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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
9,597
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15256
|
Discharge summary
|
report
|
Admission Date: [**2116-9-27**] Discharge Date: [**2116-10-9**]
Date of Birth: [**2092-12-22**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old
male with a past medical history of Crohn's, status post
small bowel resection x 3, last in [**2113**], who was recently
admitted to [**Hospital3 1280**], an outside hospital, on [**9-26**],
where he presented with 12 hours of severe abdominal pain.
He was noted to have severe abdominal pain the night prior to
admission to the outside hospital, followed by nausea and
vomiting. He is now transferred to the [**Hospital1 190**] after he developed septic parameters at the
outside hospital.
PAST MEDICAL HISTORY: Significant for Crohn's disease.
PAST SURGICAL HISTORY: Small bowel resections x 3.
MEDICATIONS: Mercaptopurine 100 mg by mouth twice a day,
folate and vitamin B12.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On examination, the patient is a white
male who appeared somnolent and was lying still. Vitals were
a temperature of 99.6, heart rate 130, blood pressure 146/74,
oxygen saturation 96% on room air. On examination, there was
a nasogastric tube in place. Pulmonary examination revealed
tachypnea though the lungs were clear to auscultation
bilaterally. Cardiac examination revealed tachycardia with a
regular rhythm. The abdomen was distended, tense. There was
guarding and rebound tenderness present. There were no bowel
sounds. The extremities were warm and well perfused.
LABORATORY DATA: From [**Hospital6 3872**], white count
17.2, with a differential of 77 neutrophils, 3 bands.
Hemoglobin was 13.2, platelets were 240. Sodium was 139,
potassium 4.4, chloride 98, bicarbonate 30, BUN 12,
creatinine 0.8, glucose 119. Lactate was 43.9. Total
bilirubin was 2.8. AST was 36, ALT 113, alkaline phosphatase
82, direct bilirubin 0.5, amylase 68. CT scan: At the
outside hospital, revealed on scanning of the abdomen and
pelvis, there was some free fluid present in the abdomen, and
the CT was read as consistent with small bowel obstruction.
HOSPITAL COURSE: The patient was admitted to the General
Surgery service. Aggressive fluid resuscitation was started,
and the patient was prepared and taken to the operating room,
at which point he was found to have a mid-gut volvulus with
severe ischemic compromise, and he underwent an exploratory
laparotomy and derotation of a mid-gut volvulus. Please see
the operative note for details.
Following the procedure, the patient was transferred to the
Post-Anesthesia Care Unit in stable but guarded condition,
and was subsequently transferred to the Surgical Intensive
Care Unit. The patient was stable following the initial
procedure, during which a second look operation was planned.
The patient was maintained intubated and sedated on
postoperative day one, and lactate was found to be 2.2.
White count was 6.2, with 14 bands.
When the patient was taken back to the operating room for the
second look laparotomy, he underwent segmental small bowel
resection with re-anastomosis. Please see the operative note
for details. The patient was transferred back to the
Surgical Intensive Care Unit following the procedure. The
patient remained intubated following the procedure, and was
subsequently intubated on postoperative day two from the
original procedure. At the time of the second operation, in
addition to intravenous fluids, the patient also received two
units of packed red blood cells, two units of fresh frozen
plasma, and a five-pack of platelets.
On postoperative day three from the original procedure, the
patient was doing well, and was transferred to the floor.
The patient was also started on total parenteral nutrition.
The patient was still noted to be febrile on postoperative
day four. Please note that postoperative antibiotics
consisted of Zosyn.
By postoperative day six, the patient was on no antibiotics,
however, he was still found to be febrile, with evidence of a
right pleural effusion on chest x-ray, with no pneumonia. A
central line tip was sent for culture.
On postoperative day seven, a KUB was obtained to evaluate
the position of the patient's nasogastric tube. It was
withdrawn slightly, with good effect. On postoperative day
eight, the patient was noted to have had a small bowel
movement overnight, with no nausea or vomiting. Total
parenteral nutrition was continued. A PICC line was to be
placed for long-term total parenteral nutrition, however, the
patient was still febrile. Oxacillin was started. A CT scan
was obtained on [**10-5**], which showed no abscess, no free
air, and no extraluminal contrast was detected, and prominent
small bowel loops were seen.
On postoperative day nine from the original procedure, the
nasogastric tube was removed. The patient continued to
improve, was passing stool, and total parenteral nutrition
was continued. A PICC line was placed in the right basilic
vein for total parenteral nutrition. The patient's diet was
advanced to sips of clear liquids.
On postoperative day 11, the patient was found to be febrile,
and was advanced to full clears. On postoperative day 12,
the patient was afebrile, and tolerated a soft diet.
Arrangements were made for the patient to continue total
parenteral nutrition at his home in [**State 760**], and the
patient was advised to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44371**] at the
[**State 43840**] regarding adjustment of total
parenteral nutrition as well as postoperative follow up.
The patient was discharged and was contact[**Name (NI) **] following
discharge and the total parenteral nutrition home services
had been set up successfully.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home with home total
parenteral nutrition services.
DISCHARGE DIAGNOSIS:
1. Crohn's disease
2. Small bowel volvulus with extensive resection
3. Status post exploratory laparotomy with derotation of
mid-gut volvulus
4. Status post second look laparotomy with small bowel
resection and anastomosis
DISCHARGE MEDICATIONS:
1. Dilaudid 2 to 4 mg by mouth every four to six hours as
needed for pain
2. Total parenteral nutrition
FOLLOW-UP PLANS: The patient was to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 44371**] at the [**State 43840**] for total
parenteral nutrition adjustment as well as to follow up at
the [**State 43840**] for management of his Crohn's
disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 44338**]
MEDQUIST36
D: [**2116-10-15**] 22:40
T: [**2116-10-16**] 00:42
JOB#: [**Job Number 44372**]
|
[
"E878.8",
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[
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[]
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781, 931
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178, 700
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,075
| 170,183
|
4346
|
Discharge summary
|
report
|
Admission Date: [**2161-10-20**] Discharge Date: [**2161-11-16**]
Date of Birth: [**2087-6-3**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ciprofloxacin / Nystatin /
Erythromycin Base / Aspirin / Epinephrine / Vancomycin
Attending:[**First Name3 (LF) 14197**]
Chief Complaint:
right thigh wound infection
Major Surgical or Invasive Procedure:
[**10-21**], [**10-23**], [**10-25**], [**10-27**], and [**10-28**]: irrigation and debridement
of wound and placement/change of vac dressing starting with
[**10-23**] procedure
[**11-11**]: removal of allograft prosthetic composite and placement
of antibiotic cement coated unipolar spacer
History of Present Illness:
The patient is a 72-year-old woman who underwent
resection of an osteosarcoma of her right proximal femur
approximately 3 weeks prior to admission and was reconstructed
with an
allograft prosthetic component. She came to the emergency
room with some drainage and erythema around her
wound and the question was whether this was a superficial
cellulitis or a deep infection. Due to concern that the
infection could be deep, the patient was taken to the operating
room for I&D.
Past Medical History:
osteosarcoma right proximal femur
hypomagnesemia
hypokalemia
status post right colectomy
hypertension
H. pylori
osteoporosis
thalassemia minor
paroxysmal atrial tachycardia
hepatic hemangioma
parathyroid adenoma
Grave's Disease
PSH:
right proximal femur resection with APC reconstruction [**2160**]
partial colectomy [**2160**]
partial thyroidectomy [**2157**]
parathyroid adenomectomy
TAH [**2136**]
Social History:
lives alone, avid ballroom dancer and walker
denies alcohol
denies tobacco
Family History:
Brother with [**Name2 (NI) 499**] cancer
Physical Exam:
Patient presented with erythema surrounding her wound and
drainage from the wound. Her right lower extremity was
neurovascularly intact.
Pertinent Results:
[**2161-10-21**] 12:40 pm SWAB RIGHT THIGH WOUND.
GRAM STAIN (Final [**2161-10-21**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
GRAM POSITIVE RODS. RARE GROWTH.
SENT TO FOCUS [**2161-10-29**] FOR IDENTIFICATION AND
SENSITIVITIES.
ANAEROBIC CULTURE (Final [**2161-11-6**]):
PRESUMPTIVE PROPIONIBACTERIUM ACNES. SPARSE GROWTH.
SENT TO FOCUS [**2161-10-29**] FOR SENSITIVITIES.
Refer to sendout system for results.
Log-In Date/Time: [**2161-10-25**] 7:50 pm
SWAB Site: LEG DEEP WOUND R LEG.
**FINAL REPORT [**2161-10-31**]**
GRAM STAIN (Final [**2161-10-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2161-10-30**]):
RESEMBLING MICROCOCCUS/STOMATOCOCCUS SPECIES. RARE
GROWTH.
ANAEROBIC CULTURE (Final [**2161-10-31**]):
GRAM POSITIVE RODS. RARE GROWTH.
Brief Hospital Course:
Patient was taken to OR the day following presentation after
starting antibiotics. We held her coumadin and started her on
lovenox post-operatively. At the initial surgery purulent fluid
was encountered deep to the fascia. On the second trip to the
OR, purulent fluid was again encountered and a wound vac was
placed. The wound continued to improve in appearance with vac
therapy and subsequent debridement. Cultures grew out P. acnes
as well as another gram positive rod that was unable to be
identified at an outside lab. Following an ID consult the
patient was started on linezolid due to her multiple antibiotic
allergies. However, this was thought to be causing mild
myelosuppression. As a result, she underwent a successful
vancomycin desensitization and has had no difficulty with
vancomycin. We discussed the option of keeping the APC in place
with further IV antibiotic treatment, and the patient decided
she would prefer to undergo surgery rather than spend six weeks
undergoing antibiotic therapy with no guarantee of resolution of
the infection. She was taken to the OR on [**11-11**] for removal of
the APC and placement of a unipolar spacer coated with
antibiotic cement. She required blood transfusions following
this surgery, and her hematocrit stabilized. She mobilized with
PT and had good pain control with oral medication. She was
discharged to rehab on long-term vancomycin per ID.
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for variable days: Continue until INR > 2.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1
doses: Adjust daily dose based on INR with goal [**1-29**].
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
11. Atenolol 50 mg Tablet Sig: 100 mg qam, 50 mg qpm Tablets PO
twice a day.
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for upset stomach.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): Please infuse over 2-3 hrs.
Continue through [**12-24**].
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
deep wound infection right proximal femur allograft prosthetic
composite s/p proximal femoral resection for osteosarcoma
Discharge Condition:
stable
Discharge Instructions:
Patient is partial weightbearing only on RLE (about 30lbs).
Please call if fevers > 101F, worsening erythema around wound,
increased drainage from wound or numbness or weakness in RLE.
Do daily dressing changes. Once wound drainage has stopped there
is no need for further dressings.
You may shower. Do not soak wound in tub.
Please have weekly LFTs and chem 7 checked while on vanco.
Physical Therapy:
Patient is to be partial weightbearing only (30lbs) on RLE.
Global hip precautions.
Treatments Frequency:
Do daily dressing changes. Once wound drainage has stopped there
is no need for further dressings.
Sutures out at follow-up with Dr. [**Last Name (STitle) **].
Continue lovenox. Will plan on restarting coumadin after
follow-up with Dr. [**Last Name (STitle) **].
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] in 2 weeks.
Please call the infectious disease office for an appointment
with them in four weeks with CPR, ESR checked beforehand.
Completed by:[**2161-11-16**]
|
[
"285.1",
"427.31",
"998.31",
"V45.3",
"401.9",
"787.91",
"728.89",
"282.49",
"V10.81",
"996.66",
"458.29",
"682.6",
"241.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"80.05",
"83.39",
"38.93",
"93.59",
"86.22",
"84.56",
"99.07",
"77.65",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
6988, 7060
|
3202, 4606
|
413, 706
|
7225, 7234
|
1959, 2340
|
8055, 8280
|
1745, 1787
|
5676, 6965
|
7081, 7204
|
4632, 5653
|
7258, 7643
|
1802, 1940
|
7661, 7745
|
7767, 8032
|
346, 375
|
2375, 3179
|
734, 1210
|
1232, 1636
|
1652, 1729
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,196
| 194,719
|
31267
|
Discharge summary
|
report
|
Admission Date: [**2191-9-13**] Discharge Date: [**2191-9-19**]
Date of Birth: [**2121-5-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cepacol / Benicar / Zaroxolyn
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
decreased activity tolerance
Major Surgical or Invasive Procedure:
[**2191-9-13**] CABG x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to
RCA)
History of Present Illness:
70 yo male with positive ETT and elevated calcium scores.
Referred for cardiac cath which revealed three vessel CAD.
Returns today for CABG.
Past Medical History:
Diabetes Mellitus, Hypertension, Hyperlipidemia, TIA [**2181**], h/o
vertigo, hearing loss, recent removal of right cataract, s/p
prior bil. mastoidectomies, s/p prior tonsillectomy
Social History:
works in high tech
lives with wife
smokes occasional cigar
1-2 drinks per week
Family History:
no premature CAD; father with AAA in his 70's
Physical Exam:
6'0" 207 #
HR 73 RR 21 135/82
NAD, lying flat after cath
skin/HEENT unremarkable
neck supple with full ROM and no carotid bruits apppreciated
CTAB anterolaterally
RRR no murmur
soft, NT, ND, + BS;protuberant
cool extremities, no edema or varicosities noted
neuro grossly intact; unable to assess gait
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**9-16**] Echo: Pre Bypass: The left atrium is moderately dilated A
small secundum atrial septal defect is present. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 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 arch is mildly dilated.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. Post Bypass:
Patient is A paced on phenylepherine infuson. Preserved
biventricular function LVEF >55%. Aortic contours intact
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
[**9-16**] CT: 1. There is no evidence of retroperitoneal hematoma.
[**9-18**] CXR: Small bilateral pleural effusions have decreased since
[**9-15**]. Severe left lower lobe atelectasis persists. Moderate
enlargement of the postoperative cardiomediastinal silhouette is
stable and small retrosternal air and fluid collections, a
common postoperative finding, have not increased. No
pneumothorax.
[**2191-9-13**] 03:33PM BLOOD WBC-17.1*# RBC-3.40* Hgb-10.7* Hct-31.7*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.6 Plt Ct-231
[**2191-9-15**] 06:40AM BLOOD WBC-7.3 RBC-2.64* Hgb-8.3* Hct-24.1*
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.9 Plt Ct-183
[**2191-9-19**] 06:20AM BLOOD WBC-6.3 RBC-3.09* Hgb-9.6* Hct-27.3*
MCV-88 MCH-31.1 MCHC-35.1* RDW-14.2 Plt Ct-339
[**2191-9-13**] 05:02PM BLOOD PT-14.7* PTT-43.5* INR(PT)-1.3*
[**2191-9-13**] 05:02PM BLOOD UreaN-16 Creat-0.7 Cl-110* HCO3-25
[**2191-9-19**] 06:20AM BLOOD Glucose-126* UreaN-17 Creat-1.0 Na-143
K-3.8 Cl-103 HCO3-27 AnGap-17
[**2191-9-19**] 06:20AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 73759**] was a same day admit and brought directly to the
operating room where he underwent CABG x 4 with Dr. [**Last Name (STitle) 914**].
Please see operative report for surgical details. Following
surgery he was transferred to the CSRU for invasive monitoring
in stable condition. Later that evening he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one beta blockers and diuretics were started and he was
gently diuresed towards his pre-op weight. Later on post-op day
one he was transferred to the telemetry floor for further care.
On post-op day two his chest tubes were removed. A slow drop in
HCT to 20 prompted a repeat CXR as well as ABD. CT scan on
post-op day three. This ruled out any active bleed and he was
transfused PRBCs. Also on this day his epicardial pacing wires
were removed. HCT slowly increased over next several days. On
post-op day four/five he had episode of atrial fibrillation
which was treated with beta blockers and amiodarone. He
converted back into sinus rhythm and remained in SR until
discharge. He was ready for discharge home with services on post
operative day 6.
Medications on Admission:
fortamet 100 mg [**Hospital1 **]
actos 45 mg daily
vytorin [**11/2164**] daily
gemfibrozil 600 mg [**Hospital1 **]
finasteride 5 mg daily
ASA daily
HCTZ 25 mg daily
toprol 25 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:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. 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. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. FORTAMET 1,000 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO BID (2 times a day).
Disp:*60 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
14. Vytorin [**11/2164**] 10-80 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day for 5 days then decrease
to 400mg daily for 7 days then decrease to 200mg daily and
follow up with Dr [**Last Name (STitle) 11493**] .
