-3.9 Cl-108 HCO3-18*
[**2171-10-20**] 04:51AM BLOOD Glucose-109*UreaN-32*Creat-2.9* Na-142
K-3.6 Cl-110* HCO3-18*
[**2171-10-19**] 05:57AM BLOOD Glucose-71 UreaN-37* Creat-3.0* Na-140
K-3.4 Cl-107 HCO3-17*
[**2171-10-18**] 07:10AM BLOOD Glucose-227*UreaN-44*Creat-3.3* Na-135
K-3.9 Cl-102 HCO3-14*
[**2171-10-17**] 06:55AM BLOOD Glucose-82 UreaN-36* Creat-3.1* Na-132*
K-3.6 Cl-101 HCO3-18*
[**2171-10-16**] 09:00AM BLOOD Glucose-152*UreaN-35* Creat-2.8* Na-139
K-3.8 Cl-105 HCO3-20*
[**2171-10-15**] 01:35PM BLOOD Glucose-42* UreaN-36* Creat-2.9* Na-143
K-3.9 Cl-108 HCO3-22
[**2171-10-14**] 09:10PM BLOOD Glucose-103 UreaN-43* Creat-2.9* Na-141
K-4.1 Cl-103 HCO3-23 -
[**2171-10-19**] 05:57AM BLOOD ALT-9 AST-8 CK(CPK)-86 AlkPhos-80
TotBili-0.3
[**2171-10-18**] 07:10AM BLOOD LD(LDH)-174 CK(CPK)-93
[**2171-10-14**] 09:10PM BLOOD ALT-13 AST-13 AlkPhos-85 Amylase-31
TotBili-0.2 Lipase-13
[**2171-10-24**] 06:50AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
[**2171-10-15**] 01:35PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
[**2171-10-16**] 09:00AM BLOOD calTIBC-267 VitB12-639 Folate->20.0
Ferritn-119 TRF-205
[**2171-10-18**] 07:10AM BLOOD Osmolal-293
[**2171-10-22**] 03:55PM BLOOD Vanco-14.4*
[**2171-10-18**] 03:45PM BLOOD Type-ART pO2-68* pCO2-28* pH-7.36
calHCO3-16* Base XS--7
[**2171-10-18**] 03:12PM BLOOD Type-ART pO2-43* pCO2-27* pH-7.38
calHCO3-17* Base XS--7
[**2171-10-18**] 03:36AM BLOOD Type-ART pO2-61* pCO2-32* pH-7.32*
calHCO3-17* Base XS--8
[**2171-10-18**] 03:12PM BLOOD Lactate-1.5
[**2171-10-17**] 07:41PM BLOOD Lactate-1.1
.
TOXOPLASMA IgG & IgM ANTIBODY (Final [**2171-10-18**]): NEGATIVE FOR
TOXOPLASMA ANTIBODY
CMV IgG & IgM ANTIBODY (Final [**2171-10-18**]): NEGATIVE FOR CMV IgG
ANTIBODY BY EIA.
MONOSPOT (Final [**2171-10-18**]): NEGATIVE BY LATEX AGGLUTINATION.
CRYPTOCOCCAL ANTIGEN (Final [**2171-10-18**]): CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
Rapid Respiratory Viral Antigen Test (Final [**2171-10-19**]): not
detected.
[**2171-10-20**] 4:52 am BLOOD CULTURES x2
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2171-10-18**] 9:44 pm BLOOD CULTURES x2
AEROBIC BOTTLE (Final [**2171-10-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2171-10-24**]): NO GROWTH.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2171-10-16**] 4:00 pm BLOOD CULTURES x3
AEROBIC BOTTLE (Final [**2171-10-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2171-10-22**]): NO GROWTH.
[**2171-10-15**] 3:50 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2171-10-21**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2171-10-21**]): NO GROWTH.
.
[**2171-10-24**] 02:11AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2171-10-23**] 07:58PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2171-10-22**] 05:11PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2171-10-20**] 10:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2171-10-19**] 10:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2171-10-17**] 11:37AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.020
[**2171-10-15**] 06:19PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2171-10-14**] 09:59PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2171-10-24**] 02:11AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-23**] 07:58PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-22**] 05:11PM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-20**] 10:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2171-10-17**] 11:37AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2171-10-15**] 06:19PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-14**] 09:59PM URINE Blood-LG Nitrite-POS Protein-500
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-24**] 02:11AM URINE RBC-31* WBC-68* Bacteri-OCC Yeast-NONE
Epi-<1
[**2171-10-23**] 07:58PM URINE RBC-25* WBC-101* Bacteri-NONE Yeast-NONE
Epi-<1
[**2171-10-22**] 05:11PM URINE RBC-27* WBC->1000* Bacteri-NONE
Yeast-NONE Epi-<1
[**2171-10-20**] 10:00PM URINE RBC-3* WBC-0 Bacteri-RARE Yeast-NONE
Epi-<1
[**2171-10-19**] 10:00AM URINE RBC-5* WBC-0 Bacteri-OCC Yeast-NONE
Epi-<1
[**2171-10-15**] 06:19PM URINE RBC-23* WBC-106* Bacteri-MANY Yeast-NONE
Epi-<1
[**2171-10-14**] 09:59PM URINE RBC-[**5-23**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-<1
[**2171-10-22**] 05:11PM URINE Eos-NEGATIVE
[**2171-10-22**] 05:11PM URINE Hours-RANDOM UreaN-612 Creat-124 Na-52
[**2171-10-19**] 10:00AM URINE Hours-RANDOM UreaN-492 Creat-56 Na-61
TotProt-119 Prot/Cr-2.1*
[**2171-10-17**] 11:37AM URINE Hours-RANDOM Creat-94 Na-34 Calcium-0.0
[**2171-10-22**] 05:11PM URINE Osmolal-474
URINE CULTURE (Final [**2171-10-24**]): NO GROWTH.
URINE CULTURE (Final [**2171-10-22**]): YEAST. 10,000-100,000
ORGANISMS/ML.
Legionella Urinary Antigen (Final [**2171-10-21**]): NEGATIVE
URINE CULTURE (Final [**2171-10-21**]) NO GROWTH. FUNGAL CULTURE:NO
YEAST ISOLATED.
.
MRI PELVIS W/O & W/CONTRAST [**2171-10-22**] 9:17 AM 1) Large simple
cyst within the mid pelvis. The ovaries are not well visualized.
The differential diagnosis includes recurrence of an ovarian
cyst vs. a urinoma or lymphocele in patient who is status post
renal transplant. 2) Hydroureteral nephrosis of the right native
kidney with obstruction of the right native ureter at the level
of the pelvic cyst mass.
.
CT ABDOMEN W/O CONTRAST [**2171-10-16**] 5:12 PM 1. Bilateral atrophic
kidneys consistent with endstage renal disease. However, mild
enlargement of the right kidney with respect to the left,with
noted mild hydronephrosis and hydroureter up to the level of a
thin band of soft tissue adjacent to the sidewall of the noted
mid-pelvic
cyst seen on ultrasound examination. This could represent the
native ovary with a large ovarian cyst although a focal lesion
at this level is not excluded. Correlation with pelvic
ultrasound is recommended. The possibility of a urinoma can't be
excluded. Other possibilities include a lymphocele or a
peritoneal inclusion cyst.2. Multiple small gallstones in
otherwise normal gallbladder.
.
PELVIS, NON-OBSTETRIC PELVIS U.S., TRANSVAGINAL [**2171-10-14**] 10:09
AM Status post hysterectomy with a right hemorrhagic cyst
adjacent to a fluid collection. This may represent a peritoneal
inclusion cyst. Although it has been only a short interval from
the prior exam, this cystic structure may represent a new
physiologic cyst.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2171-10-14**] 11:22 PM
Cholelithiasis without cholecystitis. Atrophic native right
kidney.
.
ECHO [**2171-10-21**] 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>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a fat pad,
though a loculated anterior pericardial effusion cannot be
excluded.
.
-CHEST (PA & LAT) [**2171-10-20**] 11:38 AM Allowing for differences in
technique, there is no significant change in extent or
appearance of the alveolar opacities at both bases, or the
bilateral pleural effusions.
-CHEST (PA & LAT) [**2171-10-19**] 4:23 PM The heart is enlarged. There
is mild vascular congestion with mild interstitial edema. There
are more focal alveolar opacities at both bases consistent with
bibasilar pneumonias. There are small bilateral pleural
effusions. Compared to [**2171-10-18**], the left effusion appears
slightly increased in size. No other changes are noted.
-CHEST (PORTABLE AP) [**2171-10-18**] 3:13 PM Progressive right middle
and right lower lobe pneumonia. New opacity in left lower lobe
which may represent additional site of pneumonia or aspiration
event. New bilateral septal lines, which may be due to
interstitial edema from fluid overload or may reflect an
interstitial component of the infection.
-CHEST (PA & LAT) [**2171-10-17**] 9:25 AM Focal faint opacities in the
right costophrenic angle, most likely representing pleural
effusion and atelectasis noted on the recent abdominal CT scan.
However, early pneumonia is also a consideration. Please
correlate clinically, andwith follow-up x-rays.
.
Brief Hospital Course:
46 year old lady status post living, related donor renal
transplant, IDDM, hypertension, recent total vaginal
hysterectomy and left oopherectomy who presented with
pyelonephritis, an enlarging pelvic cyst, right
hydroureter/hydronephrosis of her native kidney, rising
creatinine, and subsequently developed right middle and lower
lobe pneumonia with worsening hypoxia during her hospital
course.
.
FEVER, LEUKOCYTOSIS, BANDEMIA: Initially, her symptoms improved
but the fevers, leukocytosis, bandemia, and creatinine elevation
persisted so she was changed to ceftriaxone x 2 days for
treatment of pyelonephritis. Her nausea, vomiting, and abdominal
pain resolved within one day of starting the broad spectrum
antibiotics and she tolerated a regular diabetic and cardiac
prudent diet throughout her hospital stay. Given results of
urinalysis and the clinical picture, UTI/pyelonephritis was the
likely cause of the patient's presenting abdominal pain,
nausea/vomiting, fever, and bandemia. Right upper quadrant
ultrasound was negative for hepatobiliary abnormalities. The
gyn service was consulted since the patient had transvaginal
hysterectomy 1.5 months prior to admission. Their gynecologic
exam was negative and the surgical suture felt to be intact.
Abdominal CT with contrast and MRI showed right-sided
hydroureter of the native kidney and a large central pelvic cyst
(larger than on preoperative ultrasound). The right sided
transplanted kidney appeared normal. Because of persistent
fever, she was started on IV vancomycin (one dose, [**10-16**]) and
oral flagyl (3 doses, [**Date range (1) 25351**]). On [**10-16**] overnight, the patient
had a bout of dry coughing accompanied by acute onset dyspnea
with desaturation to 88%, possibly the result of aspiration.
Chest x ray revealed developed right middle and lower lobe
infiltrates. She was then started on zosyn [**10-18**]. Microbiological
data was negative for multiple blood cultures, including fungal
cultures. Urine cultres were negative for growth except for
culture [**10-20**] which grew 10-[**Numeric Identifier 4856**] yeast. However, urine cultures
were obtained after starting antibiotic therapy. Vaginal swab
was negative for bacterial vaginosis. Cryptococcus antigen, CMV
antibody, toxoplamosis, and monospot were all negative. In
[**2171-7-14**], CMV virus was not detected, and screens for active
EBV and toxoplasmosis were negative. Urine was negative for
legionella antigen. No flu virus has been isolated from
nasopharyngeal swab.
.
PYELONEPHRITIS was possibly secondary to obstruction created by
enlarging pelvic cyst and sharing of the ureter among the right
native and transplanted kidney. It is also possible that the
enlarging pelvic cyst has a communication with the ureter,
although this has not been demonstrated on CT or MRI. The
patient will need to follow up with transplant nephrology and
urology as an outpatient to further evaluate and treat the
hydroureter/hydronephrosis. Both services were consulted during
this admission. Serial urinalyses demonstrated reduction of
wbc's over time and the final urine culture obtained was
negative. She continued a course of oral levoquin and
fluconazole at discharge (suggsested by urology service to cover
for candiduria).
.
PELVIC CYST: The differential diagnosis on MRI included ovarian
cyst vs. a urinoma or lymphocele in patient who is status post
renal transplant. However, ovarian cyst is not likely given that
the right ovary was examined during hysterectomy without
appearance of a cyst. Additionally, the pelvic cyst had been
seen prior to hysterectomy by ultrasound, although it was much
smaller in size at the time. It is now enlarged and more
central. Drainage of this cyst will likely need to be performed
as an outpatient to relieve the renal obstruction and to aid
further diagnosis.
.
PNEUMONIA: While it is not fully clear, it is likely that the
patient developed pneumonia secondary to aspiration with
coughing in the middle of the night [**10-16**]. There was no initial
chest x ray performed at admission. After [**10-16**], she developed
worsening right middle and lower lobe infiltrates and hypoxia.
On [**10-18**], she was tranferred to the ICU for worsened hypoxia and
concern for atypical infection versus progression to ARDS. In
the ICU, the patient was treated with nonrebreather mask oxygen
supplementation, albuterol/atrovent nebulizer, IV lasix, and
changed to levoquin, zosyn, along with vancomycin that were
continued until time of discharge. Her respiratory status
improved rapidly, suggesting she may have had flash pulmonary
edema or rapid decompensation. Chest xray showed small,
bilateral effusions that were resolving. Given the patient is
immunsuppressed taking cellcept and rapamune, concern for
infection by MRSA, legionella, histoplasmosis, PCP, [**Name10 (NameIs) **] atypical
organisms was expressed by the infectious disease consultants.
Sputum culture was contaminated. She continued a course of oral
levoquin and fluconazole at discharge.
.
INCREASED CREATININE: Creatinine increased over the past 2
months from 2.2 to a peak of 3.3, with an unclear role of the
enlarging pelvic fluid mass and pyelonephritis. Creatinine had
been trending downward since [**10-19**] with IV hydration and good
urine output; however, it bumped from 2.8 to 3.4 on [**10-22**] after 2
doses 20mg IV lasix on [**10-21**]. Repeat urinalysis included sterile
pyuria (>1000 WBC). Subsequently, the patient's renal function
improved with better oral intake and witholding of lasix (3.4
-->3.0 [**10-23**]). Prerenal cause for dysfunction was suspected with
pyuria secondary to candiduria (unlikely communication with
pelvic cyst). Acute on chronic renal failure was possibly
secondary to the obstruction; however, it is not clear if the
native kidney plays any role in the analysis of creatinine
clearance. Urine output was uncompromised during the hosptial
course and the transplanted kidney appeared in good condition on
imaging. There were no clear signs of transplant rejection
although it is likely a chronic, low level process that may have
been exacerbated by use of lasix. Medications were renally
dosed.
.
CHRONIC ANEMIA: Baseline HCT usually ranges from 25-30 as a
result of chronic disease. HCT increased from 27 to 31 after 2
units PRBCs on [**10-15**]. Dosage of procrit was increased per renal
consult recommendation and iron supplementation was continued.
.
HYPERTENSION: She was continued on home regimen including
metoprolol and nifedipine. Her home dose of lasix was held.
.
HYPERCHOLESTEROLEMIA: Lipitor was continued.
.
DIABETES: She was coninued on her regular schedule of humulin 30
units daily with sliding scale administration of humalog
insulin.
.
PERIPHERAL VASCULAR DISEASE: ASA, lipitor, metoprolol, and
nifedipine were continued.
Medications on Admission:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
5. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 units Injection
QMOWEFR (Monday -Wednesday-Friday). Disp:*qs units* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous qam.
9. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as per SS
below units Subcutaneous four times a day: 2 units BG 150-200 4
units BG 201-250 6 units BG 251-300 8 units BG 301-350 10 units
BG 351-400.
10. Tricor 54 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
5. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs units* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous qam.
9. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as per SS
below units Subcutaneous four times a day: 2 units BG 150-200
4 units BG 201-250
6 units BG 251-300
8 units BG 301-350
10 units BG 351-400.
10. Tricor 54 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days: to start on [**10-25**].
Disp:*3 Tablet(s)* Refills:*0*
13. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 12 days: to start [**10-25**].
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis
pneumonia, nosocomial
candiduria
pelvic cyst
acute on chronic renal failure
s/p renal transplant
Discharge Condition:
afebrile, tolerating oral diet
Discharge Instructions:
Continue with current antibiotics to complete a 14 day course of
Levofloxacin and 14 day course of fluconazole. Return to ED in
case of recurrent fevers, abdominal pain, or inability to
tolerate oral intake. Hold iron supplementation while taking
levofloxacin.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2172-7-22**] 9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 25352**] Call to schedule
appointment
in [**2-15**] days for repeat blood work and urinalysis.
Schedule outpatient appointment with Dr. [**Last Name (STitle) **] in [**12-14**] weeks
post-discharge - ([**Telephone/Fax (1) 3618**].
Please call for a urology followup appointment with Dr. [**Last Name (STitle) **]
in one month, as there is concern for the hydroureter in your
native kidney given that your kidney is not working properly.
The phone number is ([**Telephone/Fax (1) 772**].
Call for an appointment with Dr.[**Doctor Last Name 4849**] (nephrology) at ([**Telephone/Fax (1) 18591**] for within 2-4 weeks.
|
[
"403.91",
"590.10",
"486",
"250.41",
"428.0",
"583.81",
"250.61",
"357.2",
"E878.0",
"996.81",
"574.20",
"584.9",
"250.51",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
23772, 23778
|
14410, 21239
|
320, 327
|
23934, 23966
|
3210, 7453
|
24276, 25236
|
2568, 2586
|
22375, 23749
|
23799, 23913
|
21265, 22352
|
23990, 24253
|
2601, 3191
|
7701, 14387
|
230, 282
|
7479, 7479
|
7507, 7668
|
355, 945
|
967, 2220
|
2236, 2552
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,405
| 175,935
|
40759
|
Discharge summary
|
report
|
Admission Date: [**2189-3-23**] Discharge Date: [**2189-3-26**]
Date of Birth: [**2168-1-28**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
SOB, CP, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 21 year old woman with a history of DM1 since
age 6, no prior hx of DKA, on an insulin pump, who presents with
shortness of breath and chest pain and admitted to the [**Hospital Unit Name 153**] for
DKA.
She reports that she stopped her insulin pump 2 days ago because
she did not have the proper tubing to attach it. She was
supposed to get something in the mail but has not seen it. She
was taking SC Humalog but only small amounts. She has been
stressed from exams and reports that yesterday she felt that she
had allergies with nasal congestion and a cough that was
occasionally productive of thick green sputum. She felt mildly
feverish but did not take her temperature. Later in the day she
did have chills and felt more short of breath. She stayed up
all night at the library and later in the night developed
non-bloody, non-bilous vomitting x 3. Around 2am she had a
chest pressure that was non-radiating and present on arrival to
the ED at 4/10. She reports fingersticks in the 300s yesterday
(she checked twice) and she was taking minimal insulin. She
took 3 units of Humalog last night. She felt that her abdomen
was distended yesterday. She had 1 episode of small diarrhea
yesterday but otherwise has been having regular bowel movements.
She has not seen an enocrinologist in > 1 year and last doctor
she saw was in [**State 8449**]. She has not established care in
[**Location (un) 86**]. Of note, she recently had a friend pass away [**12-8**] with
a similar presentation and in DKA.
In the ED, initial vs were: T99.4 124 164/100 18 100% RA. She
triggered in the ED for tachycardia in the 130s and tachypnea in
the 30s. ECG showed sinus tach with peaked T waves.
Fingerstick was critically high. She was given 1L/hour of NS
(had received 1.5L so far), 10 units regular insulin. Lytes
came back with K 5.3, bicar < 5 and creatinine 1.4. Anion gap
was 33. K+ 5.6. She was given 7 units of humalog bolus and
started on 7 units/hr humalog gtt. She was given 1mg Ativan for
anxiety. IV access: 2 18 gauge. Vitals prior to transfer: 122
38 168/94 100% on 2L.
On the floor, she feels short of breath. She denies chest,
abdominal pain or other pain. She is tearful.
Past Medical History:
DM type 1, no history of DKA since diagnosis at age 6
Social History:
Originally from [**State 8449**], student at [**University/College 5130**] studying
international business. No tobacco use. Drinks alcohol
socially, had 4 drinks saturday night while going out. Denies
any IVDU. Does not live in the dorms, has a studio apartment.
Family History:
No family history of diabetes or heart disease. Is an only
child, both parents are alive and healthy.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 141/71 P: 133 R: 35 O2: 100% on facemask
General: Alert, oriented, tearful
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Pertinent Labs:
[**2189-3-23**] 07:40AM BLOOD WBC-16.3* RBC-4.32 Hgb-14.3 Hct-46.9
MCV-109* MCH-33.2* MCHC-30.6* RDW-12.5 Plt Ct-338
[**2189-3-23**] 07:40AM BLOOD Glucose-718* UreaN-18 Creat-1.4* Na-133
K-6.3* Cl-95* HCO3-<5*
[**2189-3-26**] 05:35AM BLOOD Glucose-388* UreaN-5* Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21* AnGap-15
[**2189-3-23**] 09:23AM BLOOD Type-[**Last Name (un) **] pO2-55* pCO2-21* pH-6.91*
calTCO2-5* Base XS--30
[**2189-3-23**] 07:45AM BLOOD K-5.6*
Brief Hospital Course:
1. Diabetic ketoacidosis. Presented in DKA, likely the result of
her not using her insulin pump. In the ICU she was aggressively
fluid resuscitated and placed on an insulin gtt. [**Last Name (un) **] was
consulted. Her transition to [**Hospital1 **] subcutaneous NPH insulin was
complicated by a rise in her venous lactate and brief widening
of her anion gap, so she was restarted on insulin drip briefly
then transitioned back to an increased dose of NPH, then once
daily glargine.
Plan on discharge was to continue with lantus and humalog SS
with [**Last Name (un) **] follow-up. They may reinitiate the insulin pump at a
later date.
2. URI. Presented with cough, nasal congestion, single febrile
episode to 101; no signs of bacterial infection on imaging/labs,
but given initial difficulty coming off insulin drip, patient
was started on 5d course of azithro.
Medications on Admission:
Humalog insulin pump
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
Disp:*qs x1 month units* Refills:*2*
3. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: please see attached sliding scale.
Disp:*qs x1 month units* Refills:*2*
4. insulin syringe-needle,dispos. 1 mL 28 x [**11-30**] Syringe Sig:
One (1) Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diabetic ketoacidosis
2. Diabetes, type I
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 diabetic ketoacidosis
which results from elevated blood sugars.
Given that you do not have your pump supplies available here, we
have started you on subcutaneous insulin regimen which you will
continue until you follow-up with the [**Last Name (un) **].
Followup Instructions:
You have two appointments scheduled at [**Last Name (un) **]:
1. [**2189-4-2**] at 2:30 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**], NP
2. [**2189-5-1**] at 1:00 with Dr. [**Last Name (STitle) **]
In addition, you should follow-up with the providers at
[**University/College 5130**].
|
[
"V58.67",
"V45.85",
"465.9",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5617, 5623
|
4131, 4998
|
316, 322
|
5711, 5711
|
3635, 3635
|
6179, 6497
|
2958, 3062
|
5069, 5594
|
5644, 5690
|
5024, 5046
|
5861, 6156
|
3077, 3616
|
264, 278
|
350, 2582
|
5726, 5837
|
3652, 4108
|
2604, 2659
|
2675, 2942
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,448
| 185,903
|
35558
|
Discharge summary
|
report
|
Admission Date: [**2186-6-6**] Discharge Date: [**2186-6-7**]
Date of Birth: [**2107-12-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Amiodarone
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
hypotension s/p PVI procedure
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
Pressor support
ICU-level monitoring
History of Present Illness:
Ms. [**Known lastname **] is a 78 year old female with PMH of recurrent drug
refractory atrial fibrillation who presented for elective
pulmonary vein isolation procedure on [**6-6**]. After the procedure,
she was noted to be hypotensive to as low as SBP 70s. An
echocardiogram was ordered which revealed only a small
pericardial effusion. She was briefly put on a small amount of
peripheral dopa, which was able to be weaned off with SBPs in
the 90s-100s. There was no bleeding noted at the femoral
puncture site, but a repeat stat HCT returned at 26 (from 32
pre-procedure). She did receive 4L IVF during the case. She was
ordered for a CT abdomen/pelvis and 2 units of pRBCs and was
referred for CCU admission for post procedural monitoring.
.
Upon arrival to the CCU she has no complaints and feels in her
usual state of health. She specifically denies F/C, HA/blurry
vision/palpitations, CP/SOB/cough. No abdominal pain or back
pain. No dysuria or pain at femoral cath sites. She states that
she feels so well that "I could go dancing."
Past Medical History:
# Atrial fibrillation/atrial flutter - longstanding. She was
initially treated successfully with amiodarone but this was
stopped after she developed pulmonary fibrosis. She was
subsequently treated with Propafenone, however continued to have
PAF and had difficulty sleeping so this was ultimately stopped.
She has also been treated with Sotalol and Dofetilide and was
started on Digoxin in [**3-6**]. She has had multiple cardioversions,
most recently [**3-6**].
She was evaluated by Dr. [**Last Name (STitle) **] in [**2186-3-26**] who switched
her medications to Flecainide and Cardizem (Digoxin and
Dofetilide stopped). Ultimatley the patient opted for PVI in
[**6-3**]
# Hypothyroidism
# Rheumatic fever as a child with no significant valvular heart
disease-mitral insufficiency
# Osteoporosis
# Glaucoma
# Tonsillectomy
# Anemia
# Pneumonia [**3-6**]
Social History:
Married and lives on [**Hospital3 **] with her husband. Retired. [**Name2 (NI) **]
alcohol. No smoking.
Family History:
Mother died at 88 from heart failure, father died at 65
from stomach cancer.
Physical Exam:
On admission to the CCU
VS: 97.5 72 125/60 15 100%RA
GEN: pleasant caucasian female, elderly, NAD
HEENT: NC/At, MMM. No conjunctival pallor. O/P normal, no
exudates/lesions.
NECK: No elevated JVP. No carotid bruits
COR: RRR, S1 S2, 2/6 systolic murmur at LLSB with radiation to
apex
RESP: fine dry inspiratory crackles otherwise CTAB
ABD: S/NT/ND +BS
GROIN: b/l punctures sites C/D/I no bruit or hematoma
EXT: WWP no C/C/E
SKIN: no rash
Pertinent Results:
[**2186-6-6**] 04:32PM HCT-25.0*
[**2186-6-6**] 03:32PM HCT-26.2*
[**2186-6-6**] 06:30AM GLUCOSE-92 UREA N-28* CREAT-1.3* SODIUM-143
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
[**2186-6-6**] 06:30AM WBC-5.8 RBC-3.70* HGB-10.7* HCT-32.1* MCV-87
MCH-29.0 MCHC-33.4 RDW-18.5*
[**2186-6-6**] 06:30AM PLT COUNT-148*
[**2186-6-6**] 06:30AM PT-22.9* INR(PT)-2.2*
.
CT: trace free fluid in the pelvis with no retroperitoneal
bleed. No groin
hematoma.
Fluid density structure in the upper abdomen, measuring 2.5 cm
in diameter
which is new since [**2186-6-1**], of uncertain etiology.
indeterminate right renal lesion, likely a cyst. an us may be
obtained for
further evaluation.
[**2186-6-6**] ECHO
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. Valvular stenosis
and regurgitation were not adequately assessed. The aortic valve
leaflets are moderately thickened. The mitral valve leaflets are
moderately thickened. The mitral valve shows characteristic
rheumatic deformity. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a small pericardial effusion without
echocardiographic evidence of tamponade.
Brief Hospital Course:
78 year old female with atrial fibrillation s/p pulmonary vein
isolation procedure [**6-6**] c/b post-procedural hypotension and
hematocrit drop.
.
# Acute Anemia - HCT dropped from 32 to 26 but this was in the
context of 4L IVF during the procedure. There were no overt
signs of bleeding at the sheath site, and no hemoptysis or
desaturations to suggest pulmonary hemorrhage. Received 2 U PRBC
and Hct trended up to 35 prior to d/c. CT abdomen pelvis ruled
out RP bleed.
.
# Hypotension - resolved after dropping briefly post-procedure.
Required transient peripheral dopamine. Echo confirmed no
tamponade or acute pathology. Sepsis less likely given patient
afebrile, without leukocytosis.
.
# Atrial Fibrillation - Remained in NSR post procedure. INR
reversed for bleed post-procedure. D/cd on coumadin with plan to
anticoagulate for 3 months post procedure.
.
# Hypothyroidism - Continued levothyroxine
.
# Osteoporosis - Continue Ca+D, bisphosphonate
.
# Code:
-- full, confirmed with patient
.
# Communication:
-- Husband Mr. [**Known lastname **] at [**Telephone/Fax (1) 80945**]
Medications on Admission:
Cardizem 120mg daily
Coumadin 4mg 3 days per week, 6mg 4 days per week
Fosamax 70mg weekly on sat
Flecainide 100mg [**Hospital1 **]
Cosupt 1 gtt OU [**Hospital1 **]
Alphagan 1 gtt OU [**Hospital1 **]
Travatin 1 gtt OU qpm
Levothyroxine 50mcg daily
MVI daily
Calcium with D 600mg [**Hospital1 **]
Iron 325mg daily
Discharge Medications:
1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin 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 BID (2 times a day).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(MO,WE,FR).
9. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
12. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
13. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic QPM (once
a day (in the evening)).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Discharge Condition:
Good
Discharge Instructions:
You were admitted for elective pulmonary vein isolation
procedure on [**6-6**]. After the procedure, you were noted to be
hypotensive to low SBP 70s. You required brief monitoring in the
ICU to ensure that you were not bleeding or otherwise unstable.
You were discharged in good condition.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 630**] [**Telephone/Fax (1) 80946**] within two weeks
of discharge.
Completed by:[**2186-6-8**]
|
[
"458.29",
"515",
"E942.0",
"285.1",
"427.32",
"244.9",
"733.00",
"427.31",
"396.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.26",
"37.34",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
7022, 7028
|
4435, 5523
|
333, 397
|
7084, 7091
|
3039, 4412
|
7429, 7575
|
2487, 2566
|
5887, 6999
|
7049, 7063
|
5549, 5864
|
7115, 7406
|
2581, 3020
|
264, 295
|
425, 1468
|
1490, 2350
|
2366, 2471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,313
| 112,754
|
18366
|
Discharge summary
|
report
|
Admission Date: [**2130-8-13**] Discharge Date: [**2130-8-18**]
Date of Birth: [**2098-8-12**] Sex: M
Service: SURGERY
Allergies:
Oxaliplatin / Minocycline
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
ERCP
removal of portacath x 2
PTC placement
PICC line placement
History of Present Illness:
32M s/p takedown of enterocutaneous fistula [**2130-7-13**] following
pelvic exenteration 3/[**2128**]. His EC fistula takedown surgery was
complicated by a prolonged SICU admission & he was discharged
home 2 days prior to ED presentation for fevers & abdominal
pain.
Past Medical History:
Metastatic colon cancer, s/p palliative partial pelvic
exoneration (Dr. [**Last Name (STitle) 1888**]
Social History:
+ETOH, +tobacco
Married and lives with his wife
Family History:
Noncontributory
Physical Exam:
On discharge:
AVSS
AOx3, NAD, jaundiced
RRR
CTA bilat
Soft, midline VAC in place, nontender
[**Name (NI) 5283**] PTC (bilious)
[**Name (NI) 5283**] perc nephrostomy (bloody urine)
LUQ nephrostomy (urine)
RLQ ileostomy
LLQ colostomy
no CCE
Pertinent Results:
please refer to carevue for specifics
[**2130-8-13**] 09:35PM BLOOD WBC-30.6* RBC-3.30* Hgb-9.6* Hct-28.5*
MCV-87 MCH-29.1 MCHC-33.7 RDW-20.2* Plt Ct-331
[**2130-8-13**] 09:35PM BLOOD Neuts-88* Bands-2 Lymphs-1* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2130-8-13**] 09:35PM BLOOD ALT-342* AST-268* AlkPhos-542*
Amylase-113* TotBili-26.1* DirBili-18.0* IndBili-8.1
[**2130-8-13**] 09:51PM BLOOD Lactate-2.7*
[**2130-8-13**] 10:20 pm BLOOD CULTURE X3-LFTAC. (confirmed in
[**6-13**] bottles)
**FINAL REPORT [**2130-8-17**]**
AEROBIC BOTTLE (Final [**2130-8-17**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
AMPICILLIN Sensitivity testing confirmed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ 4 S
PENICILLIN------------ 16 R
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2130-8-16**]):
REPORTED BY PHONE TO [**Last Name (un) **] [**Doctor First Name **] [**2130-8-11**] 14:55.
ENTEROCOCCUS FAECIUM. FURTHER IDENTIFICATION TO FOLLOW.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
[**8-15**] nephrostomy:
IMPRESSION:
1. Closed previous nephrostomy tract.
2. Mildly dilated RIGHT renal collecting system with successful
placement of new 8-
French nephrostomy drainage catheter.
[**8-16**] ERCP ([**Doctor Last Name **]):
Impression:
1. The post bulbar/2nd portion of the duodenum appeared fixed
with wall edema, erythema and superficial erosions. The lumen
appeared narrowed. This raises the question of neoplastic
infiltration of the duodenum. The duodenoscope was able to
traverse with gentle pressure.
2. Deep cannulation of the biliary duct was unsuccessful despite
multiple attempts with a Rx sphincterotome using a free-hand
technique. Contrast medium was injected resulting in partial
opacification. The procedure was highly difficult.
3. The guidewire could not be passed beyond the distal CBD due
to severe stricturing. This may be due to neoplastic
infiltration and/or extrinsic compression/fibrosis.Due to distal
CBD stricturing, limited cholangiogram showed dilation of up to
20mm in the proximal and mid portions of the CBD.
[**8-17**] PTC ([**Doctor Last Name **]):
IMPRESSION:
1. Moderately dilated intrahepatic biliary system with 3-4 cm
distal common
bile duct stricture.
2. Successful introduction of 8-French biliary internal-external
drain, with
external bag placed.
[**8-18**] PICC
IMPRESSION: Successful placement of 41 cm double lumen PICC in
the right
basilic vein with tip in the distal SVC, ready for use.
Brief Hospital Course:
[**8-13**] Admitted to SICU in frank sepsis, with temperature 103, WBC
30K. Pancultured & started on broad spectrum antibiotics.
Right nephrostomy tube dislodged in ED.
[**8-14**] Blood cultures revealed VSE in all bottles. Ultrasound
revealed mild right hydronephrosis & dilated biliary tree.
Urology & ERCP consulted.
[**8-15**] Right nephrostomy successfully replaced in IR.
[**8-16**] ERCP unsuccessful at cannulating CBD. Portacaths removed by
Dr. [**Last Name (STitle) **] because of high grade bacteremia.
[**8-17**] PTC placed in IR.
[**8-18**] Transfused x1 RBC for blood loss anemia.
Medications on Admission:
paxil, zofran, ativan, lopressor 25", dilaudid prn
Discharge Medications:
1. Ampicillin-Sulbactam [**2-8**] g Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours) for 1 doses: take 1 dose 1 hour
prior to follow up cholangiogram.
Disp:*1 Recon Soln(s)* Refills:*0*
2. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
3. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO TID (3
times a day).
Disp:*30 ML* Refills:*2*
4. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 7 days.
Disp:*14 gram* Refills:*0*
5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*5*
6. Anzemet 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*3*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. intravenous fluids
D5 1/2 NS @ 100cc/hr x 10 hours (8pm-8am)
9. Heparin Lock Flush 10 unit/mL Solution Sig: One (1) ML
Intravenous twice a day: heparin flushes for PICC line.
Disp:*30 CC* Refills:*2*
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. IV fluid request
D5 1/2NS @ 100cc/hr x10 hrs daily (at night)
please dispense 30 bags
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
colon cancer
s/p pelvic exenteration
enterocutaneous fistula
s/p enterocutaneous fistula takedown
sepsis
enterococcal bacteremia
portacath line infection
biliary obstruction
Discharge Condition:
improved
Discharge Instructions:
Diet as tolerated. Continue intraveous fluid overnight as
ordered.
Contact your MD or report to ED if you develop fevers>101,
increasing abdominal pain, markedly decreased output from your
drains, or if you have any other concerns.
Followup Instructions:
Contact Dr.[**Name (NI) 6433**] office at [**Telephone/Fax (1) 6439**] to arrange a follow
up appointment in about 2 weeks.
Contact the interventional radiology department ([**Telephone/Fax (1) 327**])
to confirm your appointment for a follow up cholangiogram on the
morning of [**2130-8-30**].
Completed by:[**2130-8-18**]
|
[
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"785.52",
"995.92",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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6491, 6549
|
4333, 4936
|
291, 357
|
6767, 6778
|
1153, 4310
|
7060, 7387
|
862, 879
|
5037, 6468
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6570, 6746
|
4962, 5014
|
6802, 7037
|
894, 894
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908, 1134
|
246, 253
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385, 655
|
677, 780
|
796, 846
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,024
| 152,730
|
6019
|
Discharge summary
|
report
|
Admission Date: [**2125-2-9**] Discharge Date: [**2125-2-16**]
Date of Birth: [**2057-7-6**] Sex: F
Service: NEUROLOGY
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Intubation
Central line placement
Lumbar puncture x 2
History of Present Illness:
THis is a 67 year old with multiple medical problems including
DM, hypothyroidism, HTN, Spinal stenosis (s/P C4-C7
laminectomy), peripheral neuropathy, high cholesterol who
presents to the ED with prolonged seizure. Apparently, her
boyfriend (? husband) found her on the floor on all fours with
generalized shaking. She lost conciousness and had a series of
what sound like
generalized tonic-clonic movements. This went on for about
30minutes before EMS arrival. There was apparently no lucid
interval between events. EMS found her unresponsive. En route
to [**Hospital1 18**], she had another GTC seizure and was given ativan 2mg
x1 IV.
History is extremely limited as her boyfriend did not accompany
her to the [**Name (NI) **] and is not available by telephone. Remainder of
the history is from OMR notes. Her boyfriend told EMS that she
has a known history of seizures, but I cannot find any
documentation of this in OMR nor is she taking an anticonvusant
based on her med list.
In the ED, she had no further seizure activity. She was
intubated with succ and etomidate on presentation. She
subsequent received 2 mg of Versed prior to CT. She was loaded
with Dilantin 1g. Labetalol was administered (10mg) x2 with
modest effect on BP.
Past Medical History:
1. Diabetes
2. Depression.
3. Hypothyroidism -hx of goiter in the past
4. Hypertension
5. Spinal stenosis s/p C4-C7 laminectomy
6. CAD, status post MI in [**2121-7-31**]
7. frequent falls and gait difficulty
8. Hyperlipidemia
9. PVD s/p aortobifemoral bypass '[**09**] on L adn L toe amputations
10. peripheral neuropathy
Social History:
Pt lives with her fiance at home. She smokes [**1-1**] ppd. No
ETOH/drugs.
Family History:
son - seizures
Physical Exam:
On admission:
HR120 BP253/100 RR16 O2 Sat100
Gen: Intubated, eyes closed, opens eyes to noxious stimulation,
otherwise unresponsive, no spontaneous movement.
HEENT: ETT and OGT in place
Neck: in hard collar
CV: RRR, Nl S1 and S2, 2/6 SEM
Lung: Clear to auscultation anteriorly
Abd: +BS soft, non-distended
Ext: left leg more edematous than right, multiple toe
amputations
on left.
Neurologic examination:
Mental status: Unresponsive, does not open eyes to verbal
stimulation, though opens them briefly to noxious stim. Grimaces
to noxious stim and moves her arms. Doesn't follow commands.
Cranial Nerves:
No blink to threat bilaterally. Pupils: 3mm briskly reactive
bilaterally. Unable to visualize discs due to miosis. +corneal
bilaterally, VOR intact, Grimaces to nasal tickle: face appears
symmetric (limited by ETT tape), decreased gag.
Motor:
Normal bulk bilaterally. Tone increased throughout (L>>R).
Withdraws in all 4 extremities, briskly to noxious stimulation.
Sensation: Grimaces in all 4 extremities, localizes pain.
Reflexes:
B T Br Pa Ach
Right 3 3 3 3 2
Left 3 3 3 3 2
Toes upgoing bilaterally (stub on left is upgoing)
Coordination: unable to assess
Upon discharge:
MS - A&O x 3
CN - PERRL, EOMI, Face symmetric
Motor - limited by pain, moves all four extremitis. R > L
strength. [**2-4**] IP weakness - + [**Doctor Last Name 23676**] sign. Exam partly
functional.
Pertinent Results:
[**2125-2-9**] 06:38PM PLT COUNT-339
[**2125-2-9**] 06:38PM PT-13.4* PTT-22.3 INR(PT)-1.2*
[**2125-2-9**] 06:38PM CK-MB-5 cTropnT-0.01
[**2125-2-9**] 06:38PM CK(CPK)-111 AMYLASE-47
[**2125-2-9**] 06:41PM freeCa-1.07*
[**2125-2-9**] 06:41PM HGB-13.2 calcHCT-40 O2 SAT-83 CARBOXYHB-1.3
MET HGB-1
[**2125-2-9**] 06:41PM GLUCOSE-166* LACTATE-8.1* NA+-144 K+-4.4
CL--104 TCO2-24
[**2125-2-9**] 07:07PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
[**2125-2-9**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-20 RBC-3705*
POLYS-71 LYMPHS-21 MONOS-4 MACROPHAG-4
[**2125-2-9**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-2135*
POLYS-66 LYMPHS-22 MONOS-7 MACROPHAG-5
[**2125-2-9**] 10:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-80*
GLUCOSE-126
.
CT C spine: IMPRESSION: No evidence of cervical spine fracture.
Intact posterior fusion hardware.
.
CT head: IMPRESSION: No acute intracranial pathology including
no sign of intracranial hemorrhage.
.
CT ABDOMEN: The lung bases are clear. The liver is unremarkable.
The patient is status post cholecystectomy. The pancreas is
within normal limits. The spleen is diminutive in size. The
adrenal glands are within normal limits. Irregularities in the
cortex of both kidneys are noted. In addition there is a wedge
perfusion defect in the right kidney which was not present on
prior exam. There are small low attenuation bilateral renal
foci, which are too small to be fully characterized. NG tube is
noted in the stomach. Small bowel loops are unremarkable. Again
seen is a bowel containing umbilical hernia, which is
nonobstructing. There is no free air or free fluid. No
mesenteric or retroperitoneal lymphadenopathy is identified.
There are extensive aortic calcifications and the patient is
status post aortobifemoral grafts. There is prominent soft
tissue stranding along the anterior abdominal soft tissues
consistent trauma.
CT PELVIS: Foley catheter and air are observed in the bladder.
There are multiple calcified uterine fibroids. The adnexa are
unremarkable. The sigmoid colon and rectum are within normal
limits. There is no free fluid and no pelvic or inguinal
lymphadenopathy.
At the inferior limits of the images, there is a right groin
hematoma with evidence of active contrast extravasation.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions. Degenerative changes of the lumbar spine are observed,
most prominent at L2-3 with disc space narrowing, endplate
sclerosis and osteophyte formation.
IMPRESSION:
1. Right groin hematoma with active contrast extravasation.
2. Redemonstration of bowel containing umbilical hernia without
evidence of obstruction.
3. Cortical irregularities of both kidneys and interval
development of wedge shaped perfusion defect of right kidney.
This appearance could be seondary to infection, ischemia, or the
phase of contrast.
.
MRI head: FINDINGS: The FLAIR images are limited by motion.
There are periventricular hyperintensities seen as on the
previous study indicating small vessel disease. However, new
since the previous study are subtle T2 hyperintensities in both
occipital lobes. There is also evidence of hyperintensity in the
right hippocampal region. This area also demonstrates
hyperintensity on diffusion images. In absence of the ADC map,
it is unclear whether the hyperintensity involving the
hippocampal region is due to an infarct or due to T2
shine-through. The occipital changes could be due to posterior
reversible encephalopathy. There is no hydrocephalus or midline
shift seen.
IMPRESSION: Signal changes in both occipital lobes which are new
since the previous study, could be suggestive of posterior
reversible encephalopathy. Increased signal in the right
hippocampus could be due to infarct, or reversible
encephalopathy, a followup MRI is recommended.
.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. An incidental
fenestration of the proximal basilar artery is noted.
IMPRESSION: Normal MRA of the head.
.
EEG: This is an abnormal EEG due to the presence of low and
slowed background rhythms in the mixed theta frequency range
primarily. No sharp or epileptiform features were seen. This
finding is most consistent with an encephalopathy. Common causes
of encephalopathy include medications, metabolic causes, and
infectious processes. Note is made of a sinus tachycardia.
Brief Hospital Course:
The patient is a 67 year old woman with multiple medical
problems including frequent falls and shaking events (no
documented seizures), myelopathy (s/p C-spine lami and fusion),
HTN, diabetes, and PVD who presented with status epilepticus.
The initial exam showed multiple bruises of various ages,
increased tone throughout (L>>R), brisk reflexes and upgoing
toes. This seemed consistent with previously documented exams in
terms of the increased tone on the left side.
The etiology of her seizure was most likely due to hypertensive
encephalopathy. Stroke (R-hippocampus) or encephalitis (abnormal
signal R-hippocampus) were considered possibilities. The patient
was initially intubated and admitted to the Neuro ICU. She was
extubated and transferred to the floor after two days. Her
hospital course and treatments by systems are as follows:
.
1. NEURO
A head CT was negative for a bleed. MRI showed signs of
posterior reversible encephalopathy (bilateral occipital lobes;
and possibly R-hippocampus). An MRA was within normal limits. An
LP was traumatic and showed slightly increased protein (WBC 5,
RBC 2135, prot 80, glc 126). She was initially started on CTX,
Vanco, Ampicillin, and Acyclovir. HSV-PCR was sent to an oustide
laboratory. After cultures continued to remain negative,
antibiotics were d/c'd and only acyclovir was kept on. The
patient was initially loaded on dilantin (goal: 15-20) and was
then continued on 100mg PO tid. She was transitioned to keppra
500 mg [**Hospital1 **] x 5 days with a taper to 1000 mg [**Hospital1 **] starting on
[**2-23**]. At that point dilantin should be stopped. An EEG showed
changes c/w encephalopathy but no epileptiform discharges. For
secondary stroke prophylaxis she was continued on ASA 81mg,
Plavix 75mg, Lipitor 80mg.
.
2. PULM
She was intubated [**2-9**] for airway protection and extubated [**2-11**].
A CXR on admission did not show signs of PNA. CXR [**2-12**] with
mild pulmonary edema. She was diuresed appropriately and
pulmonary status remained stable for the rest of the
hospitalization.
.
3. CV
She ruled out for MI with three negative sets of cardiac
enzymes. Lisinopril 20mg was continued. The patient was also
maintained on Labetolol 200 mg po tid for BP control. Telemetry
did not capture major events.
.
4. GI
-GI: protonix
.
5. ENDO
She was started on a RISS; metformin was held. This can be
restarted upon her discharge to home. Levothyroxine was
continued for hypothyroidism. The patient had a TSH elevated to
10 on [**2-14**]. A free T4 was sent and pending at the time of
discharge.
.
6. ID
Urine culture was negative, and blood cultures were negative.
The initial LP in the ED showed 20 WBC with 3705 RBC but
negative gram stain. The patient was initially started on
acyclovir, ceftriaxone, ampicillin, and vancomycin to cover for
bacterial and viral meningitis. The antibiotics were stopped
due to the negative gram stain and culture. Acyclovir was
continued. The HSV PCR was pending at the time of discharge. A
repeat lumbar puncture was performed on the day of discharge and
showed 1 WBC with 10 RBCs. The suspicion for HSV encephalitis
and this point was felt to be low because one would expect a
continued elevation of WBCs in the CSF. The patient will be
treated with Acyclovir for a total of two weeks unless the HSV
PCR is found to be negative. If the HSV PCR is found to be
negative then acyclovir can be stopped immediately.