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Atrial Fibrillation
PMH: Diabetes Mellitus, Hypertension, Hyperlipidemia, TIA [**2181**],
h/o vertigo, hearing loss, recent removal of right cataract
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please check blood glucose follow up with PCP [**Last Name (NamePattern4) **] > 200 x2
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
see Dr. [**Last Name (STitle) 1159**] in 1 week [**Telephone/Fax (1) 20587**]
see Dr. [**Last Name (STitle) 11493**] in [**3-12**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Wound check [**Hospital Ward Name 121**] 2 please schedule with RN [**Telephone/Fax (1) 3633**]
Completed by:[**2191-9-19**]
|
[
"780.4",
"427.31",
"272.4",
"389.9",
"997.3",
"997.1",
"401.9",
"V45.61",
"511.9",
"414.01",
"250.00",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6910, 6978
|
3473, 4636
|
324, 400
|
7234, 7241
|
1299, 3450
|
7839, 8222
|
887, 934
|
4870, 6887
|
6999, 7213
|
4662, 4847
|
7265, 7816
|
949, 1280
|
256, 286
|
428, 570
|
592, 775
|
791, 871
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,986
| 126,116
|
30637
|
Discharge summary
|
report
|
Admission Date: [**2133-1-7**] Discharge Date: [**2133-1-14**]
Date of Birth: [**2086-1-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Mitral and tricuspid valve regurgitation
Major Surgical or Invasive Procedure:
[**2133-1-7**] - Mitral valve repair(34mm Ring),tricuspid valve
repair(32mm Ring).
History of Present Illness:
This 47 year old white male has known mitral valve prolapse. He
has been followed by [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] for the past two years. The
patient has been asymptomatic until recently. He has recently
developed new atrial fibrillation. He was admitted for elective
valve repair or replacement.
Past Medical History:
Mitral valve prolapse
Asthma
Nasal polyps- s/p surgical excision
Basal cell carcinoma
Social History:
Race: Caucasian
Last Dental Exam: last week- dentist will fax clearance
Lives with:Alone.
Contact person upon discharge: [**Name (NI) **] [**Name (NI) **] (sister). Her cell
phone # is [**Telephone/Fax (1) 72649**].
Occupation:Marketing.
Tobacco:
ETOH: [**2-5**] glasses wine/week and denies illicit drug use.
Family History:
Non-contributory
Physical Exam:
Admisssion:
Pulse: 80s irregularly irregular Resp: 18 O2 sat:
B/P Right: Left:
Ht: 5 feet 9 inches
Wt: 153 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits appreciated
Pertinent Results:
[**2133-1-7**] ECHO
Pre-bypass:
The left atrium is markedly dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. The right atrium is markedly dilated. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is mildly dilated with normal free wall
contractility. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 40 cm from the incisors. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
myxomatous with posterior leaflet prolapse and partial flail. An
eccentric, anteriorly directed jet of Severe (4+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
[**2133-1-7**] 04:44PM BLOOD WBC-22.9*# RBC-3.17*# Hgb-9.9*#
Hct-28.2*# MCV-89 MCH-31.1 MCHC-35.0 RDW-13.4 Plt Ct-168
[**2133-1-9**] 02:38AM BLOOD WBC-11.5* RBC-2.94* Hgb-9.4* Hct-26.0*
MCV-88 MCH-31.9 MCHC-36.1* RDW-13.2 Plt Ct-102*
[**2133-1-7**] 05:12PM BLOOD UreaN-15 Creat-0.9 Cl-111* HCO3-22
[**2133-1-10**] 06:45AM BLOOD UreaN-14 Creat-0.8 K-4.4
[**2133-1-14**] 05:20AM BLOOD WBC-9.0 RBC-2.83* Hgb-8.3* Hct-24.9*
MCV-88 MCH-29.4 MCHC-33.5 RDW-13.2 Plt Ct-355
[**2133-1-14**] 05:20AM BLOOD PT-25.5* PTT-114.6* INR(PT)-2.5*
[**2133-1-14**] 05:20AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-137 K-4.2
Cl-101 HCO3-28 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2133-1-7**] for surgical
management of his mitral and tricuspid valve disease. He was
taken directly to the Operating Room where he underwent mitral
and tricuspid valve repair. Please see operative note for
details. He weaned from bypass on low dose Epinephrine and Neo
Synephrine and Propofol infusions. Postoperatively he was taken
to the intensive care unit for monitoring. Over the next several
hours, he awoke neurologically intact and was extubated.
Pressors were weaned as he became hypertensive.
On postoperative day one, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The Physical Therapy service was consulted
for assistance with his postoperative strength and mobility. He
developed rate controlled atrial flutter in the 50s and
amiodarone and lopressor were discontinued. Chest tubes and
pacing wires were discontinued. Follow up CXR revealed small
apical pneumothorax on the left. Coumadin was started for
atrial flutter. The patient became increasingly bradycardic
into the 40s and EP was consulted. Anticoagulation was
continued and the patient will be discharged on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor with plans to follow up with Dr. [**Last Name (STitle) **] as an
outpatient.Arrangements for Coumadin/INR follow up were made
with Dr[**Doctor Last Name **] nurse, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13470**]. POD# 7 Dr.[**Last Name (STitle) **] cleared
Mr.[**Known lastname **] for discharge to home.
Medications on Admission:
AMOXICILLIN - 1000 mg prior to dental work
LISINOPRIL - 10 mg Qday
METOPROLOL TARTRATE - 50 mg [**Hospital1 **]
WARFARIN - 3 mg at bedtime, Patient has not started this
medication
*pt has never taken coumadin as of [**2132-12-30**]*
Discharge Medications:
1. Outpatient Lab Work
Serial PT/INR
dx: atrial fibrillation
goal INR 2-2.5
Results to Dr. [**Last Name (STitle) 2392**] [**Telephone/Fax (1) 67596**] ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 72650**], RN)
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:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
Disp:*1 Tablet(s)* Refills:*0*
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
9. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for nausea for 10 doses.
Disp:*10 Tablet(s)* Refills:*0*
10. Warfarin 2.5 mg Tablet Sig: MD TO ORDER Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral valve prolapse
Asthma
Nasal polyps -s/p surgical excision
Basal cell carcinoma
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 2392**] in [**12-6**] weeks ([**Telephone/Fax (1) 5723**]Please call
for appointment
Cardiologist Dr. [**First Name (STitle) 437**] in [**12-6**] weeks-please call for appointment
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Dr. [**Last Name (STitle) 2392**] will follow coumadin/INR- please call results to
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 72650**], RN [**Telephone/Fax (1) 67596**]
*[**Doctor Last Name **] of heart monitor with daily transmission called into
Dr.[**Last Name (STitle) **], arranged on discharge.
Dr.[**Last Name (STitle) **] (Electrophysiology)follow up in 1 month:
#[**Telephone/Fax (1) **]
Completed by:[**2133-1-14**]
|
[
"429.5",
"493.90",
"397.0",
"V10.83",
"512.1",
"427.1",
"287.5",
"424.0",
"997.1",
"285.9",
"427.31",
"426.0",
"V45.89",
"787.01",
"427.32",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
7193, 7251
|
3954, 5597
|
360, 445
|
7381, 7473
|
2005, 3931
|
8014, 8871
|
1272, 1290
|
5882, 7170
|
7272, 7360
|
5623, 5859
|
7497, 7991
|
1305, 1986
|
280, 322
|
1063, 1256
|
473, 816
|
838, 926
|
942, 1047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,014
| 134,923
|
52354
|
Discharge summary
|
report
|
Admission Date: [**2196-3-3**] Discharge Date: [**2196-3-7**]
Date of Birth: [**2126-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mitral regurgitation, coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass graft X 1 (LIMA-LAD),Mitral Valve
repair(30mm [**Company 1543**] 3D profile ring), ligation mof left atrial
appendage [**2196-3-3**]
History of Present Illness:
This 69 year old white male was recently admitted with
congestive heart failure. Work up revealed 3+ mitral
regurgitation. He has known coronary disease having undergone
stenting to the RCA in [**2195-7-5**]. he was admitted now for
surgical intervention.
Past Medical History:
insulin dependent diabetes mellitus
Hyperlipidemia
Depression
s/p cardiac stent
Social History:
He is married with two grown children. He does not smoke and
stopped drinking 4 months ago due to his diabetes. He is a
retired salesman.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Admission:
Neuro:intact
HEENT: wnl
Cor- RSR w/Grade 4/6 systolic ejection murmur
Extremeties: no CCE
Abd: benign
Pertinent Results:
[**2196-3-6**] 07:00AM BLOOD WBC-9.9 RBC-2.93* Hgb-9.1* Hct-26.3*
MCV-90 MCH-31.0 MCHC-34.6 RDW-14.3 Plt Ct-157
[**2196-3-7**] 06:15AM BLOOD UreaN-21* Creat-0.8 K-3.5
[**2196-3-5**] 03:06AM BLOOD Glucose-88 UreaN-27* Creat-1.0 Na-141
K-4.1 Cl-105 HCO3-29 AnGap-11
Brief Hospital Course:
Following admission he was taken to the Operating Room where
coronary artery grafting and mitral repair/annuloplasty and
ligation of the left atrial appendage were performed. See
operative note for details. He weaned from bypass on low dose
neo synephrine and Propofol. He remained stable, was weaned
from the ventilator and was extubated easily. Pressors were
weaned, he was begun on low dose beta blockade and Amiodarone
for brief atrial fibrillation.
Diuresis was begun and he was transferred to the floor. Due to
prolongation of the PR interval the EPS service was consulted.
The Amiodarone was discontinued. The PR interval normalized and
he remained in sinus rhythm. He was approaching his
preoperative weight and diuretics were continued at discharge.
Insulin was continued and he was discharged on the dose he took
at home. Pacing wires had been removed prior to discharge. He
was discharged to home having been instructed as to medications,
precautions and follow up care.
Medications on Admission:
ASA 325mg/D
Plavix 75mg/D
Lipitor 40mg/D
Folic acid, Vit D, VitC and cyannocobolamine supplements
Lasix 20mg/D
Lantus 40U/D
Starlix prn
Lisinopril 10mg/D
Lopressor 12.5mg [**Hospital1 **]
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Insulin Glargine 100 unit/mL Solution Sig: 0.4 40units
Subcutaneous once a day.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x 1, mitral valve
annuloplasty,left atrial appendage
mitral regurgitation
hyperlipidemia
depression
insulin dependent diabetes mellitus
s/p coronary stent
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
report any redness of, or drainage from incisions
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] in [**2-5**] weeks ([**Telephone/Fax (1) 53156**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks ([**Telephone/Fax (1) 108228**])
[**Hospital 409**] clinic on [**Hospital Ward Name 121**] 6 in 2 weeks
Please call for appointments
Completed by:[**2196-3-7**]
|
[
"V58.66",
"428.22",
"272.4",
"428.0",
"412",
"424.0",
"414.01",
"311",
"V45.82",
"427.31",
"250.00",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.99",
"36.15",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
4083, 4138
|
1608, 2602
|
363, 521
|
4395, 4402
|
1320, 1585
|
4751, 5223
|
1088, 1171
|
2840, 4060
|
4159, 4374
|
2628, 2817
|
4426, 4728
|
1186, 1301
|
278, 325
|
549, 809
|
831, 915
|
931, 1072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,607
| 138,347
|
10747
|
Discharge summary
|
report
|
Admission Date: [**2132-2-12**] Discharge Date: [**2132-2-13**]
Date of Birth: [**2075-4-13**] Sex: M
Service:
ADMISSION DIAGNOSIS: Sepsis and hypotension.
HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male
with a history of metastatic esophageal cancer with
metastatic disease to the lung complicated by esophageal
fistula, esophagectomy, deep vein thrombosis, and recent
Methicillin resistant Staphylococcus aureus pneumonia.
Patient initially presented to [**Hospital6 2910**]
earlier on the day of admission with complaints of increasing
weakness, decreased po intake, mild abdominal pain and
dehydration plus some shortness of breath over the past week.
He also reported a cough productive of whitish-yellow sputum,
and decreased frequency of urination. He denied any fevers,
chills, headache, chest pain, nausea or vomiting, diarrhea or
dysuria. He reports that he is only able to take one can of
feeding through his J tube each day.
At the outside hospital, his white blood cell count was 20.
His chest x-ray showed findings consistent with congestive
heart failure or right upper lobe pneumonia. Vital signs on
presentation at [**Hospital6 **] were a heart rate of 112,
blood pressure 60/palp, respiratory rate of 16 and an oxygen
saturation of 95% on room air. He was given two liters of
saline intravenously and his pressure came up to 105/57. He
was treated with 60 mg of intravenous Solu-Medrol as well as
500 mg of Levaquin intravenously. He was then transferred to
[**Hospital6 256**] for further evaluation.
On presentation in the Emergency Department, his temperature
was 96.9. Heart rate 110. Blood pressure 105/70.
Respiratory rate between 18-20. In the Emergency Room, he
was evaluated and intravenous fluid boluses were given for
his hypotension. It was noted that he had worsening
respiratory distress and his oxygen saturations diminished to
the 60% range on 100% nonrebreather. He was then electively
intubated for increasing respiratory distress. Blood
cultures were sent.
PAST MEDICAL HISTORY: Esophageal cancer treated with surgery
and x-ray therapy; he had right lower extremity deep vein
thrombosis; two prior strokes with residual right lower
extremity weakness; abdominal aortic aneurysm; esophageal
fistula; Methicillin resistant Staphylococcus aureus
infection; motor vehicle accident [**2131-1-13**] fracture; J
tube insertion after sepsis episode; chronic lower back pain
and chronic obstructive pulmonary disease.
ALLERGIES: None.
MEDICATIONS:
1. Bactrim Double Strength 1 tablet po q.d.
2. Percocet.
3. Reglan 10 mg twice a day.
4. Combivent inhaler b.i.d.
5. Ritalin b.i.d.
6. >....<MDI b.i.d.
7. Remeron 30 mg once a day.
8. Celexa 40 mg q.h.s.
9. Dilomine 30 mg once a day.
10. Darvocet prn.
11. Vistaril 25 mg q. 6 hours prn.
12. Decadron 2 mg b.i.d.
13. Lovenox 100 mg subcutaneous q.d.
SOCIAL HISTORY: He had a 60 pack year history of smoking and
lives with his wife.
HOSPITAL COURSE: The patient underwent an abdominal CT scan
which showed no evidence of intraabdominal abscess, focus of
infection, or a perforation. The CT scan did show a moderate
sized pericardial effusion. The patient was admitted to the
Medical Intensive Care Unit and upon arrival, patient was
noted minutes later to become hypotensive with a mean blood
pressure of 40 and was then noted to have a cardiac arrest
with pulseless electrical activity. CPR was immediately
initiated, and 1 mg of epinephrine was given. The Doppler
probe was then used to ascertain that a pulse was present and
the patient was started on intravenous pressor [**Doctor Last Name 360**].
Neo-Synephrine drip was started and this brought the blood
pressure back up into an acceptable range. At this point,
the Cardiology Fellow was notified who performed a bedside
ultrasound which confirmed the presence of a significant
pericardial effusion causing tamponade physiology. The
family was immediately apprised of the situation, and was
presented with the options of pursuing a decompression of the
pericardial effusion or pursuing a course of conservative
management, given the grim prognosis of the patient's
esophageal cancer. The patient's oncologist was also
[**Name (NI) 653**], who had seen the patient earlier in the day. He
felt that the patient's family was aware of all the facts
concerning the prognosis and was capable of making a wise
decision about the patient's further care. Upon further
discussion with the family, it was decided to withdrawal care
and provide supportive care only. Because of this,
decompression of the pericardial effusion was not pursued,
and pressure support was withdrawn. Approximately five
minutes after withdrawing suppressor support, the patient
went into full cardiac and then respiratory arrest and was
pronounced dead at approximately 11:10 a.m. The family was
notified and the medical examiner was [**Name (NI) 653**] who declined
to pursue an autopsy in the case.
DR [**First Name (STitle) **] [**Doctor Last Name **] 12.761
Dictated By:[**First Name3 (LF) 35146**]
MEDQUIST36
D: [**2132-2-16**] 19:44
T: [**2132-2-16**] 19:47
JOB#: [**Job Number 35147**]
|
[
"276.5",
"420.90",
"427.5",
"038.9",
"255.4",
"518.0",
"197.0",
"428.0",
"V10.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2987, 5195
|
153, 178
|
207, 2040
|
2063, 2885
|
2902, 2969
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,623
| 113,272
|
8423
|
Discharge summary
|
report
|
Admission Date: [**2191-5-11**] Discharge Date: [**2191-5-20**]
Service: MEDICINE
Allergies:
Megace
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Shortness of breath
Hypotension
Major Surgical or Invasive Procedure:
Intubation
Chest tube placement
Femoral Line placement
History of Present Illness:
84 y/o M w/dementia, LE edema, and hyperlipidemia, who presented
to ED with acute SOB. This initially happened while he was on
the toilet. His wife called EMS, and he was initially
tachycardiac to 120, bp 112/76, rr 36 . He was diaphoretic,
denied CP. He had CXR at OSH which by report showed assymm pulm
edema R>L. Pt had ECG w/sinus tach, nl axis/int, ST depression
inf/lat. ABG 7.41/25/150 on NRB. He was started on CPAP, given
MS 2 mg IV, Lasix 80 IV, nitro gtt, heparin gtt for concern of
PE. LENI at OSH of swollen LLE neg for DVT. BP dropped from
126/65 to 71/37 with the nitro, which resolved when the drip as
stopped. He was intubated at noon after not tolerating CPAP, and
becoming tachypneic on NRB. Here, he was noted to have
anisocoria not previous noted. Head CT showed no bleed, no
shift. CXR showed widened mediastinum, so he had a CTA. This
revealed bilateral PEs as well as an apical ptx. He was
restarted on the heparin gtt and a chest tube was placed. Pt
admitted to MICU for stabilization. Pt was extubated on [**5-13**].