.
7. HEME
The patient developed a groin hematoma. Her hematocrit dropped
to 22 (partly dilutional as she was 5l positive in the ICU). Her
anemia was macrocytic. VitB12 was normal. Folate was repleted.
The patient received two units of PRBCs on the floor and her HCT
remained stable.
.
8. Proph:
-heparin SC for DVT ppx
-protonix
-thiamine and folate
-bowel regimen
.
9. FEN:
-cardiac diet as tolerated
.
10. Pain:
-gabapentin 300 q HS
-duloxetine 20
-nortrypt. 50
-morphine sulphate PRN
.
11. Code Status: DNR/DNI
Medications on Admission:
multivitamin
Cymbalta
aspirin
Levothyroxine
Neurontin,
Lisinopril
Morphine
Labetolol
Plavix
Lipitor
Protonix
Metformin
Trazodone
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Insulin
Per attached sliding scale
10. Trazodone 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection three times a day.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 days.
20. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Start on [**2-19**].
21. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO HS (at bedtime) for 6 days: Please stop on [**2-22**].
22. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-5**]
hours as needed for pain.
23. Labetalol 200 mg Tablet Sig: One (1) Tablet PO three times a
day: Hold for SBP < 100 or HR < 55.
24. Acyclovir Sodium 500 mg Recon Soln Sig: Seven Hundred (700)
mg Intravenous Q8H (every 8 hours) for 6 days: Please give 250
cc NS bolus prior to each dose
This can be stopped earlier if her HSV PCR is found to be
negative.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Status Epilepticus
Possible right mesial temporal lobe stroke
Hypertension
Hypertensive encephalopathy
Diabetes
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care physician or return to the
emergency room if you experience worsened weakness, numbness,
headache unrelived by medications, neck stiffness, fever,
chills, nausea, vomiting, seizure, chest pain, shortness of
breath.
The patient is receiving empiric treatment for HSV encephalitis.
Her HSV PCR was pending at the time of discharge. This
laboratory value needs to be followed. If it is found to be
negative then acyclovir can be stopped immediately. If it is
found to be positive then the patient should receive acyclovir
for a full two week course.
The patient has been started on keppra. The patient's dose of
keppra will be increased to 1000 mg [**Hospital1 **] on [**2-19**]. Her dilantin
should be continued concurrently for three days and then stopped
on [**2-22**].
Patient has a free T4 pending at the time of discharge that will
be followed up by the neurology team and communicated to rehab
if it is found to be abnormal.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2125-3-28**] 2:00
Provider: [**Name10 (NameIs) 23675**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2125-3-14**] 2:00
|
[
"244.9",
"345.3",
"250.00",
"437.2",
"272.0",
"054.3",
"281.9",
"401.9",
"434.91",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14327, 14397
|
8016, 11970
|
286, 342
|
14553, 14562
|
3541, 4447
|
15578, 15875
|
2081, 2097
|
12150, 14304
|
14418, 14532
|
11996, 12127
|
14586, 15555
|
2112, 2112
|
239, 248
|
3319, 3522
|
370, 1623
|
2723, 3302
|
4456, 7397
|
7414, 7993
|
2127, 2498
|
2537, 2707
|
2522, 2522
|
1645, 1970
|
1986, 2065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,647
| 109,226
|
27997
|
Discharge summary
|
report
|
Admission Date: [**2151-5-6**] Discharge Date: [**2151-5-14**]
Date of Birth: [**2097-10-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Bee Pollens
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization x2
PCI to LAD and L-Cx
History of Present Illness:
53 year old male with hypertension p/w anterior STEMI and new
RBBB now s/p proximal LAD stent. Pt was in his USOH, working at
home in the morning. He was sitting at his desk when he started
to feel "uncomfortable" without specific complaints. Pt lied on
the sofa for about 15minutes without relief. He went upstairs
from his basement where he was working and started to c/o severe
Chest pain and significant SOB. Per pt's mother, pt lied on the
couch then lied on the floor as he could not get comfortable.
[**Name (NI) 1094**] mother called 911 and EMS arrived within 30minutes of onset
of severe CP. Pt did not take any medications for his pain. Per
EMS EKG strip noted ST elevations and brought to [**Hospital1 18**] ED. In ED
found to have new RBBB, ST elevations in V1-V6, ST depressions
in II, III, aVF. Pt c/o [**9-28**] CP in ED, received ASA, NTG x2 and
dropped his BP to 90/P, received 500cc IVF bolus with
improvement in BP to 138/102. He was started on Hep gtt, loaded
with Plavix 600mg and 4mg Morphine IV with symptomatic relief.
Pt was taken to the cath lab for immediate intervention.
In cath lab, pt found to have 90% thrombotic LAD lesion, had
3.0x18 cypher stent. Also with 80% mid-circumflex lesion which
was not stented. CO 3.23, CI 1.92. Wedge of 31, RA 11, PA 51/30
mean 39. O2 sats dropped to 76% on 6 liters, got lasix 20mg IV.
Sats improved, but htn, started on ntg gttp. No uop, foley
placed. Vagaled with foley placement, became hypotensive, ntg
d/c'd and given atropine. He responded, and then became htn
again, started back on low-dose ntg.
.
Pt with one prior h/o CP about 2.5 years ago while visiting
[**Country 11150**]. CP at that time was very minimal compared to current
presentation. Per physicians in [**Country 11150**] work up no CAD, negative
EKG. Pt has not had CP since then until current presentation. Pt
has a very sedentary lifestyle with minimal ambulation/activity.
He denies any DOE/SOB at rest, no orthopnea, no PND.
Past Medical History:
- borderline hypercholesterolemia
- hypothyroidism
- hypertension
Social History:
Social History: Married, lives at home with wife and [**Name2 (NI) **].
Works at home as financial analyst. No tobacco, occasional
EtOH 1-2 drinks per week. Denies any other drug use.
Family History:
Family History: uncles with CAD -MIs at age 50 & age 75 with
CABG; [**Name2 (NI) **] with DM, HTN; aunt- breast ca
Physical Exam:
Physical Exam:
VS- P=93 BP= 103/70 R= 19 97% on 2l
Gen- in NAD
HEENT- EOMI, o/p clear
CV- RR, no m/r/g
Pulm- CTA=bil
Abd- S/NT/ND
Ext- W&D, 2+ radial/DP pulses
Neuro- non-focal
Pertinent Results:
[**2151-5-6**] ECG:
Sinus rhythm with ventricular premature depolarizations. Right
bundle-branch block. Left axis deviation. Left anterior
fascicular block. Anterior wall myocardial infarction.
.
[**2151-5-6**] Cath:
COMMENTS:
1. Selective coronary angiography revealed a codominant system.
The LMCA
was angiographically normal. The LAD had a proximal 95%
thrombotic
lesion with slow flow. The LCX had a 80% lesion at the takeoff
of a
large OM1. The small nondominant RCA was angiographically
normal.
2. Hemodynamics post intervention showed elevated left sided
filling
pressure (PCWP mean 35 mm Hg with V waves to 46 mm Hg). There
was
moderate pulmonary arteriolar hypertension (PASP 55 mm Hg) in
the
setting of an elevated PCWP. The cardiac index was depressed at
1.9.
3. Patient was hemodynamically stable throughout the procedure,
but was
hypoxic to an O2 sat of 84% on a nonrebreather. He was given 40
mg IV
lasix and started on IV nitroglycerine and his sat improved to
100% with
a couple of deep breaths.
4. Successful placement of 3.0 x 18 mm Cypher drug-eluting stent
postdilated with a 3.5 mm balloon in the proximal LAD for this
acute ST
elevation myocardial infarction. Final angiography demonstrated
no
residual stenosis, no angiographically apparent dissection, and
normal
flow
.
[**2151-5-7**] Abd/Pelvis CT:
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage.
2. Patchy bilateral lower lobe opacities, worrisome for
aspiration. Atelectasis is a less likely possibility.
.
[**2151-5-7**] ECHO:
EF 40%
Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Anterior, distal
septal and apical hypokinesis to akinesis is present.
2. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
3. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
.
[**2151-5-10**] CXR PA&L:
The heart is upper limits of normal in size. There is upper zone
vascular redistribution and worsening perihilar haziness.
Additionally, there is an asymmetrical opacity at the right apex
at the level of the first anterior right rib and right clavicle.
On the lateral view, there is increased opacity overlying the
lower thoracic spine, corresponding to the posterior basilar
segments of the lower lobes. Additionally, the lungs appear
overinflated with flattening of the hemidiaphragms.
.
[**2151-5-10**] Chest CT:
IMPRESSION:
1. Widespread pulmonary ground glass opacities, scattered foci
of consolidation and diffuse septal thickening. These findings
may represent pulmonary hemorrhage and/or pulmonary edema.
Infection is less likely.
2. Small pericardial effusion, slightly enlarged in comparison
to the previous film.
3. Bilateral small nonobstructing renal stones
.
[**2151-5-13**] C. Cath:
COMMENTS:
1.The lesion was predilated with a 2.5 X 12mm Voyager balloon,
stented
with a 3.5 X 18mm Cypher stent and post dilated with a 3.5 X
13mm High
sail balloon with lesion reduction from 80% to 0%. The final
angiogram
showed TIMI III flow with no residual stenosis, no dissection
and no
embolisation. The patient left the lab in a stable condition.
2. left ventriculogram was performed in [**Doctor Last Name **] projection with 36
ml of
contrast at 12ml/sec. The entire anterior wall and the apex,
except for
a small area in the anterior basal segment was akinetic. the EF
was
30-35%.
.
Bivalirudin 45 mg bolus, 110 mg hr drip post cath
.
[**2151-5-13**] ECG:
Sinus rhythm. Left atrial abnormality. Right bundle-branch block
with left
anterior fascicular block. Q waves in the inferior leads with
minimal
ST segment elevation and terminal T wave inversion consistent
with acute
evolving myocardial infarction. Diffuse non-specific ST-T wave
changes.
Compared to the previous tracing of [**2151-5-13**] there is probably no
significant change.
.
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-5-14**] 04:45AM 36.7* 361
[**2151-5-13**] 04:55AM 10.2 3.67* 11.9* 34.3* 93 32.4* 34.7 14.4
287
[**2151-5-6**] 08:08PM 13.2* 36.7* 207
[**2151-5-6**] 12:20PM 9.4 5.04 16.5 45.6 91 32.7* 36.1* 13.9
300
.
UreaN Creat Na K Cl HCO3 AnGap
[**2151-5-14**] 04:45AM 21* 1.2 4.3
[**2151-5-13**] 09:21PM 4.2
[**2151-5-13**] 04:55AM 121* 25* 1.2 141 4.2 104 27 14
.
CE:
CK(CPK)
[**2151-5-14**] 12:45PM 362
[**2151-5-14**] 04:45AM 348
[**2151-5-13**] 09:21PM 189
[**2151-5-11**] 08:50AM 355
[**2151-5-10**] 06:40AM 507
[**2151-5-8**] 04:58AM 1849
[**2151-5-7**] 07:24PM 2437
[**2151-5-7**] 04:00AM 4580
[**2151-5-6**] 08:08PM 6445
[**2151-5-6**] 12:20PM 135
.
CK-MB MB Indx cTropnT
[**2151-5-14**] 12:45PM 21* 5.8 2.85*
[**2151-5-14**] 04:45AM 24* 6.9*
[**2151-5-13**] 09:21PM 7
[**2151-5-11**] 08:50AM 4 5.59*
[**2151-5-10**] 06:40AM 5 5.94*
[**2151-5-8**] 04:58AM 21* 1.1 5.49*
[**2151-5-7**] 07:24PM 57* 2.3
[**2151-5-7**] 04:00AM 259* 5.7 14.32*
[**2151-5-6**] 08:08PM 496* 7.7* 23.07*
[**2151-5-6**] 12:20PM <0.01
.
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2151-5-7**] 04:00AM 121 901 40 3.0 63
.
HbA1c
[**2151-5-6**] 10:54PM 5.9
.
Brief Hospital Course:
Assessment/Plan:
53 year old male with p/w anterior wall STEMI s/p proximal LAD
stent and L-Cx stent.
.
#. CV - Ischemia - Pt p/w STEMI, found to have 90% LAD lesion
and 80% occlusion of circumflex. CE were cycled and peaked on
day of admission with peak CK 6445 and Tn-T 23.07. On day of
admission underwent stenting of proximal LAD. Pt was hypotensive
post cath and required IABP for 24hrs. IABP weaned off,
maintained own BP will low range 80s-90s SBP. He was not started
on pressors, his SBP responded to IVF. He was started on ASA,
Plavix, high dose statin immediately post cath. He also
underwent an Abdomen/Pelvic CT which ruled out an RP bleed. His
HCT had a small drop but did not require blood transfusions
throughout his hospitalization. In setting of hypotension
immediately following C. Cath, pt was not started on BB until
[**5-7**]. He was started on a low dose 12.5mg [**Hospital1 **] and tolerated well
with persistent SPB in 90s-low 100s. Pt underwent 2nd C. Cath on
[**5-13**] to revascularize Cx lesion without complications, he
recieved Bivalirudin 45 mg bolus, 110 mg hr drip. He did have
elevated MBI post 2nd cath-periprocedure NSTEMI. He was symptom
free. He remained CP free since his first cath, his CE trended
down and was discharge on ASA, Plavix, Statin, BB.
.
#. CV - Pump - Wedge of 30 in cath lab. Got lasix, and also ntg
gttp, weaned off when arrived to CCU. Low cardiac index of 1.9.
He had no evidence of cardiogenic shock, perfusing well with
good urine output. Hypotension most likely [**1-21**] hypovolemia, no
evidence of bleed. Pt had Abdominal/Pelvic CT which ruled out an
RP bleed. IVF given with good response in BP. ECHO with
moderately depressed LVsys function. EF of 40% with overall left
ventricular systolic function is moderately depressed. Anterior,
distal septal and apical hypokinesis to akinesis is present. He
was started on Hep gtt for anticoagulation while awaiting 2nd
cath, however [**1-21**] hemoptysis hep gtt was turned off. He was
subsequently diuresed with low dose of lasix 10mg daily for pulm
edema. He was maintained on 10mg lasix daily, however he was
autodiuresing making ~1L UOP daily. His lasix was d/c'd as BP
was somewhat tenuous while optimizing cardiac meds. On 2nd cath
ventriculography notable for entire anterior wall and the apex,
except for a small area in the anterior basal segment was
akinetic, with an EF of 30-35%. He was started on Lovenox and
transitioned to Coumadin. He was not started on an ACE-I since
his BP remained in the low 100s. He was scheduled to f/u with
Dr. [**Last Name (STitle) **] on Tuesday, [**5-18**] to have INR drawn. Will need to
start ACE-I as outpatient.
.
#. CV - Rhythm - Pt remained in NSR throughout his hospital
course.
.
#. Hemoptysis: Pt started to have hemoptysis on [**5-8**] after
having started hep gtt. Hep gtt was turned off for hemoptysis.
His Hct remained stable. High resolution Chest CT c/w dependent
ground glass opacities most likely pulmonary edema vs. pulm
hemorrhage. He was diuresed w/low dose of lasix daily with
improvement in O2 sats. He was r/o'd for TB with a negative PPD
formally read on [**5-12**] after 48hours, no sign of induration.
Induced sputum x3 was sent for AFB which were all negative. His
hemoptysis resolved. Will need f/u Chest CT as outpatient.
.
#. Hyperglycemia: Pt had persistent hyperglycemia requiring
Insulin. He had no known dx of DM, however, both [**Month/Year (2) **] are
diabetics. Formal [**Last Name (un) **] consult was obtained for new diagnosis
of DM and further management. His Hgb AIC was 5.9%. He was sent
home with a glucometer, started on glipizide [**Hospital1 **] and was set up
with [**Last Name (un) **] follow up with a Nurse educator as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
physician.
#. Hypothyroidism - continued on home dose of levoxyl.
.
#. Htn - on hyzaar as outpt. Had transient episode of
hypotension following C. Cath, without evidence of cardiogenic
shock or bleed. Abd/Pelvic CT r/o'd RP bleed. He remained
normotensive following STEMI. Started low dose BB for
cardioprotective effect, tolerated well, did not start ACE-I
during hospitalization as BP remained low 100s.
.
#. CODE: FULL
Medications on Admission:
Medications (home):
- lipitor 5 mg QD
- levoxyl 100 mcg QD
- hyzaar QD
.
Allergies:
- sulfa (rash as a child)
- bee stings-->anaphylaxis
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Glucometer Elite Classic Kit Sig: One (1) Miscell.
twice a day.
Disp:*1 kit* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 10 days.
Disp:*20 syringe* Refills:*0*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI
CAD
HTN
DM-diagnosed during this admission
Hypercholesterolemia
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed and keep all your
follow up appointments.
.
If you have chest pain, shortness of breath, palpitations, are
lighthead or have other worisome symptoms please call your
physician and go to the emergency room.
.
Please note you were started on the following medications:
-Toprol XL 50mg daily, Aspirin 325mg daily, Plavix 75mg daily,
Atorvastatin 80mg daily, Lovenox and Coumadin for your heart
-Your were started on glipizide for your diabetes
Followup Instructions:
You have an appointment with Cardiologist, Dr. [**Last Name (STitle) **], next
week:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2151-5-18**] 1:00
.
You have an appointment at [**Last Name (un) **] on [**5-25**] with a Nurse
Educator [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2pm and with Dr. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 19862**]
at 10am on the same day at [**Last Name (un) **]. Please call [**Telephone/Fax (1) 2384**] if
you have any questions prior to your appointment.
.
You have a new PCP [**Name Initial (PRE) 648**]:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2151-5-31**]
2:00, you must call [**Telephone/Fax (1) 250**] to register prior to your
appointment to update your insurance information.
.
Please have your blood drawn in the [**Hospital Ward Name 23**] Center on the [**Location (un) **] on Wednesday, [**5-26**]. The lab is open from 7:30am-4pm,
if you have questions you may call [**Telephone/Fax (1) 250**].
Completed by:[**2151-5-15**]
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30,601
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8310
|
Discharge summary
|
report
|
Admission Date: [**2143-12-2**] Discharge Date: [**2143-12-6**]
Date of Birth: [**2088-2-4**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Anaemia
Major Surgical or Invasive Procedure:
Blood transfusion
History of Present Illness:
Mr. [**Known lastname 29436**] is a 55 y.o. Male with a h.o. EtoH cirrhosis (MELD
18) c/b portal HTN, hyerptensive gastropathy, esophageal
varicies (grade I), SBP, low grade chronic GI bleed [**2-12**]
angiodysplasias requiring transfusions who presents with
anaemia, ascites.
Pt resides at [**Hospital **] Healthcare [**Hospital **] rehab after fracture
his left leg. He has been transfusion dependent for his
angiodysplasia, his last transfusion occured [**2143-11-27**]. During
routine labs he was anaemic, per outside records his Hct was 18.
He had recurrent anemia from GI bleed ongoing for months. He
does endorse melenotic stools however these have been present
since [**2142-12-11**] and have not changed in frequency,
consistency. He states he has 2BMs a day, formed. He denies any
hematochezia, hematemesis, nausea, vomiting, fevers, chills,
shortness of breath, chest pain, episodes of confusion. In
regard to his ascites, he reports the rehab have not been giving
him furosemide and that he usually only receives it now when he
gets his transfusions. He does also endorse LLE swelling which
has occured over the past month, which he attribute to renal
dysfunction.
Of note, He has had 8 prior admissions in the past 14 weeks for
anemia and many times prior to this, treated with blood
transfusions and sent home the following day. During his most
recent admission, colonoscopy was discussed at length with him
and he did not wish to have one due to recent hip fracture.
In ED, his vs were: 99.1 77 95/53 14 100%. Self reported dark
stool but on Fe. Guaiac positive. He refused diagnostic NG
lavage or colonoscopy. Discussed with hepatorenal fellow and the
plan is to transfuse and back to rehab. He was started on PPI
gtt, not transfused yet by the time he transferred from ED to
the floor.
Past Medical History:
# HTN
# DJD of R hip
# Gout
# ETOH Cirrhosis, c/b portal hypertension, jaundice,
hypertensive gastropathy, grade 1 esophageal varices, ascites,
SBP
# Bowel perforation: lap-assisted R colectomy [**5-18**] by Dr. [**Last Name (STitle) 1120**]
for cecal perforation while on steroids for gout flare
# LGIB- [**Last Name (un) **] [**4-9**] showed angioectasias in term ileum/rectum, bx
neg
# Legally blind
Social History:
He is divorced in [**2122**] and has lived alone since. He notes that
he was drinking [**6-17**] rum and cokes daily until [**10-19**]. He says
that he has remained sober since [**2142-11-11**]. He has remote
tobacco use (8 pack years, quit 25 years ago), remote cocaine,
marijuana, and methamphetamines. He used to work as a taxi
driver until he was forced to retire [**2-20**] because he was
declared legally blind.
Family History:
Grandmother with DM.
Physical Exam:
Vitals: T:97.3 BP: 82/54 P:76 R: 16 O2: 100% on RA
General: Caucasian Male laying down in bed in NAD
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: S1, S2, systolic ejection II/VI murmur noted left sternal
border, otherwise RRR.
Abdomen: Soft, non-tender, distended with positive fluid wave,
abdominal hernia noted easily reducible, +BS x 4
Ext: [**2-13**]+ edema noted b/l to hip, with scrotal edema. No
asterixis noted
Neuro: CN II-XII intact on examination, AAO x3
Rectal: No hemorrhoids noted, stool in vault, brown but guaiac
positive
Discharge Physical exam:
GEN: NAD, cachectic
HEENT: EOMI, PERRL, sclera anicteric, poor dentition, MM dry,
OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, II/VI SEM at the LSB no otherM/G/R, normal S1 S2,
radial pulses +2
PULM: Lungs CTAB
ABD: Soft, NT, distended, +fluid wave and dullness to
percussion,
EXT: No C/C/ +2 edema, No asterixis
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
Pertinent Results:
[**2143-12-2**] 09:05PM PLT COUNT-109*
[**2143-12-2**] 09:05PM NEUTS-67.7 LYMPHS-20.3 MONOS-6.6 EOS-5.1*
BASOS-0.2
[**2143-12-2**] 09:05PM WBC-4.2 RBC-1.93* HGB-6.4* HCT-18.6*# MCV-97
MCH-33.4* MCHC-34.5 RDW-19.8*
[**2143-12-2**] 09:05PM LIPASE-40
[**2143-12-2**] 09:05PM ALT(SGPT)-18 AST(SGOT)-114* ALK PHOS-132* TOT
BILI-1.8*
[**2143-12-2**] 09:05PM estGFR-Using this
[**2143-12-2**] 09:05PM GLUCOSE-110* UREA N-45* CREAT-1.3* SODIUM-135
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-21* ANION GAP-11
[**2143-12-2**] 09:47PM PT-16.6* PTT-34.5 INR(PT)-1.5*
[**2143-12-6**] 05:20AM BLOOD Hct-28.1*
[**2143-12-5**] 06:45AM BLOOD WBC-2.8* RBC-2.48* Hgb-8.3* Hct-22.6*
MCV-91 MCH-33.3* MCHC-36.5* RDW-18.6* Plt Ct-71*
[**2143-12-5**] 06:45AM BLOOD Plt Ct-71*
[**2143-12-5**] 06:45AM BLOOD PT-20.1* PTT-44.7* INR(PT)-1.9*
[**2143-12-4**] 10:16AM BLOOD Plt Ct-88*
[**2143-12-5**] 06:45AM BLOOD Glucose-133* UreaN-42* Creat-1.4* Na-139
K-3.2* Cl-107 HCO3-21* AnGap-14
[**2143-12-4**] 10:16AM BLOOD Glucose-79 UreaN-45* Creat-1.5* Na-135
K-3.5 Cl-105 HCO3-22 AnGap-12
[**2143-12-4**] 02:43AM BLOOD Glucose-82 UreaN-46* Creat-1.5* Na-137
K-3.7 Cl-108 HCO3-21* AnGap-12
[**2143-12-5**] 06:45AM BLOOD ALT-10 AST-56* LD(LDH)-166 AlkPhos-63
TotBili-4.4*
[**2143-12-4**] 10:16AM BLOOD ALT-16 AST-102* LD(LDH)-244 AlkPhos-86
TotBili-4.1*
[**2143-12-4**] 02:43AM BLOOD ALT-18 AST-111* LD(LDH)-215 AlkPhos-106
TotBili-4.2*
[**2143-12-5**] 06:45AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.4 Mg-1.5*
[**2143-12-4**] 10:16AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6
Brief Hospital Course:
55 y.o. Male with h.o. EtoH cirrhosis c/b varicies, portal HTN,
SBP now on ppx, chronic GI bld [**2-12**] angiodysplasia requiring
frequent transfusion transferred from rehab with asymptomatic
anemia.
# Hematemesis - Developed hematemesis of 150 cc after
transfusion of 3 units PRBCs. He had been placed on a
pantoprazole ppi on admission, octreotide gtt was started.
Given history of grade 1 varices (no history of bleed) and
hypertensive gastropathy, patient was started on ceftriaxone,
and transferred to ICU for closer monitoring and EGD. While in
the ICU he declined an EGD. He did not have any further episodes
of bleeding. He was transferred back to the floor in stable
condition.
On the floor he received 1 unit of blood overnight and 1 unit of
blood in the morning of the following day. He reported no
episodes of hematemesis or change in bowel habits.
He was discharged with explicit instructions to have his
hematocrit followed up in rehab and have the results faxed to
the liver center.
.
# Anemia: Chronic, transfusion dependent. Recieved 3 units
PRBCs with appropriate increase in hematocrit. Colonoscopy
recommended as outpatient when hip fracture healed. We managed
his low hematocrit with transfusions as above.
.
# Ascites: Diuretics had been held at rebab and on admission in
setting of GI bleed. On transfer to the ICU he was noted to have
tense ascites and his urine output was declining. A therapeutic
thoracentesis was performed and 4.5L of fluid was removed. He
was given 37.5g of albumin after this procedure and another 50g
of albumin the morning after. His urine output significantly
improved after this procedure.
.
# ARF - his creatinine increased to 1.5 while inpatient, his
baseline is likely 1.2-1.3. This was felt due to hypoperfusion
of the kidneys due to low hematocrit. His creatinine responded
to transfusions and trended down.
.
# EtoH Cirrhosis: Initially continued cipro on admission for
continued SBP prophylaxis. Lactulose continued, MELD labs
trended. No paracentesis was performed on admission as patient
had no leukocytosis, fever or abdominal pain. diuretics
initially held pending evaluation of GI bleed and subsequently
hematemesis. While inpatient he was started on Ceftriaxone for
presumed SBP. He is to go home and resume his home dose of
Ciprofloxacin 250 mg Tab 1 Tablet(s) by mouth for prophylaxis.
.
# DJD of hip: He was continued pt on home regimen of Oxycodone
PRN.
.
Medications on Admission:
- Lactulose 10 gram/15 mL Oral Soln 30 mL by mouth twice a day
- Mirtazapine 7.5mg PO QHS
- Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day
- Ferrous Sulfate 325 mg (65 mg Iron) Tab 1 Tablet(s) by mouth
twice a day
- Thiamine 100 mg Tab 1 Tablet(s) by mouth once a day
- Uloric 40 mg Tab One and a half Tablet(s) by mouth daily
- Nadolol 20 mg Tab 1 Tablet(s) by mouth once daily
- Cholecalciferol (Vitamin D3) 1000 unit daily
- Ciprofloxacin 250 mg Tab 1 Tablet(s) by mouth
- Oxycodone 5 mg Tab 1 Tablet(s) by mouth as needed for pain
- Pantoprazole 40 mg Tab, Delayed Release 1 Tablet(s) by mouth
once daily
- Sucralfate 1mg PO QID
- Senna
- Docusate
- Biscolax
- Prednisone 10mg Q dailyprn gout
- Lasix 40mg PO Q Blood transfusion
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
2. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
14. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
15. Uloric 40 mg Tablet Sig: 1-2 Tablets PO once a day: 1.5 tabs
daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Cirrhosis
Chronic GI Bleed
Secondary: Hypertension
Gout
DJD
Legally blind
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 worsened anemia. While
here, you received 6 units of blood products and remained
hemodynamically stable. You are being discharged back to rehab
with plans to closely monitor your blood counts.
Please stop taking your lasix on discharge. Dr. [**Last Name (STitle) 7033**] will
reassess your need for this medication when you follow up with
him.
Please continue to have your hematocrit monitored regularly at
rehab. You should have labs drawn on [**12-9**]- please fax them to
your liver doctor.
Followup Instructions:
Department: Gastroenterology - Liver Clinic
When: Wednesday [**2143-12-11**]: Dr. [**Last Name (STitle) 7033**]. Please have your rehab
center call Dr. [**Last Name (STitle) 7033**] in the Liver Center and confirm the
appointment time with him as he will schedule a pheresis bed at
that time as well.
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/LIVER CENTER
Address: [**Doctor First Name **], STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
Fax: [**Telephone/Fax (1) 29442**]
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2143-12-11**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2143-12-18**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2143-12-25**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2143-12-6**]
|
[
"E879.8",
"584.9",
"729.73",
"572.3",
"578.0",
"578.1",
"274.9",
"789.59",
"571.2",
"998.89",
"369.4",
"585.9",
"715.35",
"280.0",
"456.21",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10216, 10299
|
5716, 8150
|
279, 299
|
10475, 10475
|
4147, 5693
|
11188, 12742
|
3013, 3035
|
8939, 10193
|
10320, 10454
|
8176, 8916
|
10626, 11165
|
3050, 3645
|
232, 241
|
327, 2134
|
10490, 10602
|
2156, 2561
|
2577, 2997
|
3670, 4128
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,416
| 152,358
|
39956
|
Discharge summary
|
report
|
Admission Date: [**2140-10-17**] Discharge Date: [**2140-10-31**]
Date of Birth: [**2086-11-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing dyspnea on exertion with her daily activities
Major Surgical or Invasive Procedure:
[**2140-10-17**] Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] Regent
Mechanical)
History of Present Illness:
53 year old female with known aortic stenosis back in [**2129**]. She
has not had any follow up for her AS since that time. She
presented earlier this fall with complaints of dyspnea on
exertion which has been progressively worse. Underwent
echocardiogram which showed worsening cardiac function and
referred for cardiac cath for evaluation for surgery.
Past Medical History:
Aortic Stenosis
Anemia
Social History:
Lives with husband and her 2 boys (also has 2 girls who live
close by)
-Tobacco history: Quit 10 years ago, smoked for 15years [**7-28**]
cigarettes per day
-ETOH: very occ.
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; father had lung cancer, died at age 45
(was a smoker), mother is in good health currently age 70.
Physical Exam:
Admission Physical Exam
Pulse: 104 Resp:16 O2 sat: 97%
B/P Right:149/102 Left: 149/104
Height:5'3" Weight:207 lbs
General: no acute distress pleasant interactive
Skin: Dry [x] Rash mid back non raised red with scabs from
scratching
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**1-23**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: murmur Left: murmur
Pertinent Results:
[**2140-10-17**] Intraop TEE
PRE-CPB:
1. The left atrium is moderately dilated. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is severely dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 15
%). After an epinephrine infusion was started, the EF increased
to 20 %.
4. The right ventricular cavity is moderately dilated with
moderate global free wall hypokinesis.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the descending thoracic aorta.
6. The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild to moderate ([**12-19**]+) aortic
regurgitation is seen.
7. There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Mild (1+) mitral regurgitation is seen.
8. Moderate [2+] tricuspid regurgitation is seen.
9. There is a small pericardial effusion.
10. There are small bilateral pleural effusions.
POST-CPB:
On infusions of phenylephrine, epi. AV pacing. Well-seated valve
in the aortic position. No AI. Preserved systolic function from
pre cpb on inotropic support. Aortic contour is normal post
decannulation.
[**2140-10-31**] WBC-7.5 RBC-3.55* Hgb-9.9* Hct-30.3* RDW-14.5 Plt
Ct-347
[**2140-10-29**] WBC-7.2 RBC-3.62* Hgb-10.2* Hct-30.9* RDW-14.4 Plt
Ct-235
[**2140-10-31**] PT-26.6* INR(PT)-2.6*
[**2140-10-30**] PT-27.0* INR(PT)-2.6*
[**2140-10-29**] PT-25.2* PTT-33.0 INR(PT)-2.4*
[**2140-10-28**] PT-24.7* INR(PT)-2.4*
[**2140-10-27**] PT-21.0* PTT-71.0* INR(PT)-2.0*
[**2140-10-31**] Glucose-85 UreaN-12 Creat-0.7 Na-134 K-4.3 Cl-96
HCO3-31 AnGap-11
[**2140-10-29**] Glucose-79 UreaN-10 Creat-0.7 Na-133 K-4.6 Cl-97
HCO3-32 AnGap-9
[**2140-10-28**] Glucose-82 UreaN-10 Creat-0.6 Na-131* K-6.4* Cl-94*
HCO3-28
[**2140-10-27**] Glucose-120* UreaN-11 Creat-0.6 Na-134 K-4.3 Cl-95*
HCO3-33
[**2140-10-29**] ALT-112* AST-41* LD(LDH)-372* AlkPhos-87 Amylase-49
TotBili-0.4
[**2140-10-28**] ALT-141* AST-65* LD(LDH)-556* AlkPhos-91 Amylase-50
TotBili-0.4
[**2140-10-28**] ALT-140* AST-67* LD(LDH)-554* AlkPhos-89 Amylase-50
TotBili-0.4
[**2140-10-27**] ALT-176* AST-53* LD(LDH)-434* AlkPhos-88 Amylase-48
TotBili-0.5
Brief Hospital Course:
[**2140-10-17**] Ms.[**Known lastname 87874**] was taken to the operating room and
underwent Aortic Valve Replacement (#[**Street Address(2) 6158**].[**Male First Name (un) 923**] Regent
Mechanical Valve Replacement) with Dr. [**Last Name (STitle) **]. Please refer to
operative report for further details. She tolerated the
procedure well and was transferred to the CVICU intubated and
sedated requiring inotropic and pressor support. She awoke
neurologically intact and was extubated without difficulty. She
transferred to the floor on [**2140-10-19**] in stable condition. On
[**2140-10-21**] she was transferred back to the CVICU for hypotension,
hyperkalemia and Cre 1.5. PA line, foley and low-dose milrinone
started. Echocardiogram revealed EF 20-25%, no tamponade, AVR
well seated, with moderate TR/MR. Over the next few days she
titrated off inotropes, tolerated low-dose ACE and
beta-blockers. She was transferred back to the floor on
[**2140-10-27**].
Respiratory: aggressive pulmonary toilet, nebs, incentive
spirometer and ambulation she titrated off oxygen with
saturations of 97% RA.
Cardiac: beta-blockers were titrated. She remained in sinus
rhythm. ACE was started on [**2140-10-20**], transfer to CVICU on
[**2140-10-21**]. On [**2140-10-23**] episode of Atrial Fibrillation 140's
amiodarone bolus and beta-blockers IV converted to sinus rhythm.
Inotropes was titrated off, carvediolol and ACE were titrated.
GI: H2 blockers and bowel regimen
Nutrition; tolerated a regular diet
Renal: ATN briefly secondary to hypotension and hyperkalemia,
peak Cre 1.8 base 0.9-1.0 resolved once hemodynamics improved.
She was gentley diuresed with good urine output. Electrolytes
were repleted as needed.
Heme: Heparin bridge to coumadin was started [**2140-10-20**] for
mechanical aortic valve replacement with INR Goal 2.5 - 3.0. INR
was followed daily.
IV access: Right Brachial PICC placed [**2140-10-27**].
Pain: IV pain medications converted to PO with good control
Disposition: followed by PT who deemed her safe for home. She
was discharged on [**10-31**] and will follow-up with Dr.
[**Last Name (STitle) **], her cardiologist and PCP for further coumadin
management.
Medications on Admission:
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
(One) Tablet(s) by mouth once a day
MVI
Flaxseed Oil
Garlic Oil
Vitamin E
Calcium
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. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. warfarin 5 mg Tablet Sig: Goal INR 2.5-3.0 Tablets PO once a
day: Dose to be adjusted for goal INR 2.5-3.0 .
Disp:*90 Tablet(s)* Refills:*2*
9. warfarin 2 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a
day: Dose to be adjusted based on INR .
Disp:*90 Tablet(s)* Refills:*2*
10. Coumadin/Warfarin
You have received prescriptions for two doses of coumadin so
that the dose can be adjusted based on your lab results
Please take 7.5 mg - [**11-1**] then INR will be checked [**11-2**] and
coumadin clinic at [**Hospital1 **] will call you with further
instructions on what dose to take
Discharge Disposition:
Home with Service
Facility:
[**Hospital 54752**] Rehab & Skilled Nursing Center - [**Location (un) 6159**]
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
Acute on chronic systolic heart failure
Anemia
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 lower extremity
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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) 170**] Date/Time:[**2140-11-17**] 2:30
Cardiologist: Dr [**First Name (STitle) **] [**2140-11-16**] @ 10:40am
Please call to schedule appointments with your
PCP Dr [**Last Name (STitle) 13275**] [**Telephone/Fax (1) 17794**] in [**3-21**] 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**
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR
Goal INR 2.5-3.0
First draw [**11-2**] wednesday
Results to phone [**Telephone/Fax (1) 87875**] fax [**Telephone/Fax (1) 31021**]
Please check INR monday, wednesday, and friday for 2 weeks then
as directed by Dr [**Last Name (STitle) 13275**]
Completed by:[**2140-10-31**]
|
[
"427.31",
"276.7",
"416.8",
"746.4",
"428.23",
"425.4",
"998.0",
"424.1",
"584.5",
"428.0",
"285.9",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.97",
"39.61",
"89.64",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
8442, 8551
|
4639, 6842
|
382, 486
|
8687, 8878
|
2146, 4616
|
9802, 10655
|
1147, 1332
|
7037, 8419
|
8572, 8666
|
6868, 7014
|
8902, 9779
|
1347, 2127
|
285, 344
|
514, 870
|
892, 916
|
932, 1131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,538
| 196,547
|
21143
|
Discharge summary
|
report
|
Admission Date: [**2122-6-22**] Discharge Date: [**2122-7-20**]
Date of Birth: [**2068-12-15**] Sex: M
Service: PSU
CHIEF COMPLAINT: The patient has a congenital right thumb
abnormality, presenting for toe-to-thumb transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
male who was born with congenital right thumb abnormality,
who presents to the Plastic Surgical Service for a toe-to-
thumb transplant.
PAST MEDICAL HISTORY: Hypertension.
Decreased hearing.
Congenital thumb abnormality.
History of alcohol abuse.
History of psoriasis.
PAST SURGICAL HISTORY: Significant for a right ear
procedure.
MEDICATIONS:
1. Percocet.
2. Atacand.
3. Chlorthalidone.
4. Atenolol.
5. Nortriptyline.
6. Methotrexate.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Noncontributory.
PHYSICAL EXAMINATION: The patient was afebrile. Vital
signs, stable, in no apparent distress. Alert and oriented
times 3. Head was atraumatic, normocephalic, and anicteric.
Neck was soft and supple with no masses. Chest was clear to
auscultation bilaterally. Heart has regular rate and rhythm.
Abdomen was benign. On extremity exam, the patient has a
deformed nonfunctional right thumb with moderate sensation
and moderate movement.
SUMMARY OF HOSPITAL COURSE: The patient is a 53-year-old man
who presents to the plastic surgical hand service for toe-to-
thumb free flap transplant on [**2122-6-22**]. The patient went to
the OR on that date for said procedure. For more detailed
account, please see operative report. Postoperatively, the
patient was transferred to the CSRU for close monitoring of
toe-to-thumb transplants. The patient was taken to the OR on
[**2122-6-22**] for amputation of right thumb with preservation of
ulnar vascular structures resection, neuroma, and soft tissue
contouring of the right index finger, and CMC arthroplasty of
the right thumb with resection of osteophytes and
degenerative joint disease. Postoperatively, the patient did
well following this procedure and was taken back to the OR on
[**2122-6-25**] for right great toe to right thumb microvascular
transfer, in addition flexor tendon transfer of flexor
digitorum superficialis from the right long finger to the
flexor pollicis longus of the right thumb. Completion of CMC
arthroplasty of the right thumb using orthosphere in addition
of local flap closure at the right foot donor site and
intrinsic muscle transfer to the right thumb at the flexor
pollicis brevis and abductor pollicis brevis and resection of
AlloDerm implantation the dorsal and radial aspect of the
right thumb. For more detailed account of this procedure,
please operative reports.
Postoperatively, the patient was transferred to the CSRU for
close monitoring of new thumb. Immediately, afterwards on
postoperative day 1 and 2, the patient noticed significant
bluish discoloration and swelling of the thumb. The patient
was taken back to the OR on [**2122-6-27**] for reexploration of the
right thumb with revisions of the arterial anastomosis and
revision of the venous anastomosis at the wrist. In addition
placement of AlloDerm approximately 10 x 10 cm and catheter
injection of TPA all under the microscope. Postoperatively,
the patient was transferred back to the CSRU for continued
monitoring and the patient's clinical texture did not
improve. The patient was then taken back to the OR again for
reexploration of the right toe-to-thumb graft with the
revision of the arterial anastomosis, exploration of the
vein, evacuation of hematoma, replacement of the AlloDerm 10
x 10 square patch all under the microscope. For more details
account please see operative reports. Postoperatively, the
patient was transferred to the CSRU for close monitoring
where the patient was placed on IV heparin with the
therapeutic range between 60 and 80 and was watched closely
for compromise of the transferred thumb. The patient
remained intubated throughout his course of take backs to the
OR and was extubated on [**2122-6-29**] postoperative day number 4
and 1. On postoperative day 5, 2, 1, respectively from the
initial toe-to-thumb transfer and take backs for revisions
the patient remained on IV heparin and was placed on leech
therapy to the thumb 1 leech q. 4h. for bluish discoloration.
The patient remained on this therapy for the following
several weeks with slowly improving color of the thumb as
well as slowly improving swelling. Eventually, the patient
was taken back to the OR on [**2122-7-9**] for split thickness skin
graft to the right hand and split thickness skin graft to the
right foot. Postoperatively, the patient did very well.
Also, then the patient was eventually transferred out of the
CSRU on to the floor approximately on postoperative day
number 10. Following the split thickness skin graft,
dressing was taken down 5 days postprocedure and the right
foot graft had a 100 percent take while the right hand graft
had 0 percent take. After the dressing was taken down on the
right wrist skin graft and seen that it had 0 percent take,
the graft was debrided with normal saline, wet-to-dry
dressing changes were begun b.i.d. In addition, on [**2122-7-17**]
the patient was discontinued on leech therapy following a
brief wean as well as discontinued on heparin therapy. On
the night following these therapeutic clinic changes, the
patient noticed some increased discoloration and the patient
was placed on q.12 leech therapy p.r.n. for increased bluish
discoloration. The patient was also started on Coumadin 5 mg
p.o. q.h.s. with the therapeutic INR between 1.5 and 2.0 not
to exceed 30 days of treatment. On [**2122-7-20**], the patient was
finally deemed well enough to go home. Bluish discoloration
of the thumb had vastly increased. The patient was receiving
dressing changes to the right wrist with good results. Skin
graft was getting Xeroform dressings q.day also with good
results. The patient was deemed well enough to go home, will
be discharged with supply of emergency leeches for
application to the thumb for dramatic increase in bluish
discoloration per patient. In addition, the patient would be
going with Coumadin q.h.s., to be followed by Dr.[**Name (NI) 23346**]
colleague in [**State 760**].
DISCHARGE DISPOSITION: To home with a VNA.
DISCHARGE DIAGNOSES: Congenital right thumb disease.
Hypertension.
The patient is to follow up with Dr.[**Name (NI) 23346**] colleague in [**State 55122**] in Plastic Surgery for right thumb evaluation, right
wrist wound evaluation, right foot skin graft evaluation, and
INR checks.
DISCHARGE MEDICATIONS: All pervious medications as well as
Coumadin 5 mg p.o. q.h.s. with therapeutic INR between 1.5
and 2.0.
DISCHARGE CONDITION: Stable.
[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**]
Dictated By:[**Location (un) 18193**]
MEDQUIST36
D: [**2122-7-20**] 10:47:49
T: [**2122-7-20**] 18:15:24
Job#: [**Job Number 56074**]
|
[
"755.57",
"726.91",
"998.12",
"253.0",
"401.9",
"715.94",
"355.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"81.75",
"86.69",
"77.64",
"99.10",
"82.69",
"04.07",
"38.03",
"82.56",
"84.02",
"84.11",
"81.74"
] |
icd9pcs
|
[
[
[]
]
] |
6338, 6359
|
6797, 7069
|
826, 844
|
6381, 6646
|
6670, 6775
|
608, 809
|
1349, 6314
|
902, 1320
|
155, 250
|
279, 445
|
468, 584
|
861, 879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,076
| 198,503
|
20420
|
Discharge summary
|
report
|
Admission Date: [**2107-3-21**] Discharge Date: [**2107-3-30**]
Date of Birth: [**2038-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
SOB, fever, hemoptysis
Major Surgical or Invasive Procedure:
Intubation
Central line placment
Swan-ganz cath placement
History of Present Illness:
Pt is a 68 yo M with history of stage 4 NSCLC w/ mets to the
sternum who presents with fever, hemoptysis and SOB. Pt was
recently hospitalized in [**Month (only) **] at which time he had a talc
pleurodesis done on the left side due to malignant pleural
effusion. He was then discharged home on levofloxacin for
possible PNA for 10 days. Pt states he continued to have
persistent fevers despite the anitbiotics. On [**3-16**] he was seen by
Dr. [**Last Name (STitle) **] and at that time his chemo regimen was changed to
Tarceva after having failed both taxol/carboplatin and taxotere.
He said after starting this chemo he developed some diarrhea, no
N/V. He has had a persistent dry cough up until 2 days ago when
he noted hemoptysis and sputum production from his cough. Also
developed progressive SOB over the past few days with
fevers/chills. Cough is associated with right sided pleuritic
chest pain. He currently denies any N/V, CP, dysuria, focal
weakness, weight loss. Pt does have h/o of TB in right apices 50
yrs ago treated with INH and streptomycin along with chinese
herbal meds.
.
ONC History: Begins in [**2-11**] when pt was visiting his father in
[**Name (NI) 651**] and developed fever/cough. At that time he had a CT scan
done which found a nodule in the LLL. Pt then had this nodule
rescanned in [**Location (un) 86**] with subsequent scans that showed interval
increase in size. He then underwent bronchoscopy and sampling
of pleural effusion in [**11-11**] which demonstrated poorly
differentiated non-small cell carcinoma. Staging PET scan
showed lesion in the sternum for metastatic disease. He then
began chemotherapy with 2 cycles [**Doctor Last Name **]/taxol with no response.
Switched to Taxotere for 2 cycles and once again no response,
then started on Tarceva on [**2107-3-16**].
Past Medical History:
-Stage 4 NSCLC- mets to sternum
-R apical TB 50 yrs ago
-s/p appy
Social History:
Retired ENT physician originally from [**Name9 (PRE) 651**]. Moved to US 6 yrs
ago. Lives with wife. [**Name (NI) **] tobacco/ETOH use or history
Family History:
Father with stomach cancer still alive at age [**Age over 90 **]. Mother died
from complications of diabetes in her 70's.
Physical Exam:
T 102.2 BP 121/65 HR 91 RR 19 O2sats 90% RA 94% 4L
Gen: pleasant, thin Asian male mildly dyspneic on speaking
Skin: warm, no rashes
HEENT: OP clear, dry mm, no JVD
Heart: S1S2 tachy but regular, no murmurs appreciated
Lungs: decrease breath sounds at the left base half way up with
rales, right otherwise clear
Abd: thin, soft, NABS, NT, ND
Extrem: 2+ pulses, no edema, full ROM
Neuro: A&Ox3, fluent speech in broken English,
,strength/sensation, CN2-12 intact.
Pertinent Results:
[**2107-3-21**] 05:50PM GLUCOSE-116* UREA N-22* CREAT-0.9 SODIUM-134
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15
[**2107-3-21**] 05:50PM WBC-14.4* RBC-3.39* HGB-9.6* HCT-28.5* MCV-84
MCH-28.2 MCHC-33.6 RDW-15.6*
[**2107-3-21**] 05:50PM NEUTS-79.8* LYMPHS-11.7* MONOS-4.8 EOS-3.4
BASOS-0.4
[**2107-3-21**] 05:50PM IRON-11*
[**2107-3-21**] 05:50PM calTIBC-195* VIT B12-810 FOLATE-11.7
FERRITIN-929* TRF-150*
CXR Interval progression of the left lower lobe opacity with
interval progression of bilateral upper lobe interstitial
opacities. These findings may be consistent with pulmonary edema
or changes related to radiation therapy. Lymphangitic spread of
tumor cannot be excluded. If clinically indicated, examination
with CT of the chest may be considered.
CTA Chest
1. Interval development of new extensive ground glass opacities
within the right upper lobe, patchy ground glass opacity within
the right middle lobe, and interval worsening of consolidation
within the left lower lobe with air bronchograms, findings all
of which suggest worsening multifocal pneumonia.
2. Relatively stable appearance of loculated small left pleural
effusion with enhancing and nodular thickening of the pleural
rim.
3. Small right pleural effusion.
4. No CT evidence of pulmonary embolism.
Brief Hospital Course:
Patient was transfered to the ICU on HD #2 secondary to
increased hypoxia. A chest xray revealed what appeared to be
multifocul pnuemonia. Patient was kept on NRB mask overnight
however the next day patient continued to fatigue and after
discussion with the patient he was intubated. Patient was
continued on broad spectrum antibiotics for empiric treatment of
pnuemonia even though no cultures came back positive. He
continued to deteriorate while intubated and it was felt that he
went into ARDS based on his chest x-ray. Patient was switched
to ARDSnet vent settings. At one point patient became
hypotensive and had poor urine output. He was started on
pressors which were able to be weaned off and his urine output
did improve slightly. However is oxygenation requirements
continued to increase. He was proned, and mutiple alveolar
recruitment efforts were tried for better oxygenation which only
produced minimal improvement. After mutiple discussions with
the family they intitially wanted to continue with aggresive
treatment since the patient had one daughter in [**Name (NI) 651**] who the
family wanted to be present before the patient passed away.
However as the patient's oxygenation continued to deteriorate
even on maximal support his wife decided to stop aggresive
treatment and make patient comfort measures only. Patient
expired soon after.
Medications on Admission:
colace, oxycodone, toprol xl 50mg qday, guaifenesin-codeine
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"995.92",
"276.1",
"787.91",
"197.2",
"486",
"197.0",
"584.9",
"276.2",
"E933.1",
"518.81",
"038.9",
"162.5",
"263.9",
"198.5",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"99.04",
"96.72",
"99.15",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
5966, 5975
|
4454, 5824
|
338, 397
|
6026, 6035
|
3133, 4431
|
6091, 6101
|
2511, 2635
|
5934, 5943
|
5996, 6005
|
5850, 5911
|
6059, 6068
|
2650, 3114
|
276, 300
|
425, 2243
|
2265, 2332
|
2348, 2495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,293
| 153,516
|
31238
|
Discharge summary
|
report
|
Admission Date: [**2108-2-14**] Discharge Date: [**2108-2-18**]
Date of Birth: [**2049-12-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 y/o female with a history of pancreatitis, s/p ERCP with
sphincterotomy and placement of PD stent [**2105**]/[**2106**], s/p CCY
[**2099**], who presented from an OSH with recurrent pancreatitis. She
initially presented to an OSH with symptoms of abdominal pain,
n/v; and was found to have a lipase of [**Numeric Identifier 4731**]. A CT of the
abdomen at the OSH demonstrated pancreatitis, but no necrosis.
She was transferred to the [**Hospital1 18**] MICU for further management.
She reports her last episode of pancreatitis was in [**9-21**],
requiring admission to an OSH for pain control and IVF.
.
MICU course: She was volume resuscitated aggressively and made
NPO. She was treated with demerol and dilaudid for pain control.
She became significantly volume overloaded, with evidence of
pulmonary edema and pleural effusions on imaging, and was
diuresed successfully with a total of 40 mg IV lasix over the
last 2 days. She was noted to be sinus tachy into the
110's-130's, and was ruled out for PE by CTA. EKG also showed no
evidence of ischemia, and CE's x 2 were negative. Tachycardia
improved slightly with diuresis. She is total LOS + 2 L. ERCP
team has been following her course and plan for no intervention
at this time.
.
Currently, the patient feels well and denies any abdominal pain,
n/v. She is tolerating clears. She has not moved her bowels
since admission. She reports an occasional cough, which is
non-productive, and began when she developed pulmonary edema. No
f/c/s. ROS otherwise negative.
Past Medical History:
#. Pancreatitis:
- [**4-20**]: Pancreatic duct stent; sphincterotomy and PD removal 1
week later
- EUS: no pancreatic ductal dilatation, no chronic pancreatitis
- [**7-22**]: ERCP, pancreatic duct stenosis
#. Mitral valve prolapse
#. Hyperlipidemia
#. Osteopenia
#. s/p cholecystectomy [**2099**]
#. s/p appendectomy
#. s/p Hysterectomy
Social History:
The patient currently lives with her husband in [**Location (un) 11790**], RI.
She is retired, previously emplouyed in pre-school screening.
She has 3 adult children. No tobacco/EtOH/illicits.
Family History:
CAD, DM
Physical Exam:
VS: Tc 100.9 99.2 138/80, 110, 20 94%2L I/O = 3760/2870
General: Pleasant female in NAD, AO x 3
HEENT: NCAT, PERRL, EOMI. MM slightly dry, OP clear
Neck: supple, JVP approx 7 cm
Chest: decreased BS over bases, L>R otherwise CTA-B
CV: tachy, s1 s2 normal, no m/g/r
Abdomen: soft, NT/ND, hypoactive bowel sounds
Ext: no c/c/e, wwp
Pertinent Results:
[**2108-2-14**] 02:05AM BLOOD WBC-18.3* RBC-5.24 Hgb-15.1 Hct-45.8
MCV-87 MCH-28.8 MCHC-33.0 RDW-13.4 Plt Ct-310
[**2108-2-18**] 06:00AM BLOOD WBC-9.2 RBC-3.44* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.7 MCHC-34.8 RDW-13.6 Plt Ct-253
[**2108-2-14**] 02:05AM BLOOD Neuts-88.6* Bands-0 Lymphs-5.0* Monos-5.7
Eos-0.5 Baso-0.2
[**2108-2-14**] 02:05AM BLOOD PT-13.8* PTT-24.9 INR(PT)-1.2*
[**2108-2-16**] 06:46AM BLOOD Ret Aut-1.1*
[**2108-2-14**] 02:05AM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-136
K-4.7 Cl-103 HCO3-24 AnGap-14
[**2108-2-18**] 06:00AM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-143
K-3.9 Cl-103 HCO3-30 AnGap-14
[**2108-2-14**] 02:05AM BLOOD ALT-46* AST-43* AlkPhos-87 TotBili-0.4
[**2108-2-17**] 05:00AM BLOOD ALT-20 AST-21 LD(LDH)-273* AlkPhos-96
Amylase-68 TotBili-0.4
[**2108-2-14**] 11:16PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2108-2-14**] 02:05AM BLOOD Albumin-2.8* Calcium-7.2* Phos-1.7*
Mg-1.7
[**2108-2-18**] 06:00AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1
[**2108-2-16**] 02:26PM BLOOD calTIBC-190* Ferritn-207* TRF-146*
[**2108-2-16**] 05:30AM BLOOD Hapto-325*
[**2108-2-14**] 02:06AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2108-2-14**] 02:06AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2108-2-15**] 10:49 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: r/o PE
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with acute pancreatitis, now with acute oxygen
requirement
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 58-year-old female with shortness of breath post-acute
pancreatitis, to rule out a pulmonary embolism.
TECHNIQUE: CT of the chest was performed without intravenous
contrast followed by CT of the chest post-administration of
intravenous contrast, reconstructions were performed in the
axial, sagittal, and coronal planes. Comparison is made with
chest radiograph of [**2108-2-14**].
FINDINGS:
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are large bibasal effusions. There is atelectasis at both
lung bases with scattered patchy opacities, likely infectious or
inflammatory. There are scattered subcentimeter mediastinal
lymph nodes.
The contrast opacification of the pulmonary arteries is
suboptimal, and the study is also limited due to large bibasal
effusions and atelectasis of the lower lobes. Within these
limitations, there are apparent small filling defects in the
subsegmental branches of the lower lobe pulmonary arteries which
may be mixing versus small distal emboli. There is no central
pulmonary embolism. There is no aortic dissection. The coronary
arteries arise from the normal expected anatomical location.
There is a well-defined hypodensity in the right lobe of the
liver which may be a cyst or a hemangioma. There is a
pneumobilia in keeping with prior sphincterotomy. There has been
a prior cholecystectomy.
MUSCULOSKELETAL: There are no worrisome bone lesions.
CONCLUSION:
Limited examination due to suboptimal opacification of pulmonary
arteries and large bibasal effusions causing passive atelectasis
of the lower lobes.
1. Filling defects in the subsegmental branches of the lower
lobe pulmonary arteries may be mixing versus small emboli. There
is no central or segmental pulmonary embolism.
2. Large bibasal effusions with passive atelectasis and patchy
opacities, likely infectious or inflammatory.
.
BILAT LOWER EXT VEINS [**2108-2-18**] 11:19 AM
BILAT LOWER EXT VEINS
Reason: SOB,FEVER ,EVAL FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with shortness of breath, fever, borderline
oxygen saturation.
REASON FOR THIS EXAMINATION:
eval for DVT
INDICATION: Shortness of breath. Evaluate for DVT.
FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] of both lower
extremities including the right and left common femoral,
superficial femoral, and popliteal veins was performed,
demonstrating normal flow, augmentation, compressibility, and
waveforms. Intraluminal thrombus was not identified.
IMPRESSION: No evidence of lower extremity DVT.
.
CHEST (PA & LAT) [**2108-2-18**] 11:16 AM
CHEST (PA & LAT)
Reason: eval for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with cough, shortness of breath, fever last
night.
REASON FOR THIS EXAMINATION:
eval for infiltrate
EXAMINATION: PA and lateral chest.
INDICATION: Shortness of breath, fever.
PA and lateral views of the chest are obtained on [**2108-2-18**] at 1115
hours and compared with the most recent study performed on
[**2108-2-15**] at 1029 hours. Bilateral pleural effusions remain
present. They likely have improved slightly since the prior
radiograph. Bibasilar atelectasis is present. Right- sided PICC
line is unchanged in position. No new areas of consolidation.
IMPRESSION:
Persistent bilateral pleural effusions which likely have
decreased slightly since the prior examination. Bibasilar
atelectasis
Brief Hospital Course:
This is a 58 y/o female with history significant for
pancreatitis, s/p CCY and pancreatic stent, p/w acute
pancreatitis.
.
#Fever: Patient developed fever to 101.1 the day before
discharge. She then developed mild oxygen requirement, and mild
tachycardia. CXR showed improving effusions. LENIS were negative
for DVT. She was stable later in the day, without O2 requirement
or tachycardia, and wa therefore discharged.
.
# Pancreatitis - Patient with history of previous pancreatitis.
Seems most likely etiology at this time is pancreatic duct
stenosis or dysfunction. Patient was treated with IVF and pain
control during her course in the MICU. On arrival to the floor
she no longer required medications for pain. She was continued
on antiemetics and her diet was advanced without complications.
.
# Volume overload - patient received aggressive fluid
resuscitation over her course in the MICU, and developed
pulmonary edema. She was therefore diuresed with lasix and her
oxygenatin improved. her oxygen saturation was 94% on room air
prior to discharge.
.
# Anemia - Hct drop from 42 on admission to 32-34. Baseline
unknown. The patient was likely hemoconcentrated to some degree
on admission. Hct remained stable. Fe studies indicate mixed
iron deficiency and ACD; hemolysis labs were normal.
.
# Hyperlipidemia - continued lipitor
Medications on Admission:
Home Medications:
Fosamax 70 mg q week
Prevacid 20 mg daily
Zantac prn
Lipitor 60 mg qhs
Belladonna
.
MEDS on transfer -
Heparin SC
Dilaudid 1 mg IV Q4H:PRN pain
Meperidine 25-50 mg IV Q4H:PRN pain
Ondansetron 8 mg IV Q8H:PRN nausea
Neutra-Phos 1 PKT PO BID
Aspirin 325 mg PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H
Atorvastatin 60 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. 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*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed.
8. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO q am for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pancreatitis.
.
Secondary Diagnosis:
#. Pancreatitis:
- [**4-20**]: Pancreatic duct stent; sphincterotomy and PD removal 1
week later
- EUS: no pancreatic ductal dilatation, no chronic pancreatitis
- [**7-22**]: ERCP, pancreatic duct stenosis
#. Mitral valve prolapse
#. Hyperlipidemia
#. Osteopenia
#. s/p cholecystectomy [**2099**]
#. s/p appendectomy
#. s/p Hysterectomy
Discharge Condition:
Good. Afebrile, stable vital signs, tolerating POs, ambulating
without assistance.
Discharge Instructions:
You were admitted to the hospital intensive care unit with
pancreatitis. You were treated symptomatically with fluids and
pain control. An ERCP was not required at this time, but may
need to be done as an outpatient, as detailed below.
.
1. Please take all medication as prescribed.
2. Please make all medical appointments.
3. Please call your physician or go to the emergency room if you
develop chest pain, shortness of breath, lightheadedness, fever
greater than 101.5 not responsive to tylenol, redness or
swelling, severe abdominal pain or distention, persistent nausea
or vomiting, diarrhea, inability to eat or drink, or any other
symptoms which are concerning to you.
Followup Instructions:
Please call your PCP [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 24717**] [**Telephone/Fax (1) 24721**] to schedule an
appointment within 1-2 weeks.
.
Dr.[**Name (NI) 2798**] office (GI) will call you regarding a follow-up
appointment. You should be seen by Dr. [**Last Name (STitle) **] in [**12-18**] weeks. If
you are not contact[**Name (NI) **] in the next week regarding an appointment,
please call Dr.[**Name (NI) 2798**] office at ([**Telephone/Fax (1) 10532**] regarding
your appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"577.0",
"272.4",
"733.90",
"285.9",
"514",
"511.9",
"424.0",
"288.60",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10795, 10801
|
7865, 9203
|
329, 336
|
11239, 11324
|
2849, 4269
|
12050, 12701
|
2475, 2484
|
9708, 10772
|
7119, 7188
|
10822, 10822
|
9229, 9229
|
11348, 12027
|
2499, 2830
|
9247, 9685
|
275, 291
|
7217, 7842
|
365, 1887
|
10878, 11218
|
10841, 10857
|
1909, 2249
|
2265, 2459
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,582
| 180,812
|
9917
|
Discharge summary
|
report
|
Admission Date: [**2200-5-25**] Discharge Date: [**2200-6-9**]
Date of Birth: [**2127-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2200-5-27**]
Coronary artery bypass graft x3 (left internal mammary artery >
left anterior descending, saphenous vein graft > obtuse
marginal, saphenous vein graft > posterior descending artery)
mitral valve repair (28 mm [**Company **] CG future ring) [**2200-5-29**]
History of Present Illness:
73 year old man who presented after 30 minutes of left-sided
chest pressure, [**11-17**], non-radiating, that started after walking
up stairs at church. He reports that he did not have any jaw or
arm pain, or diaphoresis, and that the pain resolved after 30
minutes with rest. He reports that he has had similar chest pain
but not as severe for several days, possibly 1 week. Initially
he would have the pain with ambulating, going up stairs, and
over the past two days he has had less severe chest pain wake
him from sleep. One the day prior to admission he also had 30
minutes of chest pain when climbing the stairs in his house. On
the day of admission, he had chest pain at church, and EMS was
called. He was given ASA by EMS, and the pain had resolved by
time of arrival to ED.
Past Medical History:
Coronary artery disease
s/p Coronary artery bypass grafts
Mitral regurgitation
s/p mitral vlave repair
acute kidney injury
Acute diastolic heart failure
insulin dependent Diabetes mellitus
Dyslipidemia
Hypertension
s/p Cerebral vascular accident ([**2198**])
Glaucoma
Social History:
Lives with:wife
Occupation: retired [**Name (NI) 2318**] bus driver
Tobacco:denies
ETOH:denies
Family History:
non-contributory
Physical Exam:
Admission Exam:
VS: T 97.9, 140/65, 72, 20, 98%RA
GENERAL: WDWN obese elderly 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, JVP difficult to appreciate d/t body habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral basilar
crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Bilater pitting edema to knees, calves non-tender.
No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2200-6-9**] 06:03AM BLOOD WBC-10.8 RBC-2.98* Hgb-9.1* Hct-28.2*
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.2 Plt Ct-405
[**2200-6-8**] 05:36AM BLOOD WBC-9.8 RBC-2.75* Hgb-8.6* Hct-25.5*
MCV-93 MCH-31.3 MCHC-33.7 RDW-15.6* Plt Ct-423
[**2200-6-9**] 06:03AM BLOOD Glucose-130* UreaN-62* Creat-2.7* Na-141
K-4.3 Cl-102 HCO3-30 AnGap-13
[**2200-6-8**] 05:36AM BLOOD Glucose-53* UreaN-79* Creat-3.0* Na-142
K-4.3 Cl-103 HCO3-31 AnGap-12
[**2200-6-7**] 06:28AM BLOOD Glucose-63* UreaN-93* Creat-3.5* Na-142
K-3.9 Cl-100 HCO3-31 AnGap-15
[**2200-6-6**] 03:11AM BLOOD Glucose-66* UreaN-98* Creat-3.5* Na-142
K-3.9 Cl-100 HCO3-32 AnGap-14
[**2200-6-5**] 02:35AM BLOOD Glucose-139* UreaN-100* Creat-3.7* Na-139
K-3.8 Cl-98 HCO3-28 AnGap-17
[**2200-6-4**] 01:57AM BLOOD Glucose-86 UreaN-88* Creat-3.8* Na-138
K-3.7 Cl-100 HCO3-28 AnGap-14
[**2200-6-9**] 06:03AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.3
[**2200-6-7**] 06:28AM BLOOD Mg-2.9*
[**2200-6-6**] 03:11AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.9*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 33250**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 33251**]Portable TTE
(Complete) Done [**2200-6-2**] at 11:50:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2127-4-22**]
Age (years): 73 M Hgt (in): 65
BP (mm Hg): 142/82 Wgt (lb): 260
HR (bpm): 62 BSA (m2): 2.21 m2
Indication: Ant ST elevation, Wall motion abn. S/p CABG/ MV
repair
ICD-9 Codes: 414.8, 424.0
Test Information
Date/Time: [**2200-6-2**] at 11:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2011W000-0:00 Machine: Vivid q-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Stroke Volume: 69 ml/beat
Left Ventricle - Cardiac Output: 4.29 L/min
Left Ventricle - Cardiac Index: *1.94 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - Peak Velocity: 1.6 m/sec
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - Pressure Half Time: 99 ms
Mitral Valve - MVA (P [**2-9**] T): 2.2 cm2
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.50
Mitral Valve - E Wave deceleration time: *272 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2200-5-27**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: RV not well seen. Abnormal septal
motion/position.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: No AS. No AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral
annular ring with normal gradient. No MR.
TRICUSPID VALVE: No TS. Physiologic TR. Indeterminate PA
systolic pressure.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. There is
no aortic valve stenosis. No aortic regurgitation is seen. A
mitral valve annuloplasty ring is present. The mitral annular
ring appears well seated with normal gradient. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2200-5-27**],
the LVEF remains normal.
Brief Hospital Course:
Admitted from the emergency room with chest pain after he was
noted to have an elevated BNP with evidence of acute diastolic
heart failure with acute kidney injury with cr 2.5, but ruled
out for myocardial infarction. He was worked up for cardiac
disease which included cardiac catheterization. It revealed
significant disease and an echocardiogram revealed diastolic
dysfunction. His renal function improved with cessation of his
ACE and [**Last Name (un) **]. He was then brought to the Operating [****] for
coronary artery bypass graft and mitral valve repair surgery.
See operative report for further details. He received
vancomycin and cefazolin for perioperative antibiotics and was
transferred to the intensive care unit for post operative
management. He remained hemodynamically stable and awoke
agitated twice. He was diuresed and then weaned and extubated
easily. Beta blockade was begun and he remained stable. His
chest tubes were removed on POD 2. His creatinine rose to 3 on
POD 2. Volume repletion with saline and albumin resulted in
increased urine output. He remained stable, although his
creatinine peaked at 4. Urine output improved spontaneously and
his renal function improved with a falling creatinine. Due to
wheezing he was given bronchodilator therapy and was eventually
started on a short course of steroids. His oxygenation never
suffered and he denied any respiratory distress. Over several
days he improved clinically and he continued to auto-diurese.
His chest tubes and temporary pacing wires were removed per
protocols and beta blockade begun. He experienced post-operative
confusion and agitation which improved with seroquel. Physical
therapy worked with him for strength and mobility. He was
transferred to the surgical step down floor.
He continued to make progress and was transferred to [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **] on POD 11.
Medications on Admission:
Hydralazine 25 mg by mouth TID
Simvastatin 80 mg by mouth QHS
Quinapril 40 mg by mouth daily
Amlodipine 10 mg by mouth daily
Diovan 320 mg by mouth daily
Furosemide 80 mg by mouth daily
Klor-con 10 mEq tablets, Sig: 2 tablets by mouth daily
Dorzolamide-timolol 2-0.5 % Drops, Sig: one drop in each eye
twice a day
Bimatoprost 0.03 % Drops, Sig: one drop in both eyes at bedtime
NPH insulin 30U [**Hospital1 **] and SSI
Discharge Medications:
1. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. bimatoprost 0.03 % Drops Sig: One (1) drop in both eyes
Ophthalmic QHS (once a day (at bedtime)).
3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation Q6hr () as needed for wheeze.
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. atorvastatin 80 mg 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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: 30 units with breakfast and dinner.
16. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per attached Humalog Sliding
Scale, ac & hs.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass grafts
Mitral regurgitation
s/p mitral vlave repair
acute kidney injury
Acute diastolic heart failure
insulin dependent Diabetes mellitus
Dyslipidemia
Hypertension
s/p Cerebral vascular accident ([**2198**])
Glaucoma
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema - 2+ lower extremities
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. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2200-6-23**] at 1:30 pm
Cardiologist: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 33252**]) on [**2200-6-16**] at 1:30 pm
(Dr [**Last Name (STitle) **] is the recommended cardiologist by your Primary care
physician)
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) 3845**] (7[**Telephone/Fax (1) 33253**]) in [**5-13**] 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:[**2200-6-9**]
|
[
"V12.54",
"414.01",
"285.21",
"365.9",
"584.9",
"403.90",
"585.9",
"491.21",
"V58.67",
"250.00",
"424.0",
"428.33",
"411.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"37.23",
"39.61",
"88.56",
"36.12",
"38.93",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11881, 12003
|
7817, 9738
|
319, 617
|
12315, 12548
|
2835, 7794
|
13472, 14250
|
1851, 1869
|
10207, 11858
|
12024, 12294
|
9764, 10184
|
12572, 13449
|
1884, 2816
|
269, 281
|
645, 1429
|
1451, 1722
|
1738, 1835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,045
| 192,188
|
16102
|
Discharge summary
|
report
|
Admission Date: [**2137-2-26**] Discharge Date: [**2137-3-5**]
Date of Birth: [**2106-9-7**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old
male who presented to the Emergency Department with multiple
self-inflicted knife stab wounds to the anterior chest,
center of sternum, inferior to nipple, apparently done after
stabbing his wife to death.
The patient presented with decreased bowel sounds on the left
on transfer. He had distended neck veins. The left chest
was needle decompressed with improvement in vitals, and there
was decreased distention of the neck veins.
Upon arrival to the Emergency Department, the patient was
combative with decreased left-sided breath sounds. The
patient as intubated, and a left chest tube was placed with
approximately 400 cc of bloody output immediately resulting.
Chest x-ray showed lung expansion but some persistent
hydrothorax, so a second chest tube was placed secondary to
concern of an abdominal wound given the level of the stab
wounds. A DPL was performed which was grossly negative, and
fluid was sent for studies.
Initial FAST ultrasound times two was negative for
pericardial tamponade. The patient had around 800-900 cc of
chest tube output. The initial hematocrit was 41, but he had
decreased systolic blood pressure at less than 100 after 2 L
of lactated Ringer's and blood transfusion.
Repeated FAST bedside ultrasound revealed pericardial fluid,
and the patient was noted to be desaturating into the 80s,
and he was then taken to the operating room for subxiphoid
pericardial window, which was negative. Both chest tubes now
had put out approximately 2400 cc; therefore, a left
thoracotomy was performed with the identification of
parenchymal lacerations and arterial bleeding. This was
controlled with a wedge resection, and the left chest was
explored.
Exploratory laparotomy was then performed when the
................. returned as positive with greater than 3000
red blood cells. A single left hemidiaphragmatic laceration
was repaired, and the exploration of the abdomen was
otherwise negative.
PAST MEDICAL HISTORY: Unknown.
PAST SURGICAL HISTORY: Unknown.
MEDICATIONS: Unknown.
ALLERGIES: UNKNOWN.
SOCIAL HISTORY: Unknown.
PHYSICAL EXAMINATION: Vital signs: Initial exam revealed a
temperature of 93.1??????, heart rate 100, blood pressure
130/palp, oxygen saturation 94%. General: On arrival the
patient was combative. He was promptly intubated. Head:
Atraumatic. Cardiovascular: S1 and S2 with distant sounds
and tachycardia. Pulmonary: Coarse bilateral breath sounds,
decreased on the left with knife stab wounds located in the
center of the sternum, inferior to the nipple, with active
oozing. Abdomen: Soft and nondistended, detailed as above.
Rectal: Heme negative. Back: No injuries. Extremities:
No injuries.
LABORATORY DATA: White count 17.4, hematocrit 40.5, platelet
count 294, repeat hematocrit was 25.5, with intraoperative
hematocrit of 30.2; [**Known firstname **] 14.4, PTT 52.3, INR 1.4; fibrinogen
was 124; urinalysis showed [**2-6**] red blood cells, [**5-14**] white
blood cells, occasional bacteria; DPL showed 10 white cells,
3875 red cells; chemistries with a sodium of 141, potassium
4.5, chloride 102, bicarb 19, BUN 9, creatinine 1.3; amylase
69; on presentation, lactate was 17.6; ABG was 7.41, 36, 307,
24, 0.
HOSPITAL COURSE: The patient's initial management including
going to the OR was as above. Total fluids in the OR were 7
U packed red blood cells, 8 U fresh frozen plasma, 1 six-pack
of platelets, 7 L Crystalloid, and the urine output was 1200
cc, and estimated blood loss was 1500 cc.
The patient was admitted to the Trauma Service, and left
subclavian CVL was placed. Chest tubes were in place as
previously mentioned. The patient was subsequently taken to
the Trauma Intensive Care Unit for close monitoring
postoperatively.
The patient was intubated on postoperative day #1 and
remained sedated. He was placed on perioperative antibiotics
of Kefzol.
On postoperative day #2, the patient was extubated. The
patient was subsequently deemed suitable for transfer to the
floor. A Psychiatry consult was obtained with the
differential including malingering versus delirium.
On postoperative day #3, the patient was evaluated by
Physical Therapy and was found to have good potential to
return to baseline status. Chest tubes remained in place and
continued to drain substantial amounts of fluid. On
postoperative day #2, the chest tubes were placed to water
seal.
On postoperative day #3, the patient was found to be stable.
The chest tube was continued to suction, and the patient's
diet was advanced.
On postoperative day #4, the patient was doing better
postoperatively. A head CT was obtained because of change in
mental status, and this was negative for acute hemorrhage.
On postoperative day #4, the patient continued to do well.
Chest tube was placed to water seal.
On postoperative day #5, the patient continued to do well.
The chest tube was discontinued, and the patient continued to
improve. He was tolerating a regular diet.
On postoperative day #6, the patient was stable. The
pneumothorax was continuing to resolve, and the patient was
.................. therapy. The patient was subsequently
transferred to custody of the [**Location 46046**] for
transfer to an incarceration facility. A Page 1 was prepared
and sent with the patient regarding follow-up care, including
discharge of the staples on postoperative day #14, and
information regarding follow-up was also forwarded with the
patient.
DISCHARGE STATUS: Discharged to incarceration facility.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Status post multiple self-inflicted stab wounds to the
chest.
2. Status post exploratory laparotomy.
3. Status post thoracotomy for status post placement of left
chest tubes.
DISCHARGE MEDICATIONS: Ranitidine 150 mg p.o. b.i.d., Colace
100 mg p.o. b.i.d., Vicodin 5/500 [**12-6**] tab p.o. q.4-6 hours
p.r.n. pain.
FOLLOW-UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) **] in the clinic in two weeks and was provided with
the number to call so that transport from the incarceration
facility could be made. The patient was also sent out with
instructions for the facility regarding changing of the chest
tube site dressing, as well as discontinuing the staples on
postoperative day #14.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Last Name (NamePattern1) 46047**]
MEDQUIST36
D: [**2137-3-5**] 18:57
T: [**2137-3-5**] 18:55
JOB#: [**Job Number 46048**]
|
[
"300.16",
"862.1",
"560.1",
"861.32",
"860.3",
"958.4",
"E956"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.08",
"33.43",
"96.71",
"37.12",
"34.82",
"34.09",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5957, 6757
|
5751, 5933
|
3428, 5698
|
2193, 2249
|
2299, 3410
|
174, 2136
|
2159, 2169
|
2266, 2276
|
5723, 5730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,893
| 114,454
|
41498
|
Discharge summary
|
report
|
Admission Date: [**2100-7-21**] Discharge Date: [**2100-7-22**]
Date of Birth: [**2038-3-30**] Sex: M
Service: MEDICINE
Allergies:
Latex / Verapamil
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
elective ablation for A-fib
Major Surgical or Invasive Procedure:
s/p elective blation for A-fib
s/p pericardiocentesis
History of Present Illness:
62 year old man has a history of paroxysmal atrial fibrillation
that dates back to his 20's. He has undergone about 7
cardioversions and has been trialed on several antiarrythmics
including Sotalol and Flecainide. In late [**2097**] the patient began
to experience increasing episodes of AF and underwent pulmonary
vein isolation/flutter ablation on [**2099-4-1**]. Following the
ablation he gradually weaned off of Flecainide. In [**Month (only) 1096**] of
[**2098**] he had a prolonged episode of rapid palpitations that
required cardioversion. Following this he has had almost monthly
episodes of rapid palpitations that he has treated with am
"Flecainide cocktail", described as 300mg every four hours until
resolution of symptoms. His most recent episode in [**2100-6-6**]
required admission to [**Hospital3 **] for repeat cardioversion.
He has not had further palpitations since then and is referred
for left atrial tachycardia ablation.
.
Prior to admission the patient reported feeling well except for
an occasional sensation of skipped beat. He had intermittent LE
edema which he treated with compression stockings and as needed
lasix. When he is in the arrhythmia for a prolonged period, he
is aware of palpitations and a feeling of being run down.
.
He presented on the morning of admission to the CCU for elective
ablation for A-fib complicated by pericardial effusion. MAPs
fell into the 40s. A drain was placed and 500cc were drained.
His MAPs rose into the 80-90s and he was brought to the CCU for
treatment and monitoring.
.
On arrival to the CCU, patient was intubated with normal
pressures.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (pre), + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PAF s/p multiple cardioversions, s/p ablation [**3-/2099**], s/p
ablation [**7-/2100**]
Sleep apnea (does not use machine)
Elevated PSA, three prior biopsies negative
[**2083**] Cholecystectomy
? Asthma, frequent bronchitis
Microscopic Hematuria- cystoscopy negative per patient report
Hx of Extended-spectrum beta-lactamase (ESBL)
Social History:
-Tobacco history: Never
-ETOH: one beer 1-2 times per month
-Illicit drugs: Denies
Married with two children. Works as an electrical engineer.
Family History:
His grandfather also had atrial fibrillation. He has two
daughters, one of whom is 29, has had paroxysmal atrial
fibrillation for the past five years.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.3 BP=124/73 HR=99 RR=17 O2 sat= 98%
GENERAL: WDWN male, intubated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Pericardial drain in place.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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:
Admission Labs:
[**2100-7-21**] 07:00AM BLOOD WBC-8.1 RBC-4.90 Hgb-15.3 Hct-45.3 MCV-93
MCH-31.3 MCHC-33.8 RDW-13.0 Plt Ct-193
[**2100-7-21**] 07:00AM BLOOD PT-23.0* INR(PT)-2.2*
[**2100-7-21**] 07:00AM BLOOD Glucose-167* UreaN-16 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-14
[**2100-7-21**] 04:20PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8
.
Discharged labs:
[**2100-7-22**] 05:20AM BLOOD WBC-11.4* RBC-4.30* Hgb-13.2* Hct-40.4
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.9 Plt Ct-201
[**2100-7-22**] 05:20AM BLOOD PT-21.1* PTT-32.2 INR(PT)-2.0*
[**2100-7-22**] 05:20AM BLOOD Glucose-154* UreaN-13 Creat-0.8 Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
[**2100-7-22**] 05:20AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0
.
[**2100-7-21**] TTE:
There is a small-moderate pericardial effusion visualized along
the LV apex and right ventricle. Tamponade physiology cannot be
excluded based on the initial pre-pericardiocenthesis. Following
aspiration of 400 cc of fluid, the amount of pericardial
effusion appears small without echocardiographic signs of
tamponade. After removal of an additional 100 cc of fluid, the
pericardial effusion appears trivial. Based on limited views,
global left ventricular systolic function is normal (LVEF >
55%).
.
[**2100-7-22**]: TTE
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
There are no echocardiographic signs of tamponade.
.
IMPRESSION: Focused study. Trivial pericardial effusion without
echocardiographic evidence of tamponade.
.
Compared with the prior study (images reviewed) of [**2100-7-21**],
the findings are similar (when compared to the
post-pericardiocentesis images performed at the end of the
study).
Brief Hospital Course:
62 yo male with PAF, HTN, and HLD who presented for elective
ablation for A-fib complicated by pericardial effusion.
#Pericardial Effusion: Patient's ablation procedure was
complicated with ablation through left atriam with resulting
pericardial effusion. In the cath lab, patient's MAPs fell into
the 40s during the procedure. He was placed on neo and
pericardiocentsis was perfromed with drainage of 500cc of bloody
fluid. Subsequently his MAPs rose into the 80-90s and neo was
discontinued. He was transfered to CCU for further monitoring
overnight. Per report patient ablation was not totally completed
at the time of pericardial effusions. Overnight in the CCU
patient's blood pressure reamined stable. He reported
improvement in his pleuritic chest pain. Overnight patient had
about 125ml of serosangrounes fluid in the drain with no blood
or clot therefore the drain was removed and sterile dressing
applied. He had repeat echo in the morning which did not show
any further reaccumulation of pericardial fluid. Patient was
discahrged on colchicine 0.6mg for one month to help with pain
and prevent pericarditis.
#Recurrent atrial fibrillation: He underwent a left atrial
ablation for recurrent PAF. The procedure was complicated as
above. His INR remained 2.0 and his Coumadin was continued as an
outpatient with an INR check on [**2100-7-26**] at his [**Hospital 197**] clinic.
He was continued on Metoprolol 25 mg twice daily as prescribed.
he was also started on Aspirin 325 mg daily for 1 month post
ablation. Prilosec 40 mg daily for 1 month.
#HLD: continued home atrovastatin
EMERGENCY CONTACT: [**Name (NI) 8513**] (wife) [**Telephone/Fax (1) 90267**] (cell)
#Transitional issues:
- Started patient one month of aspirin. Continued Coumadin
daily, INR goal [**1-8**]. PT/INR at [**Hospital3 3765**] on [**2100-7-26**].
- Patient will follow up with Dr. [**Last Name (STitle) **] on thursday [**8-26**], [**2099**] at 2:40pm
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Magnesium Oxide 500 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Flecainide Acetate 300 mg PO Q4H:PRN while in AF
4. Warfarin 6-8 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Furosemide 20 mg PO DAILY:PRN LE edema
7. Multivitamins 1 TAB PO DAILY
8. Calcium Carbonate 600 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY:PRN while taking lasix
Duration: 24 Hours
Hold for K > 5.0
10. Tamsulosin 0.8 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 1 Months
2. Atorvastatin 10 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
Hold HR<55, SBP<100
4. Omeprazole 40 mg PO DAILY Duration: 1 Months
5. Tamsulosin 0.8 mg PO DAILY
6. Warfarin 6 mg PO DAILY
as directed
7. Potassium Chloride 20 mEq PO DAILY:PRN while taking lasix
Duration: 24 Hours
Hold for K > 5.0
8. Calcium Carbonate 600 mg PO DAILY
9. Furosemide 20 mg PO DAILY:PRN LE edema
10. Magnesium Oxide 500 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Colchicine 0.6 mg PO DAILY Duration: 30 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pericardial effusion
Secondary: atrial fibrilation
Discharge Condition:
Hospital course; Mr. [**Name14 (STitle) 90268**] was admitted to the hospital
following an elective ablation for recurrent symptomatic atrial
fibrillation. It was complicated by a collection of fluid around
your heart. The fluid was drained and you did well. A follow up
echo did not show any further accumulation of fluid.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 90269**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admittted to the hospital following an
ablation to treat atrial fibrillation. The procedure was
complicated by a collection of fluid around your heart. The
fluid was drained and you did well.
We made the following changes to your medications:
- Please take Prilosec (omeprazole) daily for 1 month to
decrease stomach acid.
- Please take aspirin daily for 1 month to decrease
inflammation.
- Please take colchicine daily for 1 month to prevent
inflammation around the heart. This medicine may cause nausea
and diarrhea.
Followup Instructions:
Please have your INR checked at your clinic at [**Hospital1 **] on
Monday.
Department: CARDIOLOGY [**Location (un) **]
When: THURSDAY [**2100-8-26**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1536**]
Building: [**Apartment Address(1) 71186**]
([**Location (un) 1514**],MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Completed by:[**2100-7-23**]
|
[
"997.1",
"427.31",
"401.9",
"327.23",
"427.89",
"E879.8",
"493.90",
"272.4",
"423.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.26",
"99.62",
"37.34",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
8550, 8556
|
5467, 7150
|
306, 361
|
8661, 8988
|
3735, 3735
|
9786, 10236
|
2733, 2886
|
7982, 8527
|
8577, 8640
|
7440, 7959
|
9139, 9457
|
2901, 2911
|
2114, 2190
|
2933, 3716
|
7171, 7414
|
9486, 9763
|
239, 268
|
389, 2000
|
3751, 5444
|
9003, 9115
|
2221, 2554
|
2022, 2094
|
2570, 2717
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,983
| 110,033
|
39920
|
Discharge summary
|
report
|
Admission Date: [**2118-2-10**] Discharge Date: [**2118-2-14**]
Date of Birth: [**2061-3-20**] Sex: F
Service: SURGERY
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Worsening rash, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 56F with a history of hypertension, hyperlipidemia, and
depression who has had a complicated past 4-5 months history
notable for post-ERCP pancreatitis with ARDS/pneumonia requiring
extensive ICU stay, is readmitted following ERCP yesterday and
development of rash, fever, hypotension, and tachycardia at
rehab
today.
.
In [**Month (only) **] this unilingual spanish speaking patient
was admitted to [**Hospital6 3105**] w/ choledocholithiasis
and bile duct dilatation on U/S. ERCP on [**10-20**] showed a 1cm stone
that could not be removed. A bile duct stent was placed. After
ERCP, she developed pancreatitis c/b ARDS requiring ICU
admission
and mechanical ventilation. Because the
patient continued to saturate at 87% on RA, she was discharged
to rehabilitation on [**2117-11-2**] w/ 2L supplemental O2 by NC and a
steroid taper.
.
She they re-presented to [**Hospital6 3105**] w/ RUQ pain 3
days after discharge w/ worsening right upper quadrant pain. She
was transferred to [**Hospital1 18**] after CT abdomen showed a large
multilobulated pancreatic pseudocyst possibly compressing the
CBD. ERCP revealed an obstructed stent in the major papilla.
This
stent was successfully replaced and a 5mm stone removed.
Post-procedure, the patient became tachycardic with SBP in the
80s and poor O2 sats, requiring phenylephrine and NRB in the
ERCP
suite. She was admitted to the ICU where she required intubation
for hypoxic resiratory failure. The patient's shock was
initially
thought to be secondary to biliary sepsis, and she was treated
with broad spectrum antibiotics, including vanc and zosyn, for
strep anginosus and strep mileri in blood cultures.
.
The patient's liver enzymes and bilirubin trended down
indicating
that the restenting of the biliary system had succesfully
decompressed the obstruction. Repeat abdominal CT that showed
the
pancreatic pseudocyst had shrunk, but there was an increased
amount of intra-peritoneal fluid, particularly in the left
gutter. A drain was inserted into the paracolic gutter, which
showed an amylase level of [**Numeric Identifier 61575**], suggesting that the patient's
pseudocyst had ruptured, either before the patient's ERCP or at
some point in her hospital course. After draining the fluid
collection, the patient's hemodynamic status improved.
.
She remained in the ICU for over a month with persistent
hypotension and intermittent fevers. After developing a diffuse
rash, Derm consulted and thought it was possibly related to
zosyn
drug reaction, and she was treated with a course of steroids.
She
ultimately was discharged to rehab with a tracheostomy.
.
This morning, following ERCP yesterday, she spiked fevers to
102,
became hypotensive to 80s systolic and HR to 150s. She was taken
to [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] and transferred here for further care. Patient
denies pain, nausea, vomiting, diarrhea, cough, shortness of
breath. Of note, she recieved cipro and flagyl peri-procedure
the day prior to admission
Past Medical History:
Hypertension
Hyperlipidemia
Depression
Choledocholithiasis
Pancreatitis
ARDS
Elbow surgery
Tubal ligation
Social History:
Currently living at [**Hospital3 **].
- Tobacco: 2-3 per day for many years
- Alcohol: occasional
- Illicits: denies
Family History:
sister s/p cholecystectomy
Physical Exam:
On Discharge:
V/S: T 97.8 P 96 BP 100/60 RR 18 O2 96%
GEN: NAD, AAx3
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND
Pertinent Results:
[**2118-2-10**] 05:08PM BLOOD WBC-25.2*# RBC-3.56* Hgb-10.5* Hct-31.6*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.2 Plt Ct-266
[**2118-2-14**] 05:45AM BLOOD WBC-9.7 RBC-3.52* Hgb-10.4* Hct-31.9*
MCV-91 MCH-29.6 MCHC-32.7 RDW-13.8 Plt Ct-261
[**2118-2-10**] 05:08PM BLOOD Neuts-97.9* Lymphs-0.7* Monos-0.6*
Eos-0.7 Baso-0.1
[**2118-2-13**] 01:48AM BLOOD Neuts-59.8 Lymphs-14.5* Monos-2.5
Eos-22.0* Baso-1.1
[**2118-2-10**] 05:08PM BLOOD Glucose-140* UreaN-16 Creat-0.8 Na-136
K-4.8 Cl-107 HCO3-22 AnGap-12
[**2118-2-14**] 05:45AM BLOOD Glucose-121* UreaN-12 Creat-0.5 Na-137
K-4.0 Cl-103 HCO3-27 AnGap-11
[**2118-2-11**] 02:21AM BLOOD TSH-0.36
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment on [**2118-2-10**]. The patient was initially
managed in the ICU, and then transferred to the floor on [**2118-2-13**]
once stable.
Neuro: The patient did not complain of pain during her stay. No
pain medications were needed. She remained alert and oriented x3
during her entire hospital stay.
CV: The patient was initially hypotensive upon admission with
SBP in the 80s. A CVL was placed and she was started on
levo/phenylephrine drip to keep SBP > 100. The patient was also
given agressive fluid resuscitation and albumin to improve BP.
The phenylephrine was weaned as patient's BP tolerated, and by
HD3 it was stopped. The patient then remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially NPO upon admission, but
diet was advanced as tolerated without any problems. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Initially, the
patient's WBC was elevated with a peak of 34 on HD2, but this
came down rapidly and was normal upon discharge. The patient was
initially started on empiric vancomycin. ID was consulted and
recommended amikacin, aztreonam, daptomycin, and clindamycin,
which the patient was started on HD 2. Dermatology was also
consulted as well and felt that this was likely a drug induced
reaction. After 48hrs of negative cultures all atbx were
stopped. Triamcinolone cream was applied to the rash, and it
improved throughout the remainder of her stay. At time of
discharge, patient appeared less red and the rash had improved
substantially.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
Ultimately, it was felt that the patient's condition was due to
a drug reaction, likely from the cipro/flagyl that she received
after the ERCP. The patient should be avoid these medications in
the future and other healthcare providers should be aware of
this severe drug reaction. Furthermore, caution should also be
taken when giving IV contrast to this patient. It is possible
that her reaction was exacerbated by the contrast given for her
prior study.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
-Mag oxide
-Prevacid 30 daily
-lovenox 40 daily
-pravastatn 40 daily
-vitamin C, MVI
-colace
Discharge Medications:
1. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itchy rash.
Disp:*2 bottles* Refills:*0*
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care Agency
Discharge Diagnosis:
Rash, Hypotension
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 call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General 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 [**5-31**] 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.
Please monitor your rash and please notify your surgeon and PCP
if rash is getting worse or if it becomes painful or more
swollen.
Followup Instructions:
You have an appointment on [**2118-3-25**] @ 10:15 with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
You will have a CT scan performed on the day of your visit. Dr. [**Name (NI) 76749**] office will contact you with details regarding your CT
scan.
Please call [**Telephone/Fax (1) 274**] with any questions.
Completed by:[**2118-2-14**]
|
[
"995.93",
"E930.8",
"785.0",
"401.9",
"780.60",
"272.4",
"693.0",
"E931.5",
"458.29",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
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icd9pcs
|
[
[
[]
]
] |
8259, 8329
|
4465, 7697
|
293, 300
|
8391, 8391
|
3808, 4442
|
10321, 10687
|
3628, 3656
|
7841, 8236
|
8350, 8370
|
7723, 7818
|
8574, 9555
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3671, 3671
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3685, 3789
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9587, 10298
|
226, 255
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328, 3345
|
8406, 8550
|
3367, 3474
|
3490, 3612
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,337
| 132,553
|
40859+58407
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-6-28**] Discharge Date: [**2118-7-6**]
Date of Birth: [**2087-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
jaundice and abdominal pain
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
30 yo woman from [**Country 11150**] with history of treated TB (per pt) who
presented to OSH with jaundice and abdominal pain, now
transfered from OSH for concert for cholangitis and sepsis in
the setting of liver cyst.
.