Past Medical History:
Althzeimers Dementia
Hyperlipidemia
Social History:
Lives at home with wife.
Family History:
Unable to obtain
Physical Exam:
VITALS: Afebrile, 108/60, 90, 98%RA
GEN: Pleasant elderly male, NAD, NRB on although pt is not
tachypeic and appears comfortable.
HEENT: Pupils are equal, round, reactive. Head is
normocephalic, atraumatic. Neck is supple, no lymphadenopathy.
LUNGS: R ant field clear, L ant field with rale and subQ
emphysema, R base with good air movement and occ rales, L base
with rale.
HEART: Regular rate and rhythm, no murmurs, rubs, or gallops.
Carotids: Normal pulsation without bruits.
Extremities: 3+ pedal edema to knee, non-palpable pulses, feet
are warm with good color.
Abdomen: soft, nondistended, and nontender, normoactive BS.
Neurologic exam: Alert, oriented to Person only. Babinskis are
equivocal.
Skin: No rash.
Pertinent Results:
CTA of chest: CT ANGIOGRAPHY OF THE CHEST: Multiple pulmonary
emboli are seen; in the proximal portion of the right pulmonary
artery posterior branch near the bifurcation, extending into the
superior segment of the lower lobe. A smaller amount of clot is
seen in the pulmonary artery feeding the right middle lobe
medial segment. On the left, clot is seen in the pulmonary
artery feeding the posterior left upper lobe, and also in the
segment feeding the anteromedial left lower lobe. The aorta is
normal in caliber, with wall calcifications. No dissection is
seen. There are calcifications within the coronary arteries. No
pericardial effusion is present.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: A small
pneumothorax is seen on the left; additionally, there is a small
amount of mediastinal air along the left superior mediastinal
border, into the apex of the lung. Dependent atelectasis is seen
on both sides; additionally, a peripheral portion of
consolidation in the right lower lobe superior segment is distal
to the portion of largest clot, and may represent developing
pulmonary infarction. There are shotty mediastinal lymph nodes.
A nasogastric tube is seen coiling in the stomach. The patient
is intubated. The imaged portions of the abdomen, including the
superior aspect of the spleen and liver, are unremarkable. A
nasogastric tube is seen in the esophagus, which is mildly
thickened; some debris and air bubbles within it, without
obvious tear.
Osseous structures are remarkable for degenerative changes of
the spine. There is an old healed rib fracture of the anterior
aspect of right rib number seven. A small amount of air seen in
the subclavian vein on the left, probably due to phlebotomy.
Coronal and sagittal reformations were essential in delineating
the anatomy and pathology. MPR value 4.
IMPRESSION:
1. Segmental pulmonary emboli in bilateral pulmonary arteries.
Associated peripheral consolidation in the right lower lobe,
concerning for infarct vs consolidation.
2. Small left pneumothorax and pneumomediastinum in intubated
patient.
3. Nasogastric tube in mildly thickened esophagus, with debris
and small amount of air, but no obvious tear.
4. Aortic calcifications, without evidence of dissection or
dilatation.
.
.
ECHO: Conclusions:
The left atrium is normal in size. 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 probably normal
(LVEF>55%).
Right ventricular chamber size is normal. Right ventricular
systolic function is normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. The mitral
valve leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
.
.
CT HEAD W/O CONTRAST [**2191-5-11**] 1:21 PM
No intracranial hemorrhage. Diffuse chronic changes. There
appears to be interval marked atrophic change since [**2185**] which
could represent an accelerated degenerative process.
Additionally, there is marked interval enlargement of the
ventricles which may in part represent hydrocephalus (partly
related to atrophy) - there is hypo-attenuation of the
periventricular white matter which may represent chronic
ischemic changes or trans-ependymal edema. Further evaluation
with MRI might be helpful if clinically indicated.
CTA CHEST W&W/O C &RECONS [**2191-5-11**] 2:46 PM
bilateral pulmonary emboli.
left lower lobe superior segment peripheral consolidation
suspicious for infarction.
right pneumothorax, pneumomediastinum.
endotracheal tube and ng tube; esophagus has some debris and a
few air bubbles in it but no obvious tear.
.
LABS ON ADMISSION:
[**2191-5-11**] 11:34PM TYPE-ART PO2-107* PCO2-33* PH-7.47* TOTAL
CO2-25 BASE XS-0
[**2191-5-11**] 11:34PM LACTATE-2.8*
[**2191-5-11**] 11:34PM HGB-10.6* calcHCT-32
[**2191-5-11**] 06:35PM PT-14.9* PTT-50.6* INR(PT)-1.5
[**2191-5-11**] 03:50PM TYPE-ART TEMP-37.2 RATES-/15 TIDAL VOL-550
O2-80 PO2-249* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 AADO2-295
REQ O2-54 -ASSIST/CON INTUBATED-INTUBATED
[**2191-5-11**] 03:29PM PT-100* PTT-150* INR(PT)-66.1
[**2191-5-11**] 01:12PM GLUCOSE-234* UREA N-38* CREAT-1.5*
SODIUM-146* POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-18* ANION
GAP-24*
[**2191-5-11**] 01:12PM ALT(SGPT)-12 AST(SGOT)-35 CK(CPK)-102 ALK
PHOS-99 TOT BILI-0.7
[**2191-5-11**] 01:12PM CK-MB-4 cTropnT-0.04*
[**2191-5-11**] 01:12PM TOT PROT-7.2 ALBUMIN-3.3* GLOBULIN-3.9
CALCIUM-8.6 PHOSPHATE-4.4 MAGNESIUM-1.9 IRON-23*
[**2191-5-11**] 01:12PM calTIBC-205* VIT B12-412 FOLATE->20
FERRITIN-347 TRF-158*
[**2191-5-11**] 01:12PM WBC-5.1# RBC-4.00* HGB-12.5* HCT-38.7* MCV-97
MCH-31.3 MCHC-32.4 RDW-13.7
[**2191-5-11**] 01:12PM PLT COUNT-275
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM:
.
1. PE/DVT: Pt presented with resp failure and hypotension. Found
to have PE on CTA and subsequently found to have L leg DVT. Wife
reports that patient is very sedentary at home and only gets up
with assitance which may be once per day. In addition, he was on
Megase which can be prothrombotic. The patient was intubated in
the ED for ventilation and started on heparing gtt. The patient
was extubated within 48 hours and his respiratory status
continued to improve. On transfer from the MICU the patient had
an O2 sat of 95% on RA. IVC filter was considered for
prophylaxis, however it was felt that coumadin would be a better
long term management of his DVT and PE. The risk of fall was
considered, however the patient will be going to rehab and
likely a longterm care facility and would be able to ambulate
with assistance.
The patient was GUIAC neg which was checked prior to initiating
heparin. The patient was transitioned to Lovenox 50mg [**Hospital1 **] during
a bridge to a therapeutic INR. Goal INR is [**1-27**]. The Lovenox was
discontinued after the patient maintained an INR >2 for 48
hours. The patient should be maintained on coumadin for at least
6 months.
.
2. Ptx: Pt with PTX likely [**1-26**] barotrauma. Although this was a
very small PTX, pt was hypotensive in ED and thought that PTX
was expanding. Large bore needle was placed followed by a chest
tube and patiet received fluid resusciation. Pt had chest tube
removed on [**5-13**]. Serial CXR's showed PTX decreased in size and
was no longer present on [**5-18**]. Pt maintained O2 sats at 97% on
RA and SBP stable in 130's.
.
3. UTI: Pt found to have UTI after multiple days with foley
catheter in place. Foley was d/c'd and patient started on Cipro.
E.coli on cx was pan-sensitive but patient remained on quinolone
for complicated UTI. Pt should be treated for 7 days.
.
4. Hypotension: Pt was hypotensive on admission. Initially
thought to be due to sepsis vs volume depletion. Resolved with
IVF. Pt was volume repleted in MICU and BP's stable at time of
discharge. Pt is on no BP medications at home.
.
5. Anisocoria: On initial exam in ED, patient found to have
anisocoria. Pt had head CTA in MICU to assess for posterior
aneurysm. This was normal and anisocoria resolved on hospital
day 2. Unclear cause of inital exam findings.
.
6. Anemia: Pt was GUIAC neg during admission. Iron low but
ferritin elevated, likely reactive suggesting anemia of chronic
disease. Also likely decreased HCT from procedures and fluid
shifts from resucitation.
.
7. Dementia: Pt has an extensive history of Alzthiemers dementia
noted in past records. On this admission, MS improved after
infections treated and resp status stable. Pt was continued on
Exelon.
.
8. FEN: After extubation, pt was evaluated for ability to
swallow different consistencies given poor mental status. Pt
passed barium swallow study for ground solid food and thin
liquids. Pt should have a boost with every meal for added
nutritional supplementation.
.
8. Ppx: Pt was on a heparin gtt and then lovenox. Pt was started
on an PPI.
9. Code: DNR/DNI- While in MICU, wife and family physician had
long discussion with MICU team and decided to make patient
DNR/DNI.
Medications on Admission:
Exelon 0.6mg [**Hospital1 **]
Lipitor 10mg
Multivit
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary:
Pulmonary Embolism
Deep Vein Thrombosis
Urinary Tract Infection
Secondary:
Dementia
Hyperlipidemia
Discharge Condition:
Stable. Patient discharged to [**Hospital1 1501**]. Will probably require long
term placement.
Discharge Instructions:
Please return to the hospital if you experience shortness of
breath, chest pain, leg swelling, severe
nausea/vomiting/diarrhea or any other severe symptoms. Please
call your physician if you have any questions about your
symptoms.
- Please have your INR checked until a stable dose of coumadin
maintinas your INR between [**1-27**].
Followup Instructions:
Please follow-up with your PCP in one week.
Completed by:[**0-0-0**]
|
[
"415.19",
"276.5",
"518.81",
"041.4",
"453.41",
"512.8",
"599.0",
"331.0",
"294.10",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"34.91",
"38.91",
"88.43",
"96.71",
"34.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10477, 10555
|
7146, 7146
|
246, 302
|
10708, 10804
|
2269, 6046
|
11185, 11256
|
1491, 1509
|
10576, 10687
|
10401, 10454
|
10828, 11162
|
1524, 2157
|
175, 208
|
7174, 10375
|
330, 1374
|
6060, 7123
|
2175, 2250
|
1396, 1433
|
1449, 1475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,835
| 127,462
|
51668
|
Discharge summary
|
report
|
Admission Date: [**2159-12-16**] Discharge Date: [**2160-1-4**]
Date of Birth: [**2096-12-17**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Iodine; Iodine Containing / Sulfonamides /
Percocet / Latex
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
debridement R lower leg.
History of Present Illness:
62 F p/w hypotension to the ED (70's SBP), RUQ abdominal pain
and necrotic, maloderous wound on the Right medial malleolus.
Right foot pain began 5 days PTA after sustaining an insect bite
while gardening. Four days PTA abdominal pain started, w/ N/V
x2, anorexia the night PTA. Denies Diarrhea, consitpation,
blood in stool.
Past Medical History:
1. Diverticulitis s/p partial colectomy
2. PUD
3. Depression
4. Htn
5. Hypothyroidism
6. Raynauds
8. Uterine Fibroids
9. Internal carotid artery dissection
10. Asthma
11. h/o hepatitis
12. h/o TIA
13. Visual Seizures
Social History:
Retired [**Hospital1 18**] pathologist, no tobacco, no EtOH, lives with her
husband.
Family History:
non-contributory
Physical Exam:
On admission:
94.1 101 80/48 16 93% RA
A&Ox3, mod. distress, pale, +rigors
tachy, RRR
CTAB
RUQ TTP w/ guarding and rebound. reducible epigastric hernia,
no mass.
ext: cool, Right medial malleolous indurated and necrotic
abscess w/ foul smelling odor and necrotic soft tissue below.
Pertinent Results:
[**2159-12-20**] 04:58AM BLOOD WBC-11.8* RBC-3.16* Hgb-10.0* Hct-28.8*
MCV-91 MCH-31.5 MCHC-34.5 RDW-14.2 Plt Ct-368
[**2159-12-19**] 02:17AM BLOOD WBC-11.7* RBC-2.94* Hgb-9.0* Hct-27.5*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.2 Plt Ct-295
[**2159-12-18**] 02:44AM BLOOD WBC-14.4* RBC-2.76* Hgb-8.8* Hct-26.3*
MCV-95 MCH-32.1* MCHC-33.7 RDW-14.2 Plt Ct-294
[**2159-12-17**] 01:44PM BLOOD WBC-21.3* RBC-3.27* Hgb-10.2* Hct-30.2*
MCV-93 MCH-31.3 MCHC-33.8 RDW-14.0 Plt Ct-317
[**2159-12-17**] 03:49AM BLOOD WBC-16.4* RBC-3.20* Hgb-10.0* Hct-29.5*
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.0 Plt Ct-274
[**2159-12-16**] 11:15PM BLOOD WBC-19.1* RBC-3.26* Hgb-10.1*# Hct-30.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-13.8 Plt Ct-274
[**2159-12-16**] 05:55PM BLOOD WBC-21.7*# RBC-4.16* Hgb-13.7 Hct-39.9
MCV-96 MCH-32.9* MCHC-34.3 RDW-13.8 Plt Ct-297
[**2159-12-20**] 04:58AM BLOOD Plt Ct-368
[**2159-12-19**] 02:17AM BLOOD Plt Ct-295
[**2159-12-18**] 02:44AM BLOOD Plt Ct-294
[**2159-12-17**] 01:44PM BLOOD Plt Ct-317
[**2159-12-17**] 01:44PM BLOOD PT-12.6 PTT-150.0* INR(PT)-1.1
[**2159-12-17**] 03:49AM BLOOD Plt Ct-274
[**2159-12-16**] 11:15PM BLOOD PT-14.5* PTT-35.2* INR(PT)-1.4
[**2159-12-16**] 05:55PM BLOOD Plt Smr-NORMAL Plt Ct-297
[**2159-12-20**] 04:58AM BLOOD Glucose-122* UreaN-4* Creat-0.6 Na-140
K-3.6 Cl-103 HCO3-28 AnGap-13
[**2159-12-19**] 02:17AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2159-12-18**] 05:12PM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-143
K-4.3 Cl-111* HCO3-25 AnGap-11
[**2159-12-17**] 03:49AM BLOOD Glucose-102 UreaN-17 Creat-0.5 Na-139
K-3.4 Cl-109* HCO3-21* AnGap-12
[**2159-12-16**] 11:15PM BLOOD Glucose-122* UreaN-19 Creat-0.6 Na-141
K-2.9* Cl-112* HCO3-19* AnGap-13
[**2159-12-16**] 05:55PM BLOOD Glucose-102 UreaN-33* Creat-1.2* Na-134
K-4.3 Cl-91* HCO3-26 AnGap-21*
[**2159-12-17**] 03:49AM BLOOD ALT-21 AST-27 AlkPhos-55 Amylase-13
TotBili-0.3
[**2159-12-16**] 05:55PM BLOOD ALT-16 AST-37 AlkPhos-75 Amylase-17
TotBili-0.5
[**2159-12-20**] 04:58AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.8
[**2159-12-19**] 02:17AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9
[**2159-12-18**] 05:12PM BLOOD Calcium-7.5* Phos-3.2 Mg-1.8
[**2159-12-17**] 03:49AM BLOOD Calcium-7.3* Phos-2.1* Mg-1.8
[**2159-12-16**] 11:15PM BLOOD Calcium-7.4* Phos-2.8 Mg-2.0
[**2159-12-16**] 05:55PM BLOOD TotProt-6.5 Calcium-9.3 Phos-3.8 Mg-1.5*
[**2159-12-17**] 05:35AM BLOOD Cortsol-23.1*
[**2159-12-17**] 05:27AM BLOOD Cortsol-18.8
[**2159-12-17**] 05:04AM BLOOD Cortsol-16.0
[**2159-12-17**] 03:50AM BLOOD Cortsol-9.7
[**2159-12-16**] 06:01PM BLOOD Lactate-3.6*
[**2159-12-16**] 08:07PM BLOOD Lactate-2.2*
[**2159-12-16**] 10:34PM BLOOD Glucose-127* Lactate-2.2* Na-137 K-3.2*
Cl-110
[**2159-12-17**] 04:14AM BLOOD Lactate-1.4
[**2159-12-17**] 08:26AM BLOOD Glucose-97 Lactate-1.1 K-2.8*
[**2159-12-17**] 10:45AM BLOOD Glucose-138* Lactate-0.9 K-4.2
Blood Cultures 11/6: No growth
Wound Culture [**12-16**]:
[**2159-12-16**] 6:10 pm SWAB
**FINAL REPORT [**2159-12-22**]**
GRAM STAIN (Final [**2159-12-16**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2159-12-22**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
WORK-UP PER ID.
ESCHERICHIA COLI. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
ESCHERICHIA COLI. SPARSE GROWTH. 2ND STRAIN.
Trimethoprim/Sulfa sensitivity testing available on
request.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R 8 S
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 4 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- 1 S <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2159-12-20**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
******************
Tissue culture [**12-16**]
[**2159-12-16**] 10:30 pm TISSUE Site: ANKLE RIGHT.
GRAM STAIN (Final [**2159-12-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2159-12-22**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
GRAM POSITIVE RODS. MODERATE GROWTH.
OF THREE COLONIAL MORPHOLOGIES. UNABLE TO IDENTIFY
FURTHER.
gram stain reviewed: 3+ (5-10 per 1000X FIELD): were
observed
([**2159-12-20**]).
ESCHERICHIA COLI. SPARSE GROWTH STRAIN 1.
Trimethoprim/Sulfa sensitivity testing available on
request.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH. STRAIN 2.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| | ESCHERICHIA
COLI
| | |
AMPICILLIN------------ =>32 R <=2 S =>32 R
AMPICILLIN/SULBACTAM-- 8 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 4 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- 1 S 1 S 1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN------------ 0.5 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2159-12-21**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2159-12-17**]):
NO FUNGAL ELEMENTS SEEN.
ACID FAST CULTURE (Pending):
ACID FAST SMEAR (Final [**2159-12-17**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
************
Stool Culture [**12-22**], [**12-24**], [**12-25**]: Negative for C Diff
Brief Hospital Course:
#Necrotizing Fasciitis: The patient was diagnosed with spesis in
the ED and a Code Sepsis protocol was followed. In ED given 2
liters IVF with no improvement in BP. Right SC CVL placed,
levophed started with good response. Pt taken to the OR for
debridement. OR findings c/w Necrotizing fasciitis. Wound left
open and packed. Patient was admitted to the general surgery
service under Dr. [**Last Name (STitle) 107052**] and placed in the SICU. Patient was
left intubated on levophed. IV antibiotics were started
(levofloxacin/vancomycin/gentamycin/clindamycin), and an ID
consult was obtained. Tube feed were started via an OGT on
[**12-17**]. The patient was taken back to the OR on [**12-17**] for
observation of the wounds. No further debridement was necessary
as the wounds were quite clean. The wounds were again packed
open; the patient was returned to the SICU intubated and on
levophed and propofol. A plastic surgery consult was obtained
for recommendations on closure. A wound vac was placed per
their recommendations on [**2159-12-18**]. The patient was extubated
after dressing changes on [**2159-12-18**]. Clear liquids was started on
[**2159-12-19**] and advanced to regular diet on [**2159-12-20**]. On [**2159-12-22**]
antibiotics were changed to Vanco/Aztreonam/Flagyl per the ID
team. On [**2159-12-24**] a PICC line was placed by angiography. The
wound continued to be treated with a wound vac, changed every
3-4 days. On [**2159-12-27**] the patient was taken to the OR by the
plastic surgery team for a Split-thickness skin graft from right
thigh to right leg measuring 5 x 25 cm. A wound vac was again
placed in the OR and left in place for 5 days per the plastic
surgery team. Per the ID team antibiotics (Vanco, po Flagyl,
Aztreonam) to be continued for 2 weeks from this operation (to
complete on [**2160-1-10**]). On [**2160-1-1**] the wound vac was removed by
the plastic surgery team. There was 100% graft take. The
medial thigh wounds were treated with wet to dry packing and
allowed to heal by secondary intention. On [**2160-1-2**] the skin
graft and donor site were healing. The thigh wounds had good
granulation tissue without significant drainage. The patient was
ready for discharge per the general surgery, plastic surgery and
PT teams. On [**2160-1-4**] the patient was discharged to rehab.
.
#Thrombocytosis: Platletes rose to a maximum of 1,080,000.
Hematology considered this to be a acute phase reaction and did
not think intervention was warrented. She is to have a
follow-up CBC at her outpatient visit. If platelets are still
elevated, she is to have an outpatient Hematomlogy/oncology
consult.
Medications on Admission:
atenolol 25mg QD
levothyroxine 150mcg daily
albuterol
[**Doctor First Name 130**] 60mg [**Hospital1 **]
dyazide 25/37.5mg daily
flonase 2puff [**Hospital1 **]
K-dur 20meq qd
neurotin 200mg TID
nifedical xl 30BID
prilosec 20mg [**Hospital1 **]
singulair 10mg qhs
skelaxin 400mg [**Hospital1 **]
tramadol 50mg QD
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily). Cap(s)
5. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Metaxalone 800 mg Tablet Sig: 0.5 Tablet PO bid ().
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3-4hr as
needed.
Disp:*45 Tablet(s)* Refills:*0*
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Six (6)
Tablet PO bid ().
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: continue through doses on [**1-10**].
Disp:*21 Tablet(s)* Refills:*0*
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) 1gm
Intravenous Q 12H (Every 12 Hours) for 7 days: continue through
doses on [**2160-1-10**].
Disp:*14 1gm* Refills:*0*
17. Aztreonam [**2154**] mg IV Q8H
18. Aztreonam 2 g Recon Soln Sig: One (1) 2gm Injection every
eight (8) hours for 7 days: continue through doses on [**2160-1-10**].
Disp:*21 2gm* Refills:*0*
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed for 9 days.
Disp:*30 ML(s)* Refills:*0*
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
21. Outpatient Lab Work
CBC with Diff, BUN, Cr, ALT, AST, Alk Phos, T Bili
Please draw the week of [**2160-1-6**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Necrotizing fascitis
Discharge Condition:
Good
Discharge Instructions:
Please resume taking your regular medications. Take all new
medications as directed. Continue all antibiotics until [**2160-1-10**]
You may resume your regular activities. You may shower, and pat
dry the wound covered. Do not soak the wound for 2 weeks.
Please call your physician or return to the hospital if you
experience:
- Increasing pain
- Fever (>101.5 F)
- Inability to eat or persistent vomiting
- Foul discharge from your wound
- Other symptoms concerning to you
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] in [**2-11**] weeks. Call his
office, ([**Telephone/Fax (1) 2300**], to make an appointment.
2. Call Dr.[**Name (NI) 26831**] office for a follow-up appointment ([**Telephone/Fax (1) 107053**]
3. Have a CBC, BUN, Cr, LFT's drawn for your appointment with
Dr. [**Last Name (STitle) **] to check your platelet count.
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,308
| 118,938
|
47428
|
Discharge summary
|
report
|
Admission Date: [**2135-7-4**] Discharge Date: [**2135-7-6**]
Service: MEDICINE
Allergies:
Vasotec / Niaspan
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
GI bleed
syncope
Major Surgical or Invasive Procedure:
Colonoscopy
EGD
Blood transfusion
History of Present Illness:
81 year old gentleman with history of atrial fibrillation on
warfarin, chronic constipation with pancolonic diverticulosis,
anal fissure, possible hemmorrhoids, presented with syncope and
BRBPR. Patient was in his usual state of health until 5AM on the
AM of admit when he awoke to go to the bathroom. His wife also
awoke to use a different bathroom, and she heard a loud thud
from her husband's bathroom. She ran in to find him on the floor
with his pants down, incontinent of urine, though with no stool
or blood visible. The patient was confused and had apparently
injured his R face during the fall, so his wife told him not to
move and called 911. By the time the EMTs arrived, he had
produced a large bloody bowel movement, which the EMTs estimated
to be about 500cc in volume. He was transported to the [**Hospital1 18**] ER.
Recently, the patient was in [**Location (un) 7349**] to celebrate his 60th wedding
anniversary. He returned on the day prior to admission. While he
was in [**Location (un) 7349**], he had no nausea, vomiting or diarrhea, but did eat
out at a lot of restaurants and ate more than his normal. He was
feeling constipated on return to [**State 350**], and per his
norm, he took two Dulcolax before retiring to bed last PM. He
suffers from constipation chronically and takes Dulcolax every
2-3d as needed, which relieves his symptoms and generally causes
watery stools for 1 day. In the 4-5 weeks prior to his weekend
in [**Location (un) 7349**], the patient had cut his dietary intake in half,
especially carbohydrates, in an attempt to lose weight, though
he reports that this did not work and his weight has remained
stable. No recent fatigue, lightheadedness or dizziness prior to
this episode. Generally drinks one vodka drink when he goes to
restaurants but not at home, though this weekend had two drinks
per night while in [**Location (un) 7349**] restaurants. Was walking around a lot in
[**Location (un) 7349**], but does not think that he was dehydrated.
In the ER, the patient was hemodynamically stable, and from
available nursing notes did not have further episodes of BRBPR
though his family states that he did. He received IVF, 1 unit
PRBCs and Protonix 40mg x once. He had a CT scan of his head
which was negative for acute bleed or mass but did note
fractures of his R zygomatic arch, R maxillary sinus frontal and
posterior walls. An NG lavage was deferred. He also had a CT of
his neck, which showed no fracture but degenerative joint
disease. GI was consulted and he was transferred to the MICU for
further management.
Past Medical History:
-Atrial fibrillation on warfarin
-chronic constipation
-pancolonic diverticuli
-colon polyps
-BPH
-partial lung resection for suspicious nodule, [**9-27**]
-TKRs bilaterally at NEBH
-open cholecystectomy
-open appendectomy
Social History:
Worked in renovating and selling apartments; married x 60y, many
children all active in his care; last smoked tobacco >50y ago;
drinks [**1-24**] vodka drinks when he goes out to eat but not when he
is at home, no prior sig etoh history; no other drugs; full code
[**2135-7-4**]
Family History:
Non-contributory
Physical Exam:
Vitals: afeb, HR 62 irreg, BP 136/60, RR 19, Sat 100% on RA
Gen: healthy-appearing man lying in bed with cervical collar on,
NAD
HEENT: EOMI, PERRL, anicteric sclerae, conjunctivae not pale,
MMM
Neck: cerv collar in place, no post neck tenderness
Lungs: rales at bases bilaterally, otherwise CTA
CV: irreg irreg, no m/g/r
Abd: mildly obese, nd, old scar in RUQ and RLQ c/w prior
surgeries, no hernia, BS increased but not high pitched, TTP in
RLQ to deep palp, no masses
Rectal (GI fellow performed in my presence): no hemmorrhoids,
good tone, bright red blood on finger tip with small clot, no
stool
Ext: warm, dry, 2+ DP pulses b/l, no edema
Neuro: A+Ox3, approp affect, FROM x 4, CN 2-12 intact (confirmed
after collar removed), sensation intact to LT
Pertinent Results:
CT SCAN ORBIT: Multiple fractures of the right maxillary sinus
are identified, with fragments depressed and displaced into the
sinus cavity. A fracture of the right orbital floor is present,
but there is no herniation of orbital contents into the
maxillary sinus. There is also fracture of the right lateral
orbital wall and a fracture of the zygomatic arch which is
outwardly angulated and deformed.
CT HEAD: No intracranial hemorrhage is identified. There is no
mass effect or shift of normally midline structures. The
ventricles are normal in size and symmetric and the basal
cisterns are well visualized. The density of the brain
parenchyma appears within normal limits. This study is slightly
limited by motion.
There is a fracture of the right zygomatic arch as well as a
fracture of the posterior wall of the maxillary sinus on the
right. There is an air-fluid level in the right maxillary sinus.
There also appears to be a fracture of the frontal wall of right
maxillary sinus on the right. There is soft tissue swelling
surrounding the right side of the face.
CT C SPINE:
1. Marked degenerative disease without acute fracture.
2. Tortuous right vertebral artery versus aneursym C4.
Enlargement of vertebral foramen indicates chronic nature,
though further imaging (CTA neck) can be performed if clinically
indicated.
CXR: The heart, mediastinal and hilar contours are within normal
limits. The lungs are clear. Note is made that the costophrenic
sulci are not fully evaluated bilaterally. The osseous
structures are grossly unremarkable.
IMPRESSION: No evidence for CHF or pneumonia.
ECG: [**2135-7-4**] 6:10:28 AM
Atrial fibrillation with a slow ventricular response.
Intraventricular
conduction delay. Q-T interval prolonged for the rate. Since the
previous
tracing of [**2122-7-30**] probably no significant change.
[**2135-7-4**] 05:55AM PT-25.9* PTT-26.5 INR(PT)-2.6*
[**2135-7-4**] 05:55AM PLT COUNT-220
[**2135-7-4**] 05:55AM NEUTS-54.7 LYMPHS-38.1 MONOS-5.4 EOS-1.3
BASOS-0.4
[**2135-7-4**] 05:55AM WBC-7.0 RBC-3.64* HGB-11.5* HCT-32.8* MCV-90
MCH-31.4# MCHC-34.9 RDW-13.8
[**2135-7-4**] 05:55AM CK-MB-3 cTropnT-<0.01
[**2135-7-4**] 05:55AM LIPASE-36
[**2135-7-4**] 05:55AM ALT(SGPT)-16 AST(SGOT)-17 CK(CPK)-65 ALK
PHOS-43 AMYLASE-67 TOT BILI-0.6
[**2135-7-4**] 05:55AM GLUCOSE-140* UREA N-32* CREAT-1.0 SODIUM-141
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13
[**2135-7-4**] 06:15AM HGB-12.0* calcHCT-36
[**2135-7-4**] 01:13PM CK-MB-4 cTropnT-<0.01
[**2135-7-4**] 01:13PM CK(CPK)-126
[**2135-7-4**] 06:42PM HCT-30.0*
[**2135-7-4**] 10:53PM HCT-29.2*
[**2135-7-4**] 10:53PM CK-MB-3 cTropnT-<0.01
[**2135-7-4**] 10:53PM CK(CPK)-108
Brief Hospital Course:
A/P: 81 year old gentleman with a history of atrial fibrillation
on warfarin, diverticulosis, presents with syncope in setting of
BRBPR and hematocrit drop.
1) GI bleed:
Patient was admitted to the intensive care unit for monitoring.
Hematocrit was checked every four hours. Hematocrit dropped from
32 to 29. Patient received 2 units of packed red blood cells and
hematocrit increased to 33. It then stabilized and remained at
30. Hematocrit was stable for 24 hours. Patient underwent an EGD
that showed no abnormality and a colonoscopy that showed grade
three internal hemorrhoids with stigmata of recent bleeding and
diverticuli throughout the colon. Aspirin and coumadin were held
and INR of 2.6 was reversed with 3 units of FFP and 5 mg of
vitamin K. INR on discharge was 1.2. Dr. [**Last Name (STitle) **], the patient's
cardiologist was [**Name (NI) 653**], and he would like the patient to
remain off coumadin and aspirin until further surgical workup.
The patient is going to follow up with Dr. [**Last Name (STitle) 30330**] for
possible hemorrhoidal banding.
2) Syncope: Etiology was thought to be vaso-vagal in setting of
GI bleed and micturition. Patient was monitored on telemetry
during his hospital stay. He was bradycardic with rates in the
50-70s, but had no pauses and was asymptomatic. He had three
sets of cardiac enzymes to rule out for MI that were negative.
He was seen by neurology and they noted that with carotid
massage he was bradycardic. They recommended further cardiology
workup.
3) CV
a) Coronaries - No known CAD, holding aspirin given bleed.
b) Rhythm - rate controlled Afib; continued digoxin, held
coumadin.
c) Pump - no history of CHF, remained euvolemic.
d) Hyperlipidemia - continued Tricor, Lipitor
3) Facial fractures: Plastic surgery consulted on the patient
and determined that his fractures did not require surgical
repair or antibiotics. They recommended conservative management
with possible cosmetic surgery in the future if desired. Patient
was also seen by ophthalmology due to orbital fractures and they
did not find any abnormalities
4) C-spine abnormality: C spine was obtained to rule out
fracture. There was no fracture present but note was made of a
prominent vertebral foramen at c4, likely secondary to a
tortuous vertebral artery, but also possibly secondary to
aneurysm. Patient requested neurology consult with Dr. [**Last Name (STitle) **]
which was obtained. Dr. [**Last Name (STitle) **] recommended MRA as an outpatient
with possible followup in neurology.