The pt was originally admitted to OSH on [**6-22**] for abdominal pain
and jaundice. CT scan during that admission showed intra and
extrahepatic biliary duct dilatation with a large cystic
component in the biliary duct and a suggestion of a choledochal
cyst with associated infection/ inflammation. Labs were notable
for AST 103, ALT 136, Alk phos 450, Hep B Surface Ag neg, Hep B
surface Ab pos, HCV neg. The pt was treated with antibiotics and
evaluated by the OSH surgical team, and ultimately was
discharged home on oral antibiotics, with plans to follow up
with GI as an outpatient for ERCP on [**6-27**]. On [**6-25**] the pt
developed abdominal pain which was relieved with percocet. On
[**6-26**] the pt developed nausea and non-bloody emesis, and
presented to OSH ED. Labs at that time were significant for WBC
13, hct 33, plt 279, with 16% eos. Tbili was 3.8, AST 33, ALT 59
and alk phos 457. Chem 7 was normal. The pt's symptoms improved
with supportive medications, but the pt was noted to have SBP's
persistently low, sometimes in the 70's and was transfered to
the OSH ICU. During the admission from [**Date range (1) 89245**], the pt was
noted to have poor U/O, with only 2L out despite 11L in during
her length of stay. The pt was initially started on ertapenem
and flagyl for presumed cholangitis and pancreatitis, but then
it was determined that ertapenem would provide adequate coverage
and flagyl was stopped. The pt was kept NPO, and did have an
episode of hypoglycemia in the 40's that responded to an amp of
D50. The pt was transfered to [**Hospital1 18**] for ERCP and hepatobiliary
consults.
.
On the floor, SBP 96, otherwise the pt denies abdominal pain,
nausea, lightheadedness.
Past Medical History:
TB, dx [**2110**], per patient took 9 mos kanamycin, ethionamide. Her
strain was resistant to rifampin
Recent dx choledochal cyst [**6-22**]
.
Social History:
No tobacco, alcohol or drugs. Stays at home with 3 year old.
Married. Is from Indian, but Tibetan. Moved to USA one year ago.
Family History:
non contributory
Physical Exam:
Admission PE:
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: Thin, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly,
liver edge palpable, no HSM
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace bilat LE edema,
pitting
Neuro: Speech fluent, A+Ox3, 5/5 strength in bilat upper and
lower extremities. Gait assessment deferred.
Discharge PE:
Afebrile 92/62 p75 18 100RA
Pertinent Results:
Admission labs:
[**2118-6-28**] 10:42PM BLOOD WBC-8.3 RBC-3.94* Hgb-10.2* Hct-31.6*
MCV-80* MCH-25.9* MCHC-32.3 RDW-15.5 Plt Ct-278
[**2118-6-28**] 10:42PM BLOOD Neuts-41* Bands-0 Lymphs-18 Monos-3
Eos-38* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2118-6-28**] 10:42PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+
[**2118-6-29**] 06:00AM BLOOD PT-14.8* PTT-40.3* INR(PT)-1.3*
[**2118-6-28**] 10:42PM BLOOD Glucose-85 UreaN-3* Creat-0.3* Na-137
K-3.6 Cl-111* HCO3-17* AnGap-13
[**2118-6-28**] 10:42PM BLOOD ALT-35 AST-31 LD(LDH)-157 AlkPhos-453*
TotBili-2.2*
[**2118-6-28**] 10:42PM BLOOD Albumin-2.9* Calcium-8.0* Phos-1.7*
Mg-1.8
Micro:
[**6-29**] Stool O&P: negative
Echinococcus Ab: POSITIVE
Entamoeba: pending
Fasciola: 1:8 Negative
Strongyloides: Negative
Schistosoma: Negative
[**6-29**] MRCP:
1. Diffuse irregular intra- and extrahepatic biliary
dilation,with dominant massively dilated biliary structure
encompassing the majority of the right hepatic lobe. This is
felt most likely to represent diffuse choledochal cyst formation
(Todani Type [**Doctor First Name 690**]). Postinfectious biliary dilation is felt less
likely due to lack of stricturing and lack of intraductal
stones. Appearance is not typical of echinococcal disease (as
questioned).
2. Diffuse peribiliary enhancement consistent with
superinfection/cholangitis, and probable chronic right portal
venous
compression or occlusion with collateralization. However, short
interval
follow up after treatment and resolution of symptoms (within 3
months) is
recommended to ensure resolution of enhancement about the cyst,
in order to exclude an adjacent infiltrative mass. In addition,
consideration of
correlation with ERCP and brushings is suggested.
3. Perihepatic and subdiaphragmatic free fluid that could
relate to
inflammatory or infectious change or prior cyst rupture into the
perihepatic space.
4. Additional left sided intrahepatic biliary dilation and
wall enhancement. Differential includes cholangitis, biliary
stasis, and obstruction by the dominant biliary cyst.
[**6-30**] ERCP:
Extensive dilation of the common bile duct, common hepatic duct,
intra and extrahepatic bile ducts.
Extensive stones and sludge throughout the extrahepatic and
right intrahepatic biliary system.
1 cm biliary stricture noted in the right hepatic duct. Proximal
to this was severe dilation with debris inside consistent with
patient's known biliary dilation/cyst.
Successful sphincterotomy performed.
Extraction of significant amount of stones/debris, although
extensive debris remains in the right intrahepatic bile ducts at
the end of the procedure.
Brushings taken of right hepatic duct stricture.
Successful stent placement across the hepatic duct stricture.
Findings most consistent with oriental cholangiohepatitis.
[**6-30**] RUQ u/s: Preliminary Report !! PFI !!
PFI: Given limitations in comparing cross modalities, persisting
cystic
structure in the right kidney with heterogeneous echogenic
material within it, similar in size to prior MR, and draining
into a dilated bile duct. Findings are nonspecific, and as
advised on prior MR, ERCP may be considered for further
assessment.
[**7-1**] CXR: Volume loss left upper lobe probably due to old lung
infection, but mass effect is present.
[**6-30**] Bile duct brushing cytology: NEGATIVE FOR MALIGNANT CELLS.
CT CHEST W/CONTRAST Study Date of [**2118-7-2**] IMPRESSION:
1. Extensive findings consistent with prior tuberculose
exposure.
2. No evidence of echinococcal infestation of lungs or
mediastinum.
3. Several noncalcified pulmonary nodules, most likely
consistent with
noncalcified granulomas. In the absence of smoking or known
malignancy, as
[**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guidelines, no further followup indicated.
Discharge Labs:
[**2118-7-6**] 08:26 WBC 8.1 Hgb 11.3 HCT 33.5 PLT 367
[**2118-7-6**] 08:26 ALT 30 AST 32 Alk Phos 441* Tbili 1.2
[**2118-7-4**] 07:05 LYTES, BUN/Cr WNL
Brief Hospital Course:
30 year old Tibetan woman with choledochal cyst of unknown
etiology transferred from OSH for ERCP and hepatobiliary surgery
consultation presented with hypotension, eosinophilia, elevated
LFTs and abdominal pain.
# Choledochal/hepatic cyst: DDx included echinococcus, amebic,
or other parasitic cyst vs simple cyst vs. abscess vs. tumor.
Parasitic cyst was felt to be most likely due to eosinophilia
and recent immigration from [**Country 11150**]. Serologies for echinococcus
was positive at the outside hospital, multiple serologies at
[**Hospital1 18**] were sent which confirmed echinococcus positivity. Note
that entamoeba serology remains pending. Albendazole was
started empirically at the outside hospital prior to her
transfer due to concern for echinoccal cyst and possible
spillage leading to hypotension.
The surgical service was consulted given communication of this
cyst with the biliary tree and they recommended surgical removal
of the cyst. Plan was for pt to return to CHA for surgical
intervention, however, pt requested to have procedure done at
[**Hospital1 18**]. ID was consulted and followed throughout the
hospitalization. Per ID, pt will need to remain on albendazole
for one month following surgical intervention.
# Cholangitis- ERCP was consulted, as was hepatobiliary surgery
and infectious disease.She underwent an ERCP on [**6-30**] and stones
and sludge were removed. A sphincterotomy was performed and a
stent was placed. Her LFTs improved after ERCP, though there was
no obvious change in the size of her cyst on imaging. She
received empiric treatment with cipro, flagyl given concern for
cholangitis/bacterial infection. She completed a two day course
of Ivermectin for possible strongyloides. Her symptoms of nausea
and abdominal pain improved. She will complete a 2 week course
of cipro/flagyl per ERCP recommendations, given the duration of
her obstruction and the presence of the cyst.
#Hypotension: Pt was hypotensive on admission, however this
resolved with fluids and remained stable with careful monitoring
throughout her stay in the ICU. Her baseline blood pressure is
low, per pt. This may have been due to cholangitis/bacterial
infection. However, given the possibility of an echinoccocal
cyst, there was initial concern for anaphylaxis. However, she
improved with IVF alone.
Medications on Admission:
On admission to OSH)
Colace 100 [**Hospital1 **]
Percocet 5/325 q4h prn
Augmentin 875-125 [**Hospital1 **] x12d
.
(On transfer to [**Hospital1 18**] [**6-28**])
Flagyl 500mg IV q6- d/c'ed
Heparin 5000u tid
Ertapenem 1g q24h
Protonix 40IV daily
Albendazole 400mg [**Hospital1 **] (one dose at 6pm on [**6-28**])
Discharge Medications:
1. albendazole 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please continue for 1 month following surgery.
Disp:*120 Tablet(s)* Refills:*1*
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Choledochal/hepatic cyst
Cholangitis
Hypotension
Eosinophilia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and were found to have
blockage in your bile duct, this was opened up and stented with
drainage of gallstones and sludge. You were also found to have a
large fluid filled cyst pushing on your liver and liver veins;
this cyst which communicates with/connects to the bile duct
system. You will need to follow up with Surgery to remove the
cyst.
Followup Instructions:
Surgery: Please see Dr. [**First Name (STitle) **] of surgery to discuss your
surgical options. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-7-14**] 3:00 PM. [**Location (un) **] of the
[**Hospital **] Medical Building at [**Hospital1 18**]. A plan regarding your Bile
duct stent from ERCP will be made at that time.
With: [**Last Name (LF) **], [**First Name3 (LF) **]-[**Last Name (un) **]
Location: CHA-[**Location (un) 3786**] Family Health
Address: [**First Name8 (NamePattern2) **] [**Location (un) 3786**], [**Numeric Identifier 31725**]
Phone: [**Telephone/Fax (1) 25050**]
Appointment: Monday [**7-18**] at 11:40AM
Name: [**Known lastname 14150**],[**Known firstname 14151**] Unit No: [**Numeric Identifier 14152**]
Admission Date: [**2118-6-28**] Discharge Date: [**2118-7-6**]
Date of Birth: [**2087-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 128**]
Addendum:
Correction: pt discharged to home, not ECF.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**]
Completed by:[**2118-7-7**]
|
[
"251.1",
"789.01",
"038.9",
"577.0",
"790.4",
"785.52",
"576.1",
"285.9",
"V12.01",
"995.92",
"574.51",
"122.8",
"276.52",
"288.3",
"788.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.87",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
12375, 12537
|
7413, 9750
|
331, 359
|
10649, 10649
|
3365, 3365
|
11206, 12352
|
2645, 2663
|
10112, 10505
|
10564, 10628
|
9776, 10089
|
10800, 11183
|
7226, 7390
|
2678, 3299
|
3313, 3346
|
264, 293
|
387, 2320
|
3381, 7210
|
10664, 10776
|
2342, 2486
|
2502, 2629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,884
| 150,905
|
24757
|
Discharge summary
|
report
|
Admission Date: [**2122-12-3**] Discharge Date: [**2122-12-8**]
Date of Birth: [**2061-1-21**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back and leg pain
Major Surgical or Invasive Procedure:
L4-5 PLIF
History of Present Illness:
A 62-year-old gentleman had a history of neurogenic
claudication. Conservative therapy was unsuccessful. An MRI
demonstrated segmental stenosis at L4-5.
Note, there was a significantly lumbarized S1 in his counting
scheme.
Past Medical History:
1. Alcholic cirrhosis status post orthotopic liver
transplantation [**2118-5-7**]
2. Steroid induced diabetes
3. Gout, has been taking allopurinol recently
4. Hypertension
5. Low back/neck disk herniation
6. Anemia, likely secondary to chronic renal insufficiency
7. Chronic renal insufficiency with baseline creatinine 1.7-2.0
8. Hypercholesterolemia
Social History:
Lives in [**Hospital3 4634**] apartment. Not currently working; used
to work for the Transit Authority. Patient has history of
alcohol abuse but states he has not drank since prior to the
transplant. Does admit to glass of wine at [**Holiday 1451**], but no
other EtOH since. No tobacco, or illicit drug use. He is
divorced with 2 children that live independent
Family History:
Non-contrib
Physical Exam:
On examination, his motor strength is [**4-1**] in hip flexion,
extension, quadriceps, hamstrings, dorsiflexion, and plantar
flexion bilaterally. His sensory examination is intact with
respect to the modality of light touch. His reflexes are normal
and symmetric. Straight leg raise is negative bilaterally as is
[**Doctor Last Name **] maneuver. His pulses are palpable bilaterally.
upon discharge:
motor full, incision cdi
Pertinent Results:
UA [**12-7**]
Negative
Urine Cx [**12-7**]
CXR [**12-7**]
Brief Hospital Course:
Pt was admitted electively to hospital, went to OR where under
general anesthesia underwent lumbar fusion. He tolerated the
procedure well, was extubated, transferred to PACU and then
floor. Diet and actvity were advanced. Pain medication was
transitioned to PO. He had JP in place and was monitored , this
was removed on [**12-5**] without difficulty. He was evaluated by PT
and was utilizing a recumbent walker to ambulate. PT continued
to work with him and cleared him for home with rolling walker
when cleared from neurosurgical standpoint. On [**12-6**] he had
standing films and this showed good placement of spinal
instrumentation. On [**12-6**] he developed a fever to 102.4 and had a
chest x ray and UA with urine culture. CXR was negative for
infiltrate or acute process and his UA was negative. His vital
signs were monitored and he remained afebrile. he was
discharegd to home with home PT
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
COLCHICINE - (Prescribed by Other Provider) - 0.6 mg Tablet - 1
Tablet(s) by mouth once a day
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - one
Tablet(s) by mouth once daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 1 Capsule(s) by mouth twice a day
LEVOTHYROXINE [LEVOTHROID] - (record) - 50 mcg Tablet - 1
Tablet(s) by mouth daily
METOPROLOL TARTRATE [LOPRESSOR] - (Pt is not taking as
prescribed) - 50 mg Tablet - 2 Tablet(s) by mouth twice a day
MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 2 Tablet(s)
by
mouth twice a day - No Substitution
PRAVASTATIN - 20 mg Tablet - one Tablet(s) by mouth at bedtime
SIROLIMUS [RAPAMUNE] - (Dose adjustment - no new Rx) - 1 mg
Tablet - 1 Tablet(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet -
1
Tablet(s) by mouth every day
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - 500 mg
(1,250
mg)-400 unit Tablet - 1 Tablet(s) by mouth twice a day
OMEGA-3 FATTY ACIDS-FISH OIL - (Dose adjustment - no new Rx) -
300 mg-1,000 mg Capsule - 1 Capsule(s) by mouth twice a day
OMEPRAZOLE - (Dose adjustment - no new Rx) - 20 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain med.
Disp:*60 Capsule(s)* Refills:*2*
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. colchicine 0.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
5. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO every six (6) hours as needed for constipation.
15. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*28 Tablet Sustained Release 12 hr(s)* Refills:*0*
16. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day): take 600mg [**Hospital1 **] for 2 weeks then 300mg [**Hospital1 **] for 2
weeks then dc.
Disp:*90 Capsule(s)* Refills:*0*
17. methocarbamol 750 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
19. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNS of [**Location (un) 7188**]/[**Location (un) 16221**]
Discharge Diagnosis:
lumbar spondylolisthesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2122-12-7**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks ten increase activity as tolerated.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months to promote
fusion.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 10-14DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2122-12-8**]
|
[
"311",
"327.23",
"403.90",
"249.00",
"724.03",
"780.62",
"738.4",
"E932.0",
"V42.7",
"585.9",
"278.02",
"274.9",
"V85.41",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"81.07",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
6259, 6347
|
1930, 2837
|
326, 338
|
6416, 6416
|
1843, 1907
|
7424, 7703
|
1364, 1377
|
4327, 6236
|
6368, 6395
|
2863, 4304
|
6567, 7401
|
1392, 1781
|
269, 288
|
1797, 1824
|
366, 591
|
6431, 6543
|
613, 968
|
984, 1348
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,086
| 166,536
|
3199
|
Discharge summary
|
report
|
Admission Date: [**2100-10-9**] Discharge Date: [**2100-10-20**]
Date of Birth: [**2028-2-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Dyspnea/Hypoxia requiring NRB.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 72 y.o. M with nonspecific interstitial
pneumonitis diagnosed by CT in [**2094**] (no biopsy in system), small
cell lung cancer diagnosed in [**5-/2100**], s/p chemotherapy and
radiation, presents with progressive shortness of breath. Pt
states that this has been happening over 1 month. He recently
saw his oncologist on [**10-5**] where he was "clearly hypoxic" though
no vital signs recorded. He was prescribed home oxygen at that
time. Plan also included pt seeing his pulmonologist, Dr.
[**Last Name (STitle) **], to consider the role of possible steroids for his
pulmonary disease as well as possible radiation pneumonitis and
the role of steroids for this. Pt states he had chills, but
denies fevers, sore throat, rhinorrhea, nasal congestion, chest
pain, nausea, vomiting, abdominal pain, diarrhea.
.
In the ED, initial VS: T 97.9 HR 81 BP 130/82 RR 38 O2 sat
98% on 12 L NRB. Labs were drawn, including cardiac enzymes.
Blood cultures x 2 were sent. EKG, Portable CXR and CTA Chest
performed. Albuterol neb and ipratropium neb given.
Levofloxacin 750 mg IV x 1 given. In ED, maintained 95-100% NRB
but when attempted 6 L NC --> O2 sat to 86%.
.
Currently, pt feels dyspneic with talking and complains of [**4-23**]
back pain. Also very thirsty.
Past Medical History:
1. Nonspecific Interstitial Pneumonitis (NSIP)
2. COPD
3. s/p tonsillectomy
4. Pulmonary scarring
.
1. The patient presented in [**4-/2100**] with progressive difficulty
walking, ataxia, weight loss and shortness of breath.
2. The patient was admitted to the hospital between [**2100-5-9**]
and [**2100-5-12**] and again on [**2100-5-13**]. A CT scan done on
[**2100-5-13**] showed a large right paratracheal mass and right upper
lobe spiculated nodule. Bronchoscopy on [**2100-5-17**] showed a
negative brushings; however, a fine needle biopsy done in 4R
station was positive for small cell lung cancer.
3. Staging PET CT done on [**2100-5-24**] showed FDG avid right upper
lobe nodule measuring 16 mm with an SUV of 9.3. There was a
large FDG avid conglomerate nodal mass in the right paratracheal
region having an SUV max of 14.2. There was a mild tracer uptake
in the prevascular node with an SUV of 3.7. Additionally, there
was a low level uptake in the L4-L5 area on the right side and
in the T8 vertebral body, but they are likely due to
degenerative changes in the spine.
4. Staging head MRI done on [**2100-5-15**] showed no evidence of brain
metastasis.
5. First cycle of chemotherapy with cisplatin and etoposide
administered as an inpatient on [**2100-5-28**].
6. Lumbar puncture on [**2100-5-31**] showed that the CSF was negative
for malignant cells.
7. Second cycle of cisplatin-etoposide started on [**2100-6-17**].
8. Thoracic radiation started on [**2100-7-12**].
9. C4D3 etoposide [**2100-8-5**]
Social History:
Prior to his recent onset of symptoms he was living at home
alone, but since his last hospitalization has been at inpatient
rehab. Is retired, had worked in the food and beverage industry
in distrubtion. Quit smoking 5 years ago, but had smoked [**2-16**]
ppd for 40+ years. Denies alcohol or drug use.
Family History:
Denies family history of cancer.
Physical Exam:
Vitals - T: 98.1 BP: 109/59 HR: 75 RR: 14 02 sat: 93% on 100%
NRB
GENERAL: tachypneic, malaised appearing elderly male
HEENT: EOMI, anicteric, no cervical LAD appreciated
CARDIAC: RRR, nl S1, S2, no m/r/g
LUNG: dry crackles at bilateral bases, poor movement of air
throughout, no wheezes
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e
NEURO: A&O x 3
DERM: no rashes noted
Pertinent Results:
[**2100-10-9**] 11:33PM TYPE-ART PO2-26* PCO2-46* PH-7.43 TOTAL
CO2-32* BASE XS-3
[**2100-10-9**] 11:33PM GLUCOSE-110* LACTATE-1.2 NA+-137 K+-3.8
CL--96*
[**2100-10-9**] 11:33PM HGB-10.8* calcHCT-32 O2 SAT-43
[**2100-10-9**] 11:27PM GLUCOSE-104 UREA N-24* CREAT-1.1 SODIUM-139
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
[**2100-10-9**] 11:27PM proBNP-561*
[**2100-10-9**] 11:27PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-2.1
IRON-33*
[**2100-10-9**] 11:27PM calTIBC-139* FERRITIN-1189* TRF-107*
[**2100-10-9**] 11:27PM TSH-0.60
[**2100-10-9**] 11:27PM WBC-4.9 RBC-3.40* HGB-10.4* HCT-31.3* MCV-92
MCH-30.7 MCHC-33.3 RDW-14.5
[**2100-10-9**] 11:27PM PLT COUNT-211
[**2100-10-9**] 11:27PM PT-13.6* PTT-27.1 INR(PT)-1.2*
[**2100-10-9**] 05:58PM COMMENTS-GREEN TOP
[**2100-10-9**] 05:58PM LACTATE-1.8
[**2100-10-9**] 05:40PM GLUCOSE-172* UREA N-26* CREAT-1.2 SODIUM-136
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
[**2100-10-9**] 05:40PM estGFR-Using this
[**2100-10-9**] 05:40PM CK(CPK)-39
[**2100-10-9**] 05:40PM cTropnT-<0.01
[**2100-10-9**] 05:40PM CK-MB-NotDone
[**2100-10-9**] 05:40PM WBC-6.1 RBC-3.51* HGB-10.4* HCT-32.0* MCV-91
MCH-29.7 MCHC-32.6 RDW-15.1
[**2100-10-9**] 05:40PM NEUTS-82.2* LYMPHS-11.2* MONOS-3.3 EOS-3.1
BASOS-0.1
[**2100-10-9**] 05:40PM PLT COUNT-228
[**2100-10-9**] 05:40PM PT-13.4 PTT-27.5 INR(PT)-1.1
.
[**10-9**] CTA
1. Background interstitial lung disease compatible with NSIP and
emphysema,
with continued increase in areas of ground-glass attenuation and
peribronchovascular airspace opacification and consolidation,
which is most
notable in the left upper lobe as well as the lower lobes.
Findings again
concerning for superimposed infection or inflammation (such as
drug reaction),
or acute worsening of the patient's underlying NSIP. Pulmonary
edema is
considered less likely, and there is no pleural effusion.
2. Little change in mediastinal and hilar adenopathy.
3. No pulmonary embolus seen.
.
[**10-11**] Echo:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is top normal/borderline dilated. Overall left ventricular
systolic function is low normal (LVEF 50-55%). 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. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
overall low normal systolic function.
.
[**10-14**] CXR: The recently developed acute area of opacification in
the left
retrocardiac region has improved, and may be due to a resolving
area of acute aspiration. Other widespread pulmonary opacities
are unchanged allowing for slight differences in lung volumes.
Note is made of a right PICC with tip terminating at the
junction of the right axillary and subclavian veins.
Brief Hospital Course:
# Respiratory distress: Initially admitted to MICU, chest x-ray
showed bilateral hazy opacities, lymphadenopathy, and a
background of chronic interstitial lung disease. Blood cultures
and respiratory viral cultures were negative, and induced sputum
was unrevealing/contaminated. Aspergillus galactomannan and
B-glucan tests were negative. He was started on steroids and
antibiotics (vancomycin, azithromycin, cefepime). Echo revealed
mild LVH. On [**10-14**], the patient aspirated while eating breakfast
and desaturated. He recovered with with non-rebreather, and did
not require intubation. On [**10-15**], a meeting was held during which
the patient became DNR/DNI and focus was shifted to the
patient's comfort, with IV morphine and pleasure feeds. The
dyspnea was ultimately felt to be multi-factorial, including
worsening nonspecific interstial pneumonitis, radiation
pneumonitis, progression of lung cancer, or infection. He was
continued on high flow oxygen with face tent and nasal cannula
with goals of O2Sat 89-92%. On the floor his respiratory status
was stable, alternating between an open face mask and
non-rebreather mask. He received good relief of his dyspnea with
regular doses of IV morphine. He lost his last remaining
peripheral IV on [**10-18**], and was subsequently written for
sublingual morphine concentrate. Discussions were held between
the patient, HCP, primary team, & palliative care, during which
the patient & HCP ultimately favored transitioning to hospice.
Mr. [**Known lastname **] was tolerating 5 liters of oxygen via nasal cannula at
the time of discharge.
.
#ARF: Baseline creatinine 0.8 to 1.0 in Spring [**2100**]. On arrival,
BUN/creatinine was 26/1.2. Remained between 1.1-1.3 while labs
were being checked. Last labs were on [**10-15**].
.
#Hyponatremia: Thought by MICU team to be secondary to poor PO
intake. IV antibiotics were placed in normal saline instead of
D5W. Labs were discontinued after [**10-15**].
.
# Small Cell Lung Cancer: Lymphadenopathy on admission chest
imaging was believed to be consistent with his known cancer.
Followed by Dr. [**Last Name (STitle) 3274**], who reported that the cancer responded
to treatment but if this was radiation pneumonitis and if it did
not respond to steroid initially that there was little hope of
improvement.
.
# COPD: Was recently on 2 L NC at home due to increased dyspnea,
received albuterol and ipratropium nebs and IV steroids during
course, as described above. With the change of focus to patient
comfort, oxygen saturation goals were sat at >90%. Eventually,
the patient was made CMO and vitals/oxygen sats were no longer
measured.
.
# Anemia: Hct at baseline 31-33.
.
# Neuropathy/Back pain/tooth pain: The patient received
morphine, acetaminophen, fentanyl and viscous lidocaine.
.
.
# FEN: no IVFs / replete lytes prn / NPO except meds
# PPX: home PPI, heparin SQ, bowel regimen
# ACCESS: PIV
# CODE: FULL (confirmed with pt)
# CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 15014**]
# DISPO: ICU
Medications on Admission:
Gabapentin 300 mg three times a day.
Milk of magnesium as needed.
Omeprazole 20 mg once daily.
Ondansetron 4 mg as needed.
Oxycodone 20 mg twice daily.
Percocet every six hours as needed.
Compazine as needed.
Acetaminophen as needed.
Dulcolax as needed.
Polyethylene glycol as needed.
Senokot as needed.
Thiamine 100 mg daily.
Colace as needed.
Megace as needed.
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. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for dental pain.
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: [**1-15**] PO
DAILY (Daily) as needed for constipation.
8. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q2H
(every 2 hours) as needed for breakthrough pain/dyspnea.
9. Morphine Concentrate 20 mg/mL Solution Sig: Ten (10) mg PO
Q4H (every 4 hours) as needed for Pain, dyspnea: Patient may
refuse, do not need to wake patient to administer.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Hypoxia
.
Small cell lung cancer
Nonspecific interstitial pneumonitis
Chronic obstructive pulmonary disease
Spinal stenosis
Discharge Condition:
Stable for discharge to hospice care
Discharge Instructions:
Mr [**Known lastname **],
You were admitted to the intensive care unit at [**Hospital1 18**] after you
developed progressively worsening shortness of breath. Your
respiratory status was stabilized with oxygen therapy, but you
continued to have shortness of breath in spite of medication
with steroids and multiple antibiotics. You did not require
mechanical ventilation, and were transferred to the regular
medical floor. We discontinued the intravenous medications you
were receiving, after your IV line was not functioning properly.
After several discussions we shared with you, your health care
proxy ([**Name (NI) **]), and the palliative care service, we decided to
focus on making you as comfortable as possible. You received
intravenous and oral morphine which helped relieve your
shortness of breath. You were transitioned to hospice care, so
you could further focus on comfort and avoid further
hospitalizations.
.
We discharged you to hospice on the following medications:
-Morphine Sulfate concentrated oral solution, 10 mg every four
hours, as well as an additional 5-10 mg every two hours, as
needed for shortness of breath or pain
-Docusate sodium 100 mg by mouth twice daily, as needed for
constipation
-Senna 1-2 tabs by mouth twice daily, as needed for constipation
-Bisacodyl 5 mg tab, two tabs by mouth as needed for
constipation
-Lidocaine 5% (700 mg) topical patch as needed for pain
-Acetaminophen 325 mg tabs, one to two tabs as needed for pain
or fever
-Polyethylene Glycol 3350 17 gram/dose Powder by mouth daily as
needed for constipation
Followup Instructions:
Hospice Care
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,972
| 188,017
|
20929
|
Discharge summary
|
report
|
Admission Date: [**2128-11-7**] Discharge Date: [**2128-11-23**]
Date of Birth: [**2062-12-18**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Right Internal Jugular Central Line Placement
Flexible Bronchoscopy
Endotracheal intubation
History of Present Illness:
Pt is a 65 yo Vietnamese male w/ a PMH sig for Non-small cell
endobronchial lung CA s/p RMSB stent ([**5-21**]), COPD, CRI, recent
admission for respiratory distress requiring intubation, and
chest tube placement x 2 in [**6-20**], who presented to an OSH on
[**11-7**] @ ~1730 with significant tachypnea and tachycardia,
requiring 5 L NC to keep sats above 95%. The patient's
respiratory status continued to decline and he was placed on
BIPAP and treated with morphine, IV Lasix, steroids,
ceftriaxone, and azithromycin. The patient's respiratory
distress did not resolve and after obtaining an ABG of
7.17/74/226, the patient was transferred to [**Hospital1 18**] for further
management.
In the ED at [**Hospital1 18**], the patient's mental status declined and his
hypercarbia worsened considerably with an ABG 7.09/121/140 on
BIPAP. Shortly after the results of this blood gas were obtained
the patient was intubated. He became hypotensive with SBP<60
post-intubation. He was given 1400cc of fluid and started on
Levophed after a central line was placed in his right femoral
vein. His BP subsequently improved to MAP>60. The patient was
further resuscitated with 4 L of IVF in the ED before being
transferred to the MICU for further medical management.
Past Medical History:
1.Non-Small Cell Lung CA dx in [**4-20**] s/p RMSB stent [**5-21**], on
palliative chemo/radiation therapy. Carboplatin Q3weeks with 2
weeks off and XRT Qweek.
2.HTN
3.COPD
4.TB 10 yrs ago tx??????ed in [**Country 3992**]
5.? h/o DVT
6.CRI (baseline Cr 1.7)
7.Chronic b/l LE pain and paraesthesia
8.Hyperlipidemia
9.Anisocoria
10.Asthma FEV1 0.7 L
11.EF 64%, Mild MR, mild diastolic dysfxn
12.H/o MSSA pna in[**5-21**]
Social History:
Pt denies tob or EtOH use.
Family History:
GM w/ Lung CA.
Physical Exam:
vitals on presentation to ED [**11-7**]
Temp 102.4, HR 96, BP 117/72, RR 16 sats 100% on AC FiO2 0.5,
500/16 PEEP 5
GEN: intubated, sedated
HEENT: R pupil 2mm reactive, L pupil 4mm reactive, anicteric
sclera, MMM, no JVD, no bruits, no LAD
PULM: coarse rhonchi bilaterally with poor airmovement
throughout, prolonged expiratory phase, insp/exp wheezes
CV: sinus tachycardia, nl S1/S2 no m/r/g
ABD: scaphoid, soft, non-distended, +BS
EXT: no c/c/e
SKIN: no rash
Physical exam on discharge [**2128-11-23**]
VS: T 98.7 BP 100s-110s/70s-80s P 80s-100s R 16 96% RA
Gen: pleasant, cachectic appearing, NAD, walking in halls with
walker
Pulm: CTAB, occasional rales that clear easily with cough
CV: RRR, nl S1/S2, no murmurs appreciated
Abd: Soft, NT/ND, +BS
Ext: no edema
Pertinent Results:
ECHO Study Date of [**2128-11-8**]
Conclusions:
1.Technically difficult study.
2. The left atrium is normal in size.
3.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Due to suboptimal technical quality, a focal
wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic
function is low normal (LVEF 50-55%).
4.Right ventricular chamber size is normal. Right ventricular
systolic
function is borderline normal.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. 6.The mitral valve
leaflets are
structurally normal. No mitral regurgitation is seen.
7.There is an anterior space which most likely represents a fat
pad, though a
loculated anterior pericardial effusion cannot be excluded.
There is no
evidence of RV compression.
CXR [**2128-11-20**]:
Compared to the prior film of [**2128-11-14**], the patient has
been extubated and the lines have been removed. Heart size is
normal. Extensive scarring is present in both upper lobes with
upward retraction of both hila. Pleural thickening is present
over the right lung apex and there is shift of the trachea to
the right. All of these findings are unchanged since the prior
film of [**2128-11-14**]. Similarly, the tenting of both
hemidiaphragms and pleural thickening in the right costophrenic
angle are unchanged. No pneumothorax and no new lung lesions.
[**2128-11-7**] 08:50PM BLOOD WBC-25.7*# RBC-4.56* Hgb-12.2* Hct-38.2*
MCV-84 MCH-26.8* MCHC-32.0 RDW-14.5 Plt Ct-371
[**2128-11-7**] 08:50PM BLOOD Neuts-93* Bands-4 Lymphs-1* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2128-11-7**] 08:50PM BLOOD PT-12.3 PTT-30.6 INR(PT)-1.0
[**2128-11-7**] 08:50PM BLOOD Glucose-223* UreaN-18 Creat-2.1* Na-137
K-4.4 Cl-94* HCO3-29 AnGap-18
[**2128-11-7**] 08:50PM BLOOD ALT-15 AST-27 LD(LDH)-392* CK(CPK)-80
AlkPhos-71 TotBili-0.3
[**2128-11-7**] 08:50PM BLOOD Lipase-17
[**2128-11-7**] 08:50PM BLOOD Albumin-4.1 Calcium-8.6 Phos-4.8*# Mg-1.8
UricAcd-8.3*
[**2128-11-8**] 05:54AM BLOOD Cortsol-86.6*
[**2128-11-7**] 09:58PM BLOOD Type-ART pO2-140* pCO2-121* pH-7.09*
calHCO3-39* Base XS-2
[**2128-11-8**] 12:10AM BLOOD Glucose-233* Lactate-3.1* Na-138 K-3.9
Cl-110
[**2128-11-7**] 09:58PM BLOOD freeCa-1.20
[**2128-11-23**] 05:55AM BLOOD WBC-4.0 RBC-3.30* Hgb-8.8* Hct-28.1*
MCV-85 MCH-26.7* MCHC-31.3 RDW-17.4* Plt Ct-98*
[**2128-11-8**] 05:54AM BLOOD Neuts-96.3* Bands-0 Lymphs-1.6*
Monos-1.3* Eos-0.5 Baso-0.3
[**2128-11-23**] 05:55AM BLOOD Plt Ct-98*
[**2128-11-23**] 05:55AM BLOOD Glucose-102 UreaN-30* Creat-1.2 Na-141
K-4.1 Cl-108 HCO3-26 AnGap-11
[**2128-11-17**] 04:00AM BLOOD ALT-19 AST-15 LD(LDH)-195 AlkPhos-47
TotBili-0.3
[**2128-11-23**] 05:55AM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.9 Mg-1.9
[**2128-11-18**] 05:30AM BLOOD calTIBC-155* Ferritn-520* TRF-119*
[**2128-11-17**] 04:00AM BLOOD Vanco-11.4*
[**2128-11-8**] Bronchoalveolar lavage:
[**2128-11-8**] 12:48 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2128-11-8**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2128-11-11**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- 4 I
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
LEGIONELLA CULTURE (Final [**2128-11-18**]): NO LEGIONELLA
ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2128-11-9**]):
PNEUMOCYSTIS CARINII NOT SEEN.
POOR QUALITY SPECIMEN. SENSITIVITY OF DETECTION [**Month (only) **] BE
ADVERSLY
AFFECTED.
INTERPRET RESULTS WITH CAUTION.
FUNGAL CULTURE (Final [**2128-11-23**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2128-11-10**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending): pending at time of discharge
[**2128-11-8**] 12:48 pm Rapid Respiratory Viral Screen & Culture
Rapid Respiratory Viral Antigen Test (Final [**2128-11-9**]):
Positive for Respiratory Syncytial viral antigen.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
REPORTED BY PHONE TO DR. [**First Name (STitle) 55667**] 11:35AM [**2128-11-9**].
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Brief Hospital Course:
1. Respiratory distress: The patient's respiratory status was
complicated by a number of factors including his underlying
COPD, diastolic heart failure, lung Ca, and suspected infection.
The patient has significant CO2 retention at baseline with PaCO2
50-70 and a baseline compensatory metabolic alkalosis with HCO3
in the low 30s. The patient was initially intubated in the
setting of hypercarbia and impending respiratory failure. He was
started on standing albuterol/atrovent MDI's as well as stress
dose steroids. On [**11-8**] he underwent flexible bronchoscopy with
BAL at the bedside which demonstrated significant airway edema,
thick white secretions but no obstruction. The patient's RMS
stent was patent. The BAL fluid was positive for RSV antigen but
no virus was isolated. The Gram stain, fungal, AFB, and
Legionella cultures were all negative. Due to the patient's poor
airway compliance, significant bronchospasm, and anxiety, he
developed autopeep on the ventilator calculated to be ~15. This
degree of autopeep made it almost impossible for him to trigger
the ventilator on pressure support. Therefore, the patient's
sedation was increased using both fentanyl and propofol in order
to decrease the respiratory rate while still on AC and decrease
his autopeep. Once the patient's autopeep was down to <=5 he was
started on PS 16/8. The following day he was able to tolerate PS
of [**9-24**] and eventually weaned to 5/0. He was successfully
extubated on [**11-16**]. He remained stable from a respiratory
standpoint following extubation, initially requiring a face
mask, then oxygen via nasal cannula. He continue to improve
with albuterol and atrovent nebulizers and was breathing
progressively more comfortably over the next few days on the
floor with no significant oxygen need.
2. question of PNA: Patient's underlying respiratory distress
thought secondary to underlying sepsis [**1-19**] PNA aspiration vs.
MSSA PNA. The patient was placed on Vanc/Levo/Flagyl for empiric
coverage of GP/GN/anerobes. He was febrile on admission, but
afebrile throughout remainder of ICU stay. Blood cx drawn on
admission and on follow up were negative. Of note, RSV antigen
was detected in his sputum. The patient's antibiotics were
continued until extubation and then discontinued. Pt continued
to improve and follow up chest X ray showed on [**2128-11-20**] showed no
new lung lesions. Pt was maintained off antibiotics and did not
worsen from a respiratory standpoint.
3. Sepsis: Hypotension likely related to septic shock on
admission. Patient initially received 4 L of IVF in the ED and 2
L of IVF after arrival to the MICU. He initially required
pressure support with Levophed, but this was weaned off within
the first 24 hours. An ECHO was performed which showed no
evidence of pericardial effusion, a normal LA, and an EF of
50-55%. He was bolused for low CVP throughout the first several
days of his hospital stay such that by [**11-12**] the patient was
over 13 L positive, but did not show any signs of peripheral
edema. The patient was thought to be profoundly intravascularly
depleted [**1-19**] sepsis, poor nutritional status and poor PO intake.
He was given Lasix 20mg IV x 1 on [**11-13**] and subsequent
auto-diuresis with additional medication. Although he was
initially hypotensive, the patient's HR and BP slowly increased
such that his HR was in the 90's with SBP>150. He was started on
diltiazem which was quickly titrated to 120mg qid for heart rate
control. As he improved clinically, the diltiazem was decreased
and pt was sent home on 60mg po qid. Pt was somewhat
tachycardic to 110s on the floor, but this seemed to be more in
the immediate post-albuterol nebulizer setting, as well as due
to dehydration, as below. Pulse taken spaced out from nebs was
more in the 80s-90s.
4. COPD: Severe underlying disease/possible exacerbation in the
setting of RSV bronchiolitis complicated the patient's
respiratory status. He was maintained on standing
albuterol/atrovent treatments and given IV steroids that were
changed to PO prednisone after extubation. The patient was
maintained on a slow prednisone taper due to his severe disease,
and was also sent home with albuterol and atrovent nebulizers.
5. acute renal failure: The patient's Cr on presentation was
2.1. This improved over the course of his hospital stay to his
baseline Cr of 1.2, which remained stable over the rest of his
hospitalization.
6. non-small cell Lung CA: The patient's oncologist was made
aware of his admission to the hospital. She met with the family
and confirmed the patient's code status as full. Prior to
admission the patient had received carboplatin treatment.
7. Thrombocytopenia: On admission, the patient's platelets were
371. They declined slowly to a nadir of 44. The patient had no
signs of bleeding. Thrombocytopenia was felt most likely
secondary to medication administration (likely secondary to
Carboplatin, which he received prior to admission; there was
also concern over contribution from vancomycin or levaquin,
which were discontinued). An HIT antibody was sent which was
negative. Pt's platelets remained stable over the course of the
rest of his stay and had even begun to recover, reaching 98 on
the day of discharge. This favors the possibility of a
drug-induced effect, most likely bone marrow suppression due to
carboplatin.
8. Cachexia/malnutrition: Pt had poor po intake after he was
extubated and began to recover. His mental status improved, but
he became transiently hypernatremic and required free water
repletion. He was started on Megace, and uptitrated to 800mg
daily, which he said resulted in improved appetite. However, he
was still with poor po intake on discharge, which is thought to
be due to his malignancy. He was sent out on amitriptyline,
which is covered by free care. During the hospitalization, and
likely due to poor po intake, pt was dehydrated, with
hypernatremia, relative hypotension to SBP 90s, tachycardia to
110s, and a contraction alkalosis. This improved with IV
hydration but will likely continue to be problem[**Name (NI) 115**].
9. Hyperglycemia: Pt's glucose was often in the 200s. The
reasons were thought to be multifactorial, most notably in the
setting of infection and then with steroids. He was covered on
an insulin sliding scale. However, due to the fact that the
steroids will be tapered over the next 1-2 weeks, patient was
not given any antihyperglycemic agents for home use. He should
have his glucose rechecked by his new primary care physician.
10. Mental status: Pt required haldol and increased sedation
while in the ICU, even needing a sitter temporarily. After
extubation, his mental status improved, though he was markedly
confused over the first 1-2 days. A depression screen revealed
no evidence of depression, and pt was back to his baseline per
family members.
Medications on Admission:
1. Robitussin AC
2. Megestrol acetate
3. Protonix 40mg QAM
4. Metoprolol 25mg [**Hospital1 **]
5. Cozaar 50mg QAM
6. Gabapentin 100mg TID
7. Lipitor 20mg QAM
8. Prochloperazine 10mg Q8PRN
Discharge Medications:
1. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: One (1) nebulizer
Inhalation every four hours as needed for shortness of breath or
wheezing.
Disp:*180 vials* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*180 vials* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)): for cholesterol lowering.
Disp:*30 Tablet(s)* Refills:*2*
5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days: Take on [**11-24**] (wed), [**11-25**] (thurs).
Disp:*2 Tablet(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: Take on [**11-26**] (fri), [**11-27**] (sat), [**11-28**] (sun).
Disp:*3 Tablet(s)* Refills:*0*
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: take on [**11-29**] (mon), [**11-30**] (tues), [**12-1**] (wed).
Disp:*3 Tablet(s)* Refills:*0*
9. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: take [**12-2**] (thurs), [**12-3**] (fri), [**12-4**] (sat).
Disp:*3 Tablet(s)* Refills:*0*
10. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Primary:
1. Non-small cell lung cancer
2. Hypercarbic respiratory failure
3. Tachycardia
4. chronic obstructive pulmonary disease
5. RSV antigen positive
6. septic shock, resolved
7. chronic kidney disease
Secondary:
1. Thrombocytopenia, likely chemotherapy-induced
2. Hypertension
3. Peripheral neuropathy
4. Cachexia with poor oral intake
5. history of tuberculosis, treated over 10 years ago
6. hyperlipidemia
7. history of melena
8. anisocoria
Discharge Condition:
stable, tolerating po, breathing well. Cough has improved with
decreased sputum production; patient is able to ambulate well
without assistance.
Discharge Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) 55668**] [**Name (STitle) **], your new PCP, [**Name10 (NameIs) **] take
all of your medications as instructed.
You are on a prednisone taper, which means that the doses will
change every couple of days. Please look at the instructions
carefully and take the proper dose on the specific dates noted.
Please measure your Blood Pressure at home. The VNA will talk
about arranging for you to have a blood pressure cuff at home.
If you have shortness of breath, chest pain, or any other
symptom that is concerning to you, please call your primary care
doctor or go to the nearest emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 55669**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2128-12-3**] 1:50
|
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"V12.01",
"482.41",
"428.30",
"276.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"00.17",
"99.04",
"38.93",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
16487, 16549
|
7894, 14457
|
298, 391
|
17045, 17191
|
3007, 7207
|
17892, 18080
|
2182, 2198
|
15019, 16464
|
16570, 17024
|
14807, 14996
|
17215, 17869
|
2213, 2988
|
7236, 7871
|
238, 260
|
419, 1679
|
14472, 14781
|
1701, 2122
|
2138, 2166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
452
| 131,499
|
21460
|
Discharge summary
|
report
|
Admission Date: [**2110-5-13**] Discharge Date: [**2110-5-30**]
Date of Birth: [**2049-10-10**] Sex: M
Service: SURGERY
Allergies:
Flagyl
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
etoh cirrhosis
Major Surgical or Invasive Procedure:
liver transplant [**2110-5-13**]
re-exploration for decreased hepatic flow noted on duplex
[**2110-5-14**]
History of Present Illness:
60 y.o. male with etoh cirrhosis. Last etoh drink 2 years pta.
Denies fevers, or chills, problems or recent illness. Admitted
for liver transplant
Past Medical History:
1. DM2: dx 10 years ago, treated w/ glucophage until 1 year ago
when BG normalized, likely [**12-26**] weight loss, now not requiring
medication.
2. HTN: treated w/ Diovan until 1 year ago, when BP normalized,
presumably [**12-26**] weight loss.
3. Lumbar DJD w/ chronic low back pain
4. h/o c.diff
difficulty swallowing s/p esoph dilatation
basal cell ca
htn
failure to thrive
last tap [**Month (only) **]
encephalopathy
oral surgery for dentition
Social History:
lives with wife in [**Name (NI) 19407**], [**Name (NI) **]; retired salesman; drank [**5-17**]
beers per day for 40 years but quit 6 months ago; smoked 2
cigars per day for 20 years; no IV or recreational drug use.
Family History:
1. CAD: father died of MI
2. Gastric CA: brother died
Physical Exam:
A&O, NAD
CTA bilat
SEM
ABD-NT/ND, minimal ascites, no scars
Ext-wll, LLE ankle deformity
Pertinent Results:
[**2110-5-13**] 01:30AM FIBRINOGE-402*
[**2110-5-13**] 01:30AM PT-12.9 PTT-30.3 INR(PT)-1.2*
[**2110-5-13**] 01:30AM PLT COUNT-226
[**2110-5-13**] 01:30AM WBC-9.0 RBC-3.08* HGB-10.0* HCT-27.6* MCV-90
MCH-32.4* MCHC-36.2* RDW-13.6
[**2110-5-13**] 01:30AM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-2.7
MAGNESIUM-1.9
[**2110-5-13**] 01:30AM ALT(SGPT)-6 AST(SGOT)-12 ALK PHOS-97 TOT
BILI-0.4
[**2110-5-13**] 01:30AM GLUCOSE-120* UREA N-17 CREAT-1.2 SODIUM-140
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2110-5-13**] 02:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-5-13**] 02:23AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
Brief Hospital Course:
He was taken to the OR on [**5-13**] by Dr. [**First Name (STitle) **] [**Name (STitle) **] for
orthotopic liver transplant, piggyback technique,with portal
vein to portal vein anastomosis, donor celiac artery to
recipient hepatic artery, anastomosis with donor replaced left
hepatic artery and bile duct to bile duct anastomosis. Assisting
surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Please see operative report for
further details.