5) Code status was full code.
6) Disposition was to home with follow up appointment with Dr.
[**Last Name (STitle) 1728**], Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 30330**].
Medications on Admission:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO qd
().
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Coumadin 5 mg qhs 6d/wk and 2.5 mg 1 day/week
9. Aspirin
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO qd
().
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Proscar 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI Bleed
Syncope
Blood loss anemia
Atrial fibrillation
Diverticulosis
Internal hemorrhoids
Benign prostatic hypertrophy
Discharge Condition:
Stable blood pressure and hematocrit. Able to ambulate without
assistance and without syncope.
Discharge Instructions:
Call your primary care physician if you experience light
headedness, fainting, chest pain, shortness of breath, black or
bloody stools.
Continue all your prior medications except for the coumadin and
aspirin. Dr. [**Last Name (STitle) **] would like you to hold the coumadin and
aspirin until you have surgery with Dr. [**Last Name (STitle) **].
Followup Instructions:
Dr. [**Last Name (STitle) **] would like to see you next week. Please call [**Telephone/Fax (1) 15586**] to schedule an appointment.
[**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 9**] Call to schedule appointment
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**]. ([**Telephone/Fax (1) 96663**]. Call to schedule appointment
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"E888.0",
"272.4",
"802.6",
"801.01",
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"455.2",
"780.2",
"790.92",
"564.09",
"427.31",
"562.10",
"E920.9",
"285.1",
"600.00",
"427.89"
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icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10827, 10833
|
6965, 9688
|
240, 276
|
11003, 11100
|
4246, 4648
|
11496, 12003
|
3437, 3455
|
10271, 10804
|
10854, 10982
|
9714, 10248
|
11124, 11473
|
3470, 4227
|
184, 202
|
304, 2877
|
4657, 6942
|
2899, 3124
|
3140, 3421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,498
| 174,884
|
6945
|
Discharge summary
|
report
|
Admission Date: [**2188-8-19**] Discharge Date: [**2188-8-22**]
Date of Birth: [**2124-2-3**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT:
Increasing shortness of breath at rest and dyspnea on
exertion.
Chest pain and increasing fatigue.
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
gentleman with a questionable history of a myocardial
infarction in his 40s, which was medically managed. Over the
past three months, he has developed worsening shortness of
breath and anginal symptoms. In [**2188-6-11**], the patient
underwent an exercise tolerance thallium test which revealed
a left ventricular ejection fraction of 32%, down from a left
ventricular ejection fraction of 60% in [**2181**].
The patient was subsequently evaluated with a cardiac
catheterization on [**2188-7-23**], which revealed left main
20%, left anterior descending artery 50%, diagonal 50%,
diagonal two 80%, circumflex 100%, right coronary artery
100%, and left ventricular ejection fraction 41%. He was
subsequently evaluated for cardiac surgery.
PAST MEDICAL HISTORY: 1. Myocardial infarction. 2.
Insulin dependent diabetes mellitus. 3. Hypertension. 4.
Hyperlipidemia. 5. Chronic obstructive pulmonary disease.
6. Chronic right sided headache. 7. Gastroesophageal
reflux disease. 8. Peripheral vascular disease. 9.
Bilateral carotid endarterectomies. 10. Removal of penile
implant status post infection. 11. Left total knee
replacement. 12. Colonoscopy with polyp removal. 13.
Cataract, right eye.
SOCIAL HISTORY: The patient has a remote history of alcohol
abuse. He has an 80 pack year history of smoking.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o.q.d., Prevacid
30 mg p.o.b.i.d., Zocor 20 mg p.o.q.d., Zestril 10 mg
p.o.q.d., atenolol 50 mg p.o.q.d., Procardia 60 mg p.o.q.d.,
and insulin Novolin 70/30 15 units q.a.m. and 16 units q.p.m.
ALLERGIES: Naprosyn and Vioxx (gastrointestinal distress).
REVIEW OF SYSTEMS: The patient denies weight loss, rash,
sinusitis. He has chronic obstructive pulmonary disease,
palpitations, orthopnea and paroxysmal nocturnal dyspnea. He
has no gastrointestinal symptoms. He has chronic left knee
pain, status post total knee replacement. He has bilateral
claudication in his legs and a history of bilateral carotid
disease. He has no history of cerebrovascular accident. He
has insulin dependent diabetes mellitus, no thyroid or
psychiatric history.
PHYSICAL EXAMINATION: On physical examination, the patient
had a heart rate of 54, respiratory rate 10, blood pressure
148/82. General: Well nourished gentleman appearing his
stated age, in no acute distress. Head, eyes, ears, nose and
throat: Normocephalic, atraumatic, pupils equal, round, and
reactive to light and accommodation. Neck: Supple, no
jugular venous distention. Lungs: Clear to auscultation
bilaterally. Cardiovascular: Occasionally irregular without
murmur, rub or gallop. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Extremities: Well
perfused with no cyanosis, clubbing or edema.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2188-8-19**] for coronary artery bypass grafting times
four. Grafts included a left internal mammary artery to the
left anterior descending artery, saphenous vein graft to the
diagonal, saphenous vein graft to the ramus and saphenous
vein graft to the posterior descending coronary artery. The
operation was performed without complication and the patient
was subsequently transferred to the Cardiothoracic Intensive
Care Unit.
The patient was weaned off drips and extubated. He was
adequately fluid resuscitated. On postoperative day number
one, the patient was felt stable for transfer to the floor.
The patient recovered well and uneventfully on the floor.
His Foley catheter and chest tubes were discontinued on
postoperative day number two. He was tolerating an oral
diet. He was ambulating well and his pain was under good
control on oral medications. On [**2188-8-22**], the patient
was felt stable for discharge to home.
Physical examination on discharge: Vital signs: Temperature
99.3, pulse 80, blood pressure 139/66, respiratory rate 20
and oxygen saturation 93% on three liters. Cardiovascular:
Regular rate and rhythm. Lungs: Clear to auscultation
bilaterally. Incision: Clean, dry and intact. Abdomen:
Soft, nontender, nondistended, positive bowel sounds.
Extremities: Without cyanosis, clubbing or edema.
DISCHARGE MEDICATIONS:
Simvastatin 20 mg p.o.q.d.
Atenolol 50 mg p.o.q.d.
Aspirin 325 mg p.o.q.d.
Prevacid 30 mg p.o.b.i.d.
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Docusate 100 mg p.o.b.i.d.
Zestril 10 mg p.o.q.d.
Novolin insulin 70/30 15 units q.a.m. and 15 units q.p.m.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) **] in four weeks and with Dr. [**Last Name (STitle) **] in three to four
weeks.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass grafting times four.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2188-8-22**] 17:45
T: [**2188-8-22**] 18:59
JOB#: [**Job Number **]
|
[
"411.1",
"443.9",
"V15.82",
"272.0",
"412",
"414.01",
"401.9",
"250.01",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4518, 4774
|
5050, 5368
|
1689, 1961
|
3107, 4115
|
2480, 3089
|
4130, 4495
|
1981, 2457
|
171, 271
|
300, 1073
|
1096, 1548
|
1565, 1662
|
4799, 5029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,337
| 176,063
|
55176
|
Discharge summary
|
report
|
Admission Date: [**2163-10-13**] Discharge Date: [**2163-10-17**]
Date of Birth: [**2087-6-20**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Lipitor / Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76M with hx of CAD s/p CABG x 2 ([**2140**],[**2148**]), multiple NSTEMI,
and PTCA ([**2154**],[**2156**]), HTN, DM2, MM on dex/Revlimid/Velcade
presents with chest pain. It started at 5pm and went away with
SL nitro at home. Returned at 6pm, took another nitro which did
not help. Chest pain similar in quality to pain with prior MIs.
Called 911. EMS gave ASA 325mg, morphine 4mg, and another SL
nitro.
.
Of note, patient was recently d/c'ed from [**Hospital1 2025**] on [**9-30**] after
NSTEMI with trop to 0.25 complicated by cardiac catherization in
which rotoblade became lodged in the left circumflex. CT surgery
felt emergent bypass was not possible. ECG at this time showed
STDs in V1-V5, II, III, and aVF. He was admitted to the CCU,
started on nitro gtt and lasix. He was medically managed with
ASA, carvedilol, statin. Not anticoagulated given his
thrombocytopenia and hx of HIT. The blade was thought to be the
cause of a subsequent left lateral wall infarction, leading to
inferior wall hypokinesis, mod/severe MR due to papillary muscle
infarct, and a drop in EF from 60 to 40%. Patient was
subsequently re-admitted to [**Hospital1 2025**] from [**Date range (1) 112543**] for recurrent
chest pain and rising troponins (peaked at 2.27) thought to be
related to continuing infarction.
.
Currently on Revlimid/Velcade/dex for MM (cycle 2, day 1
[**2163-10-13**]). Episode of chest pain leading to first [**Hospital1 2025**] admission
was also preceded by chemotherapy that day.
.
In the ED, initial vitals were 7, 96.0, 74, 132/89, 18, 99% 4L.
ECG showed ST depressions in V3-V6. Labs and imaging significant
for lactate 4.1, trop 0.65, glu 381 with gap 13, UA with trace
ketones and large glucose, calcium 10.9, WBC 2.5, Hct 30.8, Plt
92, and INR 1.4. CXR showed small bilateral effusions and some
vascular fullness. In the ER, the patient still c/o of CP after
additional SL nitro. Chest pain improved with morphine, but did
not resolve. Chest pain finally resolved with nitro gtt.
.
On arrival to the [**Hospital1 18**] CCU, patient was free of chest pain.
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L.
Past Medical History:
- Diabetes
- Dyslipidemia
- Hypertension
- CABG: [**2140**] 3v with LIMA to LAD, double right sided SVG; [**2148**]
redo SVG to circumflex OM1, main right and posterior left
ventricular coronary arteries
- [**2144**] stent placement to vein in RCA; [**2156**] native distal LAD to
LIMA anastomosis
- T2 [**Doctor Last Name **] 8 prostate ca x/p XRT
- Multiple myeloma diagnosed in [**7-/2163**] on revlemid/velcade/dex
(cycle 2 day 1 [**2163-10-13**])
- Gout
- Type II HIT (PF4 Ab positive)
Social History:
-Tobacco history: 1ppd x 21 years, quit [**2126**]
-ETOH: negative
-Illicit drugs: negative
-Lives with his wife.
Family History:
No h/o heart disease. Father died of esophageal cancer.
Physical Exam:
ADMISSION:
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: 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. No wheezes or rhonchi.
Mild decrease in breath sounds bilaterally. Crackles at the L
base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT dopplerable
Left: DP 2+ PT 1+
.
DISCHARGE:
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: 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. No wheezes or rhonchi.
Mild decrease in breath sounds bilaterally. Crackles at the L
base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT dopplerable
Left: DP 2+ PT 1+
Pertinent Results:
ADMISSION:
[**2163-10-13**] 08:02PM BLOOD WBC-2.5* RBC-3.19* Hgb-10.8* Hct-30.8*
MCV-97 MCH-33.8* MCHC-34.9 RDW-17.1* Plt Ct-92*
[**2163-10-13**] 08:02PM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.4*
[**2163-10-13**] 08:02PM BLOOD Glucose-381* UreaN-22* Creat-0.8 Na-133
K-4.9 Cl-99 HCO3-21* AnGap-18
[**2163-10-13**] 08:02PM BLOOD ALT-31 AST-43* AlkPhos-118 TotBili-0.9
[**2163-10-14**] 01:43AM BLOOD CK-MB-4 cTropnT-0.54*
[**2163-10-13**] 08:02PM BLOOD Calcium-10.9* Phos-3.3 Mg-1.7
.
STUDIES:
([**10-13**]) CXR:IMPRESSION: Mild pulmonary edema with bilateral
small pleural effusions, left greater than right, and adjacent
atelectasis.
.
([**10-15**]) CXR: There is substantial interval improvement up to
almost complete resolution of pulmonary edema. Heart size and
mediastinum are unchanged in appearance including tortuous
aorta. Small amount of pleural effusion cannot be excluded.
There is no pneumothorax.
.
([**10-14**]) ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the basal half of the inferior
and inferolateral walls. The remaining segments contract
normally (LVEF = 40-45 %). 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 leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (PDA
distribution). Moderate mitral regurgitation most likely due to
papillary muscle dysfunction. Dilated ascending aorta. Pulmonary
artery hypertension.
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on [**2157**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 1 year. The patient has a mildly
dilated ascending aorta. Based on [**2161**] ACCF/AHA Thoracic Aortic
Guidelines, if not previously known or a change, a follow-up
echocardiogram is suggested in 1 year; if previously known and
stable, a follow-up echocardiogram is suggested in [**2-25**] years.
Based on [**2158**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
OTHER LAB RESULTS:
[**2163-10-17**] 06:03AM BLOOD WBC-1.8* RBC-3.12* Hgb-10.4* Hct-29.7*
MCV-95 MCH-33.3* MCHC-35.0 RDW-16.9* Plt Ct-59*
[**2163-10-16**] 03:05AM BLOOD PT-14.0* PTT-31.7 INR(PT)-1.3*
[**2163-10-17**] 06:03AM BLOOD Glucose-148* UreaN-14 Creat-0.4* Na-135
K-4.0 Cl-103 HCO3-27 AnGap-9
[**2163-10-14**] 03:10PM BLOOD CK(CPK)-43*
[**2163-10-14**] 03:10PM BLOOD CK-MB-4 cTropnT-0.71*
[**2163-10-14**] 08:40AM BLOOD CK-MB-5 cTropnT-0.69*
[**2163-10-14**] 01:43AM BLOOD CK-MB-4 cTropnT-0.54*
[**2163-10-17**] 06:03AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.9
[**2163-10-14**] 02:16AM BLOOD Lactate-3.8*
.
EKGs: 2-3mm ST depressions in V3-V6 on admission; these
decreased to ~1mm ST depressions on discharge when patient was
asymptomatic
Brief Hospital Course:
76M with extensive hx of CAD including multiple CABG with most
recent cath on [**9-23**] c/b rotorblade impaction in the LCx presents
to ED with chest pain, elevated troponin, and EKG changes. The
chest pain appears to be associated with the timing of his
chemotherapy for multiple myeloma.
.
# Chest Pain: Suspect demand ischemia secondary to chemotherapy
agents (direct effect or volume induced pulmonary edema). Based
on literature review, cardiac effects commonly seen with
Revlimid/Velcade, and given his EF 45%, some aspect of overload
could also contribute to this problem. In CCU, pt had an episode
of [**9-2**] chest pain accompanied by shortness of breath and
increased O2 requirement, which was likely ischemia with flash
pulmonary edema. This resolved with Lasix, nitro drip, beta
blocker, and morphine. Following this episode, he was without
pain, and enzymes show negative CKMB and mildly elevated trop,
indicating likely ischemia rather than new infarct. Nitro gtt
was weaned later the day of admission, and he was placed on
Imdur 30mg/day (in place of home isosorbide dinitrate). Pt was
continued on ASA 81, but Plavix was held given thrombocytopenia
(PLT in 50s). We continued his home BB (Metop tartrate 50 [**Hospital1 **],
which was eventually switched to metop succinate XL 100mg
daily), [**Last Name (un) **] (Valsartan 20 daily), and statin (pravastatin 80mg,
increased from home dose of 40mg daily). We spoke with oncology,
and they recommended holding chemotherapy in case it is
implicated in the patient's demand ischemia. We communicated
this to a covering colleague of the patient's outside
oncologist. The oncologist may need to adjust the chemotherapy
regimen to avoid further cardiac issues. On day of discharge, pt
was without CP or SOB; he was breathing room air, had flat neck
veins, trace ankle edema, and his lung sounds were clear.
.
# Acute on Chronic Systolic CHF: No change in LVEF on repeat
ECHO (40%). Pt was admitted with oxygen requirement to 4L NC. On
the first morning of his admission, he had what appeared to be
an episode of flash pulmonary edema, which resolved with
metoprolol, nitro drip, morphine, and Lasix. O2 was weaned over
2 days to room air on discharge (his baseline). CXR showed
significant acute pulmonary edema which resolved over the next
several days with diuresis. Electrolytes were stable and wnl
during the diuresis. Pt was started on PO Lasix 40/day prior to
discharge.
.
# Multiple Myeloma: Currently on chemo with pancytopenia without
evidence of bleeding. Patient is neutropenic and afebrile. Cr
WNL. Pt received Revlimid/Velcade/dex for MM (cycle 2, day 1
[**2163-10-13**]). The patient will meet with his oncologist on the day
following discharge to discuss the potential impact of his
chemotherapy on his cardiac disease and whether there are
alternative agents.
.
# DM2: Patient was on high doses of home insulin with blood
sugar in 300s and glucose in his urine. Pt was seen by [**Last Name (un) **]
(endocrinology consult) who recommended 70U Lantus qHS, then
standing 15U Humalog prior to each meal with ISS after. Will
need to monitor closely as outpatient. He has follow up with his
PCP the day after discharge.
.
# GOUT: Not active. We continued home allopurinol.
.
TRANSITIONAL
- Will need to avoid prior chemotherapy regimen (he has
appointment with Dr.[**Name (NI) 7517**] the day following discharge)
- Will need to follow his blood sugar control with outpatient
PCP and home [**Name9 (PRE) 269**]
- Will send d/c summary to cardiologist Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 79852**] at
[**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 20468**] (he has an appointment with him in early
[**Month (only) 359**])
- Patient is confirmed DNI/DNR
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from dc summary.
1. Valsartan 20 mg PO DAILY
2. Oxybutynin 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Pravastatin 40 mg PO HS
7. Allopurinol 300 mg PO DAILY
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D [**2151**] UNIT PO DAILY
10. Glargine 70 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Isosorbide Dinitrate 40 mg PO TID
12. Fish Oil (Omega 3) 600 mg PO DAILY
Discharge Medications:
1. Allopurinol 300 mg PO DAILY
RX *allopurinol 300 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
2. Aspirin 81 mg PO DAILY
3. Glargine 70 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Oxybutynin 10 mg PO DAILY
5. Pravastatin 80 mg PO HS
RX *pravastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
6. Prochlorperazine 10 mg PO Q8H:PRN nausea
7. Valsartan 20 mg PO DAILY
8. Vitamin D [**2151**] UNIT PO DAILY
9. Furosemide 40 mg PO DAILY
Hold for SBP<90
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<90
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
11. Metoprolol Succinate XL 100 mg PO DAILY
Hold for SBP<90, HR<60
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
12. Fish Oil (Omega 3) 600 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease
Acute coronary syndrome
Acute on chronic systolic heart failure
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 112544**],
Thank you for choosing [**Hospital1 18**]. You were admitted to the hospital
for chest pain. Your symptoms are related to your coronary
artery disease. Your acute increase in chest pain may have been
related to the chemotherapy that you received prior to
admission. Please talk to your oncologist at your appointment
tomorrow about alternative medications for your multiple
myeloma.
You were also found to have extra fluid around your lungs, which
we think was related to "heart failure," that is, decreased
ability of your heart to pump blood. This improved significantly
after you received water pills (Lasix, also known as
furosemide). Please follow up with your cardiologist on [**10-27**] about the ongoing treatment of your heart disease.
While you were in the hospital, you were seen by our diabetes
specialist who recommended some changes in your insulin doses to
better control your blood sugars. Attached you will find
specific information about how much insulin you should take and
when. Please follow up with your primary care doctor tomorrow
about ongoing treatment of your diabetes.
We made the following changes to your medications:
STOP
- isosorbide dinitrate
- metoprolol tartrate
START
- furosemide 40 mg daily
- isosorbide mononitrate extended release 30 mg daily
- metoprolol succinate XL 100mg daily
CHANGES IN DOSE
- pravastatin, now take 80 mg daily
- insulin (see attached for details)
Thank you for allowing us to take part in your care.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 112545**],MD
Specialty: Hematology/Oncology
When: Tuesday [**2163-10-18**] at 9am
Location: [**Hospital **] CANCER CENTER
Address: [**2163**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 83767**]
Please be sure to keep this appointment. You need to see Dr.
[**Last Name (STitle) **] before your next chemotherapy appointment.
Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Specialty: Primary Care and Endocrinology
When: Tuesday [**2163-10-18**] at 1:30pm
Address: [**State **], [**Apartment Address(1) 101800**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 98031**]
** It is VERY important that you keep this appointment. The
office is closed on Wednesday and you need to be seen soon after
discharge from the hospital.
Name: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 112546**], MD
Specialty: Cardiology
When: Thursday [**2163-10-27**] at 8:40am
Location: [**Hospital1 **] CARDIOLOGISTS
Address: [**2163**] STE. 562, [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 18278**]
|
[
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"203.00",
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"287.5",
"410.72",
"412",
"414.00",
"428.0",
"V45.81",
"V45.82",
"250.02",
"401.9",
"274.9",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13651, 13708
|
8156, 11920
|
337, 343
|
13849, 13849
|
4760, 6685
|
15533, 16758
|
3155, 3213
|
12577, 13628
|
13729, 13828
|
11946, 12554
|
14000, 15161
|
3228, 4741
|
6708, 8133
|
15191, 15510
|
287, 299
|
371, 2494
|
13864, 13976
|
2516, 3008
|
3024, 3139
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,857
| 180,261
|
49563
|
Discharge summary
|
report
|
Admission Date: [**2102-7-14**] Discharge Date: [**2102-8-29**]
Date of Birth: [**2018-9-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
s/p Open Gastrotomy
s/p Wound exploration, fascial closure for dehiscence
VAC placement
s/p bedside tracheostomy/PEG placement
s/p Chest tube placement
History of Present Illness:
83 y/o male w h/o CAD (90% stenosis of LAD with BMS deployed in
'[**87**]), HTN, & LE edema who presented with painless BRBPR starting
on the morning of admission. His BMs were initially streaked w/
blood which then became very loose and mostly bright red blood.
This happened multiple times throughout the day, and continued
at [**Hospital1 18**] ED totalling 5 bloody bowel movements in the ED, as
well as lot of blood in and around the toilet bowl. The pt
denied abdominal pain, N/V, rectal pain, pain w/ BM, CP/SOB,
lightheadedness/dizziness.
.
In the ED initial vital signs were 98.4, 88, 166/77, 20 @ 97% on
RA. H/H 12.5/34.6, BUN/Cr was 25/0.9; EKG: NSR, LAD, NI, NSST,
c/w previous. He got 1L NS, NO blood. Vital signs prior to
transfer: 96.5, HR 73, BP 147/61, RR 18, 100% on RA.
.
On the floor he was HD stable, and without complaints. At 745pm
patient walked to toilet had large bloody BM, he vagalled in the
setting of seeing the blood and lowered himself to the floor. He
was normotensive at the time, with transient hypotension to the
90s, which resolved. He has not been tachycardic. He continued
to have bloody bowel movements overnight, got 1unit of PRBCs,
getting another unit on transfer, and ordered for an additional
1 unit. Crossed for 4 more units. IR consulted and surgery to
eval. IR recommends CTA of abdomen. He has an 18 and 20gauge IV.
Past Medical History:
Basal cell carcinoma s/p mohs resection
Diverticulosis
CAD s/p PCI in [**2087**] with stent placement to the LAD
Social History:
Married, lives in a townhouse w his wife. Retired businessman
Family History:
Aunt w diverticulitis, but no other colorectal disease that he
knows of. Father died on an unknown cancer, mom lived to 85.
.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, Mildly dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Normal rate and regular rhythm, II/VI SEM no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact. No deficits. Old Cataract surgery.
Pertinent Results:
[**2102-8-29**] 02:41AM BLOOD WBC-13.0* RBC-2.36* Hgb-7.1* Hct-22.8*
MCV-96 MCH-30.2 MCHC-31.4 RDW-15.0 Plt Ct-372
[**2102-8-25**] 02:31AM BLOOD Neuts-85* Bands-0 Lymphs-7* Monos-6 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2102-8-29**] 04:05AM BLOOD PT-22.6* PTT-27.9 INR(PT)-2.1*
[**2102-8-29**] 02:41AM BLOOD Glucose-142* UreaN-59* Creat-1.0 Na-145
K-3.7 Cl-104 HCO3-27 AnGap-18
[**2102-8-29**] 02:41AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
[**2102-8-23**] 05:13AM BLOOD Type-ART Rates-/30 Tidal V-505 PEEP-5
FiO2-50 pO2-213* pCO2-44 pH-7.43 calTCO2-30 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
Brief Hospital Course:
In the MICU, the patient was thought to be having a lower GI
bleed from diverticulosis. He had 2 peripheral IVs (18s) and a
3rd (20g) was placed. He was given 4 more units of RBCs. IR,
surgery, and GI were all consulted, and the patient was sent for
a CTA abdomen, which did not show signs of extravasation. He
subsequently had a tagged RBC scan which showed bleeding at the
hepatic flexure. The patient was sent to the interventional
radiology suite for potential embolization of the bleeding
source; IR was unable to localize the source of bleeding.
Of note, prior to the Tagged RBC scan, Mr. [**Known lastname **] experienced
what appeared to be a vagal episode with a malfunction of the
EKG leads as he arose to use the bedpan -- it was treated at the
time as PEA arrest -- and the patient regained consciousness
spontaneously upon starting of chest compressions.
Stable after his trip to IR, he was taken back to the MICU but
experienced further episodes of BRBPR early into the morning.
He was becoming hypotensive and required further blood
transfusion.
In total, Mr. [**Known lastname **] required 7 units of blood in just over 24
hours and was continuing to bleed after unsuccessful attempt at
IR control. He was urgently taken to the OR at this point by
the general surgery team for a right hemicolectomy.
Please refer to Dr.[**Name (NI) 88810**] operative summary for more details.
In short, the right colon was removed and a primary anastomosis
was made. He was transferred to the Surgical ICU
post-operatively.
His post-operative course, by systems:
Neuro: Pt was started on a dilaudid PCA which he tolerated well.
During his SICU admission, there was concern for seizure
activity which was documented on subsequent EEG directed by
Neurology consultation. Anti-epileptics were initiated and
subsequently discontinued following multiple conversations with
the Neurology consultants and final determination that suspicion
for ongoing seizures was low. At the time of discharge, he was
receiving haldol for agitation and PO pain medications with good
results.
CV: Pt went into atrial fibrillation in the early post-operative
period. He was started on an amiodarone drip for rate control.
This was weaned to off on POD 1 and he was transitioned to his
home dose of PO diltiazem which he tolerated well. Pt was
transiently on single vasopressor during this admission during
concern for septic shock which was subsequently successfully
weaned off with broadening of antibiotic regimen. He remained in
rate controlled Afib until discharge without pressor requirement
or hemodynamic instability. The patient was also started on
lisinopril. A TTE was performed and showed an EF of 50-55% with
moderate-severe TR and severe PA systolic HTN. Coumadin was
started on HD32 and dosed according to the INR.
R: Pt underwent endotracheal intubation for the OR without
incident. Post-operatively, he had difficulty weaning from
mechanical ventilation and was noted to have a LLL PNA via
surveillance CT torso for which he was treated (please see ID
section). On POD 23, pt underwent successful bedside
percutaneous tracheostomy for prolonged intubation and
subsequently tolerated weaning ventilation to trach collar.
On HD 30 a R pigtail drain was placed for increasing pleural
effusion and discontinued on HD 44.
GI: GI bleed issues preop, as described above.
Post-operatively, he was kept NPO with an NGT until he had a
return of bowel function. Concern for a wound infection was
noted along his midline abdominal incision which was partially
opened and subsequently dressed with a VAC. Fascia was noted to
be intact during each VAC dressing change. Wound cultures
demonstrated Enterobacter and E.coli which was treated (please
see ID section). In addition, concern for a pelvic fluid
collection was pursued with IR drainage which ultimately was
culture and gram stain negative with drain subsequently removed.
Concern for CDiff colitis which was empirically treated with PO
and IV antibiotics given concordant leukocytosis and watery
stool with all toxin assays negative. On HD33 a PEG was placed
and TF were started the following day and well tolerated.
GU: Urine output was adequate but borderline low on POD 0 into
POD 1. He was additionally fluid resuscitated with crystalloid
and some albumin into POD 2 and subsequently had improved urine
output. During his SICU admission, concern for uremia was
raised and CVVH electively initiated in consultation with Renal
Consult Service with excellent results. Lasix drip and
subsequent CVVH were also utilized to titrate pt's fluid balance
and discontinued without complication. At no point was there a
significant concern for unrecoverable renal damage. The patient
was given intermittent lasix toward the end of his ICU stay to
decrease fluid overload. Renal function remained stable.
MSK/Skin: Rheumatology was consulted on HD26 for swollen and
warm R wrist. Joint aspiration was performed and fluid analysis
was negative for infection and gout or pseudogout.
Heme: He received 2 additional units of PRBCs in the OR and his
Hct responded appropriately from 24 to approximately 30. Post
operatively his Hct was 27 which was deemed appropriate for the
fluid resuscitation that he received intraoperatively. His Hct
was stable post operatively, initially checked q6 hours.
ID: Active ID issues by problem.
Leukocytosis - peak 27 [**7-22**] for which pt was subsequently
pancultured
Fever Curve - transient spikes >101.4
Bacteremia - Bacteroides x2 btl [**7-19**] which was successfully
cleared with IV antibiotics (see below)
Wound Infection - midline abdominal wound with purulent
drainage, subsequently opened with VAC dressing placed.
Pneumonia - Concern for HAP noted on CT torso and subsequent CXR
which was treated per hospital protocol.
C Diff - Toxin assay negative, empirically treated with PO and
IV antibiotics
At time of discharge, pt was afebrile with white count trending
down
Dispo: Family very involved during this admission and was
regularly updated.
Medications on Admission:
ASA 81', diltiazem SR 120', lasix 40', hydralazine 25",
lisinopril 40', amlodipine
Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation prn 4hrs () as needed for wheeze.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
5. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
11. warfarin 1 mg Tablet Sig: Three (3) mg PO Once Daily at 4
PM.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
13. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
16. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for PRN Pain.
17. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
18. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
19. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day).
20. lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed) as needed for urethral pain.
21. levothyroxine 25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Foreign Object Ingestion
Ventilator associated pneumonia
s/p Open Gastrotomy
s/p Wound exploration, fascial closure for dehiscence
s/p bedside tracheostomy/PEG placement
s/p Chest tube placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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 [**4-4**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow-up in Acute Care Surgery Clinic in 2 weeks when
Dr. [**Last Name (STitle) **] is the surgeon available. Please call ([**Telephone/Fax (1) 2537**] to
schedule an appointment or with any questions.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] (cell phone) - [**Telephone/Fax (1) 103668**], please call with
any questions.
Completed by:[**2102-8-29**]
|
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"263.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
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icd9pcs
|
[
[
[]
]
] |
11657, 11723
|
3421, 9460
|
330, 484
|
11962, 11962
|
2802, 3398
|
14257, 14651
|
2112, 2240
|
9593, 11634
|
11744, 11941
|
9486, 9570
|
12138, 13119
|
13744, 14234
|
2255, 2783
|
13151, 13729
|
263, 292
|
512, 1880
|
11977, 12114
|
1902, 2017
|
2033, 2096
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,577
| 172,023
|
49600
|
Discharge summary
|
report
|
Admission Date: [**2145-2-10**] Discharge Date: [**2145-2-19**]
Service: General Surgery
ADMISSION DIAGNOSIS: Partial small bowel obstruction.
DISCHARGE DIAGNOSIS: Partial small bowel obstruction.
PROCEDURES DURING ADMISSION: Exploratory laparotomy with
lysis of adhesions.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female who presents to the emergency room with 24 hours of
abdominal pain on the right side, no radiation, no nausea but
emesis x 7 with no flatus since [**65**] hours prior to admission.
PAST MEDICAL HISTORY: 1. Myocardial infarction in [**2136**]. 2.
History of small bowel obstruction status post lysis of
adhesions. 3. Multiple endocrine neoplasia type IIa status
post bilateral adrenalectomy for pheochromocytoma and
thyroidectomy with radiation therapy for thyroid cancer. 4.
Status post cholecystectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: 1. Florinef 100 mcg once a day.
2. Prednisone 7.5 mg in the morning, 5 in the evening. 3.
Levoxyl 0.15 mg once a day. 4. Lopressor 150 mg twice a day.
5. Aspirin 325 mg once a day. 6. Celexa 10 mg once a day.
7. Oxycodone 5 mg every 4-6 hours as needed. 8. Lorazepam 5
mg once a day as needed. 9. Lomotil 2 tablets four times a
day. 10. Opium 10 drops t.i.d. 11. Prilosec 20 mg two times
a day. 12. Morphine as needed. 13. Urimar 15 mg once a day.
PHYSICAL EXAMINATION: Temperature 97.1, heart rate 99, blood
pressure 150/44, respiratory rate 20, saturating 90% on room
air. She was alert, uncomfortable, heart was regular. Her
abdomen was soft, mildly distended with tenderness on the
right side and also in the left lower quadrant. Her rectal
examination was heme negative.
LABORATORY DATA: White count 13, hematocrit 36, bicarbonate
22, liver function tests normal. Abdominal ultrasound was
normal. Common bile duct was 8 mm. KUB had positive
air-fluid levels.