Estimated blood loss was about [**2103**] cc. 250 cc were given as
cell [**Doctor Last Name 10105**]. The patient received 8000 units of crystalloid,
6units of FFP, 11 units of packed RBCs, no platelets. Two [**Doctor Last Name 406**]
drains were place with one below the right lobe of the liver and
the other behind the hilum of the liver. He received induction
immunosuppression consisting of solumedrol and cellcept. Postop,
he was transferred in stable condition to the SICU where he
remained intubated. LFTs increased from preop ast 12, alt 6, apk
phos 97 and t.bili 0.4 to postop ast 3274, alt [**2098**], alk phos
109, and t.bili 10.1.
On [**5-14**] a liver duplex demonstrated the following: 1)
Non-visualized right hepatic artery, normal arterial waveform
identified within the left hepatic artery.
2) Fatty liver.
3) Blunted hepatic vein waveforms suggesting "stiff" liver or an
element of narrowing at the IVC anastomosis.
4) Small amount of ascites. He was taken back to the OR on [**5-14**]
by Dr. [**First Name (STitle) **] [**Name (STitle) **] for compartment syndrome and exploratory
laparotomy, liver biopsy and closure
of fascia with mesh under general anesthesia. There was good
flow in the hepatic artery, portal vein and hepatic veins. He
was readmitted to the SICU postop where he was weaned off
propofol and extubated on [**5-15**]. LFTs trended down to ast 26, alt
87, alk phos 182 and t.bili 1.2. Prograf was initiated on postop
days 2 and 1. Prograf was adjusted to 2mg [**Hospital1 **] per levels 7.7.
Subsequent levels were 9.9 and 11 by pod 7. Solumedrol was
tapered to prednisone 20mg qd. He will continue slow taper per
transplant clinic over the next 3 months. Cellcept 1gram po bid
continued. Creatinine increased to 1.9 on pod 5 and 4 then
decreased to 1.3 by pod [**6-30**].
Diet was gradually advanced. Nutrition followed making
recommendations for his diet given recent esophageal dilatation.
This included a speech and swallow eval. Findings included no
evidence of aspiration with suggestion to continue on the
current PO diet of thin liquids and regular consistency solids.
He experienced some nausea and vomiting on post op day [**5-29**] after
taking am meds. A kub was done for mild abd distension and
hypoactive bowel sounds. This revealed relatively markedly
distended segment of small bowel over the mid abdomen with air
seen in the distal colon and rectum of uncertain significance.
He was given a dulcolax suppository with passage of bm. N/V
resolved. PO intake was only fair and calorie counts were ~1500
kcal.
On [**5-21**] his wbc increased to 22. A urine culture was negative.
An abdominal CT was done to rule out intra-abd abscess. This
revealed moderate abdominal/pelvic fluid, moderate bilateral
pleural effusions with associated atelectasis and right adrenal
hematoma. A cxr showed bibasilar atelectasis left greater than
right. He also had some URI symptoms that improved. Levaquin was
started on [**5-25**] for a ten day course. On [**5-29**] he complained of a
sore mouth. Several 4mm punctate ulcerations (aphthous
appearing) were noted on his tongue and gum. This was cultured
for bacterial and viral organisms. Maaolox/benadryl/lidocaine
swish was ordered.
PT followed and recommended rehab.
He experienced serosanguinous leaking via the right side of his
incision. Several staples were removed and a gauze dressing was
loosely packed into the wound. The medial JP was removed on pod
[**5-29**] and the lateral JP remained in place given outputs of 200cc.
His hct trended down slightly each day to 24 on [**5-29**]. He was
ordered for 2 units of prbc. He continued on lasix 80mg [**Hospital1 **] for
edema.
Condition is stable. He is alert and oriented.
He remained in the hospital pending a bed at [**Hospital **] rehab with
labs every Monday and Thursday for cbc, chem 10, lfts, and
trough prograf levels with results fax'd to the [**Hospital1 18**] Transplant
office attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] RN ([**Telephone/Fax (1) 697**]). He is scheduled to
f/u in the clinic.
Patient was discharged home on [**2110-5-30**] after being deemed
capable by team.
Medications on Admission:
lactulose 30''', lasix 80', protonix 40', spironolactone 100',
zoloft 100', iron, mycelex, propranolol 10'', sertraline 100',
lasix 80', ativan PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
ML PO DAILY (Daily).
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
12. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection every six (6) hours.
13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
15. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
16. Maalox/Benadryl/Lidocaine
5ml po prn qid for sore mouth ulcers
Discharge Disposition:
Home with Service
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
h/o etoh abuse
DM II
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability
to take medications, jaundice, redness/bleeding/pus from
incisions or increased drainage, abdominal pain or any
questions.
Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili,albumin, and trough prograf level. fax results to
[**Hospital1 18**] Transplant office [**Telephone/Fax (1) 697**]
Followup Instructions:
Please call Transplant office [**Telephone/Fax (1) 673**] to schedule follow up
appointment
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-5-30**] 1:15
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2110-6-5**] 1:00
Completed by:[**2110-5-30**]
|
[
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"V10.83",
"428.0",
"571.2",
"570",
"574.20",
"486",
"996.82",
"530.3",
"528.9",
"401.9",
"729.9",
"273.8",
"564.00",
"250.00",
"518.0",
"721.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.11",
"99.00",
"54.72",
"50.59",
"88.76",
"00.93",
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] |
icd9pcs
|
[
[
[]
]
] |
8452, 8535
|
2230, 6911
|
282, 391
|
8600, 8609
|
1467, 2207
|
9051, 9414
|
1288, 1343
|
7109, 8429
|
8556, 8579
|
6937, 7086
|
8633, 9028
|
1358, 1448
|
228, 244
|
419, 567
|
589, 1039
|
1055, 1272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,673
| 132,038
|
26389
|
Discharge summary
|
report
|
Admission Date: [**2132-8-15**] Discharge Date: [**2132-8-24**]
Date of Birth: [**2058-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
SOB, somnulent
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 y/o with COPD, OSA, CHF, recnet PNA presents with SOB and
somulence. Pt is disoriented and Farsi only speaking . History
obtained via daughter. daughter reports. 3 days of progressive
SOB, and increasing fatigue. On 2.5 to 3.5 L NC at baseline,
reports sats in 70s on this amount with only minor increase in
sat with increase to 8L. USes Bipap at night at 16/8, no change
in recent use. Daughter notes progressive confusion, near falls.
Denies Fevers, chills, cough, chest pain, palpatations, abd
pain, urinary sytmpoms
.
In the ED, initial vs were: T 97.6 P 84 BP 110/58 R 28 O2 sat
100 RA. Patient was given 125 IV solumedrol 125mg x1 and levo
750 mg x 1. started on BIPAP after ABG on 4L NC showed
7.24/105/67, 94% on BIPAP.
.
On the floor, pt delerious but appears comfortable on BIPAP
Past Medical History:
- CAD; s/p 4 vessel CABG in [**2119**]
- CHF; EF 55%, mild AS
- obesity hypoventilation syndrome
- obstructive sleep apnea
- DM2
- ventricular tachycardia; s/p ICD in [**2127**]
- hypothyroidism
- schizophrenia
- COPD
- Pneumona treated in [**4-7**] at [**Hospital1 **]
Social History:
- lives in [**Hospital3 **] alone w/home health aide
- daily visits from daughter
- smoked 1.5 ppd X 30 years, quit in [**2123**]
- at baseline can do most ADLs (wash face, comb hair, etc)
Family History:
- mother died of MI (age unknown)
Physical Exam:
Vitals: T:97.7 BP: 137/46 P: 71 R: 20 O2: 98% on Bipap 8/5
General: Alert, dis-oriented, mild resp distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to interperate [**3-3**] body habitus, no LAD
Lungs: diffuse expiratory wheeze. Minimal Left LL crakles.
Diffusely diminished breath sounds. no ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: tense , non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly. tympanic to
percussion
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema.
Pertinent Results:
Labs on Admission [**2132-8-15**]:
WBC-8.1 RBC-3.02* Hgb-8.9* Hct-26.2* MCV-87 MCH-29.4 Plt Ct-185
Neuts-82.1* Lymphs-11.7* Monos-3.2 Eos-2.7 Baso-0.3
PT-11.7 PTT-22.7 INR(PT)-1.0
Glucose-204* UreaN-28* Creat-1.1 Na-132* K-4.8 Cl-88* HCO3-38*
AnGap-11
CK-MB-NotDone proBNP-2578*
Calcium-9.9 Phos-3.0 Mg-1.8
Lactate-0.8
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
[**2132-8-15**] 09:47PM BLOOD Type-ART pO2-67* pCO2-105* pH-7.24*
calTCO2-47* Base XS-12 Intubat-NOT INTUBA
[**2132-8-16**] 12:46AM BLOOD Type-ART pO2-61* pCO2-80* pH-7.31*
calTCO2-42* Base XS-9
[**2132-8-15**] Blood culture x2: no growth to date
[**2132-8-15**] Urine culture: no growth
Other Studies
[**2132-8-15**] Portable AP CXR: Findings consistent with volume
overload, likely due to congestive failure. Repeat radiography
following appropriate diuresis recommended to assess for
underlying infection.
[**2132-8-15**] RLE U/S: No DVT of the right lower extremity.
[**2132-8-18**] CXR: Resolving pulmonary edema. No definite
consolidation.
[**2132-8-18**] CTA chest: No PE, + PA HTN, cardiomegaly and CA
atherosclerotic disease, stable prominent mediastinal and b/l
hilar LN (unchanged since [**29**])
[**2132-8-20**] CXR: prelim unchanged
Brief Hospital Course:
This is a 73 y/o with COPD, OSA, obesity hypoventilation
syndrome, CHF presents with SOB and somulence x 3 days
.
# Hypercarbic resp failure: CO2 of 105 on admit ABG, improved to
baseline of 80s with BIPAP. Was using home oxygen and bipap.
Unclear [**Name2 (NI) 65268**] of COPD exacerbation, but may be related to
BIPAP noncompliance. She was initially treated in the MICU with
IV steroids for COPD exacerbation, then transitioned to PO
steroids. She was treated also with a short course of
azithromycin.
She was transferred from the MICU to the floor on [**8-17**], but then
was transferred back to the MICU after becoming somnolent and
agitated, as well as hypoxic. She was again treated with bipap,
with improvement in her mental status. She had a CTA negative
for PE and cxr consistent with improving volume overload. She
was seen by the sleep service, who diagnosed obstructive sleep
apnea and obesity hypoventilation syndrome. They recommended
initiation of BIPAP at a higher pressure, with ABG checks, and
allowing hypoxia to stimulate respiratory drive, so that goal O2
sat in the mid 80% range. She will need a formal sleep study as
an outpatient to test different masks as well as different
pressure settings. At discharge, her O2 sat was 87% on 2L, and
her most recent ABG showed a HCO3 of 71, ph 7.41.
.
She remains DNR/DNI.
.
# Acute diastolic CHF exacerbation: Her respiratory
decompensation appeared multifactorial, with admission CXR
appearing volume overloaded. She was diuresed on her home dose
of lasix, until she developed evidence of contraction alkalosis,
and then it was held. She was discharged on her home dose of
lasix, with daily weights.
# NSVT: She had a single 9-beat run of NSVT in the ICU. Repeat
EKG and lytes NL.
.
# DM2: While in the MICU the patient had elevated blood sugars.
She was managed with her glyburide and sliding scale insulin.
Her glyburide was increased at discharge to 10 mg po bid.
# Hyperlipidemia: simvastatin
.
# Acute encephalopathy: [**3-3**] hypercarbia exacerbated by
steroids. She was initially continued on her home regimen of
abilify, risperdal, and artane with haldol prn for extreme
agitation. Ultram, rozerem, benadryl were held. On her second
visit to the ICU, due to [**Month/Day (2) **] agitation, she was also seen
by psychiatry. They recommended holding risperdal as needed for
acute agitation. Her mental status improved to baseline with
improvement in her hypercarbia. Her benadryl and ultram were
not restarted.
.
# FEN: She underwent swallow evaluation, and failed. She
appears to aspirate chronically. Her daughter [**Name (NI) 65262**] (also HCP)
was aware but refused recs and instead compromised to soft,
thickened liquids.
.
# Code: DNR/DNI.
-has ICD in place, interrogated 1m ago. Still active.
Medications on Admission:
tylneol 100mg q6h
tramadol 50mg q6h
lidocaine patch daily
fluticacone propionate nasal spray QID
rozerem 8mg qhs
lasix 80mg qam
glyburide 5mg [**Hospital1 **]
toprolol 25mg daily
ASA 81mg daily
colace 100mg qhs
levothyroixine 125mcg daily
medroxyprogestrone 10mg daily
simvastatin 20mg daily
diphenhydramine 50mg qhs
abilify 40mg qhs
risperdal 3mg qhs
artane (ictrihexyphenidyl) 2mg qhs
prenatal multivit daily
calcium wiht Vit D
selenium 200 mcg daily
phoslo 667 x 2 TID
KLor-con
zinc
vit B1
duo neb [**3-5**] x daily
advair HFA daily
spriva 18mcg daily
NTG prn
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILYI ().
3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal four times a day.
5. Rozerem 8 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): 10 mg in AM, 5 mg in PM.
Disp:*90 Tablet(s)* Refills:*0*
7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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: One (1) Tablet PO DAILY
(Daily).
11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
13. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. Trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO three times a day.
17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
19. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for SOB, wheezing.
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for SOB.
22. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Hypercarbic Respiratory Failure
Obstructive Sleep Apnea
Obestiy Hypoventilation Syndrome
Acute diastolic CHF exacerbation
Chronic diastolic CHF
Schizophrenia
Acute encephalopathy, metabolic
Discharge Condition:
Stable, O2 sats 87 % on 2L, BIPAP 18/10 at night.
Discharge Instructions:
You were admitted with confusion due to your breathing problems.
[**Name (NI) **] improved with BIPAP in the ICU, as well as with removing
fluid from your lungs. Your oxygen level should stay between
83 and 88%, but less than 90%.
You need to use your BIPAP every night at home. The sleep
doctors [**Name5 (PTitle) **] contact [**Name5 (PTitle) **] to set up an appointment for a new
sleep study.
Weigh yourself every day and call your doctor if your sweight
goes up more than 3 lbs.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L
Return to the ED if you develop more confusion, trouble
breathing, chest pain, palpitations, nausea, vomiting, diarrhea.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2132-9-2**] 11:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2132-9-2**] 12:00
.
Call the sleep clinic at [**Telephone/Fax (1) 65269**] to set up an appointment
with Dr. [**Last Name (STitle) **] in [**2132-9-30**]. The sleep center will call
you regarding a sleep study before then ( in the next 2 weeks) .
.
Call the [**Hospital6 733**] at [**Telephone/Fax (1) 1247**] to get a
primary care doctor here at the [**Hospital1 18**].
.
|
[
"278.00",
"414.00",
"295.60",
"V45.81",
"427.1",
"348.31",
"327.23",
"285.9",
"518.81",
"V45.02",
"491.21",
"428.33",
"564.00",
"428.0",
"244.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9120, 9206
|
3663, 6466
|
331, 337
|
9439, 9490
|
2365, 3640
|
10277, 10935
|
1681, 1716
|
7079, 9097
|
9227, 9418
|
6492, 7056
|
9514, 10254
|
1731, 2346
|
277, 293
|
365, 1163
|
1185, 1458
|
1474, 1665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,188
| 189,827
|
15201
|
Discharge summary
|
report
|
Admission Date: [**2163-12-28**] Discharge Date: [**2163-12-30**]
Date of Birth: [**2085-4-11**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
gentleman with a history of nonsmall lung cancer, diagnosed
in [**2151**], status post left main stem bronchus stent placement
in [**2160**], which was subsequently removed after the stent was
displaced. The patient was admitted recently for a complaint
of shortness of breath. There was a plan for a new stent
placement on [**2163-11-29**], however, the device did not
fit correctly and the patient had to have a custom made
Y-stent. Therefore, the patient was readmitted on [**2163-12-28**] for placement of a Y-stent in his main stem bronchus
bilaterally.
PAST MEDICAL HISTORY:
1. Nonsmall cell lung cancer, diagnosed in [**2151**], status post
left main stem bronchus stent placement, status post
radiation therapy, status post Taxol and carboplatin times
six months, status post Navelbine and carboplatin times 12
months in [**2160**].
2. History of colon cancer in [**2158**], status post resection
with positive lymph nodes, recurrent in [**2163**], status post
laser treatment.
3. History of pericardial effusions in [**2161**], status post
pericardial window.
4. Gastroesophageal reflux disease.
5. Benign prostatic hypertrophy, status post transurethral
resection of prostate.
6. Appendectomy.
7. Hernia repair.
MEDICATIONS ON ADMISSION: Combivent meter dose inhaler one
to two puffs q.6h.p.r.n., Proscar 5 mg p.o.q.d., Prevacid 30
mg p.o.q.d.
PHYSICAL EXAMINATION: Physical examination on admission was
not noted in the chart, however, on physical examination on
transfer, the patient had a temperature of 100.1, heart rate
75, blood pressure 110/60, respiratory rate 24 and oxygen
saturation 94%. General: Alert and oriented times three,
sitting in a chair, conversant without shortness of breath.
Cardiovascular: Regular rate and rhythm, normal S1 and S2,
no murmur, rub or gallop, no elevated jugular venous
pressure. Respiratory: Coarse breath sounds, port in place
over anterior chest wall, no erythema or tenderness over
port. Abdomen: Soft, nontender, nondistended, positive
bowel sounds, no hepatosplenomegaly. Extremities: Thin,
warm without edema, no splinting of nails, no clubbing or
cyanosis.
LABORATORY DATA: Admission laboratory testing was within
normal limits.
HOSPITAL COURSE: 1. Pulmonary: The patient had Y-stents
placed bilaterally in his main stem bronchus. The patient
tolerated the procedure well and was doing well
postoperatively. The patient was extubated on the day
following the procedure. The patient did well throughout
that day, ambulating without shortness of breath. The
patient maintained oxygen saturations of 94% to 96% in room
air. The patient was regularly using his incentive
spirometer. During the procedure, the patient had a
respiratory broncho-alveolar lavage, which was negative for
organisms. Therefore, antibiotics were discontinued post
procedure.
2. Fluids, electrolytes and nutrition: The patient was
advanced from clear liquids to a house diet during the
postoperative day. The patient was tolerating food well and
drinking Boost supplements.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS:
Combivent meter dose inhaler one to two puffs q.6h.p.r.n.
shortness of breath or wheezing.
Proscar 5 mg p.o.q.d.
Prevacid 30 mg p.o.q.d.
FINAL DIAGNOSES:
1. Nonsmall cell lung cancer.
2. Status post bilateral bronchus Y-stent placement.
RECOMMENDED FOLLOW-UP: The patient was to call Dr. [**Last Name (STitle) **]
[**Name (STitle) 24787**] in one week for follow-up. He was also to follow up
with his pulmonologist in [**State 108**]. In addition, the patient
may return to [**Location (un) 86**] in two months for a follow-up visit with
Dr. [**Last Name (STitle) **], however, the patient will discuss this with his
pulmonologist in [**State 108**], with Dr. [**Last Name (STitle) **] and with Dr. [**Last Name (STitle) 24787**]
for final arrangements for follow-up in [**Location (un) 86**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36
D: [**2163-12-30**] 05:54
T: [**2163-12-31**] 18:05
JOB#: [**Job Number 44261**]
|
[
"162.8",
"458.29",
"530.81",
"600.00",
"519.1",
"196.2",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"33.24",
"96.05",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3330, 3468
|
1458, 1565
|
2431, 3244
|
3485, 4391
|
1588, 2413
|
168, 760
|
782, 1431
|
3269, 3307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,025
| 170,945
|
3673
|
Discharge summary
|
report
|
Admission Date: [**2102-11-20**] Discharge Date: [**2102-11-29**]
Date of Birth: [**2040-1-30**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic endometrial cancer to the liver plus diaphragmatic
involvement.
Major Surgical or Invasive Procedure:
[**2102-11-20**] Right hepatic lobectomy, cholecystectomy, resection of
a portion of the right hemidiaphragm with repair, a 32-French
chest tube placement and excision of cystic duct lymph node.
History of Present Illness:
Per Dr.[**Name (NI) 1369**] note: "The patient is a 62-year-old female who
underwent exploratory laparotomy, peritoneal washings, total
abdominal hysterectomy, tumor debulking, sigmoid colectomy and
primary anastomosis, infracolic
omentectomy for endometrial adenocarcinoma. She has been treated
with chemotherapy and radiation therapy but first presented with
liver metastases on a CT scan in [**2101-8-21**]. At that time
there was a 4.0 x 2.5 cm mass that was thought to be either
within the liver or represent a serosal implant.
Follow-up CT scans since then have shown continued enlargement
of the mass. A CT on [**10-24**] demonstrated a large
heterogeneous lesion in segment VII/VIII of the liver that
increased in size and now measures 11.9 x 8.5 cm. The
right hepatic vein was occluded and the lesion extended to the
border of the left middle hepatic vein. The portal vein and
splenic vein and SMV were patent. CT scan of the chest
demonstrated no evidence of pulmonary metastases. CT of the
pelvis demonstrates a mass in the left pelvis that has also
increased in size compared to last exam. Therefore, the plan is
for combined procedure with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] from GYN oncology. She
has provided informed consent for right hepatic lobectomy,
cholecystectomy, and intraoperative ultrasound."
Past Medical History:
Met endometrial ca, s/p TAHBSO, sigmoidectomy ('[**96**]), chemo/XRT
Social History:
non-smoker, non-ETOH
She is a retired teacher. Never married. No children
Family History:
paternal aunt with endometrial CA
Physical Exam:
97.5 94 120/62 20 100%RA 5'6", 59.5kg
A&O,thin
HEENT:anicteric sclerae
Neck: free range of motion
Lungs: clear
Cor: RRR,
Abd: ND/NT, soft, no palpable massess, liver palpable beneath
the right costal margin on inspiration
Ext no edema
Pertinent Results:
On admission: [**2102-11-20**]
WBC-9.7# RBC-2.99* Hgb-9.8* Hct-27.8* MCV-93 MCH-32.9*
MCHC-35.4* RDW-14.5 Plt Ct-325
PT-14.3* PTT-30.0 INR(PT)-1.2*
Glucose-158* UreaN-13 Creat-0.5 Na-143 K-3.9 Cl-111* HCO3-22
AnGap-14
ALT-310* AST-460* AlkPhos-75 TotBili-1.9*
Albumin-3.1* Calcium-8.7 Phos-3.7 Mg-1.6
On Discharge: [**2102-11-29**]
WBC-7.7 RBC-3.61* Hgb-11.3* Hct-32.8* MCV-91 MCH-31.3 MCHC-34.5
RDW-14.0 Plt Ct-265
Glucose-113* UreaN-11 Creat-0.5 Na-136 K-3.3 Cl-96 HCO3-35*
AnGap-8
ALT-55* AST-31 AlkPhos-135* TotBili-0.9
Albumin-2.8* Calcium-8.3* Phos-3.8 Mg-1.7
Brief Hospital Course:
On [**2102-11-20**], she underwent right hepatic lobectomy,
cholecystectomy, resection of a portion of the right
hemidiaphragm with repair, a 32-French chest tube placement and
excision of cystic duct lymph node for metastatic endometrial
cancer to
the liver plus diaphragmatic involvement. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative reports from Drs. [**Last Name (STitle) **]
and [**Doctor Last Name **] Per Dr.[**Name (NI) 1369**] note, "after resection of the
mass,margins were felt to be 1-2 mm, although with argon beam of
the cut surface of the liver that provides an additional 3-4 mm
of margin. The microscopic sections were negative for
involvement of the margin."
Exploration of the pelvis demonstrated a mass in the left
pelvis. Also, per Dr.[**Name (NI) 1369**] note, "It should be noted in
closing the diaphragm, we had to be careful not to narrow or
distort the vena cava going through into the right atrium."
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] performed a primary repair of the umbilical
hernia.
Postop, she was transferred to the SICU intubated for
management. She received IV boluses and albumin for hypotension
and low urine outputs with good response. Hct trended down to 25
from 34.7 on [**11-10**]. The chest tube was maintained to suction.
Pain was well controlled with an epidural. She was extubated on
[**11-21**]. LFTs trended down.
On [**11-23**] she became tachycardic to the 120-140 range. An EKG
revealed sinus tach. A chest xray demonstrated apical
pneumothorax. Hct was stable at 27.3. Urine output was low.
Albumin was given. A repeat hct was 25. Two units of PRBC were
given.
On [**11-26**] she was started on beta blockade with good response.IV
lasix was given to diurese her as her wt was up significantly
from baseline.
Chest tube was put to water seal and then removed on [**11-27**]. CXR on
[**11-28**] showed the right apical pneumothorax to be smaller, and on
[**11-29**] showed further resolution.
She was ambulatory, vital signs were stable and she was
tolerating a regular diet. The JP drain continued to have
outputs ranging between 400-700cc of yellow-gold colored fluid,
she will d/c home with this drain. A JP bilirubin was 2.5 on
[**11-25**]. The incision was c/d/i. Staples and sutures removed by the
respective teams prior to discharge.
Medications on Admission:
Coenzyme Q10, Compazine, fish oil, flaxseed, glucosamine, MTV
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed: PRN Pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Medications
[**Month (only) 116**] continue Home regimen of supplements/Vitamins
Discharge Disposition:
Home
Discharge Diagnosis:
metastatic endometrial CA to liver
right apical pneumothorax
sinus tachycardia
pelvic mass
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever >101,
chills, nausea, vomiting, yellowing of eyes or skin, inability
to eat,take or keep down medications.
Measure and record drain output at least twice daily, more often
as necessary. Note changes in drain output, color changes or if
it develops a foul odor. Bring record of drain output with you
to Dr [**Last Name (STitle) 4727**] office.
Monitor incision for redness, drainage or bleeding.
Continue stool softener as long as you are taking narcotic pain
medications
Do not drive if taking narcotic pain medication
No heavy lifting
You may shower, pat incision dry. Place dressing around drain
site, change daily
You have started on a new medication called metoprolol, that
will help control your heart rate. When standing up, do so
slowly. Monitor for dizziness, lightheadedness as this
medication can also lower blood pressure
Followup Instructions:
Dr [**Last Name (STitle) 4727**] office ([**Telephone/Fax (1) 673**]) will contact you for appointment
Weds [**2102-12-6**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2102-12-21**] 11:30
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2103-3-7**]
9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2102-11-29**]
|
[
"276.50",
"512.1",
"198.89",
"196.2",
"553.1",
"197.7",
"197.5",
"V10.82",
"E878.6",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.81",
"51.22",
"34.04",
"50.3",
"40.11",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
6011, 6017
|
3020, 5434
|
344, 541
|
6152, 6159
|
2430, 2430
|
7120, 7655
|
2119, 2154
|
5546, 5988
|
6038, 6131
|
5460, 5523
|
6183, 7097
|
2169, 2411
|
2745, 2997
|
229, 306
|
569, 1919
|
2444, 2731
|
1941, 2011
|
2027, 2103
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,598
| 163,243
|
11396+56236
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-12-9**] Discharge Date: [**2136-12-20**]
Date of Birth: [**2086-6-10**] Sex: M
Service: Medicine
NOTE: This is an interim discharge summary.
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
male with past medical history significant for biventricular
heart failure with an ejection fraction of 20 to 25%, no coronary
artery disease per catheterization in [**2135-10-20**], insulin
dependent diabetes mellitus, congestive heart failure,
hypertension and chronic renal insufficiency who presented to the
Emergency Department with complaints of nausea, vomiting as well
as progressive shortness of breath x24 hours. In addition, he is
also having bilateral shoulder pain. Prior to his symptoms, the
patient felt he had a "cold" coming on with chills, but no
fevers. His nausea and vomiting prevented him from taking his
medications, including his Lasix and also had a decreased po
intake. The patient denied any cough, abdominal pain, urinary
symptoms, and shortness of breath prompted him to come to the
Emergency Department.
In the Emergency Room, the patient was intubated for hypoxic
respiratory therapy. The patient was given 140 mg intravenous of
Lasix and 10 units of regular insulin, 5 mg Lopressor
intravenous, sedation, and intravenous fluids only initially.
The patient received 2 gm of ceftriaxone.
PAST MEDICAL HISTORY:
1. Biventricular heart failure, unclear etiology (left
ventricular ejection fraction of 20 to 25% in [**2135-10-20**])
2+ mitral regurgitation, 2+ tricuspid regurgitation, moderate
pulmonary hypertension
2. Of note, the patient had catheterization [**2135-10-20**]
that revealed no coronary artery disease.
3. Insulin dependent diabetes mellitus
4. Chronic renal failure with a baseline creatinine of 4.2
to 4.5.
5. Diabetic retinopathy
6. Hypertension
7. Hypercholesterolemia
8. Congestive heart failure
MEDICATIONS:
1. Prilosec 40
2. Lipitor 10
3. Lasix 120
4. Digoxin 1.25 q od
5. Toprol XL 50
6. Zaroxolyn 5
7. Norvasc 10
8. Amaryl 4 q hs
9. Iron sulfate [**Hospital1 **]
10. Humalog 6 units, 7 units, 8 units
ALLERGIES: ACE INHIBITOR CAUSES COUGH. ASPIRIN WAS NOT
RECOMMENDED PER OPHTHALMOLOGY.
SOCIAL HISTORY: The patient is on disability, lives with
wife, denies smoking, alcohol use, intravenous drug use.
PHYSICAL EXAM UPON PRESENTATION:
VITAL SIGNS: 95.8??????, blood pressure 158/78, heart rate
between 98 to 121, respiratory rate in 30s and patient was
98% though per Emergency Department note ventilation setting
was nausea and vomiting.
GENERAL: The patient was intubated and sedated.
HEAD, EARS, EYES, NOSE AND THROAT: Reactive left pupil and a
surgical right pupil.
CARDIAC: Normal, S1, S2 and tachycardia.
LUNGS: Diffuse coarse rales bilaterally.
ABDOMEN: Benign.
EXTREMITIES: No cyanosis, clubbing, edema, no bilateral
extremities.
LABORATORY DATA UPON ADMISSION AND IMAGING: White blood cell
count was 17.1, hematocrit 33.2, platelets 272, MCV 88 with a
differential of 93% neutrophils, no bands 4.4 lymphocytes,
2.1 monocytes, no eosinophils. Chem-7 notes a sodium 131,
potassium 5.3, chloride 98, bicarbonate 8, BUN 91 which is up
from a baseline of 70 to 90 and a creatinine of 5.1 up from a
baseline of 4.2 to 4.5 and a glucose of 375. Phosphate 6.8,
magnesium 1.5, PT 14.4, INR 1.4, PTT of 29.9. AST 30, ALT
42, alkaline phosphatase 118, LDH 507, amylase 54, lipase 49.
Serum acetone was negative. In initial cardiac enzymes, CK
of 966 with an MB of 7 and troponin of 0.3.
Electrocardiogram showed sinus tachycardia with left axis
deviation, normal intervals, T-wave inversions in V5 through
V6, questionable ST elevation of V3 and left atrial
enlargement compared to baseline. A chest x-ray showed
bilateral patchy diffuse infiltrates consistent with
congestive heart failure, ARDS versus a multilobar pneumonia.
Preintubation arterial blood gas showed a pH of 7.19/23/70.
HOSPITAL COURSE: The patient is a 50-year-old male with
history of biventricular heart failure nonischemic in origin,
diabetes mellitus, hypertension, chronic renal failure
presenting with apparent congestive heart failure
exacerbation, acute on chronic renal failure and metabolic
acidosis.
1. Hypoxic respiratory failure: Secondary to congestive heart
failure exacerbation given no history of biventricular failure,
though exact etiology unclear. [**Name2 (NI) 116**] be secondary to decreased
medication compliance in the setting of viral syndrome and poor
po intake. Cardiac enzymes may remain negative, however patient
had an increased CK. The patient was given Lasix in the Medical
Intensive Care Unit and diuresed about 6 liters over the first
two hospital days. The patient was successfully extubated on
hospital day #3 and was called out to the floor on the following
day with O2 saturation of 97% on 4 liters nasal cannula. The
patient was diuresed throughout the remainder of his hospital
stay. The patient was also continued on hydralazine, Imdur, and
digoxin. The patient remained fluid restricted with strict Is
and Os. The patient was treated with bicarbonate in the Medical
Intensive Care Unit, with improvement of his acid based status.
Upon transfer to the floor, the patient had a resolved metabolic
acidosis.
2. Acute on chronic renal failure: The renal service was
consulted for further diagnosis and management of the renal
issues. Impression is that this acute on chronic renal failure
was likely to be secondary to ATN due to perhaps a component of
elevated CPKs and hypoperfusion. The patient's creatinine level
peaked to a level 5.6 on hospital day #3 and then remained stable
with continued improvement and decrease in daily creatinine
levels throughout the remainder of hospital stay. The patient
continued to have good urine output through this time and the
patient was continued on Epo and Phos-Lo for his renal failure.
3. Infectious disease: The patient presented with a viral type
syndrome. However, in the Medical Intensive Care Unit, the
patient developed fevers of unclear source. The patient was pan
cultured, though culture remained negative and was started on
antibiotics which was discontinued upon arrival to the floor
given patient's defervescence by that time. The patient remained
afebrile with a decreased white blood cell count through the
remainder of hospital stay. Source of fever is unknown at the
time of discharge.
4. Endocrine: The patient has a history of diabetes mellitus
and requires an insulin drip while in the unit. Prior to transfer
to the floor from the Intensive Care Unit, this insulin drip was
discontinued and the patient was covered with a regular insulin
sliding scale. The patient was then started on NPH and continued
on a regular insulin sliding scale throughout the remainder of
hospital stay with good glycemic control.
5. Gastrointestinal: Upon returning to the floor, the patient
again experienced symptoms of nausea and episodes of emesis. The
patient was treated symptomatically with Compazine and diet
changed to clear liquids at the time of discharge. This is
likely due to perhaps similar gastroenteritis that the patient
experienced at presentation.
He is to be discharged to a rehabilitation facility. He will
follow up with his PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in [**Company 191**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 4626**]
MEDQUIST36
D: [**2136-12-15**] 17:58
T: [**2136-12-20**] 10:49
JOB#: [**Job Number 36443**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6502**]
Admission Date: [**2136-12-9**] Discharge Date: [**2136-12-20**]
Date of Birth: [**2086-6-10**] Sex: M
Service: [**Location (un) 571**]
Place of discharge to be filled in later, likely short term
rehabilitation.
Hospital course, from Dr.[**Name (NI) 6503**] date of last dictation, which
will be [**2136-12-16**] to [**2136-12-19**].
This is a 50 year old male with biventricular CHF and EF of 20%
who was admitted with acute on chronic renal failure and CHF
exacerbation.
1. CHF. The patient's respiratory status improved and he
began to saturate well in room air at 96% at the time of this
dictation. Patient was at his dry weight of 55 kg at the time of
this dictation as well. We will continue Lasix 80 q.d. which
seems to strike a good balance between his congestive heart
failure and his acute on chronic renal failure.
2. CAD. The patient had no further episodes of coronary
complaints. He will be continued on his beta blocker.
3. Renal. The patient had improvement of his acute on
chronic renal failure and was back to his baseline creatinine
of 4.6 at the time of this dictation. He will continue to have a
2 liter per day fluid restriction and Lasix 80 p.o. q.d.
4. Insulin dependent diabetes mellitus. Patient's blood sugars
were controlled fairly well on the schedule of NPH 16 units in
the a.m., 6 units in the p.m. and Humalog insulin sliding scale
starting with 2 units at 150 and going up 2 units for every 50 of
blood sugar increase.
5. FEN. The patient had previously complained of some nausea
and had orthostatic blood pressure changes earlier on in his
diuresis. At this time he is no longer nauseous and no longer
orthostatic and euvolemic. He should be on a [**2133**] cc per day
fluid restriction and a p.o. diabetic diet of 1800 calories.
DISCHARGE MEDICATIONS:
1. Lasix 80 mg p.o. q.d.
2. Humalog insulin sliding scale.
3. NPH 16 units in a.m., 6 units in p.m.
4. Ipratropium one two puffs inhaled q.i.d.
5. Calcium acetate two tabs t.i.d. with meals.
6. Percocet one to two q.six hours p.r.n.
7. Epo 4000 units subcu t.i.weekly.
8. Hydralazine 50 mg p.o. q.six hours.
9. Metoprolol 25 mg p.o. t.i.d.
10. Amlodipine 10 mg p.o. q.d.
11. Isosorbide mononitrate 30 mg p.o. q.d.
12. Digoxin 0.125 mg p.o. q.o.d.
13. Protonix 40 mg p.o. q.d.
The patient should have daily weight and Is and Os checked.
If he begins to be consistently greater than 500 cc positive,
he can have his Lasix increased to 100 to 120 mg p.o. q.d.
and perhaps have his renal electrolytes checked to make sure
that this increase is not worsening his renal function.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Acute on chronic renal failure.
3. Acidosis.
4. Diabetes.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Last Name (NamePattern4) 6504**]
MEDQUIST36
D: [**2136-12-19**] 12:27
T: [**2136-12-19**] 12:23
JOB#: [**Job Number 6505**]
|
[
"250.51",
"362.01",
"584.5",
"518.81",
"403.91",
"276.2",
"272.0",
"780.6",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.13",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10395, 10743
|
9589, 10374
|
3946, 9566
|
215, 1369
|
1391, 2213
|
2230, 3928
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,427
| 107,136
|
33560
|
Discharge summary
|
report
|
Admission Date: [**2150-3-15**] Discharge Date: [**2150-3-24**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
New onset atrial fibrillation, poor urine output
Major Surgical or Invasive Procedure:
RIJ CVL placement and removal
Arterial line placement
RIJ temporary HD catheter placement
R PICC placement
Hemodialysis
History of Present Illness:
75 yo M h/o obesity, DM2, CRI (baseline cr 2.5), CHF,
chronically vent dependent [**1-17**] [**12-23**] PNA, presented from [**Hospital 671**]
Rehab after pt was noted to be in new atrial fibrillation. Pt's
available medical records are minimal at this time. Pt was
admitted to [**Location 1268**] VA in [**12-23**] for hypoxemic and subsequent
hypercarbic respiratory failure, ultimately requiring two
intubations.During that hospitalization, because of failure to
wean, pt was trached. Pt was diagnosed with VAP (microorganism
unknown), treated with cefepime. Pt was discharged ([**2-9**]) to
[**Hospital 671**] Hospital for longterm vent management/weaning. The
patient developed a gradual decline in his urine output. Labs at
the time revealed a cr elevated to 5.3. The patient was admitted
to [**Hospital6 **] on [**2-20**] for further evaluation of his
renal failure. During that admission the patient became volume
overloaded and was admitted to the MICU for initiation of HD.
The patient's course was complicated by citrobacter and VRE
bacteremia as well as acinetobacter growing from the sputum. The
pt was started on a 2 week course of linezolid and imipenem. The
pt's UOP improved to the point he no longer needed dialysis. He
was discharged [**3-4**]. Following discharge the pt was stable until
today when it was noted that his UOP had fallen to less than 20
130s (A fib) with stable BP. He was transferred to [**Hospital1 **] for futher
management.
Past Medical History:
# DM2
# CRI (baseline 2.5)
# CHF
# Trached and vent dependent [**1-17**] PNA
# Morbid obesity
Social History:
lives with wife, who is HCP
Family History:
Non-contributory
Physical Exam:
# VS: T102.4, BP117/65, HR151, RR32, O2sat 91, PS 15/10 Fi 100%
Gen: slightly anxious, mouthing answers to questions
appropriately
HEENT: MM dry
CV: irreg irreg, tachy, no murmurs
Chest: diffusely poor air movement, minimal at bases
Abd: obese, soft, NT, ND, +BS
Ext: brawny edema in LE, venous stasis changes
Neuro: following commands
Pertinent Results:
Admission Labs:
[**2150-3-15**] 09:05PM BLOOD WBC-10.7 RBC-3.73* Hgb-10.4* Hct-32.8*
MCV-88 MCH-27.9 MCHC-31.8 RDW-18.7* Plt Ct-174
[**2150-3-15**] 09:05PM BLOOD Neuts-86.2* Bands-0 Lymphs-8.9*
Monos-1.7* Eos-3.0 Baso-0.3
[**2150-3-15**] 09:05PM BLOOD PT-15.0* PTT-31.5 INR(PT)-1.3*
[**2150-3-15**] 09:05PM BLOOD Glucose-129* UreaN-129* Creat-4.4* Na-137
K-4.7 Cl-99 HCO3-24 AnGap-19
[**2150-3-15**] 09:05PM BLOOD ALT-5 AST-13 CK(CPK)-11* AlkPhos-169*
TotBili-0.3
[**2150-3-15**] 09:05PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier **]*
[**2150-3-15**] 09:05PM BLOOD cTropnT-0.20*
[**2150-3-15**] 09:05PM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-2.2
.
Studies:
CXR [**3-15**]: Markedly limited study. A PICC line from a right upper
extremity approach is evident with the line extending at least
to the superior vena cava. The exact tip is not seen. There is
diffuse interstitial and alveolar edema. A left lower lobe
consolidation cannot be excluded. Small bilateral pleural
effusions are noted
.
EKG [**3-15**]: afib, rate 127, VPCs, RBBB
.
Renal US [**3-17**]:
Note is made that this is an extremely limited ultrasound due to
the patient's body habitus. The left kidney was not visualized
on this examination. The right kidney measures 12.0 cm, and no
hydronephrosis is appreciated. Ultrasound is unable to further
characterize the kidney due to the poor visualization.
.
Bronchoscopy [**3-24**]:
No evidence of trauma, thin frothy pink secretions consistent
with pulmonary edema.
Brief Hospital Course:
A/P: 74M h/o morbid obesity, DM2, CRI, chronic vent dependency,
p/w poor UOP and A fib, now with clinical picture concerning for
sepsis
.
# Sepsis: Patient met SIRS criteria with temperature >102 and
hypotension with SBP 80s. He was given broad spectrum abx
including linezolid given his h/o VRE,
cefepime for broad gram neg coverage in this longterm rehab and
hospital resident, as well as his home flagyl. His cefepime was
changed to meropenem per ID given his h/o resistant
acinetobacter. A RIJ CVL was placed for pressors and CVP
monitoring. He was given IVF to maintain CVP>8 and initially
required neo to maintain MAP >60. Pressors were weaned off on
HD #2. The patient was pan-cultured including urine, blood and
sputum. In addition, his R PICC line was removed and tip was
sent for culture. His urine was felt to be the source as
cultures returned positive for >100,000 colonies of
pan-sensitive pseudomonas. He was continued on meropenem and
his flagyl and linezolid were discontinued. Stool was c diff
negative. In addition, the patient had 2 species of GNR in his
sputum, these were not identified at the time of transfer. The
patient remained hemodynamically stable and afebrile for the
remainder of his hospital stay. Blood cultures were negative at
the time of transfer. He was continued on meropenem to cover
possible pulmonary infection as well as UTI, last dose to be
given [**2150-3-25**].
.
# Acute on chronic renal failure: Cr on admission was elevated
to 4.4 which was above his baseline of 1.9. His acute renal
failure was felt to be in the setting of sepsis. On prior admit
he required aggressive treatment with pressors to resume UOP
after being oliguric for a period. A renal consult was obtained
who felt that his renal failure was [**1-17**] ischemic ATN in the
setting of sepsis. A renal US was obtained that showed a normal
right kidney without hydronephrosis. Left kidney was not
visualized due to body habitus. His Cr continued to trend up
and was 4.8 on [**3-20**]. A trial of diuresis with diuril 500mg and
lasix 160mg was attempted per renal with only 60cc of UOP.
Given his volume overload and oliguria a temporary RIJ HD line
was placed by IR on [**3-20**] and HD was initiated the same day. His
last HD session was [**3-23**] which he tolerated well. His
medications were renally dosed.
.
# Respiratory distress: Admission CXR showed possible b/l
infiltrates vs. pulmonary edema, however was extremely limited
due to body habitus. Was on broad-spectrum antibiotics with GNR
in sputum. He was primarily maintained on PS ventilation 12/5,
however patient was subjectively SOB and his pressure support
was increased to 15 on [**3-20**] despite stable O2 sats. He was tried
on trach collar, however the patient requested to be placed back
on vent due to SOB. He did not have a significant amount of
secretions and remained afebrile and his b/l infiltrates were
felt to be [**1-17**] pulmonary edema rather than infection. He was
initiated on HD for fluid removal on [**3-20**]. Anxiety was felt to
be contibuting significantly to his inability to wean from the
vent. He was started on Klonopin and Celexa on [**3-21**] to be
uptitrated as necessary. On [**3-23**] the patient developed some
bloody secretions from his trach in the setting of initiating
anticoagulation. A bronch was performed on [**3-24**] that showed
****. His coumadin was held and decision to restart deferred
*****.
.
# Atrial fibrillation: new onset in the setting of sepsis.
Remained in afib throughout his hospital stay. He was started
on low dose BB for rate control with good effect. Once his PICC
and HD line were placed he was started on coumadin. His BB was
uptitrated as his BP tolerated to a dose of 50mg tid. His HR
remained well-controlled with HR 80s-90s. INR on day of
discharge was 2.5 on a dose of 5mg coumadin. He should continue
his coumadin dose with close INR monitoring - every three days
for the first two weeks, and then prn for appropriate coumadin
dose adjustments to keep INR at goal of [**1-18**].
.
# hemoptysis: on the day of discharge the patient was having
scant hemoptysis and bronchoscopy was performed. He had pink
frothy secretions consistent with pulmonary edema and no
evidence of trauma. The etiology of his scant hemoptysis is
likely pulmonary edema only.
.
# DM2: He was maintained on his outpatient regimen of lantus
54units qam and RISS.
.
# FEN: He was continued on TFs per nutrition
.
# ppx: he was kept on PPI while in-house but this is
discontinued as of [**3-24**], no heparin to be given after discharge
as he is therapeutic on warfarin.
.
# Access: R IJ removed [**3-19**], R PICC placed [**3-19**], RIJ temp HD line
placed [**3-20**].
.
# Comm: son [**Name2 (NI) **] and wife/HCP [**Name (NI) 77789**] [**Telephone/Fax (1) 77790**]
.
# Code: Full (per discussion with wife and son)
Medications on Admission:
lantus 54 units QAM
pro-amatine 5 mg daily
aranesp 40 mcg
novolog sliding scale
lactulose 30 mL qid
combivent 4 puffs qid
silvadene
desenex
vitamin c
dulcolax
phoslo 667 mg tid
nexium 40 mg daiily
asa 81 mg daily
flagyl 500 mg tid
tylenol
bicitra 30 ml [**Hospital1 **]
heparin 5000 tid
zocor
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP<100 or HR <65.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Titrate dose to goal INR [**1-18**].
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN ()
as needed for anxiety.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Meropenem 500 mg Recon Soln Sig: 500mg Recon Solns
Intravenous Q12H (every 12 hours) for 1 days.
13. Insulin Glargine 100 unit/mL Solution Sig: Fifty Four (54)
units Subcutaneous qam.
14. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection with meals.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Sepsis
Acute on Chronic Kidney Disease
Atrial fibrillation, new onset
Pseudomonas UTI
Chronic respiratory failure, vent dependent
Diabetes
Morbid obesity
Discharge Condition:
Afebrile. Vent dependent.
Discharge Instructions:
You were admitted to the medical ICU with rapid heart rate and
low urine output. You were found to have an infection in your
urine that was likely causing your symptoms. You were started
on an IV antibiotic called meropenem and will need to complete a
10-day course. You have 1 more day of antibiotics.
.
You were also found to be in an irregular heart rate called
atrial fibrillation. You were started on a medication called
metoprolol to help control your heart rate. Given your
increased risk of stroke you were also started on a
blood-thinning medication called coumadin. This will have to be
monitored closely by your doctor to keep the level between [**1-18**].
.
We also started you on two new medications for your anxiety.
These are called celexa and Klonopin. Your doctors [**Name5 (PTitle) **] adjust
the doses of these to help with your anxiety.
.
Your kidney function declined in the setting of your infection
and the kidney doctors followed [**Name5 (PTitle) **] for this. It was decided to
initiate dialysis and a temporary catheter was placed and you
were started on dialysis. This will have to be continued
indefinitely or until your kidney function improves.
.
Please take all of your medications as prescribed.
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your PCP for coumadin dosing, which will
be adjusted based on bloodwork.
.
Please follow up with nephrology regarding ongoing dialysis.
.
Please check INR in three days and every three days for the next
2 weeks, then as needed to monitor coumadin dosing.
Completed by:[**2150-3-24**]
|
[
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"278.01",
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icd9cm
|
[
[
[]
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] |
[
"96.72",
"38.95",
"39.95",
"33.21",
"38.93",
"38.91",
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icd9pcs
|
[
[
[]
]
] |
10566, 10581
|
4057, 8928
|
363, 485
|
10779, 10808
|
2547, 2547
|
12146, 12454
|
2156, 2174
|
9272, 10543
|
10602, 10758
|
8954, 9249
|
10832, 12123
|
2189, 2528
|
275, 325
|
513, 1977
|
2564, 4034
|
1999, 2095
|
2111, 2140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,661
| 123,365
|
23307
|
Discharge summary
|
report
|
Admission Date: [**2150-11-29**] Discharge Date: [**2150-12-29**]
Date of Birth: [**2124-11-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Chest pain and shortness of breath.
Major Surgical or Invasive Procedure:
-pericardiocentesis in cardiac catheterization laboratory on
[**2150-11-30**]
-Classical Caesarian section on [**2150-12-8**]
History of Present Illness:
The pt is a 26 year-old G1P0 female at 27 [**5-8**] wks who initially
presented to an OSH complaining of fever and pleuritic chest
pain. Five days PTA, the pt developed onset of substernal chest
pain while sitting. She rated the intensity of the pain as a
[**4-11**], radiating to L arm. She added that the pain got steadily
worse over the next several days. She noted that the pain was
exacerbated by exertion. She also developed fevers to 102-103,
and shortness of breath over the days prior to admission. She
was recently seen in OSH ED with complaints of fever, and was
admitted to an OSH from [**Date range (1) 59852**] when she presented again
with fever, weakness, pleuritic cp, and tachycardia at which
time she underwent suboptimal CTA (problem w/ contrast bolus)
and nuclear perfusion scan (ventilation portion not performed)
which was read as normal.
On the day of admission at the outside ED, she was noted to be
tachycardic to 150, saturating 99% on 4L O2 via nasal cannula.
Blood cultures were drawn, and she was started on a heparin drip
over the concern for pulmonary embolus.
On presentation to [**Hospital1 18**], she denied dysuria, urinary frequency,
hematuria, abdominal pain, change in bowel habits, BRBPR,
contractions, vaginal bleeding or spotting, rashes, or skin
breakdown.
She did admit to recent onset of right knee pain and swelling
following syncopal episode 3 weeks PTA, but did not notice pain
until five days PTA. There was no previous history of joint or
muscle pain. She also complained of orthopnea and PND but
denied any increased lower extremity edema.
She also complained of a sore throat that began five days PTA.
She stated that she initially had difficulty swallowing and
could not take solids but had improved over the two-three days
PTA.
Past Medical History:
-h/o malaria as a child
-hypertension
-? PID
Social History:
Originally from [**Country 4574**], she emigrated to the US in [**2140**].
The pt. denied use of tobacco, alcohol or illicit drugs.
Worked as CNA in NH up until three weeks PTA.
Family History:
No history of clotting disorders, CAD lupus.
Physical Exam:
Vitals: T:100.6, BP: 117/59, P: 140, R: 50 SaO2: 95% on 4L via
NC
General: Obese female in mild respiratory distress, speaking in
short sentences, c/o increased SOB w/ speaking.
HEENT: PERRL. Anicteric, MMM, R buccal mucosa 0.5cm white lesion
that cannot be scraped.
Neck: JVP not appreciated [**2-2**] body habitus, 1+ shotty mobile sm
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l
Cardiac: Tachycardic, Regular, s1,s1. no m/r/g
Lungs: CTA b/l
Abdomen: Obese. +bs. soft. nt. nd.
Extremities: 1+ le edema, 2+ dp pulses b/l
Pertinent Results:
CBC and Coags:
[**2150-11-29**] 03:15PM WBC-20.6* RBC-3.48* HGB-9.3* HCT-28.5* MCV-82
MCH-26.8* MCHC-32.6 RDW-13.3
[**2150-11-29**] 03:15PM NEUTS-73* BANDS-21* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2150-11-29**] 03:15PM PT-14.3* PTT-48.7* INR(PT)-1.3
Electrolytes:
[**2150-11-29**] 03:15PM GLUCOSE-134* UREA N-6 CREAT-0.4 SODIUM-133
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
[**2150-11-29**] 03:15PM ALT(SGPT)-63* AST(SGOT)-86* LD(LDH)-218
CK(CPK)-19* ALK PHOS-118* AMYLASE-22 TOT BILI-0.6
[**2150-11-29**] 03:23PM LACTATE-1.1
[**2150-11-29**] 03:15PM LIPASE-21
[**2150-11-29**] 03:15PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-3.0
MAGNESIUM-1.9
[**2150-11-29**] 03:15PM CK-MB-2 cTropnT-0.04*
[**2150-11-29**] 03:15PM FDP-40-80
[**2150-11-29**] 03:15PM FIBRINOGE-700*
[**2150-11-29**] 03:15PM RET AUT-1.3
[**2150-11-29**] 03:15PM TSH-1.8
[**2150-11-29**] 03:15PM HAPTOGLOB-251*
ABG:
[**2150-11-29**] 03:23PM TYPE-ART PO2-67* PCO2-32* PH-7.43 TOTAL
CO2-22 BASE XS--1
Urine:
[**2150-11-29**] 04:30PM URINE HOURS-RANDOM CREAT-130 TOT PROT-168
PROT/CREA-1.3*
[**2150-11-29**] 04:30PM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.020
[**2150-11-29**] 04:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-MOD
[**2150-11-29**] 04:30PM URINE RBC-0 WBC-28* BACTERIA-FEW YEAST-FEW
EPI-8
Joint Fluid:
[**2150-11-29**] 10:15PM JOINT FLUID WBC-[**Numeric Identifier 59853**]* RBC-400*
[**2150-11-29**] 10:15PM JOINT FLUID NUMBER-NONE
CTA: prelim- no PE.
ECG: 140, st elev I,II,III, F, V1, V2, V3, V4 V5, V5, std aVR,
Qw II,III,F
Brief Hospital Course:
1) Pericarditis: The pt's. symptoms and EKG findings were
suggestive of pericarditis. As she also presented with fever and
leukocytosis with bandemia, she was empirically started on
ceftriaxone and azithromycin on admission for a possible
infectious etiology. Given the constellation of the pt's
symptoms, a rheumatologic cause was also in the differential and
a number of serologic tests were sent (all of which eventually
returned negative). On the morning of the second hospital day,
an echocardiogram was performed which revealed a large
pericardial effusion. She was started on indomethacin. A
central venous catheter was inserted and a Swan-Ganz catheter
was floated. This revealed tamponade physiology. Therefore,
the pt. was taken emergently to the cardiac catheterization lab
where she underwent fluoroscopically guided pericardiocentesis.
The pt. tolerated the procedure well and approximately 400 ccs
of viscous yellow fluid was drained. A drain was left in place
for 24 hours which drained approximately 80 more cc of
serosanguinous fluid. The fluid was sent for gram stain as well
as bacterial, fungal, viral and acid fast cultures. On HD #4,
the pericardial fluid grew out [**Female First Name (un) 564**] albicans, at which time
the pt. was started on ambisome. Numerous repeat
echocardiograms were performed over the course of the next week
and a half to assess for reaccumulation of the pericardial fluid
given the pt's. persistent tachycardia and hypoxia. None of
these studies revealed reaccumulation. On HD #3, the pt. was
started on IV steroids as indomethacin was discontinued
secondary to ARF. The pt. reported dramatic improvement in her
chest pain on steroids. She was eventually transitioned to a
slow p.o. steroid taper. The ID service had recommended
treating possible infectious causes with a 2 week course of
ceftriaxone and a 6 week course of ambisome. The patient was
then changed to fluconazle to complete a [**4-7**] week course. She
will be discharged on fluconazole to followup in [**Hospital **] clinic. She
should take 4 more days of prednisone 5mg/ day upon discharge.
2) Fever/Leukocytosis: The pt. was noted to have a low-grade
fever on admission, but defervesced shortly after admission
after initiation of treatment with ceftriaxone and azithromycin.
She began to spike fevers again 9 days into her hospital stay
after her caesarian section. All of the pt's. indwelling lines
were removed and sent for culture. IV vancomycin was
empirically begun for IV empiric treatment. Blood cultures
eventually grew out coagulase negative staph. She was treated
with a total of a 10 day course.
3) Hypoxia: The pt. was noted to be hypoxic on admission. A CTA
was performed which was not suggestive of pulmonary embolus.
She consistently required oxygen by nasal cannula and, at times,
facemask. Her arterial blood gases showed both hypercarbia and
hypoxemia. It was thought that her hypoxia was secondary to
splinting from chest pain, atelectasis and a component of CHF.
After delivery of her baby, the pt's. O2 requirements decreased
and the pt. was noted to be less tachypneic and saturating well
with minimal O2 via nasal cannula.
4)Right knee effusion: The pt. was noted to have an effusion of
her right knee on admission. It was tapped by the rheumatology
service on the night of admission. The fluid was sent for gram
stain and culture which was unrevealing. The knee was re-tapped
for reaccumulation of fluid on HD # 3. An Xray was performed to
rule out fracture given the history of fall and was negative.
The swelling eventually subsided and no further intervention was
undertaken.
5) Pregnancy: The maternal and fetal medicine service as
intimately involved with the pt's. care throughout her MICU
stay. They monitored the fetus daily with ultrasound and
nonstress tests, all of which showed reassuring fetal status.
On HD #9, after concern over the possible development of
preeclamsia secondary to mild epigastric discomfort and rising
LFTs, an elective Caesarian section was performed. The pt.
tolerated the procedure well and delivered a healthy boy who was
immediately transferred to the NICU.
6) Acute renal failure: On HD #2, the pt. was noted to be in
oliguric renal failure, thought to be secondary to both prerenal
and intrinsic renal (ATN) components. She was placed on a lasix
drip for 2 days and was also fluid resuscitated. In addition,
all nephrotoxic agents including indomethacin were discontinued.
Her urine output and serum creatinine improved by HD#4 and the
lasix drip was discontinued. Her renal function remained stable
for the duration of her hospital stay.
7) Anemia: The pt. was noted to have a low hematocrit on
admission. Iron studies, B12 and folate levels and hemolysis
labs were sent. This workup was consistent with anemia of
chronic inflammation. She was transfused a total of 3 units of
PRBCs over the course of HD [**2-4**] to keep her hematocrit above 25
in light of her pregnancy. Her hematocrit remained within the
26-31 range for the remainder of the hospital stay, and she
required no further transfusions.
8) Steroid-induced hyperglycemia: The pt. was noted to have very
elevated serum and fingerstick glucose levels after the
initiation of steroid treatment for pericarditis (which was
further complicated by pregnancy). She was treated with an
insulin drip with success. After tapering of her steroid dose,
her insulin requirements decreased and she was transitioned to a
sliding scale of regular subcutaneous insulin. On day of
discharge her hyperglycemia had mainly resolved and she not
discharged on insulin.
9)F/E/N. Poor PO intake secondary to anorexia. Patient
received boost supplements. Additionally, she had a large
potassium requirement (120meq/day) and large magnesium
requirement (1600mg/day) thought secondary to poor PO intake and
effects of ambisome. She was discharged on multivitamin,
potassium, and magnesium supplements and should continue to
supplement her diet with shakes.
Medications on Admission:
-celexa
-singulair
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*80 Tablet(s)* Refills:*0*
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
4 days.
5. Magnesium Oxide 600 mg Capsule Sig: One (1) Capsule PO twice
a day.
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Three (3) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*180 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
pericarditis
fever of unknown origen
pregnancy, s/p caesarian section
knee effusion
pleural effusions
hypokalemia
candidemia
hypomagnesemia
anorexia
post-partum depression
Discharge Condition:
good
Discharge Instructions:
take all your medicines as prescribed.
Have your labs checked in one week at [**Hospital3 **].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2151-1-19**] 9:30
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13675**] (MATERNAL FETAL MEDICINE)
Where: [**Doctor Last Name 13675**] (MATERNAL FETAL MEDICINE) Date/Time:[**2151-1-21**] 10:00
Completed by:[**0-0-0**]
|
[
"420.99",
"646.21",
"674.82",
"401.9",
"995.91",
"642.01",
"996.62",
"112.0",
"647.61",
"648.91",
"648.61",
"276.8",
"647.81",
"785.0",
"518.0",
"719.06",
"428.0",
"112.89",
"038.19",
"E879.8",
"648.21",
"669.42",
"V27.0",
"644.21",
"648.42",
"311",
"648.81",
"584.5",
"078.5",
"285.29",
"574.20",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"81.91",
"99.04",
"93.90",
"37.0",
"74.1",
"88.72",
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11611, 11617
|
4840, 10879
|
307, 434
|
11833, 11839
|
3156, 4817
|
11982, 12465
|
2537, 2583
|
10948, 11588
|
11638, 11812
|
10905, 10925
|
11863, 11959
|
2598, 3137
|
232, 269
|
462, 2257
|
2279, 2326
|
2342, 2521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,797
| 193,921
|
16097
|
Discharge summary
|
report
|
Admission Date: [**2127-7-3**] Discharge Date: [**2127-7-25**]
Date of Birth: [**2069-1-12**] Sex: M
Service: MED
Allergies:
Prednisone
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
sob/decreased PO
Major Surgical or Invasive Procedure:
stent placement in airway and esophogus
History of Present Illness:
HPI: 58 y/o male with history of small cell lung cancer with a
large mass encircling esophogus and aorta, was first admitted to
the [**Hospital Unit Name 153**] from [**Hospital3 **] Hospital because of fear of erosion of
the tumor into esophogus or aorta and catastrophic bleed and
massive mediastinitis. Pt had symptoms of dysphagia for 2
months, lightheadedness, and hematemesis ([**1-10**] cups). When
trasferred to [**Hospital1 **] EGD was done on [**7-4**] which showed a necrotic,
obstructing mass in the esophogus. There seemed to be evidence
of airway compression as well. CT showed Ulcerated necrotic
mass, 9.7 x 7.5 cm encasing the esophogus and freely
communicating with esophogeal lumen. It also confirmed widely
metastatic disease. Subsequently, an airway stent and
esophogeal stent was placed. PEG tube was not recommended since
increased risk of aspiration with esophogeal stent. Pt
currently has some nausea, cough productive of sputum and some
SOB. Now being transferred to omed service awaiting placement.
Past Medical History:
Small Cell Lung Ca-Initially presented with dysphagia. CT chest
revealed large med. Mass compressing esophagus and mainstem
bronchus. Now s/p VATS and med. Bx [**2-18**]. Had chemotherapy and
XRT.
HBV, cirrhosis, Hodgkins, HTN, Lyme, Anxiety, CVA, CRI,
Physical Exam:
PE: v/s HR:110-123 (post- ambulation), BP: 80-100/60-90, RR 12,
O2 sat:85% on 4L
General: Cachectic male lying in bed, in NAD, coughing
CV: Tachycardic, RRR s1 s2
Lungs: Course rhonchi bilaterally
Abd: +bs, no r/g no masses palpated, soft, ND
ext: warm, dry, no c/c/e, 2+ pulse
Pertinent Results:
[**2127-7-3**] 11:00PM URINE COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.010
[**2127-7-3**] 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2127-7-3**] 07:45PM GLUCOSE-142* UREA N-25* CREAT-1.3* SODIUM-141
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16
[**2127-7-3**] 07:45PM WBC-9.4 RBC-2.82* HGB-9.2* HCT-27.2* MCV-97
MCH-32.7* MCHC-33.9 RDW-18.2*
Brief Hospital Course:
Pt is a 58 yo with end stage small cell lung cancer with mass
impinging on airway and esophogus, who, during this hospital
stay, had placement of esophogeal and airway stent. Now patient
able to tolerate clears. He understands the nature of his
disease and agrees that he does not want a PEG tube. Pt is at
end stage and does not want extremely invasive procedures. Case
management has been following and meeting with pt's family
regarding wishes for placement. Pt and team discussed overall
status and prognosis, and pt decided to be comfort measures
only.
Pt had presumptive mediastinitis on admission and was treated
with antibiotics until CMO.
Tachycardia: Associated with episodes of hypoxia, pt would
become dyspneic and hypoxic usually around [**3-13**] am and,
associated with this (somtimes before, sometimes after) would
develop palpitations with an ECG that showed rates in the 150's.
The rapidity made it unclear whether the rhythm was sinus (read
by computer as afib, but very regular). Pt started on [**Hospital1 **]
metoprolol for rate control.
Hypoxia: Increasing oxygen demand and dyspnea with movement.
[**7-12**] cxr prelim with poor aeration-no change, and slight inc in
left pleural effusion. Pt declined to have interventional
pulmonology repeat bronchoscopy and to only have comfort
measures taken.
Nausea: This was well controlled with po phenergan and zofran.
SOB/hypoxia: Throughout course, pt required increasing doses of
supplemental o2 and continued to experience desats, usually
around 3-4am without clear etiology. Pt responded well to 9L O2
by face mask and morhpine prn.
Cough: This remained stable throghout. Tried guaifenisen,
mucomyst nebs, and albuterol/atrovent nebs, all without much
relief.
DVT: Pt developed left upper extremity DVT during admission with
edema, pt declined lovenox once made CMO.
Dispo: Given the stage and prognosis of the patient's cancer, he
decided to continue his DNR/DNI status and change to comfort
measures only.
Medications on Admission:
ASA, Hepsera, Klonopin and Potassium
Discharge Medications:
1. Codeine Phosphate 30 mg/mL Syringe Sig: .5 syringe Injection
Q4-6H (every 4 to 6 hours) as needed. syringe
2. Morphine Sulfate 0.5-2 mg IV Q4H:PRN pain
hold for sedation
3. Codeine Phosphate 15 mg IV Q4-6H:PRN
4. Promethazine HCl 12.5 mg IV Q4-6H:PRN nausea/vomiting
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb ih
Inhalation Q6H (every 6 hours).
6. Ondansetron 4 mg IV Q4H
7. Pantoprazole 40 mg IV Q24H
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for Anxiety.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb ih
Inhalation Q3-4H () as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb IH
Inhalation Q2-3H (every 2-3 hours) as needed for Low O2 sats;
Shortness of breath. neb IH
14. Lidocaine HCl (Local Anesth.) 0.5 % Solution Sig: Five (5)
mg/ML Injection Q1H (every hour) as needed for cough.
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO TID (3 times
a day).
Disp:*500 ML(s)* Refills:*2*
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Hospice Care of [**Doctor Last Name **]
Discharge Diagnosis:
metastatic lung cancer
Discharge Condition:
stable
Discharge Instructions:
Please follow up with Dr. [**Last Name (STitle) **], if needed
|
[
"280.0",
"519.2",
"197.1",
"070.32",
"799.4",
"197.8",
"571.5",
"789.5",
"162.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.05",
"88.44",
"42.23",
"42.81",
"33.22",
"33.91"
] |
icd9pcs
|
[
[
[]
]
] |
5928, 5994
|
2446, 4444
|
282, 324
|
6061, 6069
|
1979, 2423
|
4531, 5905
|
6015, 6040
|
4470, 4508
|
6093, 6158
|
1679, 1960
|
226, 244
|
352, 1388
|
1410, 1664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,460
| 153,552
|
46179
|
Discharge summary
|
report
|
Admission Date: [**2198-7-26**] Discharge Date: [**2198-7-31**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal Pain, Low Blood Pressure
Major Surgical or Invasive Procedure:
Interventional Radiology - Vessel Embolization
CVL
Chest Tube placement
History of Present Illness:
85F PMH dementia and CHF who presented initially on [**7-12**] after a
fall down the stairs at home with pelvic fractures, and was
admitted to the trauma service. She had embolization of a
bleeding pelvic artery by IR, and otherwise
she was managed conservatively. Patient also with C1/C2
fracture, managed conservatively.
Patient was now readmitted from [**Hospital1 **] with low blood pressure
and concern for rebleeding into her pelvis. Patient also
recently diagnosed with UTI, being treated with levofloxacin.
Patient denies chest pain, fevers, chills, abdominal pain,
shortness of breath, LE swelling, nausea, vomiting, BRBPR.
Past Medical History:
Dementia
Hypothyroidism
CHF
Depression
pelvic fx c/b hematoma
Social History:
No alcohol or drugs. Comes in from [**Hospital1 **]. Used to live at
home. Retired secretary.
Family History:
Noncontributory
Physical Exam:
(ON ADMISSION)
VITALS: AF 121 70's/P 97RA
HEENT: PERRL, EOMI
NECK: C collar in place
CV: RRR S1/S2 no m/g/r
LUNGS: CTA b/l no w/r/r
ABD: Palpable hematoma anterior abdominal wall, tender to
palpation
EXT: no edema, no CT
NEURO: grossly intact
Pertinent Results:
[**2198-7-26**] 11:46PM HCT-32.3*
[**2198-7-26**] 07:31PM TYPE-[**Last Name (un) **] PH-7.31* COMMENTS-GREEN TOP
[**2198-7-26**] 07:31PM freeCa-0.99*
[**2198-7-26**] 07:16PM GLUCOSE-166* UREA N-34* CREAT-1.5* SODIUM-135
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13
[**2198-7-26**] 07:16PM CK(CPK)-157*
[**2198-7-26**] 07:16PM CK-MB-4 cTropnT-0.01
[**2198-7-26**] 07:16PM CALCIUM-7.5* PHOSPHATE-5.0*# MAGNESIUM-1.8
[**2198-7-26**] 07:16PM WBC-29.0* RBC-3.59* HGB-11.5* HCT-32.4*
MCV-90 MCH-32.1* MCHC-35.5* RDW-21.8*
[**2198-7-26**] 07:16PM NEUTS-81* BANDS-8* LYMPHS-1* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-1*
[**2198-7-26**] 07:16PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-OCCASIONAL
[**2198-7-26**] 07:16PM PLT SMR-HIGH PLT COUNT-462*
[**2198-7-26**] 07:16PM PT-13.9* PTT-31.1 INR(PT)-1.2*
[**2198-7-26**] 01:45PM LACTATE-3.4*
[**2198-7-26**] 01:45PM HGB-9.4* calcHCT-28
[**2198-7-26**] 01:23PM URINE HOURS-RANDOM
[**2198-7-26**] 01:23PM URINE HOURS-RANDOM
[**2198-7-26**] 01:23PM URINE UHOLD-HOLD
[**2198-7-26**] 01:23PM URINE GR HOLD-HOLD
[**2198-7-26**] 01:21PM WBC-21.0* RBC-2.98*# HGB-9.3* HCT-28.3*
MCV-95# MCH-31.3 MCHC-33.0 RDW-22.5*
[**2198-7-26**] 01:21PM NEUTS-80* BANDS-4 LYMPHS-5* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-3*
[**2198-7-26**] 01:21PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL
[**2198-7-26**] 01:21PM PLT SMR-HIGH PLT COUNT-547*
[**2198-7-26**] 12:17PM K+-4.7
[**2198-7-26**] 12:17PM HGB-8.4* calcHCT-25
[**2198-7-26**] 12:00PM GLUCOSE-146* UREA N-39* CREAT-1.7* SODIUM-140
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-24*
[**2198-7-26**] 12:00PM ALT(SGPT)-16 AST(SGOT)-62* LD(LDH)-1411*
CK(CPK)-82 ALK PHOS-211* AMYLASE-137* TOT BILI-2.8* DIR
BILI-0.8* INDIR BIL-2.0
[**2198-7-26**] 12:00PM LIPASE-122*
[**2198-7-26**] 12:00PM CK-MB-NotDone cTropnT-0.02*
[**2198-7-26**] 12:00PM WBC-35.6*# RBC-2.34* HGB-8.0* HCT-24.4*
MCV-104* MCH-34.1* MCHC-32.7 RDW-21.6*
[**2198-7-26**] 12:00PM NEUTS-85* BANDS-6* LYMPHS-3* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2198-7-26**] 12:00PM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-3+ OVALOCYT-OCCASIONAL
TEARDROP-OCCASIONAL
[**2198-7-26**] 12:00PM PLT SMR-VERY HIGH PLT COUNT-937*#
[**2198-7-26**] 12:00PM PT-13.3* PTT-51.4* INR(PT)-1.2*
[**2198-7-25**] 04:40AM GLUCOSE-90 UREA N-30* CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-13
[**2198-7-25**] 04:40AM TOT BILI-2.3* DIR BILI-0.8* INDIR BIL-1.5
[**2198-7-25**] 04:40AM HAPTOGLOB-<20*
[**2198-7-25**] 04:40AM WBC-11.4* RBC-2.43* HGB-8.1* HCT-24.6*
MCV-101* MCH-33.5* MCHC-33.0 RDW-21.3*
[**2198-7-25**] 04:40AM PLT COUNT-575*
[**2198-7-25**] 04:40AM FIBRINOGE-566*
[**2198-7-25**] 04:40AM RET MAN-6.4*
[**2198-7-25**] 12:15AM HCT-24.9*
Brief Hospital Course:
Patient was admitted from the [**Hospital1 18**] ED directly to the angio
suite where she underwent embolization of R internal iliac
branch, please see procedure note for details. While in the
emergency department the patient received a central line in the
R subclavian vein and had a resulting pneumothorax which
required chest tube placement. After embolization the patient
was transfered to the ICU for observation. Cultures were taken
from the abdominal hematoma as well as blood and urine, which
were all negative for growth. Chest tube was removed on HD3 and
patient was transferred to the floor. Patient was in stable
condition while on the trauma surgery [**Hospital1 **], she was evaluated by
speech and swallow who recommended a soft solid/thin liquid diet
after eval on video swallow. At the time of discharge the
patient's pain was well controlled and she was tolerating
adequate PO intake.
Medications on Admission:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours).
5. Alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO QTUES (every
Tuesday).
6. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
7. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
10. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
11. Levothyroxine 50 mcg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
14. Oxycodone 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every 4
hours) as needed.
15. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pelvic Hematoma
CHF
Type II Dens Fx
Discharge Condition:
Stable
Discharge Instructions:
Please call physician or return to ED if any of the following
occur:
1. Fever > 101.5
2. Increased pain
3. Change in mental status
4. Chest pain/difficulty breathing
5. Any other concerning symptoms
Please notify your primary care physician if you have increasing
pain, chest pain/shortness of breath, headache/dizzyness,
fever/chills.
Please wear your hard cervical collar at all times for three
months time per orthopedics recommendations.
Please take all of your medications as directed and follow up
with your appointments.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-13**] weeks. Please call
[**Telephone/Fax (1) 6429**] for appointment.
Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine Surgery, in 4 weeks,
call [**Telephone/Fax (1) 3573**] for an appointment.
Existing follow-up appointments:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2198-8-9**] 9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2198-8-9**] 10:10
Completed by:[**2198-7-31**]
|
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icd9cm
|
[
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icd9pcs
|
[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,875
| 126,012
|
41319
|
Discharge summary
|
report
|
Admission Date: [**2181-2-9**] Discharge Date: [**2181-2-26**]
Date of Birth: [**2115-10-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis
Pericardial tap and window
History of Present Illness:
65M with HTN, DM, recent cath 1 week ago for STEMI c/b
pericarditis/DVT/PE with 2 day h/o [**Hospital **] transfer from OSH,
bedside ultrasound with pericardial effusion concerning for
tamponade physiology.
.
Patient was discharged from [**Hospital1 18**] on [**2-5**]. He initially
presented to [**Hospital3 **] in the setting of URI symptoms and chest
pain. EKG with anterior ST elevations. Heparin and plavix were
initiated and patient was medically managed for two days as he
was felt to be outside the window for acute PCI. He was
eventually taken to Cath revealing 98% mid-LAD lesion. He had a
CK that peaked at 992 and a troponin that was 2.25. He was
transferred to [**Hospital1 18**] for percutaneous coronoary intervention
where a [**Hospital1 **] was placed in the LAD. ECHO revealed anterior wall
hypokinesis/akinesis.
.
His course was complicated by a superficial femoral vein clot
secondary to known Factor V Leiden mutation (heterozygous). He
has been treated for DVT in the past, and therefore will require
life long anti-coagulation. Due to his persistent sinus
tachycardia both at the time of presentation, transfer to [**Hospital1 18**]
and his hospital stay, it was presumed that he had a pulmonary
embolus. He was started on warfarin empirically for his apical
hypokinesis, and his INR prior to discharge was 1.4. He was
sent home with Lovenox.
.
His course was further complicated by pericarditis thought to be
secondary to recent STEMI and not dressler's syndrome given the
proximity of this event.
.
Finally, patient was diagnosed with HCAP and empirically started
on Levaquin. He then spiked an additional fever, and was
transitioned to Vancomycin, Cefepime, and Ciprofloxacin. He was
then transitioned to oral antibiotics, and discharged home with
oral cefpodoxime to complete an 8 day course.
.
Since discharge, patient was doing ok until [**2-7**], when he
started to experience fatigue, difficulty breathing,
palpitations, and dull chest pressure. Denied syncope, blood in
his urine, sputum, stool. He was compliant with his discharge
medications.
.
In the ED initial vitals 100.4 136 97/67. Transferred from OSH
where ECHO was peformed and revealed pleural effusion with
question of tamponade physiology. In ED patient was tachycardic
and borderline hypotensive. Pulsus noted at 20mmHg. Bedside US
with pericardial effusion and evidence of RV collapse. CXR
revealed cardiomegaly. EKG with a question of pericarditis
noted. Patient give 2.5 liters of NS. Vitamin K 10mg IV. Vitals
prior to transfer 120 110/70.
.
In the CCU, patient was tachycardic to the 130s, tachypneic to
30, pulsus was 15 mmHg, sBP 110s. He was fairly uncomfortable
and reports a dull left-sided chest pressure that was similar to
prior presentation of STEMI.
.
On review of systems, he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. He denies recent
fevers but did feel chills. He denies exertional buttock or calf
pain.
.
Cardiac review of systems is notable for absence paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: [**Month/Year (2) **] to LAD ([**1-/2181**])
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
DM II, diagnosed last year on oral medications, HgbA1C 8.7
Asthma: Medication controlled
HTN
Diabetes
Dyslipidemia
Status Post Tosillectomy
Renal Calculi
PNA/Bronchitis recently given Azithromycin 250 mg PO daily (last
dose [**2181-1-31**])
Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Engineer instructor part time. Lives at home with his wife.
Previously Independent with ADL's
Family History:
No family history of MI or CVA. No history of PE, DVT or blood
diathesis.
Physical Exam:
VS: T=98 BP=90-100/35-45 HR=127 RR=30 O2 sat=93% 2L NC
GENERAL: Oriented x3. Breathing fast, slightly distressed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4. No rub. Pulsus 15 mmHg.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Tachypneic. Some accessory muscle use. Decreased breath sounds
bilaterally. Egophony left side, 2/3 up to the apex. No tactile
fremitus.
ABDOMEN: Soft, slightly extended, non-tender. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
1. Labs on admission:
[**2181-2-9**] 03:15AM BLOOD WBC-15.5*# Hct-38.0* Plt Ct-461*
[**2181-2-9**] 03:15AM BLOOD PT-22.3* PTT-40.8* INR(PT)-2.1*
[**2181-2-9**] 03:15AM BLOOD Glucose-182* UreaN-41* Creat-2.0* Na-129*
K-7.6* Cl-100 HCO3-18* AnGap-19
[**2181-2-9**] 03:15AM BLOOD CK(CPK)-116
[**2181-2-9**] 03:15AM BLOOD cTropnT-0.50*
[**2181-2-9**] 12:51PM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9
.
[**2181-2-10**] 05:33AM BLOOD TSH-0.11*
[**2181-2-10**] 05:33AM BLOOD T4-8.2 T3-94 calcTBG-0.82 TUptake-1.22
T4Index-10.0 Free T4-1.6
[**2181-2-9**] 12:51PM BLOOD CK-MB-2 cTropnT-0.33*
[**2181-2-10**] 05:33AM BLOOD CK-MB-2 cTropnT-0.29*
.
3. Imaging/diagnostics:
- Echo ([**2181-2-9**]): Overall left ventricular systolic function is
severely depressed (LVEF= 20-25 %) with distal LV and apical
akinesis (there is spontaneous echo contrast (stasis) seen in
the LV apex and an apical thrombus cannot be fully excluded). RV
systolic funciton is depressed. There is a large pericardial
effusion. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology.
.
IMPRESSION: Moderate to large pericardial effusion with echo
evidence of tamponade.
.
ECHO [**2-20**]:
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w CAD. Mild aortic and mitral regurgitation.
Spontaneous echocontrast in the LV apex, c/w low-flow state.
Very small residual echodense pericardial effusion.
.
CXR [**2181-2-25**]: The left-sided PICC line is unchanged. Mild
cardiomegaly is unchanged. There is a small left pleural
effusion. There is no pneumothorax. There is retrocardiac
opacity consistent with volume loss/infiltrate/consolidation
that is slightly increased in comparison to the prior study. The
right lung shows some minimal volume loss/infiltrate
inferomedially but otherwise is clear.
.
Pericardium biopsy: Pericardium; pericardial window (A): Fibrous
and adipose tissue consistent with pericardium, with surface
fibrin, acute and chronic inflammation and reactive changes.
.
Pleural Fluid [**2-20**]: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells, lymphocytes, neutrophils, and histiocytes.
.
Labs on Discharge:
[**2181-2-26**] 07:10AM BLOOD WBC-6.1 RBC-4.17* Hgb-11.4* Hct-35.0*
MCV-84 MCH-27.3 MCHC-32.6 RDW-14.2 Plt Ct-345
[**2181-2-26**] 07:10AM BLOOD Glucose-131* UreaN-26* Creat-1.3* Na-134
K-4.1 Cl-104 HCO3-22 AnGap-12
[**2181-2-22**] 05:42AM BLOOD ALT-31 AST-42* LD(LDH)-184 AlkPhos-83
TotBili-0.4
Brief Hospital Course:
HOSPITAL COURSE: 65 year-old gentleman with DM2 and HTN who
presented with dyspnea and dull chest pain several days after
hospitalization for STEMI, which was initially treated medically
at an outside hospital for several days prior to admission to
[**Hospital1 18**] for cardiac catherization with PCI ([**Hospital1 **] to mid LAD). That
hospital course had been complicated by post-MI pericarditis and
DVT, for which he was started on anticoagulation with lovenox.
On readmission he was admitted to the Cardiac Intensive Care
Unit for treatment of cardiac tamponade, initially thought to be
hemorrhagic, but most likely representing Dressler's Syndrome. A
pericardial drain was initially placed and pulled; however, the
fluid reaccumulated and a pericardial window was performed.
Serial echocardiograms demonstrated left regional systolic
dysfunction, with depressed ejection fraction of 30%, and
resolution of the effusion. His hospital course was further
complicated by presumed hospital acquired pneumonia, for which
he was treated with 8 days of vancomycin and cefepime, a
recurrent inflammatory pleural effusion that was drained twice
by Interventional Pulmonary, and atrial fibrillation with rapid
ventricular response for which he was started on amiodarone.
.
#. Pericardial Effusion/Tamponade: Echocardiogram on admission
showed a pericardial effusion with tamponade physiology. A drain
was placed and fluid studies reflected an exudative effusion. On
HD 3 the drain was pulled and the patient was transferred to the
floor. He remained in house for completion of IV antibiotic
therapy of presumed HAP and was restarted on anticoagulation for
Factor V Leiden thrombophilia and DVT. On HD 8, he developed
chest pressure in the setting of a vagal episode with TWIs in
the lateral leads and flat cardiac biomarkers. A repeat echo
demonstrated reaccumulation of the pericardial effusion without
tamponade physiology. The patient was readmitted to the CCU and
a pericardial window was performed by Cardiac Surgery. This
effusion was also exudative and thought to be secondary to
Dressler's Syndrome. A repeat echo demonstrated small residual
echodense pericardial effusion. His inflammatory pericarditis
was treated with colchicine, which was continued at discharge
and will be tapered as outpatient.
.
# Pleural Effusion: The patient presented with small bilateral
pleural effusions, fever, and leukocytosis concerning for an
interval development of parapneumonic effusions. A CTA chest
confirmed small bilateral effusions, and a ground glass opacity
in the right upper lobe concerning for infection. He received an
8 day course of vancomycin and cefepime for empiric treatment of
hospital acquired pneumonia, and the exudative pleural effusion
was drained by Interventional Pulmonology. After re-accumulation
of the pericardial effusion, an interval increase in the size of
the left pleural effusion was noted. Interventional Pulmonology
was consulted again and performed a second diagnostic and
therapeutic thoracentesis, which revealed an exudative effusion.
Cell count, culture, and cytology of the pleural effusion showed
no malignant cells and no signs of infection. This effusion was
likely related to the same post-MI inflammatory process
contributing to his pericardial effusion.
.
# Sinus Tachycardia/Atrial Fibrillation with RVR: The patient
was persistently tachycardic after the pericardial effusion was
initially drained. Given his history of Factor V Leiden
thrombophilia and prior DVT, we were concerned for pulmonary
embolism, which was ruled out by CT Angio. Given his CHF, he was
started on Metoprolol, which was uptitrated accordingly. Towards
the end of his hospital course the patient developed atrial
fibrillation with intermittent rapid ventricular response
(likely related to his underlying effusions). He was started on
Amiodarone, which was continued at discharge. He was
anticoagulated with a Heparin gtt, that was then transitioned to
Coumadin 2mg daily at time of discharge.
.
# Anticoagulation: The patient has many reasons to continue
lifelong anticoagulation (Factor V Leiden thrombophilia, history
of two DVTs, depressed ejection fraction, and atrial
fibrillation). He remained on a Heparin gtt while in house, and
transitioned to Coumadin in anticipation of discharge.
.
# CAD complicated by STEMI s/p [**Hospital1 **] to LAD ([**2180-1-31**]): The
patient did not experience any signs or symptoms of ACS during
this admission. He was kept on daily Aspirin, Plavix, and
Atorvastatin. He was also started on Lisinopril and Metoprolol.
Initially, initiation of a beta blocker was considered with
hesitance secondary to a reported history of bronchospam with
beta blockade in the past; however, he tolerated the Metoprolol
well.
.
#. Ischemic Cardiomyopathy with EF 30%: Currently on Metoprolol
200 mg XL [**Hospital1 **], Lisinopril 10 mg, Lasix 20 mg, and Epleronone 25
mg daily. The patient was taught about signs of volume overload
and counseled on a low sodium diet and mponitoring daily
weights.
.
#. Acute Kidney Injury: Presented with Creatinine of 2. Baseline
Cr 1.3. Creatinine improved to baseline, likely secondary to
improved cardiac output once tamponade was relieved.
.
#. Asthma: Continued on home medication regimen of advair,
zarfikulast, advair.
.
#. Diabetes: Metformin was held on admission and restarted at
discharge.
.
#. Glaucoma: Continued on home regimen of methazolamide and
betaxolol drops.
.
#. CODE: FULL
.
# FOLLOW-up:
1. Will need repeat TFT's as an outpatient
2. Will need outpatient monitoring of his INR by Dr. [**Last Name (STitle) 17744**]
3. Will need a follow up ECHO in 1 month around his appt with
Dr. [**Last Name (STitle) **].
Medications on Admission:
1. Aspirin 325 mg Daily
2. Lisinopril 20 mg Daily
3. Lasix 20 mg Daily
4. Methazolamide 50 mg Tablet Sig: 0.5 Tablet PO BID
5. Clopidogrel 75 mg Tablet Daily
6. Betaxolol 0.25 % Drops one drop daily
7. Zafirlukast 20 mg Tablet Sig: One Tablet PO BID
8. Atorvastatin 80 mg Tablet Sig: One Tablet PO DAILY
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two Puff
Inhalation [**Hospital1 **]
10. Albuterol Inhaler PRN
11. cefpodoxime 100 mg Tablet [**Hospital1 **] for 4.5 days.
12. warfarin 5 mg Tablet Sig: Daily
13. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
14. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **]
15. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
2. betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
3. Outpatient Lab Work
Please check INR, chem 7 on Wedensday [**2-28**], call results to
Dr. [**Last Name (STitle) 17744**] at Phone: [**Telephone/Fax (1) 43460**]
Fax: [**Telephone/Fax (1) 70142**]
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. methazolamide 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
14. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO BID (2 times a
day).
Disp:*120 Tablet Extended Release 24 hr(s)* Refills:*2*
15. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months: then decrease to one tablet daily.
Disp:*60 Tablet(s)* Refills:*2*
17. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**3-6**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pericardial Effusion
Pleural Effusion
Pneumonia
Acute Systolic dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pericardial effusion that was removed by tap that was
causing you to be short of breath. There was no evidence of
unusual cells or infection in this fluid. The effusion
reaccumulated so a window was placed that could continuously
drain any further fluid that accumulates. In addition, you had
an effusion in your lungs that was tapped and removed, we think
this was because of your pneumonia. You were treated with 7 days
of intravenous antibiotics that should completely eliminate the
infection. Your heart is still weak after the heart attack last
month and we have continued to give you medicines to help the
heart pump stronger. Please take all of your medicines every day
and eat a low sodium diet. Weigh yourself every morning, call
Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5
pounds in 3 days.
.
We made the following changes to your medicines:
1. Decrease Lisinopril to 10 mg daily
2. change Fluticasone to Advir twice daily, this seems to
control your wheezes better
3. Decrease warfarin to 2mg daily
4. Discontinue Cefpodoxime, Lovenox and Diltiazem
5. Start Metoprolol Succinate to lower your heart rate and help
your heart beat better
6. STart Epleronone to help keep the fluid from accumulating in
your lungs
7. Start Amiodarone to help keep your heart in a regular rhythm.
You will take 2 tablets for one week, then decrease to one
tablet daily. You will need to have your thyroid, lungs and
liver function checked on a regular basis while you are on this
medicine.
8. Start taking Colchicine to prevent the chest pain from your
heart lining friction. You will take this twice daily for one
month, then decrease to one tablet daily thereafter.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] N
Location: [**Hospital **] MEDICAL GROUP-[**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 59119**]
Phone: [**Telephone/Fax (1) 43460**]
Appt: Wednesday [**2-28**] at 10:15am.
Department: CARDIAC SERVICES
When: Monday [**4-2**] at 3:20pm
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"411.0",
"250.00",
"414.8",
"428.21",
"486",
"511.89",
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] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.04",
"37.12",
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
16290, 16339
|
7784, 7784
|
324, 367
|
16458, 16458
|
5307, 5315
|
18336, 18920
|
4232, 4307
|
14357, 16267
|
16360, 16437
|
13522, 14334
|
7801, 13496
|
16609, 18313
|
4322, 5288
|
3662, 3775
|
265, 286
|
7465, 7761
|
395, 3548
|
5329, 7446
|
16473, 16585
|
3806, 4049
|
3570, 3642
|
4065, 4216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,983
| 138,085
|
17524
|
Discharge summary
|
report
|
Admission Date: [**2182-4-9**] Discharge Date: [**2182-4-17**]
Date of Birth: [**2110-12-12**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man
transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48910**] Hospital for cardiac
catheterization. The patient states he had chest pain while
out walking his dog on Sunday afternoon, relieved with rest
and nitroglycerin. In the emergency room his enzymes were
elevated with a CK of 508, CK MB of 2.9, troponin 0.5. He
was transferred here for catheterization. He had a stress
echocardiogram two weeks ago that showed aortic
regurgitation. The patient denied chest pain, shortness of
breath, dyspnea on exertion, fevers, sweats, chills, diabetes
mellitus, cerebrovascular disease, cancer, or claudications.
PAST MEDICAL HISTORY: 1. Coronary artery disease. 2.
Valvular heart disease. 3. Benign prostatic hypertrophy. 4.
Hypertension. 5. Chronic obstructive pulmonary disease. 6.
Asthma. 7. Ulcerative colitis. 8. Enlarged prostate. 9.
Chronic renal insufficiency.
PAST SURGICAL HISTORY: 1. Partial colectomy. 2.
Appendectomy.
MEDICATIONS AT HOME: 1. Coreg 12.5 twice. 2. Norvasc 5 mg
b.i.d. 3. Zestril 20 mg b.i.d. 4. Proscar 5 mg q.d. 5.
Lasix 40 mg q.d. 6. Advair 150 one puff b.i.d. 7. Colazal
750 mg three tablets t.i.d. 8. Nitroglycerin paste 1 inch q.
6.
SOCIAL HISTORY: No tobacco use.
Cardiac catheterization showed an ejection fraction of 41%,
aortic regurgitation 3+, LM 60, LAD normal, OM 80, circumflex
and RCA normal, left ventricular end-diastolic pressure 22,
PA 37/11.
PHYSICAL EXAMINATION: Temperature 97.4, heart rate 70 in
sinus rhythm, blood pressure 190/99, respiratory rate 20, O2
saturations 97% on room air. General: The patient was alert
and oriented x 3, moved all extremities, followed commands.
HEENT: Pupils were equal, round, and reactive to light.
Extraocular movements intact. Anicteric, noninjected
sclerae. Neck: Supple, no lymphadenopathy, no jugular
venous distension, no bruits. Mucous membranes were moist,
no erythema or exudate in the oropharynx. Lungs: Clear to
auscultation bilaterally. Cardiac: Regular rate and rhythm.
Abdomen: Soft, nontender, nondistended, no
hepatosplenomegaly. Extremities: Warm and well perfused
with no cyanosis, clubbing or edema.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2182-4-9**] and taken to the
operating room where a three-vessel coronary artery bypass
grafting was performed as well as an aortic valve
replacement.
Postoperatively the patient was transferred to the
cardiothoracic surgical intensive care unit. He had
mediastinal and chest tubes in place, pacing wires in place.
He received prophylactic vancomycin doses x 4. On his first
postoperative day the patient experienced ventricular
tachycardia x 20 beats. He required milrinone and Levophed
drips. At the appropriate times the patient's drips were
stopped. He was started on beta blockade. He was also
started on amiodarone when his ventricular tachycardia
recurred. When his creatinine fell he was started on Lasix.
He was also started on amlodipine. Once the patient's
hypertensive medications were regulated to appropriately
control his blood pressure the patient was transferred to the
regular cardiothoracic surgery floor where he thrived. He
has been visited by physical therapy who has worked with him
extensively and is comfortable with him going to a
rehabilitation facility. Therefore today, [**2182-4-17**], he is
being discharged to rehabilitation.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 70**] in
six weeks, Dr. [**First Name (STitle) **] in one to two weeks, and cardiology in
two to three weeks.