HOSPITAL COURSE: The patient was admitted on [**2145-2-10**]. CAT
scan was obtained which revealed a transition point. The
patient continued to have a large amount of pain and given
the fact that she was on steroids, she was taken to the
intensive care unit, hydrated and then taken emergently to
the operating room for an exploratory laparotomy. The
patient's operation went without complications. She
underwent an exploratory laparotomy with lysis of adhesions
on [**2145-2-10**]. Of note, postoperatively the patient went into
atrial fibrillation. A cardiology consultation was obtained.
She was started on beta blockade. Her heart rate was
controlled with diltiazem as well. She was given stress dose
steroids and started on a taper subsequently. She was also
given perioperative antibiotics. Her heart rate was
adequately controlled and the patient was transferred to the
floor. An endocrine consultation was obtained as well. She
was restarted on her Florinef. Given the fact that the
patient was in and out of atrial fibrillation it was decided
that she would be anticoagulated and that she would be placed
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor when she went home.
Her postoperative course was otherwise uneventful. Her bowel
function returned and she began to have diarrhea again which
is her baseline. She was started back on her Lomotil. She
was kept on 15 b.i.d. of prednisone given the stress of the
surgery and the fact that endocrine felt that this was an
appropriate dose. Of note, her INR did rise fast and was 4.8
on [**2145-2-18**]. Her Coumadin was held. On [**2145-2-19**] her INR was
3.3. The patient was doing well, tolerating a regular diet,
ambulating and it was decided that she would be discharged
home.
DISCHARGE MEDICATIONS:
1. Coumadin to be dosed daily with results called to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 250**].
2. Lopressor 50 mg p.o. b.i.d.
3. Amiodarone 400 mg p.o. b.i.d. until [**2145-2-20**] and then 400
mg p.o. q.d. until [**2145-2-25**] and then 200 mg p.o. q.d.
ongoing.
4. Florinef 100 mcg p.o. q.d.
5. Levoxyl 0.15 mg p.o. q.d.
6. Lorazepam 5 mg q.h.s. p.r.n.
7. Celexa 10 mg p.o. q.d.
8. Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n.
9. Lomotil 2 tablets p.o. q.i.d.
10. Prednisone 15 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS:
1. Daily INR checks with results called to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 250**] with a goal INR of [**1-11**].
2. [**Doctor Last Name **] of Hearts monitor.
3. Blood pressure checks.
4. Follow up with Dr. [**Last Name (STitle) **], call for an appointment.
5. Follow up with Dr. [**Last Name (STitle) 73**] regarding her atrial
fibrillation.
6. Follow up with Dr. [**Last Name (STitle) 13059**], her endocrine specialist,
regarding steroid taper.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2145-2-19**] 09:59
T: [**2145-2-19**] 10:29
JOB#: [**Job Number 103744**]
|
[
"427.31",
"199.1",
"427.32",
"E878.8",
"V10.87",
"112.0",
"997.1",
"560.81",
"252.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
3754, 4271
|
179, 292
|
948, 1406
|
1950, 3731
|
4295, 4767
|
1429, 1932
|
123, 157
|
321, 539
|
562, 921
|
4792, 5082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,932
| 132,297
|
43648
|
Discharge summary
|
report
|
Admission Date: [**2180-6-19**] Discharge Date: [**2180-6-25**]
Date of Birth: [**2114-10-11**] Sex: M
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: Prior to our consultation, the
patient was referred in for cardiac catheterization by Dr.
[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] to the Cardiology Service for outpatient
cardiac catheterization due to an abnormally stress test.
This 65-year-old male had known history of coronary artery
disease and had suffered an acute inferior myocardial
infarction in [**2164**], status post percutaneous transluminal
coronary angioplasty of his right coronary artery. He had a
repeat percutaneous transluminal coronary angioplasty of his
right coronary artery in [**2166**]. In [**2173**], he had a
percutaneous transluminal coronary angioplasty/stent to his
left anterior descending with two Bard stents.
On [**2180-6-8**] he had an exercise tolerance test Myoview
which showed ST depressions in leads I, II, III, aVF, and V2
through V6. His Myoview showed dilated left ventricle with
reversible inferior and apical defects with an ejection
fraction of 65 percent and no wall motion abnormalities. He
had noticed that recently his daily 2-mile walk had required
a little more effort than usual. He denied any shortness of
breath or chest pain.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Inferior myocardial infarction; status post percutaneous
transluminal coronary angioplasty in [**2164**], [**2166**], and stenting
in [**2173**].
Colon polyps.
Hypertension.
Hypercholesterolemia.
Left leg cellulitis.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: His is allergic to PENICILLIN.
MEDICATIONS ON ADMISSION: (Medications when he was seen by
Cardiothoracic Surgery were as follows)
1. Diltiazem 240 mg by mouth once per day.
2. Simvastatin 40 mg by mouth once per day.
3. Aspirin 325 mg by mouth once per day.
4. Isosorbide 30 mg by mouth once per day.
REVIEW OF SYSTEMS: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] was consulted, and the
patient was seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from Cardiac Surgery
who noted his prior coronary history with multiple stents and
percutaneous transluminal coronary angioplasty. Past medical
history as above. With the exception of the left leg
cellulitis is noted to be in [**Month (only) 359**] - approximately two and
a half years ago - but it recently recurred, but it was now
better. On review of systems, the only other remarkable
thing was his history of the cellulitis in his left leg.
SOCIAL HISTORY: The patient also stated that he had a
history of viral hepatitis in the [**2146**]. He is married with
two sons. [**Name (NI) **] is a construction worker. He lives with his
wife. [**Name (NI) **] denied any use of tobacco, or alcohol, or other
recreational drugs.
PREOPERATIVE LABORATORY DATA ON ADMISSION: White blood cell
count was 6.1, his hematocrit was 41.5, and his platelet
count was 197,000. Sodium was 141, potassium was 4.3,
chloride was 106, bicarbonate was 29, blood urea nitrogen was
14, creatinine was 1.3, with an INR of 1.
RADIOLOGY: The patient had his cardiac catheterization
performed on [**6-19**] prior to our consultation which revealed
a 60 percent mid left main lesion, a proximal aneurysm of the
left anterior descending, with a hazy lesion prior to the
stents, and an eccentric 50 percent restenosis in the
proximal stent. The circumflex was not obstructed, and the
right coronary artery was subtotally occluded with severe
disease.
PHYSICAL EXAMINATION ON PRESENTATION: His blood pressure was
142/78. He was 5 feet 9 inches with a weight of 215 pounds.
He was alert and well oriented. His skin and head, eyes,
ears, nose, and throat examination were benign. His neck had
no tenderness or masses. His chest was clear. His heart
revealed good first heart sounds and second heart sounds.
His abdomen was soft with no masses. His extremities were
unremarkable. His right lower leg was okay, but his left leg
had varicosities as well as the notation of recent
cellulitis. He had positive femoral pulses, dorsalis pedis,
posterior tibial pulses, and radial pulses bilaterally. He
had no audible bruits in the bilateral carotids.
SUMMARY OF HOSPITAL COURSE: The plan was that he would have
coronary artery bypass surgery the following day by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**]. On [**6-20**], the patient underwent coronary artery
bypass grafting times two by Dr. [**Last Name (STitle) 70**] with a left
internal mammary artery to the left anterior descending and a
vein graft to the obtuse marginal. He was transferred to the
Cardiothoracic Intensive Care Unit in stable condition on a
phenylephrine drip at 0.5 mcg/kilogram per minute and a
propofol drip at 10 mcg/kilogram per minute. He was
extubated at 6:00 p.m. on the day of his operation. He was
alert and oriented. He was on an insulin drip.
On postoperative day one, he remained on a Neo-Synephrine
drip at 0.1 mcg/kilogram per minute. He started his Plavix
and aspirin. His temperature maximum was 99. He was A-paced
at 80. His blood pressure was 103/55. His central venous
pressure was 3. He was saturating 98 percent on 4 liters
nasal cannula.
His postoperative laboratories were as follows. White blood
cell count was 18.1, his hematocrit was 32.1, and his
platelet count 197,000. Sodium was 140, potassium was 4.7,
chloride was 106, bicarbonate was 25, blood urea nitrogen was
16, creatinine was 1.1, and his blood glucose was 107. He
was awake, alert, and oriented. His heart was regular in
rate and rhythm. No murmurs or rubs. His breath sounds were
coarse at the bilateral bases. He had positive bowel sounds.
The abdomen was soft, nontender, and nondistended. His
extremities had 1 plus edema. His incisions were clean, dry,
and intact. The plan was keep his chest tubes in and wean
him off the Neo-Synephrine. He was transferred out to the
floor on [**6-21**] (on postoperative day one) later in the day
as planned. He was seen by Case Management.
On postoperative day two, he did have some premature
ventricular contractions and premature atrial contractions on
telemetry. His Lasix and potassium were held for a low blood
pressure. He complained of some mild back pain. He had a
temperature maximum of 101.4. His heart rate was 75 with
some premature atrial contractions. His blood pressure was
100/90. He was saturating 98 percent on 2 liters. He was
not in any distress. His heart rate was irregularly
irregular. He had some mild crackles bilaterally at the
posterior part of his lungs. His dressings were clean, dry,
and intact. His chest was stable. His Foley catheter was
removed. He was switched over to Percocet for pain. Follow-
up laboratory work was done. The chest tubes were pulled on
postoperative day three, and the pacing wires were also
pulled. He was also seen and evaluated by Physical Therapy
and continued with telemetry for monitoring of his premature
atrial contractions. He also had some asymptomatic
ventricular bigeminy which was captured on [**6-23**] in the
afternoon on telemetry. However, the patient continued to do
well and was ambulating well and tolerating this with good
improvement.
On postoperative day three, he continued with some premature
atrial contractions, narrow complex. His vital signs were
unremarkable. He was stable and saturating 95 percent on 2
liters. He was back in a sinus rhythm with the premature
atrial contractions that were noted. The chest tubes were
pulled on postoperative day three in the morning. His
examination was unremarkable other than the slight crackles;
again posteriorly bilaterally in his lungs. He was doing a
level IV with Physical Therapy. His chest x-ray showed no
pneumothorax after chest tubes. He was continued on strict
ins and outs. He was doing very well with a plan to
discharge him home soon. However, he continued to be
monitored for his premature ventricular contractions that
occurred on telemetry over the next couple of days. He was
independently ambulating frequently, on telemetry, and using
his incentive spirometer. He continued to work with Physical
Therapy.
On postoperative day four, the patient did have some
premature ventricular contractions on telemetry. He had a
run of 12 premature atrial contractions that were narrow
complex with some question of atrial fibrillation. On
examination later, he was in a sinus rhythm at 72 with a
blood pressure of 134/67. His respiratory rate was 20, and
he was saturating 94 percent on room air. Again, his
examination was unremarkable. His incisions were clean, dry,
and intact. His chest was stable. He had some crackles
posteriorly bilaterally. He did have that short run of
atrial fibrillation, but was otherwise doing very well.
Laboratory work was repeated. His metoprolol was increased
to 37.5 mg by mouth twice per day.
On postoperative day five, the date of discharge, the patient
did have a couple of very short runs of atrial fibrillation;
on a couple of beats. He was in a sinus rhythm at 83. His
blood pressure was 110/62. His temperature maximum was 99.8.
He was saturating 96 percent on room air. His examination
was completely unremarkable. He was doing very well and was
discharged on [**6-25**].
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times two.
Status post coronary artery disease with an inferior
myocardial infarction with multiple stents and percutaneous
transluminal coronary angioplasties.
Hypertension.
Hypercholesterolemia.
Colon polyps.
Left leg cellulitis.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 37.5 mg by mouth twice per day.
2. Colace 100 mg by mouth twice per day
3. Ranitidine 150 mg by mouth twice per day.
4. Enteric coated aspirin 325 mg by mouth once per day.
5. Percocet 5/325-mg tablets one to two tablets by mouth
q.4h. as needed (for pain).
6. Simvastatin 40 mg by mouth once per day.
7. Plavix 75 mg by mouth once per day.
8. Lasix 20 mg by mouth twice per day.
9. Potassium chloride 10 mEq by mouth twice per day.
DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed
to follow up with his cardiologist in two to three weeks as
well as with his primary care physician in two to three weeks
and to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in the office in approximately
six weeks for his postoperative surgical visit.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE STATUS: To home on [**2180-6-25**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2180-7-25**] 09:45:16
T: [**2180-7-25**] 11:23:10
Job#: [**Job Number 93845**]
|
[
"414.01",
"412",
"272.0",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"88.53",
"36.15",
"89.62",
"38.93",
"89.61",
"88.56",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
9461, 9743
|
9769, 10568
|
1753, 1999
|
1666, 1726
|
4361, 9439
|
2019, 2643
|
188, 1359
|
2974, 4332
|
1382, 1642
|
2660, 2959
|
10593, 10957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,603
| 179,237
|
34395+57923
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-8-23**] Discharge Date: [**2181-8-30**]
Date of Birth: [**2102-3-8**] Sex: M
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 79yo M with PMH of PE on coumadin, sytolic HF
(EF 35%), AS, Prostate CA, ETOH use who presented to OSH with
SOB and increased swelling of right leg with known DVT. + Cough
and ? low grade temps. AT [**Location (un) 620**], VS: T99.6, 107, [**11/2156**], 20,
93% 4L. LENI noted extension of DVT and patient was given
lovenox 100mg x 1. Also noted to have elevated troponin 0.33 and
BNP 10,190. Given lasix 10mg IV x 1. Also 1" nitropaste. Patient
then transfered to [**Hospital1 18**] for further management.
.
In the ED, VS: T 99.6 HR 107 BP 111/87 RR 20 93% on 4L. Patient
underwent CTA that showed interval improvement in previously
noted PEs with no new thrombi. Patient was given dose of
ceftriaxone, azithro for concern of pneumonia.
.
On review of systems, he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. 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,
paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope.
.
Of note, patient triggered on the floor at time of evaluation.
He developed acute shortness of breath, tachycardia with sats of
85% on 5L (though patient was mouthbreathing). Lung exam was
notable for poor air movement and diffuse wheezes. He improved
with ipratropium, levalbuterol, 10 IV lasix.
Past Medical History:
# Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE
of RML, RLL, LLL distal vessels
# Extensive mural thrombus of aortic arch and descending
abdominal aorta
# RLE DVT
# Prostate CA s/p radiation
# Hypercholesterolemia
# COPD
# Hx of ETOH abuse
Social History:
Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son.
Family History:
FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: T 98.2 BP 115/48 HR 65 RR 24 97%5L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm at 60 degrees
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 labored with poor air movement, diffuse wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: R leg 3+ pitting edema to knee;
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:
[**2181-8-23**] 07:05PM cTropnT-0.55*
[**2181-8-23**] 07:05PM CK(CPK)-224*
[**2181-8-23**] 07:05PM
WBC-8.7 RBC-3.75* HGB-11.5* HCT-35.1* MCV-94 MCH-30.7 MCHC-32.8
RDW-13.7
NEUTS-70.9* LYMPHS-17.1* MONOS-5.8 EOS-5.9* BASOS-0.3
PLT COUNT-272
PT-19.3* PTT-39.2* INR(PT)-1.8*
GLUCOSE-113* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-4.6
CHLORIDE-95* TOTAL CO2-30 ANION GAP-15
[**2181-8-23**] 07:15PM URINE
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0-2
URINE HYALINE-0-2
CTA [**2181-8-23**]:
1. No new pulmonary emboli. Small resolving pulmonary emboli in
the lower lobes bilaterally, right middle lobe, and left upper
lobe, smaller than the prior CTA of the chest [**2181-7-12**].
2. Increasing mediastinal and hilar lymphadenopathy of unclear
etiology. Attention should be paid on followup exams to ensure
resolution.
3. Two small pulmonary nodules measuring 3 and 6 mm in the right
lung, the larger of which is likely related to atelectasis and
unchanged from recent prior exam. Followup CT in six months is
recommended to ensure stability.
[**2181-8-24**] 03:30AM BLOOD CK-MB-12* MB Indx-7.0* cTropnT-0.66*
[**2181-8-25**] 05:41AM BLOOD CK-MB-NotDone cTropnT-0.26*
[**8-26**] LENI:
1. Right lower extremity nonocclusive DVT involving the right
external iliac,
common femoral, superficial femoral, and popliteal veins.
Questionable
extension into the IVC. This can be better evaluated at time of
dedicated
venogram during IVC filter placement.
2. No left-sided deep venous thrombosis.
Brief Hospital Course:
A+P [**8-29**]: 79y/o with PE, [**Month/Year (2) 7792**], COPD exacerbation, transfered
back to floor from CCU after breathing improved with diuresis,
steroid, and NIPPV.