RECOMMENDATIONS: He should observe a heart healthy diet. He
may shower although he should not take baths. The patient
should avoid strenuous activity and should not drive while on
pain medications.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg q.d.
2. Advair 2 puffs b.i.d.
3. Hydralazine 10 mg IV q. 3 p.r.n. systolic blood pressure
greater than 160.
4. Amlodipine 10 mg q.d. p.o.
5. Hydralazine 25 mg q. 6 p.o.
6. Albuterol 1-2 puffs q. 6 p.r.n.
7. Benadryl 25 mg p.o. q.h.s. p.r.n. sleep
8. Milk of Magnesia 30 mg p.o. q.d. p.r.n. constipation.
9. Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n. pain.
10. Ibuprofen 400 mg p.o. q. 6 p.r.n. pain.
11. Tylenol 650 mg p.o. q. 4 p.r.n. pain.
12. Enteric-coated aspirin 325 mg p.o. q.d.
13. Ranitidine 150 mg b.i.d.
14. Colace 100 mg b.i.d.
15. Lopressor 25 mg b.i.d.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2182-4-17**] 10:46
T: [**2182-4-17**] 11:11
JOB#: [**Job Number 48911**]
|
[
"556.9",
"414.01",
"410.71",
"427.1",
"600.9",
"593.9",
"396.3",
"398.91",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"35.21",
"88.72",
"36.15",
"37.23",
"88.53",
"36.12",
"39.61",
"88.56",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
4038, 4936
|
2407, 3631
|
1210, 1432
|
1147, 1188
|
3643, 4015
|
1682, 2389
|
184, 856
|
879, 1123
|
1449, 1659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,968
| 103,054
|
25791
|
Discharge summary
|
report
|
Admission Date: [**2124-10-20**] Discharge Date: [**2124-11-16**]
Date of Birth: [**2066-12-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
[**2124-10-25**]: Orthotopic liver [**Month/Day/Year **] (retransplant)
[**2124-11-5**]: Exploratory laparotomy, Roux-en-Y, hepaticojejunostomy
History of Present Illness:
Mr. [**Known lastname 64239**] is a 57 year-old man with a history of hepC
cirrhosis s/p OLT [**12-31**]. He was recently admitted [**Date range (1) 64240**] and
found to have hepatic artery thrombosis. He was anticoagulated
and transitioned to coumadin. During that admission he was also
found to have bile lakes, likely secondary to biliary ischemia
secondary to hepatic artery thrombosis, as well as a common bile
duct stricture, for which sphincterotomy with placement of two
stents was peformed.
.
In light of the hepatic artery thrombosis, he also underwent
evaluation for repeat [**Date range (1) **]. He was recently re-listed for
[**Date range (1) **] on [**10-12**] with a MELD of 25. Rapamycin was stopped and
prograf started during that admission.
.
Since the time of his [**Month/Year (2) **], Mr. [**Known lastname 64239**] has had loss of
appetite with failure to thrive. He initially required tube
feeds that were stopped [**3-30**]. He reports no nausea, vomitting,
or abdominal pain, but "lack of taste buds." His weight was 206
lbs prior to [**Month/Year (2) **], fell peri-[**Month/Year (2) **] to 136 lbs. He
then gained weight and was 158 in [**4-30**], but since then has been
gradually losing weight. Since the time of his recent discharge
two weeks ago, he has not eaten more than a few bites daily. He
continues to drink water. He has tried supplemental shakes but
can not stand them. His current weight is 128.
.
He has also not been able to carry out his usual activities and
has not been working. He attributes this to physical weakness,
including shortness of breath with walking more than
room-to-room. His sleeping pattern is unchanged (helped by
Ambien), no trouble concentrating, reports mood is generally
"fine."
.
He has also been having fevers as high as 101-102 intermittently
since the time of [**Date Range **]. No nausea or vomitting, no change
in bowel movements or blood in bowel movements. No change in
urine output or dysuria. No chest pain.
Past Medical History:
-History of UGIB ([**2120**])
-Hepatitis C cirrhosis - s/p OLT [**12-31**] in the setting of
decompensated liver failure [**12-25**] infection. Hepatitis thought to
be from blood transfusions vs tattoos, noticed on random LFTs.
Genotype 1, treated with Peg-IFN and ribavirin several times
with no response. He has three Grade II varices with portal
gastropathy s/p banding. Last EGD in [**5-29**] showed Varices at the
lower third of the esophagus w/ scarring from previous banding,
portal hypertensive gastropathy.
-hx L leg cellulitis, necrotizing fascitis, osteomyelitis and
group A strep sepsis [**11/2123**], requiring skin graft
-Chronic thrombocytopenia
-Hypersplenism
-Cellulitis [**2119**]
-MVA [**2101**], surgery to R leg, multiple fractures to L leg
-Failure to thrive after liver [**Year (4 digits) **]
-Multiple episodes of acute renal failure with unclear baseline
creatinine (was as low as .8 in [**12-31**], range .8-4.5)
Social History:
Denies tobacco use. No alcohol x 18 years. Denies ever using IV
drugs. Lives with wife, has 6 children, 5 grandchildren. Owns
his own towing/auto body repair business.
Family History:
Son died of colon cancer, grand father died of colon cancer. No
history of liver disease
Physical Exam:
PE: VS T 95.5 BP 84/58 Pulse 60 RR 20 O2 96% on RA
Gen: NAD, cachectic, pale
HEENT: oropharynx clear, dry mucous membranes
CV: RRR, no murmurs
Lungs: clear bilaterally
Abd: well-healed y-scar. Normoactive bowel sounds. Nondistended,
nontender. No appreciable ascites.
Ext: warm, no cyanosis. Left leg extensively scarred below
mid-shin with nonpitting edema below ankle, nontender, distal
pulses strong.
Skin: multiple tattos on trunk and arms
Pertinent Results:
Admission labs: [**2124-10-20**]
WBC-11.4*# RBC-2.89* Hgb-7.5* Hct-23.9* MCV-83 MCH-25.9*
MCHC-31.2 RDW-15.8* Plt Ct-257#
PT-36.3* PTT-49.4* INR(PT)-3.9*
Glucose-121* UreaN-64* Creat-3.1*# Na-131* K-4.9 Cl-98 HCO3-22
AnGap-16
ALT-59* AST-94* LD(LDH)-200 AlkPhos-789* TotBili-0.6
Albumin-2.8* Calcium-8.9 Phos-4.3 Mg-2.1
At Discharge [**2124-11-15**]
WBC-3.5* RBC-3.27* Hgb-10.0* Hct-28.2* MCV-86 MCH-30.5
MCHC-35.4* RDW-17.3* Plt Ct-108*
PT-32.5* INR(PT)-3.4*
Glucose-76 UreaN-64* Creat-1.4* Na-134 K-5.7* Cl-110* HCO3-19*
AnGap-11
ALT-50* AST-41* AlkPhos-201* TotBili-0.6
Calcium-8.8 Phos-2.7 Mg-2.0 Alb 2.3
TacroFK-9.2
Brief Hospital Course:
A 57 year-old man 9 months s/p OLT and 2 weeks after hepatic
artery thrombosis presents with failure to thrive, acute renal
failure, hypotension, leukocytosis, and fevers.
WBC on presentation was 11.7 with 14% bands. Wife and patient
both stated that he had been having intermittent fevers as high
as 102 measured at home since the time of [**Month/Day/Year **], although
this had not previously been documented. Blood cultures grew
enterococcus and Neisseria, and urine cultures grew pseudomonas.
He underwent CT guided drainage of a hepatic collection on [**10-23**].
The fluid grew out Enterococcus and [**Female First Name (un) 564**]. Vanc and Zosyn were
initially started, then coverage was broadened to Vanco, Zosyn,
Cipro and Caspofungin.
US showed there is slow flow in the main hepatic artery with a
tardus and parvus waveform (velocity up to 32 cm/s), but no flow
in the right hepatic artery. There is no intrahepatic biliary
dilation. The portal vein and its branches are patent.
Patient was continued on coumadin.
Regarding failure to thrive: This was likely multifactorial,
with acute bacteremia and renal failure playing a role.
However, he had a long history of weight loss and poor PO intake
(had required feeding tube for several months after [**Female First Name (un) **])
and was thought to also have some underlying depression. Given
that he was on the [**Female First Name (un) **] list, feeding tube was considered
however patient had refused initially at admission and then was
transplanted. He was maintained on TPN post [**Female First Name (un) **] and was
using PO supplements with good tolerance and was encouraged to
use the supplements at home following discharge.
On [**2124-10-25**] a liver became available and the patient
underwent a second orthotopic liver [**Year (4 digits) **] due to the
hepatic artery thrombosis and subsequent biliary necrosis and
hepatic abscess. He was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
An Orthotopic deceased donor liver [**Last Name (NamePattern1) **] (piggyback),
portal vein - portal vein
anastomosis, common bile duct -common bile duct anastomosis (no
T tube). Donor iliac artery conduit from the supraceliac aorta
was performed. He received routine induction immunosuppression
to include Cellcept, solumedrol with prednisone taper and
Prograf restarted on the evening of the [**Last Name (NamePattern1) **]. The broad
coverage with antibiotics was continued with patient receiving
12 days of Vanco, 15 days of Cipro, 19 days of Zosyn and 14 days
of Caspo which was then converted to PO fluconazole.
He initially did well in the SICU, remained afebrile. On POD 6
his coumadin was restarted. The lateral drain was removed on POD
3. The medial drain was noted to be becoming more bilious in
nature and he was having increased abdominal pain and an
elevation in his WBC. An ERCP was attempted and extravasation of
contrast was noted at the duct to duct anastamosis and a stent
was placed. However, it was determined that he was going to
require Roux-en-Y hepaticojejunostomy and was taken back to the
OR with Dr [**Last Name (STitle) **]. He did well following the surgery but was
continued on the TPN until he was able to start tolerating
liquids and started supplements. He was still refusing Dobhoff
tube placement and instead wanted to eat and use supplements.
Calorie counts showed him getting about [**11-24**] to [**12-26**] of caloric
needs and he was instructed to take 4 of the Ensure bottles
daily.
On POD 13/3 he was switched to oral Fluconazole off the
Caspofungin with appropriate adjustment in the Prograf dosing.
ID recommended changing to Ceftrixone and getting him off the
other antibiotics and keeping him on the antibiotic until the
second JP drain was removed. That drain continued with about 1
Liter output daily, but remained serous, so it was decided to
remove the drain and suture. The Ceftrixone was taken off at
this time.
His Coumadin was managed, INRs followed daily. The INR was 5.4 2
days prior to discharge and the dose was dropped with followup
with outpatient labs.
Cholangiogram on [**11-10**] showed no leak and tube was capped with
no subsequent fever.
LFTs dropped appropriately and were WNL at time of discharge.
Medications on Admission:
metoprolol 25 mg [**Hospital1 **]
Cellcept [**Pager number **] mg [**Hospital1 **]
tacrolimus 2 mg [**Hospital1 **] (previously 3 mg [**Hospital1 **])
metoprolol 25 [**Hospital1 **]
Bactrim SS qd
calcium carbonate 500 mg tid (takes [**Hospital1 **])
coumadin 1 mg qd (previously 2 mg qd)
Ambien 5 mg qhs
Senna, Docusate PRN (not using)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO once a day: Per
[**Hospital1 **] clinic taper.
Disp:*105 Tablet(s)* Refills:*2*
10. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
11. 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*
12. Outpatient Lab Work
CBC, Chem10, AST, ALT, alk phos, albumin, T.bili, and tacrolimus
PT/INR
biweekly - Monday and Thursday
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
INR/PT
Discharge Disposition:
Home With Service
Facility:
Diversified VNA
Discharge Diagnosis:
Hepatic artery thrombosis
s/p re-[**Hospital1 **]: orthotopic liver [**Hospital1 **]
s/p Exploratory laparotomy, Roux-en-Y, hepaticojejunostomy
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call the [**Hospital1 **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting , diarrhea, increased abdominal
pain or girth, inability to take or keep down food, fluids or
medications.
Monitor the incision for redness, drainage or bleeding
No heavy lifting
Drink enough fluids to keep urine light yellow in color.
You may shower, allowing water to run over abdomen. Pat dry, do
not rub. No tub baths
No driving if you are taking narcotic pain medication
Please call your PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] at [**Telephone/Fax (1) 64241**], to
manage your coumadin levels with outpatient INR/PT labs.
Followup Instructions:
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-1-30**] 1:00
Please call the [**Year/Month/Day 1326**] Surgery Clinic at [**Telephone/Fax (1) 673**] to set
up a follow up appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2124-11-17**]
|
[
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"263.9",
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"V12.09",
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icd9cm
|
[
[
[]
]
] |
[
"99.07",
"54.12",
"50.91",
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"50.4",
"99.15",
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] |
icd9pcs
|
[
[
[]
]
] |
10999, 11045
|
4875, 9151
|
334, 479
|
11233, 11247
|
4230, 4230
|
11970, 12365
|
3660, 3750
|
9538, 10976
|
11066, 11212
|
9177, 9515
|
11271, 11947
|
3765, 4211
|
277, 296
|
507, 2496
|
4246, 4852
|
2518, 3459
|
3475, 3644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,180
| 155,002
|
38084
|
Discharge summary
|
report
|
Admission Date: [**2114-8-9**] Discharge Date: [**2114-8-14**]
Date of Birth: [**2030-10-2**] Sex: M
Service: SURGERY
Allergies:
Keflex / Bactrim
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Peripheral vascular disease, non-healing ulcer on right foot.
Major Surgical or Invasive Procedure:
Right Popliteal to Dorsalis Pedis Bypass graft and Right 4th toe
amputation.
History of Present Illness:
This is an 83-year-old male with peripheral arterial disease and
right lower extremity ulceration at the right fourth toe.
Past Medical History:
PAD, hyperlipidemia, HTN, A-fib with pacer, Cardiac stent, renal
insufficiency cr 1.7, [**Location (un) **] cell cancer, reflux
PSHx- [**Location (un) **] cell tumor [**2091**], RHR [**2110**], CABG [**2110**]
Social History:
Former smoker quit>1yr
Family History:
NC
Physical Exam:
Vitals 97.6 60 131/51 16 96%RA
Gen- AxOx3, NAD
CV-RRR, no MRG
Pulm- CTABL
Abd-soft, NT, ND
Ext/Pulses- R DP/graft palpable. L-DP/PT dopplerable
Incision- CDI
Brief Hospital Course:
Pt was admitted to the vascular service on [**2114-8-9**] for Right
popliteal to pedal bypass graft using saphenous vein, angioscopy
valve lysis, 4th toe amputation right foot. Pt did well
post-operatively with goop BP and pain control. He was kept on
bedrest status and had an ACE bandage to his R leg. Pt began
tolerating a regular diet on POD 1. Pt was OOB to the bathroom
only on POD. He continued to do well with minimal oozing of
blood from the lower aspect of the incision that resolved. A CT
scan of the chest was ordered to follow-up on a possible mass
finding on a previous CXR. That CT scan was negative. Pt
continued to do well and was discharged to rehabilitation to
follow up with Dr. [**Last Name (STitle) 1391**] in clinic.
Medications on Admission:
Norvasc 5mg, aspirin 81, lipitor 20, plavix 75, HCTZ 25,
Flonase, Isosorbide mononitrate 30, lisinopril 5, nexium 40,
votaren 50, sotolol 120''
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare and hospice
Discharge Diagnosis:
Right Lower Extremity peripheral vascular disease
Discharge Condition:
Stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the vasuclar surgery service for R leg
bypass graft and R 4th toe amputation for ischemic disease of
that leg.
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 [**2-14**]
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
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] in [**2-14**] weeks.
|
[
"707.14",
"V43.64",
"793.1",
"707.15",
"403.90",
"427.31",
"585.9",
"V45.01",
"440.23",
"V45.81",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"84.11"
] |
icd9pcs
|
[
[
[]
]
] |
2762, 2829
|
1063, 1804
|
337, 416
|
2923, 2932
|
5935, 6015
|
857, 861
|
1999, 2739
|
2850, 2902
|
1830, 1976
|
3083, 5502
|
5528, 5912
|
876, 1040
|
236, 299
|
444, 568
|
2947, 3059
|
590, 801
|
817, 841
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,228
| 147,901
|
34952
|
Discharge summary
|
report
|
Admission Date: [**2146-7-4**] Discharge Date: [**2146-7-21**]
Date of Birth: [**2087-2-16**] Sex: M
Service: SURGERY
Allergies:
Ativan
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Fevers /Centarl Abdominal Pain
Major Surgical or Invasive Procedure:
[**2146-7-4**] [**Doctor Last Name 3379**] procedure
History of Present Illness:
This patient is a 59 year old male who complains of acute severe
abd pain around 3 pm [**7-3**] assoc w/ fever transferred from
[**Hospital3 2783**] with h/o of HCC/ mets with alcohol-induced
liver cirrhosis associted with varices and portal hypertension.
He was given 3mg Dilaudid, 2g Ceftriaxone at OSH. U/S showed
hernia and a gallstone.
He has a TIPS in place for bleeding caput medusae and PV
thrombosis and he has an enlarging mass in the left lobe of his
liver, which has been biopsy proven to be hepatocellular
carcinoma. He had a chemoembolization of liver mass at [**Hospital **]
hospital on [**6-9**].
His case has been discussed at the Liver Tumor Conference at
[**Hospital1 1444**] and he is not a good candidate
for radiofrequency ablation or Cyber Knife therapy.
The possibility of surgical resection was discussed at the Liver
Tumor Conference and it was not felt to be feasible given the
degree of portal hypertension. Liver transplantation is not an
option given the size of this mass. He is not on transplant
list.
Past Medical History:
-Class A liver alcoholic cirrhosis w/portal hypertension, caput
medusa, esophageal varices
- HCC s/p chemoembolization at [**Hospital **] hospital
-Peptic ulcer disease with duodenal perforation status post
[**Location (un) **] patch repair, complicated by wound infection (yeast).
-Hypertension
-Hyperlipidemia
-Insulin resistance that resolved after weight loss
-Acute pancreatitis
-Side branch intraductal papillary mucinous neoplasm (IPMN) -
incidental finding on CT & MRI
-Abdominal wall herniation
-[**2146-7-4**] [**Doctor Last Name 3379**] Procedure
Social History:
He has not had any EtOH since [**2143-1-14**]. Quit smoking 20
years ago. He lives with his wife (who is a cardiology nurse).
He has 1 son in college. He works full time in sales in floor
covering. He exercises (cardio) 3-4 times per week. No recent
weight lifting d/t abdominal distention/bleeding. No sick
contacts, no travel history. Denies other drug abuse.
Family History:
His father died of esophageal cancer. His mother is 91 and
healthy. He has 2 brothers; one drinks & smokes, the other one
is healthy.
Physical Exam:
Temp 102.1 Pulse 130 BP 155/73 RR 15 SATS 96%
Exam sp 8 mg of IV Morphine /ED
General cooperative, Moderately distressed
NEURO Oriented awake alert, no global or local deficits.
HEENT no thyromegaly, no lymphadenopathy, no carotid bruit.
CHEST decreased breath sounds bases bilat
CARDIAC S1 S2 audible no murmurs appreciated.
ABDOMEN Firm, tender lower abdomen , distended, Ascitic, BS
diminished, midline incisional hernia, abd wall /domain loss
defect.Guaic negative @ [**Hospital3 2783**]. Not repeated here.
EXTREM Mild edema, distal pulses palpable +1
LABS:
4.8 > 43.9 < 158
33 bands
Lactate 4.1> 5.7 > 7.3
140 108 12 AGap=17
-------------< 153
4.0 19 0.8
PT: 15.3 PTT: 23.3 INR: 1.3
ALT: 49 AP: 200 Tbili: 2.2 Alb: AST: 85
pH7.29 pCO25 pO281 HCO313 BaseXS -12
IMAGING:
US TIPS: [**Last Name (un) **] patent with slightly decreased velocities
compared
to baseline study. Right posterior and left portal veins with
appropriate. Small amount of free
fluid.
CT torso
No PE, no hepatoma rupture.
Free air and fluid in the abdomen tracking along the sigmoid
mesocolon, likely perforated diverticulitis. No PV thrombosis.
Pertinent Results:
[**2146-7-20**] 05:20AM BLOOD WBC-8.2 RBC-3.09* Hgb-10.4* Hct-29.4*
MCV-95 MCH-33.7* MCHC-35.5* RDW-16.2* Plt Ct-158
[**2146-7-19**] 05:33AM BLOOD PT-17.8* PTT-32.3 INR(PT)-1.6*
[**2146-7-20**] 05:20AM BLOOD Glucose-120* UreaN-9 Creat-0.8 Na-135
K-3.7 Cl-103 HCO3-23 AnGap-13
[**2146-7-20**] 05:20AM BLOOD ALT-18 AST-44* AlkPhos-125 TotBili-4.4*
[**2146-7-20**] 05:20AM BLOOD Albumin-3.1*
Brief Hospital Course:
59 y.o. male admitted from ED with perforated diverticulitis
with worsening lactic acidosis (Lactate 7.3). He required
intubation in ICU due to worsening respiratory status. IV
vanco,zosyn and iv fuid resuscitation were given. On [**2146-7-4**], he
underwent exploratory laparotomy; sigmoid colectomy;Hartmann's
procedure; descending colon colostomy. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Please refer to operative note for details. Postop, he
was left intubated and required pressor support.
Blood cultures were sent on [**7-3**] after spiking to 101.4. He was
pancultured. On [**7-7**] a post pyloric feeding tube was placed and
trophic tube feeds were started. He was diuresed to aid
ventilator wean. Ventilator was weaned and he was extubated 4
days later.
Sips were started. Mental status worsened with increased
agitation on [**7-9**]. Lactulose was started. The original blood
cultures isolated GNR/GPCs. Vanco, zosyn and flagyl continued.
Ostomy output was appropriate. On [**7-10**], diet was advanced to
clear liquids. On [**7-10**], he transferred out of the SICU.
On [**7-11**], ID was consulted for persistent elevated wbc while on
antibiotics. Zosyn dose was increased. It was noted that he had
HSV on lips. Acyclovir was started. Picc line was ordered and
placed. Vancomycin was stopped. On [**7-13**], temps were still low
grade. An abd ct was done showing a large subcapsular
collection. 900cc of turbid, yellow fluid was aspirated. Fluid
had pmn's, but no growth. Drain was not left in place. Patient
self d/c'd picc line. Picc was replaced.
On [**7-15**], Vancomycin was restarted. Hepatology was consulted and
iv albumin/rifaximin were started.
PT worked with him. Mobility and safety improved. PT cleared him
for home safety.
Repeat abd CT was done on [**7-18**] noting reaccumulation of the
subcapsular collection. [**7-19**], IR placed an 8Fr drain with 550 cc
removed. Fluid had 50,200 with 85 polys. This fluid isolated
citrobacter. The patient felt well enough to go home. ID was
contact[**Name (NI) **] and asked for po antibiotic regimen. A 4 week course
of po cipro and flagyl was recommended. F/u CT and ID
appointment were recommended.
Enterostomal therapy followed him and did teaching. Stoma was
beefy red. There was a circumferential junctional separation.
[**Last Name (un) **] wafer and coloplast pouch were recommended. VNA services
were ordered. He was discharged to home with stable vital signs,
ambulatory, and tolerating regular diet.
Medications on Admission:
CIPROFLOXACIN 500 mg q 12
GLYBURIDE - 2.5 mg q 12
Dilaudid- 2 mg q6hr PRN
ZOLPIDEM - 5 mg QHS
All: Ativan
Discharge Medications:
1. Thiamine HCl 100 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet [**Last Name (un) **]: One (1) Tablet PO once a day.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
5. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Rifaximin 550 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
9. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical PRN
(as needed) as needed for skin care: Apply under ostomy
site/under bag with every ostomy bag change. .
Disp:*1 bottle* Refills:*0*
10. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
Weekly labs: cbc with diff, chem 7, ast, alt, alk phos, t.bili
fax to ID [**Telephone/Fax (1) 1419**]
can obtain on [**7-29**]
13. Oxycodone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO prn: every 4
hours.
Disp:*30 Tablet(s)* Refills:*0*
14. Glyburide 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
15. Coloplast Closed Pouch Misc [**Month/Year (2) **]: One (1) pouch
Miscellaneous every seventy-two (72) hours: and prn
Coloplast 1 piece pouch
supply: 1 box
refill: 2.
Disp:*1 box* Refills:*2*
16. [**Last Name (un) **] seal [**Last Name (un) **]: One (1) seal every seventy-two (72)
hours: supply: 1 box
refill: 5.
17. Stomahesive Protective Powder [**Last Name (un) **]: One (1) Topical prn
to junctional separation with each pouch change.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
perforated diverticulitis
encephalopathy
ascites
bacteremia, bacteroides fragilis
subhepatic fluid collection
peritonitis
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 call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
any of the warning signs listed below.
Change ostomy pouch every 3 days.
Weigh yourself and record.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-7-29**] 1:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2146-8-8**]
10:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-9-2**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 12838**], Infectious Disease [**Telephone/Fax (1) 457**],
*****appt to be schedule for 2 weeks from now
Completed by:[**2146-7-21**]
|
[
"562.11",
"272.4",
"518.81",
"571.2",
"276.2",
"348.30",
"054.9",
"572.3",
"155.0",
"995.92",
"401.9",
"038.3",
"567.29",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.11",
"45.76",
"54.91",
"96.04",
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9115, 9198
|
4140, 6671
|
297, 351
|
9364, 9364
|
3727, 4117
|
9751, 10405
|
2401, 2538
|
6829, 9092
|
9219, 9343
|
6697, 6806
|
9547, 9728
|
2553, 3708
|
226, 259
|
379, 1420
|
9379, 9523
|
1442, 2001
|
2017, 2385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,999
| 153,543
|
24426
|
Discharge summary
|
report
|
Admission Date: [**2119-6-26**] Discharge Date: [**2119-7-4**]
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides) / Hydrochlorothiazide / Ace Inhibitors /
Metoprolol
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Intracranial hemorrhage
Major Surgical or Invasive Procedure:
CT Scan
History of Present Illness:
The patient is a 81 yr old who presents to [**Hospital1 18**] as transfer
from OSH for intracerebral bleed. History from daghter as pt.
incoherent. At baseline, the patient is mildly dememented and
forgetful, but was functional enough to
take care of herself and be independent. Then, this past Friday
her daughter noticed that she became very incoherent with her
speech and was non-sensical. She also became fatigued and
eventually bedbound over the next three days. The patient was
taken to OSH which showed a well circumscribed 20-30cc
intracerebral hemorrhage in the left frontal lobe located
subcortically. No midline shift or edema. There is also
encephalomalacia of right fronto-parietal lobe suggestive of
remote R MCA stroke.
There has been no recent head trauma, HA, photphobia, n/v.
Patient not hypertensive previously.
Past Medical History:
CHF
CVA [**26**] yrs ago p/w left sided weakness
Social History:
Lives alone and attends to own ADL's
Physical Exam:
T-97.6 BP-180/80-> 130's SBP HR-68 RR-16
Gen: lying in bed mumbling incoherently
Heent: NCAT, oropharynx clear
Neck: supple, no carotid bruits
Chest: [**Month (only) **] BS at bases CV:regular rate, normal s1s2, no m/r/g
Ext: no c/c/e, 2+ dorsalis pedis
Neurologic Exam:
MS:
Pt. is awake, eyes open, and attentive to speech. She is
mumbling "[**Known firstname 61825**], [**Known firstname 61825**]" when asked what her name. Not
oriented to place or time. She cannot perform tests of
attention. She can follow simple midline commands, but cannot
show me her left hand or left thumb. She intermittently follows
the neurologic exam.
CN:
Visual fields intact to confrontation
Pupils normal round 3mm->2mm with light.
Blinks to threat b/l.
Eomi without nystagmus.
Normal facial sensation and musculature.
Palate rises symmetrically. Tongue midline.
Motor:
Patient cannot follow full exam but is antigravity in all 4
extremities and moves left side greater than right
Reflexes:
There are [**2-24**] reflexes in UE
Plantar reflexes extensor b/l
Sensory:
Localizes to painful stimulus x 4
Coordination:
No ataxia when reaching out hands
Gait:
unable to assess
Pertinent Results:
[**2119-6-26**] 09:15PM BLOOD WBC-11.1* RBC-4.55 Hgb-14.0 Hct-40.9
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-208
[**2119-7-2**] 07:15AM BLOOD WBC-15.2* RBC-3.78* Hgb-11.2* Hct-34.1*
MCV-90 MCH-29.6 MCHC-32.8 RDW-12.7 Plt Ct-194
[**2119-7-2**] 07:15AM BLOOD Plt Ct-194
[**2119-7-1**] 07:15AM BLOOD PT-13.1 PTT-23.6 INR(PT)-1.1
[**2119-7-2**] 07:15AM BLOOD Glucose-121* UreaN-16 Creat-1.0 Na-143
K-3.7 Cl-104 HCO3-31* AnGap-12
[**2119-6-29**] 03:00PM BLOOD ALT-15 AST-36 AlkPhos-58 TotBili-0.8
[**2119-6-27**] 03:00AM BLOOD Triglyc-81 HDL-70 CHOL/HD-2.6 LDLcalc-98
[**2119-6-29**] 03:00PM BLOOD TSH-0.41
UA ([**6-29**]) RBC 0 WBC 12, blood tr, LE small
UCx ([**6-29**]) <10,000 organisms
NCHCT ([**6-26**])
Large intraparenchymal hemorrhage (32 x 44 mm) with edema or
encephalomacia in the left frontal lobe. Large areas of
hypodensity in the right frontal and parietal lobes, with areas
of encephalomalacia. Possible left petrous meningioma
NCHCT ([**6-29**])
Unchanged
Brief Hospital Course:
She was admitted to the Neuro ICU for management of intracranial
hemorrhage. Neuro exam at that time was significant for waxing
and [**Doctor Last Name 688**] alertness, inattention and nonsensical speech. There
is more spontaneous movement on L> R. No cranial nerve findings.
1. Neuro: Left frontal ICH (likely secondary to amyloid
angiopathy)
Antiplatelet agents were held. Her blood pressure was
controlled on outpatient regimen (Coreg). Rpt head CT showed
bleed unchanged. She was transfered to the floor on [**6-29**]. Neuro
exam remained stable (fluctuating arousal, inattention,
disorientation, follows simple commands, strength normal).
Though the etiology of the bleed is likley to be amyloid
angiopathy, she could have an MRI/MRA with gado as an outpatient
to exclude other possible causes (mass lesion, AVM)-though these
seem unlikely and to confirm susceptibility changes on MR that
would be c/w amyloid.
2. CV:
Continued on antihypertensives, BP well controlled. Lasix and
aldactone were held secondary to dehydration. Ruled out for MI
with 3 sets negative CE.
3. Pulm:
No active pulmonary issues
4. ID: WBC increased, low grade temp 100.6 on [**7-3**]. Repeat CXR
negative. UA showed 8 WBCS, awaiting Urine Culture. She was
started on amoxicillin and clarithromycin on [**6-28**] for recently
diagnosed (and untreated) H. pylori infection. She should
continue on antibiotics until [**7-17**].
5. Nutrition: Speech and Swallow suggested nectar thick liquids
6. GI: COntinued on Protonix. + constipation, KUB negative for
obstruction. Started on colace and senna, lactulose PRN for
constipation.
6. PT/OT:
d/c to rehab for further management
7. DVT Ppx:
pneumoboots
Medications on Admission:
remeron 15
trazodone
lasix 40
coreg 6.25 [**Hospital1 **]
aldactone 25 qd
asa 81
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 7 days.
6. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q12H
(every 12 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Left frontal intracranial hemorrhage
H. Pylori infection
Discharge Condition:
Improved
Discharge Instructions:
You should continue PT/OT at rehab. Do NOT take aspirin or
NSAIDs (such as Motrin or Advil). Please call the Dr. [**Last Name (STitle) **]
or report directly to the ER for worsening headache, new speech
difficulty, weakness, numbness or other concerning symptoms.
Followup Instructions:
1. [**Hospital 4038**] Clinic (Dr. [**Last Name (STitle) **]: please call to arrange follow up
appointment [**Telephone/Fax (1) 657**]
2. Primary Care: please call Dr. [**Last Name (STitle) **] to arrange follow up
appointment after discharge from rehab
|
[
"438.89",
"401.9",
"362.50",
"041.86",
"729.89",
"277.3",
"276.5",
"431",
"564.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6397, 6494
|
3505, 5210
|
304, 314
|
6595, 6605
|
2509, 3482
|
6919, 7179
|
5341, 6374
|
6515, 6574
|
5236, 5318
|
6629, 6896
|
1319, 1581
|
241, 266
|
342, 1177
|
1598, 2490
|
1199, 1250
|
1266, 1304
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,333
| 185,644
|
27821
|
Discharge summary
|
report
|
Admission Date: [**2167-12-23**] Discharge Date: [**2168-1-8**]
Date of Birth: [**2094-1-21**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Aspirin / Cephalosporins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Septic Shock, Respiratory [**Hospital 67809**] transfer from OSH
Major Surgical or Invasive Procedure:
intubation, central venous line
History of Present Illness:
This is a 73 year-old female with a PMH history of Parksinson's,
protein C/S deficency, multiple VTE off anticoag [**1-4**] to RP
hematoma with IVC filter, CKD, s/p partial colectomy with ostomy
who is transferred to the [**Hospital Unit Name 153**] from OSH ([**Hospital1 14579**])a for further management and evaluation of septic shock
and respiratory failure.
Patient presented to OSH ED on [**2167-12-18**] with 2-3 days of general
malaise and abdominal pain at her colostomy site. She was
treated with Toradol and discharged back to her nursing home
with a diagnosis of constipation. She subsequently developed
respiratory distress and was sent back to the ED where she was
hypotensive and in shock. CXR revealed interstitial edema and
B/L PNA. She was given Lasix 80 mg IV x 1 for possible CHF. She
was started on levofloxacin, Flagyl, and vancomycin. She was
admitted to the ICU on [**2167-12-19**] with septic shock, acute
hypoxemic respiratory failure requiring intubation, and PNA. A
right IJ Precept catheter was placed along with a right arterial
line and she was aggressively resuscitated with IVF. She was
also started on levophed. She was found to have bibasilar E.coli
PNA and E.coli UTI. Nephrology was consulted for ARF on CRI
which was thought to be [**1-4**] to ATN from hypotension/sepsis.
Prior Toradol may also have contributed. TTE on [**2167-12-21**] showed
an EF of 55-60% with RV pressure of 46 mmHg. Initial creatinine
was 4.1, down to 3 on transfer. Levophed was weaned on [**2167-12-22**].
UCx and SCx grew E.coli, resistant to levofloxacin. ABx were
changed to aztreonam given her drug allergies. She was started
on tube feeds as well. Also presented with mild rhabdomyolysis
at 837 which improved with hydration.
ROS (per report): Denies F/C. Positive for nonproductive cough.
Denies CP or palpitations. No LE edema.
Past Medical History:
h/o B/L PNA
h/o septic shock in [**12-9**]
Parkinson's disease
Protein C and S deficiency
h/o multiple VTE including PE, briefly off anti-coagulation
because of large retroperitoneal hematoma in [**11-7**], s/p IVC
filter, and currently anticoagulated with coumadin
Colectomy for colon cancer
CRI with baseline creatinine around 2
Pancreatitis [**12/2164**], unclear cause
Hyperlipidemia
Large ventral hernia
Depression
h/o TIA
Postural hypotension
Restless leg syndrome
Social History:
Non smoker, non drinker. Lived independently until [**11-7**].
Daughter is HCP. Currently lives in nursing home (The [**First Name4 (NamePattern1) 6382**]
[**Last Name (NamePattern1) **] in [**Location (un) 8973**]).
Family History:
Non-contributory
Physical Exam:
Vitals: Per Metavision
GEN: NAD, intubated and sedated, opens eyes to verbal stimuli
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, ET tube in place.
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline.
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: B/L Rhonchi.
ABD: Soft, NT, ND, +BS, no HSM, no masses, colostomy in place.
EXT: No C/C/E, no palpable cords, chronic venous stasis changes.
NEURO: Sedated. Toes downgoing. Reflexes normal and symmetric.
Pertinent Results:
[**2167-12-23**] 09:40PM GLUCOSE-141* UREA N-95* CREAT-2.8*
SODIUM-148* POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-20* ANION
GAP-16
[**2167-12-23**] 09:40PM ALT(SGPT)-3 AST(SGOT)-13 ALK PHOS-79 TOT
BILI-0.2
[**2167-12-23**] 09:40PM ALBUMIN-3.2* CALCIUM-7.8* PHOSPHATE-4.1
MAGNESIUM-4.4*
[**2167-12-23**] 09:40PM WBC-13.7*# RBC-3.36* HGB-10.1* HCT-30.5*
MCV-91 MCH-30.2 MCHC-33.3 RDW-15.5
[**2167-12-23**] 09:40PM NEUTS-89* BANDS-3 LYMPHS-5* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2167-12-23**] 09:40PM PLT SMR-LOW PLT COUNT-132*
[**2167-12-23**] 09:40PM PT-19.4* PTT-27.7 INR(PT)-1.8*
[**2167-12-23**] 10:09PM LACTATE-0.7
[**2167-12-23**] 10:09PM TYPE-ART TEMP-36.5 RATES-20/ TIDAL VOL-550
PEEP-10 O2-50 PO2-64* PCO2-37 PH-7.37 TOTAL CO2-22 BASE XS--3
-ASSIST/CON INTUBATED-INTUBATED
OSH CXR [**2167-12-23**]: LLL infiltrate with unchanged right basilar
infiltrate.
OSH Labs:
ABG on arrival to OSH ED: 7.29/57/52 on 10L NC
ABG on BiPAP: 7.20/64/126
ABG at time of transfer: 7.34/36/80 on AC, TV 550, rate 20, PEEP
10, FiO2 50%.
ABG prior to intubation: 7.39/57/52.
BNP 143, initial K 2.7, AG 19, WBC 4.5, HCT 39, PLT 185, INR
1.25. Lactate 0.9.
C.diff negative x 1
UCx positive for E.coli, only sensitive to Cefazolin, tobra,
imipenem, and zosyn.
SCx: E.coli, same sensitivities
BCx: NGTD
EKG: NSR, no acute ST changes, normal axis and intervals.
Imaging:
CXR ([**12-23**]): Portable AP chest radiograph was compared to prior
study obtained on [**2166-12-31**]. No recent radiographs
obtained in the outside hospital are available for comparison.
The current study demonstrates ET tube tip being approximately
3.5 cm above the carina. The right internal jugular line tip
cannot be visualized but most likely in the right atrium. The NG
tube tip is in the stomach. The patient is after placement of
IVC filter. Left retrocardiac consolidation is demonstrated, new
compared to the prior study and might represent pneumonia.
Bilateral pleural effusions are seen. Vascular engorgement is
present but no pulmonary edema is demonstrated.
Brief Hospital Course:
The following is a detailed discussion of her MICU course
through [**2168-1-8**]. Briefly, she was admitted with respiratory
failure and septic shock complicated by failure to wean from the
ventilator. She had gram negative rod infection of lung and
urinary system. Sepsis did resolve with antbiotic therapy over
initial week of hospitalization. She had aggressive diuresis
with negative fluid balance. Despite this she had persistent
and recurrent hypoxemia with attempts to wean from the
ventilator and required elevated PEEP pressures of >12 to
maintain PaO2>65 despite diuresis, ongoing antibtiotics and
recruitment maneuvers. She had heparin continued outside of
times of active tracheal bleeding and there was no clinical
evidence to suggest PE. She had prolonged course and had
clearly stated to her family that return to a level of function
to allow independent living prior to illness. When faced with
decision to pursue Trach/PEG after > 14 days on ventilator in
the setting of weakness and persistent hypoxemia extensive and
repeated family meetings were held. After discussion with her
family and health care proxy, she was made comfort measures only
and she was extubated on [**2168-1-7**]. She passed away from
cardiopulmonary arrest at 4am [**2168-1-8**].
MICU COURSE:
73 year-old female with a PMH history of Parkinson's, protein
C/S deficency, multiple VTE off anticoag [**1-4**] to RP hematoma with
IVC filter, CKD, s/p partial colectomy with ostomy who is
transferred to the [**Hospital Unit Name 153**] from OSH ([**Hospital6 8972**])
for further management and evaluation of septic shock and
respiratory failure.
# Sepsis/recent septic shock: Sources previously found to be
resistant E. coli in urine and sputum, and MRSA in her sputum.
Sputum culture sensitivity shows sensitivity to meropenem,
zosyn, and cephalosporins. Pt unfortunately has an allergy to
beta lactams. Initially treated with vanc, levo, flagyl and
switched to Aztreonam once sensitivities returned however per
ID, aztreonam not a good singel source [**Doctor Last Name 360**], changed to
meropenem. Spurum cx returned with MRSA, initially treated with
vancomycin but changed to Linezolid for better MRSA coverage. Pt
also noted to have a positive fungal culture from [**12-23**], her
subsequent bld cultures have not been positive however even with
one positive result fungemia is a concern. Pt was started on
Caspofungin. Sensitivities fort Voriconazole and Fluconazole
have been ordered and are pending. Recent sputum cx with no
growth. Bronch on [**1-1**] showed mucous plugging.
She will be continued on linezolid for 14 days for MRSA PNA ??????
day 1- [**2167-12-30**]; meropenem for 14 days ?????? day 1 [**2167-12-28**]; and
caspofungin for [**Female First Name (un) **] in blood ?????? day 1 [**2167-12-26**]. Her WBC has
been trending downwards.
# Respiratory failure/Pneumonia: PNA with E.coli from OSH, grew
MRSA in sputum here. DFA for flu and urine legionella negative.
Vent weaning very difficult. Treated with meropenem and
linezolid as above. Given the amount of secretions and blood
suctioned from the bronchoscopy pt??????s PEEP dependance may be due
to the amount of secretions she has in her lungs. Unfortunately
even though suctioning would aid with secretion removal it would
likely worsen the blding providing more trauma. Have been
instilling normal saline and suctioning from within the
ventilator tube system if she appears to have mucous plugging.
She has also been undergoing gentle diuresis as her SBPs
tolerate with a lasix gtt with a daily goal negative of 500 cc
to 1 L. Her LOS fluid balance is ***. Her heparin gtt was
stopped given the trauma seen on the bronch.
# UTI: E.coli on cx from OSH, negative here. ABX as above.
# Nongap metabolic acidosis: Resolved, was likely [**1-4**] to
increased colostomy output. C.diff negative.
# ARF on CRI: Resolved, at 1.6 which is below the patient's
reported baseline of 2. The patient's ARF was thought to be
secondary to ATN given hypotension/septic shock plus recent
Toradol. Her Cr improved greatly with IVF.
# Parkinson's Disease - The patient was continued on Sinemet and
Requip.
# LUE Swelling: L >R, has anasraca so difficult to assess. Has
been off heparin gtt recently. U/S several days ago was noted to
be negative, however given the worsening of edema one the left
side as well as the erythema and tenderness this morning will
re-order an U/S for DVT. Will be done Monday morning.
# Protein C/S deficiency - The patient has a h/o of DVT and PE.
As her INR was subtherapeutic she was started on a heparin gtt
initally, however this was stopped after the bronch showed
tracheal bleeding.
# Anemia - Likely anemia of chronic disease. Her initial HCT was
39 at OSH ED, likely concentrated. No clinical evidence of
bleeding, except the tracheal bleeding seen on bronch. She has
been trending down throughout her hospitalization. Was 21.1 on
[**1-3**], so was given 1 unit of PRBC with an appropriate rise in her
Hct. Her heparin gtt was held as above.
# Comm: Daughter [**First Name4 (NamePattern1) **] [**Name (NI) 67810**], cell ([**Telephone/Fax (1) 67811**]
Medications on Admission:
Home Medications:
Oxycodone (unclear dose)
[**Name (NI) 29470**]
Ativan 0.5 mg PO Q12H PRN anxiety
Tylenol PRN
Albuterol/Atrovent PRN
Requip 4 mg PO TID
Sinemet 25/100 one TAB PO TID
Zocor 20 mg PO daily
Protonix 40 mg PO daily
KCL 40 mEq PO daily
Spironolactone 25 mg PO daily
Feosol 325 mg PO daily
OxyContin 80 mg PO BID
Lasix 80 mg PO daily
Advair 250/50 1 puff [**Hospital1 **]
Fexofenadine 60 mg PO BID
Renagel 1600 mg PO TID/meals
Cod Liver Oil
Vitamin D
Medications on transfer:
Zoloft 100 mg PO daily
Zocor 20 mg PO daily
Coumadin 7.5 mg PO daily
Requip 4 mg PO TID
Sinemet 25/100 one TAB TID
Aztreonam 1 g Q8H
Combivent 6 puffs Q4H
Protonix 40 mg IV daily
Versed gtt
Vancomycin 1 gram IV Q48H
Hydrocortisone 50 mg IV Q6H
Nystatin powder TID
Docusate 100 mg daily
Tylenol PRN
Morphine PRN
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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"482.82",
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"038.19",
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"785.52",
"289.81",
"599.0",
"568.81",
"998.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"38.91",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11723, 11732
|
5696, 10873
|
361, 394
|
11795, 11804
|
3605, 5673
|
11860, 11870
|
3020, 3039
|
11753, 11774
|
10899, 10899
|
11828, 11837
|
3054, 3586
|
10917, 11362
|
257, 323
|
422, 2274
|
11387, 11700
|
2296, 2768
|
2784, 3004
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,545
| 196,386
|
2490
|
Discharge summary
|
report
|
Admission Date: [**2199-3-26**] Discharge Date: [**2199-4-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F, h/o A fib on Coumadin, who fell twice 3/12am in
bathroom and 5-6pm again in her bedroom, both time struck her
left side of head on to ground. She was uncertain the cause of
the falls, thought she may have lost balance. Denied LOC, HA,
N/V, dizziness/lightheaddeness. No bladder/bowel incontinence.
Able to ambulate after the falls.
Past Medical History:
CHF- ECHO in '[**96**] showed EF 55%
Afib
ventral hernia
neuropathy on L side s/p "neck" tumor surgery
Diverticulitis
.
PSHX:
-LAR complicated by CHF post-op. Echo at that time EF >55%, mild
LVH, mild MR.
[**Name14 (STitle) 12753**] of cervical spinal tumor c/b L sided neuropathy and
weakness
Social History:
Lives in FL during winter. Recently moved back. Volunteer at
Hebreb. No Etoh, no smoking hx. Has 24 hour caregiver
Family History:
NC
Physical Exam:
T: 99.0 BP: 150/102 HR:96 R 20 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs full. No rhinorrhea. No
otorrhea.
Neck: no tenderness. on c-collar, ROM not examined.
Lungs: CTA bilaterally.
Cardiac: irregular HR 98, +S1S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.0mm to
1.5mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: 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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-18**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: 1+/4 throughout and symmetrical.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Pertinent Results:
[**2199-3-26**] 05:50AM PT-36.7* PTT-34.5 INR(PT)-4.0*
[**2199-3-26**] 05:50AM PLT COUNT-293
[**2199-3-26**] 05:50AM NEUTS-91.1* LYMPHS-5.2* MONOS-3.6 EOS-0
BASOS-0.1
[**2199-3-26**] 05:50AM WBC-17.2*# RBC-4.43 HGB-13.4 HCT-39.3 MCV-89
MCH-30.3 MCHC-34.1 RDW-14.4
[**2199-3-26**] 05:50AM CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2199-3-26**] 05:50AM CK-MB-9
.
IMAGING:
NCHCT [**3-26**] - FINDINGS: High-density material is seen tracking
along the left hemisphere consistent with acute subdural
hematoma. High-density material also seen tracking along the
falx and left tentorium, also consistent with subdural hematoma.
Hematoma measures approximately 1 cm in greatest width and
demonstrates mass effect, with subfalcine herniation, with
rightward shift of approximately 6 mm. Mass effect is seen on
the left lateral ventricle. The posterior aspect of the left
lateral ventricle is not well visualized. Left temporal [**Doctor Last Name 534**] is
also not well seen. Evidence of previous right MCA territory
infarct again seen. Dentate nucleus calcifications also again
noted. Visualized paranasal sinuses appear normally aerated.
IMPRESSION: Left-sided subdural hematoma, with subfalcine
herniation with
rightward shift of approximately 6 mm. Mass effect also seen on
the left
lateral ventricle.
.
CT C spine [**3-26**] - 1. No evidence of acute fracture or
dislocation.
2. Stable appearance to extensive degenerative disease and
vertebral body/ right facet fusion from C5-C7.
3. Reidentification of extensive subdural hematoma. Please
consult CT
examination report from same date for further details.
.
Shoulder x-ray [**3-26**] - No evidence of acute fracture or
dislocation.
.
NCHCT [**3-27**] - Large left-sided acute subdural hemorrhage which
appears to be unaltered in extent compared to the prior study of
[**3-26**]
.
CXR [**3-28**] - 1. Persistent retrocardiac opacity is concerning for
ongoing pneumonia. 2. Superior mediastinal prominence is
consistent with goiter seen on prior chest CT.
.
NCHCT [**3-29**] - Little change seen from prior study. Again seen is
large left subdural hematoma. There is no significant change
seen in the mass effect, or right temporal hyperdensity.
Calcifications are again noted in the folia of the cerebellar
hemispheres. No new hemorrhage identified.
.
CTA chest [**3-29**] - 1. No evidence of pulmonary embolus or
thoracic aortic dissection.
2. Bilateral lower lobe opacities, concerning for pneumonia.
Small right
pleural effusion.
3. Mild CHF.
4. Stable mediastinal mass, likely representing goiter.
.
LABS ON DISCHARGE:
[**2199-4-1**] 05:40AM BLOOD WBC-9.2 RBC-3.86* Hgb-12.2 Hct-34.8*
MCV-90 MCH-31.5 MCHC-35.0 RDW-14.7 Plt Ct-298
[**2199-4-1**] 05:40AM BLOOD Glucose-97 UreaN-13 Creat-0.6 Na-137
K-4.3 Cl-100 HCO3-28 AnGap-13
[**2199-4-1**] 05:40AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8
Brief Hospital Course:
Ms [**Name13 (STitle) **] was admitted to the ICU for frequent neurological
examinations and blood pressure control. She had repeat head
CTs which showed no evidence of new hemorrhage. She was ruled
out for an MI. On [**3-28**] she was transferred to the surgical
floor her Dilantin level was low and she was rebolused with
Dilantin and became quite lethargic. A repeat CT showed no
change or evidence of new stroke, however she was noticed to
have some expressive aphasia which continued into [**3-28**],
otherwise her exam was fairly intact. An MRI was ordered to eval
for new stroke but on transport, patient became hypotensive and
was returned to the floor and evaluated by MICU team for
transfer.
.
S/p MICU transfer:
# Respiratory distress: Thought to be secondary pneumonia seen
on CT. Given fever, tachypnea, hypoxia, tachycardia, was treated
for pneumonia. [**Month (only) 116**] be community-acquired (as had been going on
since prior to admission) vs aspiration (with altered mental
status) vs hospital acquired. Was treated as aspiration
pneumonia with levofloxacin and flagyl. No evidence of CHF on
exam or xray, and had actually been getting double her usual
lasix dose on the medical floor and appeared dry on exam. CTA
chest negative for pulmonary embolus. Upon transfer back to the
medical floor, the pt's oxygen requirement was weaned down to 2L
NC and she was sating in the upper 90s by the time of discharge.
She was discharged to complete a 10 day course of antibiotics at
rehab.
.
# SDH: Was maintained on dilantin 100 mg [**Hospital1 **]. Her dilantin level
was stable in the 10-15 range s/p her repeat dilantin load in
the SICU. Coumadin was held throughout hospital course. Per
neurosurgery, she will need to finish a 7 day course of dilantin
for seizure prophylaxis. Neurosurgery also cleared the pt to
restart coumadin in 4 weeks time with a NCHCT to be performed
once her INR is therapeutic again. Her PCP will decide as an
outpatient whether or not to resume her coumadin.
.
# Altered mental status: Etiology unclear. Possibilities
included medication effect (dilantin) vs. sepsis and pneumonia,
vs expanding SDH. Head CT unchanged. Dilantin held. Treated
pneumonia as above. Culture data negative. Per neurosurgery,
restarted dilantin [**3-29**] at decreased frequency (100 [**Hospital1 **]). Upon
transfer to the floor, the pt was alert and oriented X 3 without
any deficits noted on neuro exam, including aphasia and
dysarthria. She remained AAO X 3 during her remaining hospital
course.
.
# AFib: Well rate controlled on atenolol prior to transfer to
MICU. Home atenolol continued. Held coumadin given SDH.
.
# HTN: Continued atenolol as above.
.
# Neuropathic pain: Continued home regimen of neurontin.
.
FULL CODE
She was discharged to [**Hospital 100**] Rehab in good condition to finish a
course of antiobiotics, dilantin, and for PT/OT.
Medications on Admission:
Coumadin 4mg/d, Tue - Fri; 3mg/d, Mon and Sat; atenolol 25mg/d;
neurontin 400mg, [**Hospital1 **].
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atenolol 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day) for 3 days.
Disp:*6 Capsule(s)* Refills:*0*
6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
every eight (8) hours as needed for sore throat.
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Left sided subdural hematoma
Aspiration Pneumonia
Discharge Condition:
Neurologically stable
Discharge Instructions:
You were diagnosed with subdural hematoma (bleeding in your
brain) after having a fall while on coumadin. You also
developed a pneumonia during your ICU stay. Your coumadin was
stopped during this hospitalization. Do not restart your
coumadin unless instructed by your doctor; you must be off this
medication for at least 4 weeks.
You were also started on Levaquin and Flagyl to treat your
pneumonia. Please complete the full course as instructed below.
All of your other medications were continued as prior to your
hospitalization.
If you develop worsening headache, dizziness, visual problems,
gait difficulties, or any other concerning symptom, please call
your doctor or report to the nearest ER.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 12646**] at [**Telephone/Fax (1) 4615**] to schedule a follow
up appointment 1-2 weeks after discharge.
Please call Dr [**Last Name (STitle) 548**] (the neurosurgeon) at [**Telephone/Fax (1) 2992**] to
schedule a follow up appointment 4 weeks after discharge. He
would like for you to have a repeat CAT scan of your head just
prior to this appointment.
Completed by:[**2199-4-1**]
|
[
"909.3",
"784.5",
"355.9",
"780.97",
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"427.31",
"852.21",
"276.50",
"V12.59",
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"348.4",
"241.1",
"V58.61",
"428.0",
"518.82",
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"E878.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9589, 9655
|
5356, 7372
|
267, 274
|
9749, 9773
|
2461, 5048
|
10530, 10953
|
1128, 1132
|
8387, 9566
|
9676, 9728
|
8263, 8364
|
9797, 10507
|
1147, 1465
|
222, 229
|
5067, 5333
|
302, 661
|
1682, 2442
|
7387, 8237
|
683, 979
|
995, 1112
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,953
| 162,049
|
21742
|
Discharge summary
|
report
|
Admission Date: [**2127-9-18**] Discharge Date: [**2127-11-14**]
Date of Birth: [**2088-5-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever and Abominal Pain
Major Surgical or Invasive Procedure:
Cholecystectomy, G-Tube Placement and Removal, J-Tube Placement
and Removal, Bone Marrow Biopsies.
History of Present Illness:
Patient is a 39 year old female with a history of endocarditis
S/P MVR/AVR, MI, Stroke, and Asthma who presented to an outside
hospital on [**2127-9-16**] with one week of RUQ/RLQ abdominal pain and
vomiting. The patient reported dark red blood in her vomit.
Prior to the onset of her abdominal pain, she felt well and in
her usual state.
ROS: Mild SOB. No fatigue, abd pain, n/v, diarrhea, or
constipation.
OSH Course ([**Hospital3 417**]): RLL pneumonia per CXR - Levaquin
commenced. CBC showed WBC of 56K (6%PMN,35%L,42%M,14%BLASTS),
HCT41, and PLTS of 33. Evaluated by Heme-Onc and transferred to
[**Hospital1 18**].
Past Medical History:
Endocarditis ([**2125**]: C/B ARF) S/P MVR/AVR, MI, Stroke (Mild
Residual L Paresis), HCV Infection, GERD, and Asthma (Requiring
Intubation x 1).
Social History:
She was married but her husband died three years ago. She was a
former computer programmer. The patient does not smoke
cigarettes or use ETOH. She is a former Heroin IV user. She quit
one year ago.
Family History:
There are no known malignancies. Her mother has hypertension and
her father died at age 57 from a myocardial infarction.
Physical Exam:
T101.3 HR102 RR20 BP115/74
GEN: MILD ABD DISTRESS. PLEASANT AND CONVERSATIONAL.
Skin: SCATTERED PETECHIAE ON ALL EXTREMETIES (UE>LE).
HEENT: ANICTERIC. DRY MMM. OROPHARYNGEAL THRUSH.
RESP: DIMINISHED BS THROUGHOUT. INSP/EXP WHEEZES. NO
CRACKES/RHONCHI.
CV: TACHYCARDIC. RR. MECHANICAL S1 AND S2. III/VI SEM AT LSB TO
APEX.
ABD: S/ND. RUQ MOD TENDERNESS IN RUQ. PALP OF LUQ CAUSING RUQ
PAIN. NO REBOUND OR GUARDING.
EXT: NO CCE. DP 2+.
NEURO: A&OX3. CN II-XII GROSSLY INTACT. STRENGTH AND [**Last Name (un) **] TO LT
INTACT THROUGHOUT.
Pertinent Results:
OSH STUDIES:
CT ABD: large gallstone, thickening of the gallbladder wall and
mild dilatation fo the GB, infiltration of RUQ fat c/w
inflammatory change. ? enlargement of pancreatic head. No free
air. Enlarged spleen. Prominence of ovaries.
CT CHEST: (r/o PE) small densities in both lungs related to
scarring. Fullness of subcarinal soft tissues c/w adenopathy.
U/S RUQ: diffuse GB wall thickening. Septated appearance to
some solid gallbladder material. Large nonmobile stone lodged
in neck of GB and some probable sludge. CBD slightly dilated
5-6 mm. Free fluid in [**Location (un) 6813**] pouch.
URINE TOX SCREEN: + benzos and opiates, - PCP, [**Name10 (NameIs) 57131**],
amphetamine, marijuana, barbiturate, tricyclic
ECG REPORT: 'NSR, nonspecific ST/T wave changes.'
HEPATITIS VIRAL PANEL: HBSAg neg, Hep A IgM neg, Hep B core IGM
neg, Hep C Ab positive.
Labs on admission:
[**2127-9-18**] 09:30PM WBC-61.4* RBC-3.47* HGB-9.9* HCT-28.7* MCV-83
MCH-28.6 MCHC-34.6 RDW-17.1*
[**2127-9-18**] 09:30PM NEUTS-2 BANDS-1 LYMPHS-8 MONOS-38 EOS-2
BASOS-0 ATYPS-0 METAS-1 MYELOS-1 OTHER-47*
[**2127-9-18**] 09:30PM PLT SMR-VERY LOW PLT COUNT-30*
[**2127-9-18**] 09:30PM PT-15.0* PTT-39.5* INR(PT)-1.4
[**2127-9-18**] 09:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2127-9-18**] 09:25PM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-6 RENAL EPI-<1
[**2127-9-18**] 04:30PM FIBRINOGE-699*
[**Hospital1 18**] STUDIES:
CXR ([**2127-9-18**]): IMPRESSION: Patchy and linear opacities in the
right lower lobe with a nonspecific appearance, consistent with
either atelectasis, aspiration, or pneumonia.
RUQ U/S ([**2127-9-18**]): IMPRESSION: Large stone impacted in the
gallbladder neck with appearance of the gallbladder highly
suggestive of cholecystitis.
BONE MARROW BIOPSY ([**2127-9-18**]): RESULTS: Three color gating is
performed (light scatter vs. CD45) to optimize blast yield. B
cells are polyclonal, and do not express aberrant antigens. T
cells express mature lineage antigens and have a normal helper
cytotoxic ratio of 1.3 (usual range in blood 0.7-3.0). Cell
marker analysis demonstrates two large distinct populations of
abnormal cells. One population, identified within the "blast
gate," comprising 80% of gated (17% of total) bone marrow cells
expresses immature antigens CD34, HLA-DR, myeloid associated
antigens CD33, 13, 11c, and 117, a small subset CD64 and CD71,
and lack CD4, 14, and 56. A second population (95% of gated, 40%
of total) expresses HLA-DR, CD33, and 13, along with 11c, 4, 14,
64, 71, and CD15 (subset), but lack CD34 and CD56. In both
gates, cells lack T cell-associated antigens, and are CD10
negative. INTERPRETATION: Immunophenotypic findings consistent
with involvement by acute leukemia of myelomonocytic
differentiation.
CT ABD/PELV ([**2127-9-19**]): IMPRESSION: 1) Acute cholecystitis with
multiple small abscesses in the gallbladder fossa as well as
extending into the hepatic parenchyma consistent with a
contained perforation. Large stone in the fundus of the
gallbladder. No intrahepatic biliary ductal dilatation. 2)
Massive lymphadenopathy involving the portahepatis, celiac
access region as well as the retroperitoneal in the upper
abdomen related to the patient's underlying disease. There is
mild adenopathy in the right paratracheal and subcarinal region.
3) Patchy opacities in both lungs which are likely infectious in
origin. 4) Hypodense lesions in the right kidney might represent
areas of pyelonephritis. 5) Cystic lesion in the upper pole of
the left kidney likely represents a complex cyst. This could be
further evaluated with ultrasound.
GALL BLADDER PATHOHISTOLOGY ([**2127-9-19**]): DIAGNOSIS: 1.
Gallbladder wall (A, B): a. Acute hemorrhagic gangrenous
cholecystitis and pericholecystitis. b. Extensive infiltration
by malignant cells consistent with patient's known acute myeloid
leukemia; see diagnosis 3. 2. Gallbladder and contents (C): a.
Acute hemorrhagic gangrenous cholecystitis and pericholecystitis
with colonies of Gram (+) cocci on Gram stain (with satisfactory
control). b. Cholelithiasis. c. Extensive infiltration by
malignant cells consistent with patient's known acute myeloid
leukemia; see diagnosis 3. 3. Lymph node, root of mesentery (D):
Lymph node extensively infiltrated by acute myeloid leukemic
cells with features highly suggestive of acute myelomonocytic
leukemia with abnormal eosinophils (M4EO). NOTE: The malignant
cells are negative for L-26 and CD3 and positive for CD43. This
profile is consistent with a myeloid phenotype of the malignant
cells. Some of the reagents used in these assays may not be
approved for diagnostic use.
ECHO/TTE ([**2127-9-26**]): 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. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is normal for this prosthesis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. A
bioprosthetic ttricuspid valve is present. The gradients are
higher than expected for this type of prosthesis. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
ERCP ([**2127-10-6**]): IMPRESSION: Leak of contrast in the region of
the cystic duct in this patient status post cholecystectomy.
CT ABD/PELV ([**2127-10-9**]): IMPRESSION: 1. No significant interval
change in the perihepatic fluid collections, some of which
contain air. Additionally, there is no interval change in the
appearance of the fluid tracking along the right colic gutter
and through the subcutaneous tissues, consistent with the
patient's history of biliary cutaneous fistula. 2. Peripheral,
ill-defined, nodular appearing, bilateral lower lobe opacities,
some of which are new and others of which have changed in
configuration since the prior exam, suggestive of an
inflammatory/infectious
or embolic process (either bland or septic emboli). 3. Stable
bronchovascular bundle thickening and unchanged appearance of
other peripheral nodules raises concern for underlying leukemic
infiltration. 4. Stable retroperitoneal lymphadenopathy and
splenomegaly, consistent with the patient's history of leukemia.
ECHO/TTE ([**2127-10-27**]): The left atrium is normal in size. 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. The ascending aorta is mildly dilated. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic
leaflets appear normal with good motion and normal gradient. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. A bioprosthetic tricuspid valve is
present with mildly thickened, but mobile leaflets. The
gradients are slightly increased for this prosthesis. There is
mild valvular tricuspid regurgitation. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the report of the prior study (tape
unavailable for review) of [**2127-9-26**], the transtricuspid
gradient is slightly reduced and borderline pulmonary artery
systolic hypertension is now identified. The aortic valve
gradient is similar and aortic regurgitation is no longer seen.
SKIN BIOPSY (RIGHT FLANK) ([**2127-10-29**]) : DIAGNOSIS: Skin, right
flank: Vascular endothelial swelling and sparse interstitial
mononuclear infiltrate with occasional eosinophils (see note).
CT ABD/PELV ([**2127-11-4**]): IMPRESSION: 1) No evidence of bowel
obstruction.
2) Status post J-tube removal. 3) Stable appearance of
subhepatic gas-containing fluid collection. 4) Persistent marked
ascites and anasarca. 5) Unchanged celiac axis lymphadenopathy.
6) Unchanged patchy opacities at the lung bases and small
bilateral pleural effusions.
CT HEAD ([**2127-11-4**]): IMPRESSION: Limited study. No definite acute
hemorrhage. Low density focus in the left internal capsule that
is of uncertain etiology.
BONE MARROW BIOPSY FLOW CYTOMETRY ([**2127-11-10**]): INTERPRETATION:
Immunophenotypic findings are non-specific. CD34 positive blasts
are not increased (<3%). Monocytic cells comprise 12% of total
events. See separate morphology report (S04-[**Numeric Identifier 57132**]).
Brief Hospital Course:
Ms [**Known lastname 57133**] presented to an outside hospital with acute
cholecystitis (which was secondary to malignant infiltration of
her gall bladder) and was transfered to [**Hospital1 18**] for the surgical
management of her cholecystitis as well as the management of her
newly discovered acute myelogenous leukemia.
1. AML: On routine labs at the outside hospital, the patient was
noted to have an elevated WBC (>60) with blasts (50% of the
WBC). A bone marrow biopsy at [**Hospital1 18**] confirmed acute leukemia of
myelomonocytic differentiation. The patient was initially
managed with daily Hydroxyurea until she recovered from the
surgical management of her acute cholecystitis. Upon
stabilization she was started on the (7+3) chemotherapeutic
regimen for her AML. Her cell lines prompty decreased. She had
intermittent fevers throughout her course during neutropenia. No
bacteria or fungii were ever grown from her blood or urine. She
was prophylaxed with acyclovir (she developed an HSV lesion on
her upper lip during her course), vancomycin, along with the
empiric fungal (caspofunging or ambisome) and gram negative
(which included imipenem, amikacin, cefipime and levofloxacin at
different times in her course). Her ANC steadily rose to >1000
(upon discharge), the patient's fevers abatted. A repeat bone
marrow biopsy late in her course was unremarkable and thus,
showed no signs of leukemia. She was discharged with oncologic
follow-up and planned for consolidation chemotherapy.
2. Cholecystitis: The patient presented to the outside hospital
with an acute abdomen. A right upper quadrant ultrasound
confirmed obstruction of the gall bladder. She was transferred
to [**Hospital1 18**] for management of her acute cholecystitis. An initial
plan for percutaneous placement of a cholecystostomy tube for
stabilization was pursued, but due to imaging findings revealing
the unlikliehood of successful drainage of her gallbladder
contents, surgical cholecystostomy and intrahepatic biliary
stenting was pursued. Jejunal and Gastric tubes were placed
intraoperatively [which were removed late in her course after
clinical improvement and improving PO intake.] A necrotic
gallbladder with multiple septations and intrahepatic abscess
collections, which extended down the right pericolic gutter
along the right colon were noted. Pathologic analysis showed
malignant infilitration (with leukemic cells) of the gallbladder
and extrahepatic biliary tree. Post-operatively, the patient had
excessive amounts of bilious drainage from her surgical wound.
ERCP was pursued to divert biliary flow into the duodenum. After
unsuccessful attempts, the procedure/sphincterotomy was
complicated by a large gastrointestinal bleed and the patient
required monitoring and blood/volume resucitation in the ICU. A
repeat ERCP was pursued and epinephrine injection and biliary
stenting resulted in tamponade of the bleeding site and
successful diversion of biliary drainage. Her cholecystectomy
was also complicated by post-operative hemoperitoneum requiring
repeat laporatomy. A large volume of bloody fluid was removed
from the abdomen, but active bleeding was not seen. The patient
had persistence of abdominal pain, nausea and vomiting
throughout most of her course, but repeat imaging studies did
not reveal and obvious source of her symptoms. Fortunately,
after continuous empiric antimicrobial coverage along with bone
marrow recovery from chemotherapy (rising ANC), her clinical
picture improved dramatically late in her course. On discharge,
her nausea and vomiting had resolved and her abdominal pain was
controlled with low-dose narcotics. She was discharged with
surgical follow-up for biliary stent removal.
3. Pneumonia: Upon admission, a RLL infiltrate was noted. She
was empirically covered on broad-spectrum antibiotics, including
vancomycin (given her history of MRSA) as noted above.
4. Altered Mental Status (AMS): The patient had intermittent AMS
over her course. For several days, late in her course, she
became incoherent and could not follow commands. There was a
concern for an infectious (toxic-metabolic encephalopathy) or
possibily malignant etiology. However, AML CNS involvement was
considered unlikely. A Head CT only showed a nonspecific
unilateral internal capsule abnormality. The patient soon
returned to her baseline and further work-up was not pursued.
5. HCV Infection: The patient was a known HCV carrier prior to
admission. She was a previous heroin (by injection) user. Early
in her course, her HCV viral load was two million. An HCV viral
load was rechecked during recurrent abominal pain, nausea,
vomiting and altered mental status: at that point, the viral
load was 154,000. Anti-HCV therapy was not instituted.
6. H/O Endocarditis: The patient had previously been
hospitalized with endocarditis. The inoculum was believed to be
introduced via intravenous drug use. Her native aortic and
mitral valves were surgically replaced with porince prosthetics.
Of note, her infective endocarditis was complicated by stroke.
The neurologic deficits (weakness) resolved prior to this
admission.
Medications on Admission:
Home meds: Ambien, Ativan, Oxycontin, Flovent, Combivent,
Albuterol, and Protonix
Transfer meds: Acyclovir, Colace, Senna, Oxycontin, Morphine
PRN, Ativan, Zofran, Nebs, Flovent, Zosyn, Vanco, Fluconazole,
RISS.
Discharge Medications:
1. Tramadol HCl 50 mg Tablet Sig: 0.5 Tablet PO four times a day
as needed for pain for 1 weeks.
Disp:*qs 1 week Tablet(s)* Refills:*0*
2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*90 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
4. Senna 8.6 mg Capsule Sig: [**12-6**] Capsules PO twice a day as
needed for constipation.
Disp:*qs 2 weeks Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital1 1474**]
Discharge Diagnosis:
Primary Diagnosis: Acute Myelogenous Leukemia.
Secondary Diagnosis: Malignant Cholecystitis, Pneumonia.
Discharge Condition:
Good/Stable.
Discharge Instructions:
1) Please contact the on-call oncologist at [**Telephone/Fax (1) 2756**], your
doctor or come to the [**Hospital1 18**] emergency room if you have any
nausea, vomiting, increased abdominal pain, bleeding, fevers,
chills, or any other concerning symptoms.
2) Please take your medications as instructed.
Followup Instructions:
1) Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3237**]) in the [**Hospital 18**]
[**Hospital **] Clinic on Tuesday, [**2127-11-18**]. Please call to
confirm or change your appointment:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT
Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2127-11-18**] 2:30
2) Please arrive at 4:00PM for the following radiology
appointment for a CAT scan on the same day as your appointment
with Dr. [**Last Name (STitle) **]:
CAT SCAN Where: [**Hospital6 29**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2127-11-18**] 5:00
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22,792
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46466
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Discharge summary
|
report
|
Admission Date: [**2173-10-20**] Discharge Date: [**2173-10-27**]
Date of Birth: [**2096-5-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Percocet / Sulfa (Sulfonamides) / Niacin /
Spironolactone / Shellfish Derived / Iodine; Iodine Containing /
Fruit Flavor
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
left fibrothorax
Major Surgical or Invasive Procedure:
left vats decortication
History of Present Illness:
Mr. [**Known lastname 8026**] is a 77-year-old
gentleman who has had progressive dyspnea. He has a right
hemidiaphragm paralysis as well as a loculated left pleural
effusion with a suggestion of slight fibrothorax. We have
explained the risks, benefits and moving forward to
decortication, including bleeding, infection, incomplete
expansion of the lung, damage to the lung, respiratory
failure, injury to the airway, diaphragm, heart vessels or
other intrathoracic structures, and risk of reoperation. Mr.
[**Known lastname 8026**] understands these risks and wished to proceed.
Past Medical History:
1. Atrial fibrillation.
2. Right phrenic nerve paralysis.
3. Temporal lobe epilepsy.
4. Status-post CABG.
5. Persistent left pleural effusion.
6. Exertional dyspnea.
7. Pulmonary hypertension, likely secondary.
8. Hypothyroidism
PSH:
s/p MVR(31mm Perimount
bioprosthesis)/CABGx1(SVG->LAD)/MAZE/Ligation of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**]
[**2170-11-30**]
Social History:
electrical contractor, lives with wife
quit smoking 35 years ago ( was smoking up to 3 ppd);
has one drink per day
Family History:
non-contributory
Physical Exam:
general: alert, oriented and in NAD.
vs: 98.2, 81, 110/62 18, 91% on [**2-10**] liter (99% on 2 liters; 86%
on RA w/ amb)
HEENT: unremarkable
Chest: CTA bilat. VATs port sites healing w/o redness or
drainage.
abd: soft, NT, Nd, +BS
extrem: no edema.
Neuro: intact.
Pertinent Results:
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with s/p L chest tube removal
REASON FOR THIS EXAMINATION:
r/o PTX
Final Report
HISTORY: Left chest tube removal, to evaluate for pneumothorax.
FINDINGS: In comparison with the earlier study of this date, the
left chest
tube has been removed. No evidence of pneumothorax. Little
change in the
appearance of heart and lungs.
Brief Hospital Course:
pt was admitted and taken to the OR for left vats decortication
and flexible bronchoscopy. 3 chest tubes were placed at the time
of surgery and were placed to sxn
In the PACU had low u/o requiring IVF and neo for BP support.
Also had rapid afib requiring IV lopressor. Baseline rhythm is
afib on chronic atenolol.
Remained intubated and was extubated on POD#1. Transferred from
the pacu to the icu for ongoing pulmonary management and
hemodyanmic support on POD#2. Readily weaned from pressors and
transferred to the floor for ongoing post-op care.
Heparin gtt was resumed on [**2173-10-24**] for afib in the setting of
tissue MVR. Pt continued to preogess well. All chest tubes were
placed to -40 of sxn to help the lung adhere to the parietal
pleura. the amount of sxn was weaned over the ensuing days to
-20 then the apical tubes were placed to water seal on [**2173-10-25**]
w/ stable cxr and were subsequently removed. Basilar tube
remained on -20 sxn and was placed to water seal on [**2173-10-26**] and
subsequently d/c'd w/ stable cxr. PCA was d/c'd and pain was
controlled on po pain med. Physical therapy screened pt for
readiness to return to home. Pt desat to 86% on roomair and
reqiured 2 liters oxygen to recover. He was cleared to return
home w/ supplemental oxygen. His heparin gtt was d/c'd and his
lovenox and po coumadin were resumed. Dr. [**Last Name (STitle) 696**] was notified
of anticoag plans.
pt was d/c'd to home on [**2173-10-27**] with VNA, home oxygen and will
have an INR check on thursday and Dr. [**Last Name (STitle) 696**] will cont to
follow his anticoagulation. INR at the time of d/c was 1.3
Medications on Admission:
candesartan 2', tegretol XR 200", digoxin 62.5 Tues/Sat & 125
every other day, dorzolamide 2% 1gtt OU", erythromycin 500mg
proph prior to oral procedures, lasix 40', synthroid 125',
lopressor 50", omeprazole 40', testosterone cypionate 300 IM
q3weeks, coumadin 1', tylenol prn, MVI'
Discharge Medications:
1. Candesartan 4 mg Tablet Sig: 0.5 Tablet PO daily ().
2. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
3. Digoxin 125 mcg Tablet Sig: .0625 Tablet PO QTUES (every
Tuesday).
4. Digoxin 125 mcg Tablet Sig: .0625 Tablet PO QSAT (every
Saturday).
5. Digoxin 125 mcg Tablet Sig: .125 Tablet PO Q MON, WED, THURS,
SUN ().
6. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mgs
Subcutaneous [**Hospital1 **] (2 times a day) for 10 doses: take until your
INR is greater than 2.0 or until your doctor advises you
otherwise.
Disp:*10 doses* Refills:*1*
18. oxygen
oxygen 2 liters/min via nasal cannula continuous
conserving device for portability
Room air saturation 86%
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Restrictive lung disease, Temporal lobe epilepsy,
Hypothyroidism, GERD, gout, AF on coumadin, R phrenic nerve
paralysis, CAD s/p MI [**2170**], HTN, ^cholesterol, Nephrolithiasis,
Pulmonary HTN, chronic L pleural effusion, h/o Epistaxis, BLE
edema, erectile dysfunction, cervical myelopathy, subjective
right foot drop per patient.
PSH: CABG/MAZE/MVR [**2170**], L3-L5 laminectomy [**2161**] for spinal
stenosis, inguinal hernia repair [**2171**]
Discharge Condition:
requires 2 liters of oxygen at all times to maintain oxygen
saturation of >92%
On lovenox bridge to coumadin
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough, or sputum production
-Chest pain
-Incision develops drainage
Chest-tube site remove dressing Thursday cover with a bandaid
until healed. Should site begin to drain cover with a clean
dressing and change as needed to keep site clean and dry.
You may shower on Thursday: No tub bathing or swimming for 6
weeks
No driving while taking narcotics. Take stool softners with
narcotics.
Take your lovenox until your are instructed to stop by DR.
[**Last Name (STitle) 696**]. have your INR checked on thursday and continue to take
your coaumdin as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2173-11-9**] 10:45 on the [**Hospital Ward Name **] [**Hospital Ward Name **] bulding
[**Hospital1 **] one chest disease center. Please arrive 45 minutes
prior to your appointment and report to the [**Location (un) 470**] radiology
for a chest XRAY.
Completed by:[**2173-10-27**]
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icd9cm
|
[
[
[]
]
] |
[
"34.52",
"38.91",
"99.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
5995, 6053
|
2347, 3978
|
420, 446
|
6544, 6655
|
1933, 1933
|
7397, 7804
|
1615, 1633
|
4313, 5972
|
1973, 2019
|
6074, 6523
|
4004, 4290
|
6679, 7374
|
1648, 1914
|
364, 382
|
2051, 2324
|
474, 1056
|
1078, 1465
|
1481, 1599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,062
| 137,930
|
48704
|
Discharge summary
|
report
|
Admission Date: [**2191-4-7**] Discharge Date: [**2191-4-13**]
Date of Birth: [**2114-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2191-4-7**] Redo-Sternotomy, Aortic Valve Replacement w/ 21mm CE
perimount pericardial tissue valve
History of Present Illness:
76 y/o male with h/o CABG in [**2185**] and Aortic Stenosis c/o
increased shortness of breath along with fatigue and chest pain.
Most recent echo revealed severe aortic stenosis.
Past Medical History:
Aortic Stenosi, Coronary Artery Disease s/p Coronary Artery
Bypass Graft [**2185**], Hypertension, Hyperlipidemia, Depression s/p
ECT therapy, Benign Prostatic Hypertrophy, Sleep Apnea, Venous
Insuff. w/ superficial venous thrombosis, s/p Nasal polypectomy,
Chronic pleural effusion s/p VATS and pleurodesis
Social History:
non- smoker. no exposure
retired lawyer, lives w/ wife
Family History:
Non-contributory
Physical Exam:
VS: 76 12 128/80 5'[**94**]" 195#
Gen: WDWN in NAD
Skin: Warm, dry with well healed sternotomy, left radial and
right EVH incisions, multiple nevi and keratosis
HEENT: NC/AT, EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD
Chest: CTAB, diminished left base
Heart: RRR, 3/6 systolic murmur
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, 1+ LLE edema, LLE grossly varicosed
Neuro: A&O x 3, MAE, non-focal
Discharge
Vitals 99.2, 118/70 SR 80, 20 RR, RA sat 98% wt 101.8kg
Skin: Warm dry, rash on back red no draining improving
Chest CTA bilat
Card RRR no murmur/rub/gallop
Abd soft, NT, ND +BS + flatus BM [**4-11**]
Ext warm pulses palpable +1 edema LE
Neuro A/0 x3 nonfocal MAE
Sternal inc healing no drainage/erythema sternum stable
Pertinent Results:
[**2191-4-12**] 06:30AM BLOOD WBC-6.1 RBC-3.54* Hgb-11.0* Hct-32.8*
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.8 Plt Ct-185
[**2191-4-7**] 01:21PM BLOOD WBC-15.3*# RBC-3.20*# Hgb-10.0*#
Hct-29.7*# MCV-93 MCH-31.2 MCHC-33.6 RDW-14.9 Plt Ct-89*#
[**2191-4-12**] 06:30AM BLOOD Plt Ct-185
[**2191-4-11**] 03:08AM BLOOD PT-13.4* PTT-28.2 INR(PT)-1.2*
[**2191-4-7**] 01:21PM BLOOD Plt Smr-LOW Plt Ct-89*#
[**2191-4-7**] 01:21PM BLOOD PT-16.6* PTT-56.8* INR(PT)-1.5*
[**2191-4-12**] 06:30AM BLOOD Glucose-126* UreaN-23* Creat-1.0 Na-142
K-4.1 Cl-104 HCO3-32 AnGap-10
[**2191-4-7**] 02:43PM BLOOD Glucose-200* UreaN-20 Creat-0.9 Na-142
K-3.6 Cl-112* HCO3-21* AnGap-13
[**2191-4-10**] 04:12AM BLOOD ALT-16 AST-58* LD(LDH)-518* AlkPhos-64
Amylase-41 TotBili-0.6
[**2191-4-10**] 04:12AM BLOOD Lipase-19
[**2191-4-11**] 03:08AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.5
RADIOLOGY Final Report
CHEST (PA & LAT) [**2191-4-12**] 8:38 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p AVR
REASON FOR THIS EXAMINATION:
evaluate effusion
REASON FOR EXAMINATION: Follow up of patient after aortic valve
replacement.
Heart size is mildly enlarged but unchanged. Mediastinal
contours are unremarkable. No pneumothorax is identified. There
is no evidence of congestive heart failure.
There is unchanged loculated left pleural effusion, elevated
left hemidiaphragm and left lower lobe opacity which may
represent atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2191-4-12**] 10:57 PM
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2191-4-10**] 10:20 AM
PORTABLE ABDOMEN
Reason: eval obstruction
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p redo sternotomy/ AVR with abd pain
REASON FOR THIS EXAMINATION:
eval obstruction
PORTABLE ABDOMEN SINGLE VIEW, [**2191-3-23**] AT 10:24 A.M.
HISTORY: Redo sternotomy and AVR, presenting with abdominal
pain.
COMPARISON: No prior radiographs.
FINDINGS: Single supine view demonstrates gas-filled loops of
nondilated small bowel throughout the abdomen. There is
scattered colonic air and stool as well. The rectum is not well
visualized on the submitted view. There is mild gaseous
distention of the stomach. There is suggestion of a left pleural
effusion. Preperitoneal fat stripes are not well defined and
there is mild central clumping of the bowel loops. These may be
seen in the setting of ascites.
IMPRESSION: Suggestion of possible ascites. No frankly dilated
loops of small bowel noted, although there is diffuse gaseous
distention. This may be seen in the setting of ileus. Continued
surveillance as indicated is recommended. No definitive
radiographic evidence of obstruction noted.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: SUN [**2191-4-10**] 1:13 PM
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 102401**],[**Known firstname 412**] [**2114-7-6**] 76 Male [**-5/1971**] [**Numeric Identifier 102402**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **]. SAMEDI/mtd
SPECIMEN SUBMITTED: AORTIC VALVE TISSUE.
Procedure date Tissue received Report Date Diagnosed
by
[**2191-4-7**] [**2191-4-7**] [**2191-4-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/mrr??????
Previous biopsies: [**Numeric Identifier 102403**] RT. NASAL MASS.
[**-3/4603**] LEFT PARIETAL PLEURAL BIOPSY, LEFT PARIETAL PLEURA
[**Numeric Identifier 102404**] SKIN RT UPPER ARM.
[**-2/4340**] R. ARM SKIN.
(and more)
DIAGNOSIS:
Aortic valve tissue:
Aortic valve with degenerative changes and calcification.
Clinical: Aortic valve stenosis, aortic valve replacement, redo
sternotomy.
Gross: The specimen is received fresh labeled with the patient's
name, "[**Known firstname **] [**Known lastname 1726**]", the medical record number and "aortic
valve tissue". It consists of a fragment of yellow-tan and
calcified tissue measuring 3.4 x 2.5 x 1.1 cm in aggregate. The
specimen is represented in cassette A, and also submitted for
decalcification.
Cardiology Report ECHO Study Date of [**2191-4-7**]
PATIENT/TEST INFORMATION:
Indication: Intraop redo sternotomy AVR. Evaluate Aorta,
valves, Biventricular function
Height: (in) 71
Weight (lb): 195
BSA (m2): 2.09 m2
BP (mm Hg): 129/69
HR (bpm): 58
Status: Inpatient
Date/Time: [**2191-4-7**] at 09:29
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm)
Left Ventricle - Inferolateral Thickness: *1.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 1.8 cm
Left Ventricle - Fractional Shortening: 0.47 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 45% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.4 cm (nl <= 3.4 cm)
Aorta - Arch: 2.1 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *4.1 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 67 mm Hg
Aortic Valve - Mean Gradient: 44 mm Hg
Aortic Valve - LVOT Peak Vel: 0.80 m/sec
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT Diam: 2.0 cm
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
Mitral Valve - Peak Velocity: 1.2 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 90 ms
Mitral Valve - MVA (P [**11-23**] T): 2.4 cm2
Mitral Valve - E Wave: 1.2 m/sec
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Severe symmetric LVH. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior
- hypo; mid inferior - hypo;
RIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall
hypokinesis.
AORTA: Complex (>4mm) atheroma in the aortic arch. Normal
descending aorta
diameter. Complex (>4mm) atheroma in the descending thoracic
aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR. Eccentric AR
jet.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral
annular calcification. Minimally increased gradient consistent
with trivial
MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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. No TEE
related
complications. See Conclusions for post-bypass data The
post-bypass study was
performed while the patient was receiving vasoactive infusions
(see
Conclusions for listing of medications).
Conclusions:
PRE-BYPASS: The left atrium is moderately dilated. The right
atrium is
moderately dilated. There is severe symmetric left ventricular
hypertrophy.
Overall left ventricular systolic function is mildly depressed.
The right
ventricular cavity is dilated. There is mild global right
ventricular free
wall hypokinesis. There are complex (>4mm) atheroma in the
aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2).
Trace aortic regurgitation is seen. The aortic regurgitation jet
is eccentric.
The mitral valve leaflets are moderately thickened. There is a
minimally
increased gradient consistent with trivial mitral stenosis. Mild
(1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive
infusions including Norepi, Epi, Vasopressin, Milrinone. The
patient was AV
paced . A well-seated bioprosthetic valve is seen in the aortic
position with
normal leaflet motion and gradients (mean gradient = 20 mmHg,
peak 22 mmHg).
No aortic regurgitation is seen. RV is now moderately
hypokinetic. LV function
is slightly improved on inontropes with unchanged wall motion.
Aortic contours
are intact. Remaining exam is unchanged. All findings discussed
with surgeons
at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2191-4-12**] 18:51.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 1726**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day of admission he
was brought to the operating room where he underwent a
redo-sternotomy and aortic valve replacement. Please see
operative report for surgical details. Following surgery he was
transferred to the CSRU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. Over the next couple of
days his Inotropes were weaned and he was started on beta
blockers and diuretics. He was gently diuresed towards he pre-op
weight. On post-op day two his chest tubes were removed. On
post-op day three he had some abd. pain but abd. x-ray was
negative for obstruction. On post-op day four he was transferred
to the telemetry floor and began working with physical therapy
for strength and mobility. He continued to make improvements
without complications and was discharged home with VNA services
and the appropriate follow-up appointments on post-op day five.
Medications on Admission:
Simvastatin 40mg [**Last Name (LF) **], [**First Name3 (LF) **] 60mg [**Hospital1 **], Digoxin 0.125mg qd, Folic
Acid 1mg qd, Lopressor 50mg [**Hospital1 **], Uroxatral 10mg qd, Detral LA
4mg qd, DDAVP 0.1mg qd, Miralax 17g qd, Aspirin 81mg qd, MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. 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*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. UROXATRAL 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO daily ().
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1*
7. Miralax 17 g (100%) Powder in Packet Sig: One (1) PO twice a
day as needed for constipation.
Disp:*30 * Refills:*1*
8. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
13. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Senna 187 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): decrease to 400mg once a day [**4-15**] for 7 days then
decrease to 200mg daily .
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
Aortic Stenosis s/p Redo-Sternotomy, Aortic Valve Replacement
PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft
[**2185**], Hypertension, Hyperlipidemia, Depression s/p ECT therapy,
Benign Prostatic Hypertrophy, Sleep Apnea, Venous Insuff., s/p
Nasal polypectomy, Chronic pleural effusion s/p VATS and
pleurodesis
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 contact the [**Name2 (NI) 5059**] at
([**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. Please shower and wash incisions daily. No bathing or
swimming for 1 month. Use sunscreen on incision if exposed to
sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**].
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 2472**] after discharge from rehab [**Telephone/Fax (1) 133**]
Dr. [**First Name (STitle) **] in [**12-26**] weeks
please call to schedule all appointments
Completed by:[**2191-4-13**]
|
[
"401.9",
"424.1",
"V45.81",
"414.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
14302, 14332
|
10875, 11927
|
339, 443
|
14701, 14707
|
1858, 2812
|
15435, 15717
|
1070, 1088
|
12226, 14279
|
3743, 3798
|
14353, 14680
|
11953, 12203
|
14731, 15412
|
6336, 10815
|
1103, 1839
|
280, 301
|
3827, 6310
|
471, 651
|
10852, 10852
|
673, 982
|
998, 1054
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,171
| 115,910
|
34585
|
Discharge summary
|
report
|
Admission Date: [**2138-10-6**] Discharge Date: [**2138-10-11**]
Date of Birth: [**2079-3-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
[**2138-10-6**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
DIAG, SVG to OM, SVG to LPDA)
History of Present Illness:
59 yo male with known CAD and stent placement in [**2136**]. Had a +
ETT in [**8-29**] and suubsequent cath revealed 3V CAD. Referred for
CABG.
Past Medical History:
Coronary Artery Disease s/p CX stent [**12-27**], Hypercholesterolemia
Social History:
lives with wife, works as an educator, quit smoking at age
20,several drinks per week
Family History:
NC
Physical Exam:
5' 11" 160#
HR 76 RR 14 (at PAT : right 175/80 left 150/80)
NAD
skin unremarkable
EOMI, PERRL, NCAT
neck supple, full ROM, no JVD or carotid bruits appreciated
CTAB no W/ R/R
RRR no murmur
soft, NT. ND, + BS
warm, well-perfused, no edema or varicosities noted
nonfocal neuro exam, alert and oriented x3, MAE
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**2138-10-6**] Echo: PREBYPASS: 1. The left atrium is normal in size.
No atrial septal defect or PFO is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
3. Right ventricular chamber size and free wall motion are
normal. 4. There are simple atheroma in the aortic arch and
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. 5 .The mitral
valve leaflets are structurally normal, with slight ballooning
of A2 segment although coaptation point remains below the level
of the annulus. Mild (1+) mitral regurgitation is seen. 6. Left
ventricular function is good with EF 50-55%. During exam it was
noted that the basal lateral, inferolateral and inferior walls
became hypokinetic, but this resolved on it's own. 7. There is
no pericardial effusion. 8. Dr. [**Last Name (STitle) **] was notified in person
of all results. POSTBYPASS: 1. Patient is on nitroglycerin
infusion. 2. Left ventricular function is unchanged. No wall
motion abnormalities are noted. 3. Aortic contours smooth after
decannulation 4. All other parts of the exam are unchanged. 5.
Dr. [**Last Name (STitle) **] was notified of the findings.
[**2138-10-6**] 03:51PM BLOOD WBC-10.4# RBC-3.06*# Hgb-9.5*# Hct-26.4*#
MCV-86 MCH-31.0 MCHC-35.9* RDW-12.1 Plt Ct-139*
[**2138-10-10**] 05:44AM BLOOD WBC-8.6 RBC-3.04* Hgb-9.5* Hct-26.4*
MCV-87 MCH-31.3 MCHC-36.1* RDW-13.7 Plt Ct-197
[**2138-10-6**] 03:51PM BLOOD PT-16.6* PTT-46.6* INR(PT)-1.5*
[**2138-10-7**] 04:23AM BLOOD PT-14.7* PTT-33.6 INR(PT)-1.3*
[**2138-10-6**] 05:17PM BLOOD UreaN-14 Creat-0.7 Cl-114* HCO3-26
[**2138-10-9**] 05:20AM BLOOD Glucose-122* UreaN-20 Creat-0.8 Na-139
K-3.7 Cl-103 HCO3-30 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 79388**] was a same day admit after undergoing all
preoperative workup as an outpatient. and underwent surgery with
Dr. [**Last Name (STitle) **]. On day of admission he underwent a coronary artery
bypass graft x 4. Please see operative report for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Later that day he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta blockers and diuretics
and gently diuresed towards his pre-op weight. Later on post-op
day one/two his hematocrit was found to have decreased, he
received a transfusion with good response. Also underwent chest
x-ray which showed small effusions and apical pneumothorax. On
post-op day two he appeared to be well despite his lowered
hematocrit and two of his chest tubes were removed and was later
transferred to the telemetry floor for further care. Again on
post-op day three he received blood transfusion and also had his
epicardial pacing wires and the remainder of his chest tubes
removed. He also required re-insertion of urinary catheter due
to urinary retention. He continued to remain stable while
working with physical therapy for strength and mobility. His
hematocrit also appeared to be stable but slightly lower than
normal. He was discharged home on [**10-11**], POD 5 with VNA services
and the appropriate follow-up appointments.
Medications on Admission:
ASA 325 mg daily
toprol XL 25 mg daily
vytorin 10/10 mg daily
Discharge Medications:
1. 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*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
.Caregroup home care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: s/p CX stent [**12-27**], Hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
no lifting greater than 10 pounds for 10 weeks
shower daily and pat incisions dry
call for fever greater than 100.5, redness or drainage
no driving for one month AND until off all narcotics
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in [**1-22**] weeks
Dr. [**Last Name (STitle) 12526**] in [**2-23**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2138-10-11**]
|
[
"414.01",
"511.9",
"413.9",
"E878.2",
"272.0",
"997.5",
"V45.82",
"512.1",
"788.20",
"414.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94",
"36.15",
"99.04",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6181, 6232
|
2965, 4422
|
337, 439
|
6388, 6394
|
1204, 2942
|
6678, 6921
|
825, 829
|
4534, 6158
|
6253, 6367
|
4448, 4511
|
6418, 6655
|
844, 1185
|
283, 299
|
467, 612
|
634, 706
|
722, 809
|
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