.
#. [**Month/Year (2) 7792**]: Pt ruled in with [**Month/Year (2) 7792**] with troponin peak of 0.66.
Pt denies having Chest pain at all, however he is not a could
historian and is unclear of his presenting symptoms. Talked with
family, was SOB, and consfused upon admission. There are no EKG
changes, although it is hard to evaluate it in setting of LBBB.
Medically manage [**Name (NI) 7792**], pt did not get cath on admission
because to unstable on presentation. No cath at this time since
the ischemic event is complete. Unable to do stress test at
this time, can not exercise (fall risk), reluctant to do
dobutamine in setting of ACS, Persantine contraindicated in COPD
exacerbation. Will need chemical stress when COPD treatment
complete likely after pt d/c to rehab.
Was on heparin gtt, stoped [**8-29**] after INR was 2.0 x 3. Also on
ASA 81mg daily, simvastatin 80mg, Metoprolol 12.5mg [**Hospital1 **],
lisinopril 5mg, Plavix 75 daily, will continue for 9 months in
setting of [**Hospital1 7792**]
.
#. Resp failure: Patient triggered for desaturation which caused
transer to CCU. Multifactorial, including systolic CHF (EF
30-35%), PE, COPD exacerbation. Pt significantly improved with
nebs, steroids, levofloxacin, and diuresis. Pt denies any meds
as outpt, however family confirms on ipatropium. CHF management,
as below.
For COPD exacerbation, finished steroid taper 8/21(2nd day
20mg), nebs, levofloxacin [**6-16**] day course. Pt aslso has PE,
improving as per CTA this admission, s/p IVC filter this
admission. Pt responding inappropriately on questioning [**8-29**].
ABG 7.48/48/62/37, lactate 2.4. Metabolic alk with compensatory
resp acidosis. Bordreline O2 on RA. F/u with VBG 7.39/56/41/35,
lactate 2.1. Lactate improving with hydration. Started on Oxygen
to improve PO2. Pt clinically improved since out of CCU,
breathing unlabored, lungs with decreased crackles
.
# PUMP/ acute on chronic systolic CHF: [**7-16**] echo moderate
regional left ventricular systolic dysfunction with sveere
hypokinesis of the basal to mid septum and anterior wall, EF
30-35%. severe aortic valve stenosis (area 0.8-1.0cm2). Mild to
moderate ([**1-10**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. BNP over 10,000 at admission. Depressed
EF likely [**2-10**] CAD given focal abnormailites. Hessitant to
aggressively overdiurese given severe AS. Records state on 20mg
PO lasix at home. Had incrased lasix to 60 PO daily with one
additional 10IV lasix dose in setting of increased crackles.
This caused a Cr increase to 1.7 and pt was orthostatic with PT
on [**8-28**]. Lasix stoped for 2 days now, had bolus IVF, with
improved BP and Cr and crackles on lung exam has also
diminished. [**Month (only) 116**] need to restart maintance dose of 20 PO lasix in
future. Continue lisinopril 5mg, BB.
.
#HTN - On BB, ACE, prn lasix. Pt was orthostatic [**8-28**] with SBP
to 80, improved BP with boluses
.
#PE: PE discovered on previous admission in [**Month (only) 205**]. Resolving
according to CTA on this admission. Recent for DVT and PE
unclear. Distant h/o Prostate CA. The pt will need
hypercoagulable / CA workup as outpt. There was concern that the
PE lead to the [**Month (only) 7792**] and SOB/COPD flare. Repeat LENIs showed
extension of R DVT, possibly to IVC. Therefore pt had IVC filter
placed [**8-27**]. Pt was on heparin gtt until [**8-29**], as Warfarin
became theraputic. INR now 2.0 on 4 straight measurements. On
Warfarin 5mg daily plus 2.5mg [**8-29**]. Continue to monitor INR
.
# Metabolic alkalosis: ABG gotten [**8-29**] because of high HCO3 and
inapropriate question answering [**8-29**]. ABG 7.48/48/62, lactate
2.4. Met alk with compensatory resp acidosis, likely contraction
alk [**2-10**] diuresis. No GI losses noted. Repeated VBG after small
bolus, was 7.39/56/41/35, lactate 2.1, improving with hydration.
Continue to hold lasix and hydration if needs. KCL as needed.
HCO3 downtrending from 37 to 32 with this regimen. Etiology of
lactate elevation unclear, likely [**2-10**] recent MI or DVT/PE. No
evidence of infection.
.
#Eosinophilia - present for 2 months, now downtrending since
starting steroids. Dx includes Neoplasm (as above, needs
screening), undiagnosed asthma?, adrenal insufficiency (no e/o
hypotension or hypoglycemia, but has evidence of adrenal disease
on ct scan with normocytic anemia), connective tissue disease,
sacrdoidosis, parasites (do not know travel history). CTA did
show Increasing mediastinal and hilar lymphadenopathy of unclear
etiology which needs 6 month f/u. [**Month (only) 116**] work up for connective
tissue disorders as an outpt.
#Etoh abuse: Pt states drinkes 5-6 beers and 2 shots of vodka a
day, however family states has not had etoh since [**Month (only) 205**]
admission. Was on CIWA with valium, but not requiring doses.
Continue folic acid, thiamine. LFTs normal except elevated LDH
.
#change in MS: Pt is poor historian, unclear of what events
occured prior to or while in hospital, although he is oriented
x3. Family claims is at baseline. Ddx includes steroid or unit
induceed delirium, or Wernickes considering significant Etoh
history. Pt has waxing and [**Doctor Last Name 688**] orientation. Pt angry [**8-29**]
about not going home. family is concern he will try to leave
hospital. Told them we would get psych to determine decision
making capacity if necessary
.
# ARF: Cr trending down from 1.7 to 1.4 (.9 to 1.0 baseline).
Felt to be prerenal since downtrending with decreased diuresis
and hydration.
.
# GERD - PPI
.
#FEN: cardiac diet, repleat lytes prn
.
#Prophylaxis: Theraputic on coumadin, PPI, ISS while on steroids
(now may stop since done steroids)
.
#Code: DNR/DNI, confirmed with pt and family
.
#Dispo: plan for Rehab. PT wants agreeable with rehab on [**8-30**],
.
# Comm: Health care proxy #1 [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], #[**6-11**] [**Last Name (NamePattern1) 79102**].
They are also co-durable power of attorny. Will bring it
paperwork to have on chart.
Medications on Admission:
ASA 325mg daily
Coumadin
Lasix 20 daily
Lisinopril 2.5 daily
Simvastatin 10mg daily
Pantoprazole 40 PO daily
Ipatropium
Albuterol
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Continue through [**8-31**].
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Non ST elevation MI ([**Location (un) 7792**])
systolic congestive heart failure
acute renal failure
aortic stenosis - moderate to severe
mulitiple Pulmonary Embolism - R-upper/R-middle lobe artery, ext
mural thrombus aortic arch and descending abdominal aorta
RLE Deep Vein Thrombosis
Prostate CA s/p radiation
Hypercholesterolemia
COPD - unknown pfts, on albuterol med list at-home
Hx ETOH abuse
GERD
Discharge Condition:
stable: [**Location (un) 7792**] medically managed, needs stress test once COPD
exacerbation controled. PE resolving, s/p IVC filter. CHF
controled but needs further management of lasix dose. Waxing and
[**Doctor Last Name 688**] MS.
Discharge Instructions:
You were admitted to the hospital because you were short of
breath and were confused at home. You were found to have a
heart attack ([**Doctor Last Name 7792**]) and be in heart failure (CHF) which
contributed to your shortness of breath. We are treating your
heart attack and heart failure with medicines. However your
fluid level continues to need adjustment and your lasix dose
with continue to be changed at the rehab facility. You will
need further testing (a stress test) of your heart after you are
finished being treated for your COPD exacerbation. You should
discuss this when you go for your cardiology appointment.
You also had an exacerbation of your COPD (breathing problem)
and are being treated with steroids, an antibiotic
(Levofloxacin), and breathing treatments.
You were found to have a blood clot in your right leg (DVT) as
well as your lungs (pulmonary embolus) on your previous
admission to the hospital. The imaging of your lungs during this
admission (CTA) showed that the clot in your lung is resolving.
However imaging of your leg showed that the clot is getting
bigger. Therefore you got a IVC filter placed in your vein to
prevent future clots in your lungs. You are also on blood
thinners to treat the clot
The CTA (chest imaging) also showed enlarged lymph nodes
"increasing mediastinal and hilar lymphadenopathy" of unclear
etiology which needs follow up imaging in 6 months. You should
discuss this with your doctor.
In is important that you continue your efforts to stop drinking
when you return home. You are at increased risk for seriously
bleeding becuase of blood thinner if you fall.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3
lbs.
Adhere to 2 gm sodium diet
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
If you became acutely short of breath or develop chest pain you
should return to the Emergency room.
Followup Instructions:
PCP: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Location (un) **], MA ([**Telephone/Fax (1) 79103**]). You need to
call for a appointment within the next two weeks. You should
discuss the need for further imaging of your chest in six months
to follow up 'increasing mediastinal and hilar lymphadenopathy'
of unclear etiology. Also showed discuss your eosinophia.
Cardiology: You have an appoint with [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-9-18**] 2:20. The clinic is
located at [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 23**]
CLinical Center [**Location (un) 436**]. You should discuss the need for a
stress test to evaluate your heart disease at that time.
Completed by:[**2181-8-30**] Name: [**Known lastname 12733**],[**Known firstname 1340**] Unit No: [**Numeric Identifier 12734**]
Admission Date: [**2181-8-23**] Discharge Date: [**2181-8-30**]
Date of Birth: [**2102-3-8**] Sex: M
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**Last Name (NamePattern1) 2539**]
Addendum:
Spoke with daughter of Mr [**Known lastname **], [**First Name5 (NamePattern1) 302**] [**Name (NI) 12735**] [**Telephone/Fax (1) 12736**]
who is the health care proxy and power of attorny about the
transfer to [**First Name9 (NamePattern2) 12737**] [**Location (un) 407**] today. She informed me that Mr
[**Known lastname 12738**] PCP is no longer Dr [**Last Name (STitle) 12739**] who was documented in the
chart. He is now seeing Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 12740**]. They
perfered to arrange an apointment with Dr. [**Last Name (STitle) **] on there own
schedule rather than myself arranging one for her. She also
imformed me that Mr. [**Known lastname **] had seen a cardiologist in [**Location (un) 407**]
prior to admission. She will discuss with the family whether
they will f/u in [**Location (un) 407**] or attend the standing apt I arranged
with Dr [**Last Name (STitle) 12741**].
Unfortunately Mr [**Known lastname **] had already left for [**Known lastname 12737**] with d/c
paperwork prior to this update. The family was glad to update
[**Known lastname 12737**] of the change of PCP.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 176**] Of [**Location (un) 407**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(1) 2541**]
Completed by:[**2181-8-30**]
|
[
"V10.46",
"305.1",
"428.0",
"276.4",
"518.0",
"444.0",
"584.9",
"401.9",
"458.0",
"410.71",
"518.81",
"453.41",
"415.19",
"303.91",
"396.2",
"491.21",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
17901, 18147
|
4961, 11224
|
298, 304
|
13206, 13442
|
3285, 4938
|
15425, 17878
|
2355, 2416
|
11405, 12659
|
12780, 13185
|
11250, 11382
|
13466, 15402
|
2431, 3266
|
239, 260
|
332, 1822
|
1844, 2207
|
2223, 2323
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,447
| 135,968
|
6627
|
Discharge summary
|
report
|
Admission Date: [**2170-4-12**] Discharge Date: [**2170-5-29**]
Date of Birth: [**2095-7-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine / Salicylates
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea, chest pressure
Major Surgical or Invasive Procedure:
[**2170-4-13**] - Cardiac Catheterization
[**2170-4-13**] - Emergency salvage coronary artery bypass graft x4:
Saphenous vein grafts to left anterior descending artery,
diagonal I, diagonal II and obtuse marginal arteries. Mitral
valve repair with a size 26 CG Future Ring
[**2170-4-17**] - chest closure
History of Present Illness:
This is a 74-year-old female retired psychologist with a history
of presumed coronary artery disease (no history of cardiac
catheterization, but hypokinetic mid-to-basal inferior and
inferolateral walls and distal septal wall on echocardiogram on
[**2169-12-4**]), subdural hematoma s/p left craniotomy and
evacuation on [**2169-11-24**], known infrarenal AAA, and moderate
mitral regurgitation who presents with left arm and shoulder
heaviness, shortness of breath, and headache over the last 2
weeks, worsening today. The patient initially presented to [**Hospital1 **]
[**Location (un) 620**], where she was borderline tachycardic to the 90s and
hypotensive to the 90s sBP. It is unclear whether she was
hypoxic prior to administration of a few liters oxygen. EKG
showed sinus rhythm with STD in V4-V6 and TWF inferiorly and
laterally; there was also submillimter STE
in aVR. These changes were similar but more severe than the
STTW changes noted on EKG dated [**2169-11-25**]. TnT 0.657 and
BNP>[**Numeric Identifier **]. After discussion with the patient's neurosurgeon and
initiation of heparin, she was transferred to [**Hospital1 18**] for further
management.
Upon evaluation at the [**Hospital1 18**] ED, she remained hypotensive and
borderline tachycardic. Physical exam notable for poor breath
sounds but R>L basilar crackles. JVP elevated to 12cmH20.
Regular rhythm with II/VI holosystolic murmur at left sternal
border and apex. Repeat EKG revealed improving STD in V4-V6.
CTA was performed and was negative for aortic dissection or PE,
but did show moderate-sized pleural effusions larger than prior
with the suggestion of right-heart strain. Na 140, K 4.4,
BUN/pCr 20/1.1. TnT here 0.68. CT showed small left SDH and
right frontal subdural hypodense collection, slightly smaller
than prior, with no new hemorrhage. Bedside echocardiogram
showed large pleural effusions with slightly worsening left
ventricular systolic function compared with 11/[**2169**]. She
transferred to [**Hospital1 18**] and was cath today which showed significant
CAD RCA, LAD and wide open ischemic MR. She was very hypotensive
and IABP was attempted but was unable to be placed. She was on
max dopa and levo added for support. She was seen by Dr [**First Name (STitle) **]
and the plan was made for her to go to the OR for emergent
CABG/MVR.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Systolic CHF with EF 40% [**11/2169**]
-Peptic ulcer disease
-Pernicious anemia, peripheral neuropathy
-Hyperlipidemia
-Macular degeneration
-Hypothyroidism
-Chronic Migraines
-Anxiety
-Infrarenal AAA
-S/p Partial gastrectomy with Bilroth 1 for PUD in [**2146**]
-S/p "Gastric aneurysm" repair in [**2157**]
-S/p appendectomy
-S/p total hysterectomy
-S/p cesarean section x2
-S/p ventral hernia repair with mesh in [**2158**].
-S/p C5-C6 fusion
Social History:
-Tobacco history: denies
-ETOH: 4-5 drinks/week
-Illicit drugs: denies
Divorced, Retired psychologist. Lives by herself.
Family History:
Father with lung ca at 79. Mother with leukemia at 84. No
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 97.9 BP 89/62 HR 15 RR 15 O2 sat 99% on 4L
GENERAL: Thin elderly woman in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm while sitting up.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. +systolic murmur, best heard in mitral
region with radiation to the axilla. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. +Scattered crackles
throughout both lung fields, bibasilar decreased breath sounds
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+
NEURO: AAOx3, pt is legally blind, EOMI, no sensation abn
appreciated, strength 5/5 throughout, reflexes 2+ and equal b/l.
Pertinent Results:
TTE [**2170-4-28**]
There is mild to moderate regional left ventricular systolic
dysfunction with mid to distal anterior and apical akinesis.
Basal inferior wall is hypokinetic. Right ventricular chamber
size is normal. with borderline normal free wall function. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. A mitral valve annuloplasty ring is present.
There is moderate thickening of the mitral valve chordae.
Moderate to severe (3+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2170-4-21**], a
wire is no longer seen in RA/RV. The wall motion abnormalities,
LV function, Mitral regurgitation are all similar. The pulmonary
artery systolic pressures can be estimated and are moderately
elevated.
[**2170-4-24**] CT Scan
1. Post median sternotomy, MVR, and CABG. There has been
decreased size of
the bilateral pleural effusions with basal atelectasis noted.
2. Stable left-sided pneumobilia and minimally enlarged
infrarenal abdominal aortic aneurysm as described.No intra
abdominal fluid collections.
3. New thrombus in the left internal jugular vein
[**2170-4-27**] Video Swallow
No gross aspiration or penetration seen.
[**2170-4-21**] Upper extremity ultrasound
1. Limited examination however no evidence of deep venous
thrombosis in the left upper extremity.
2. Ovoid hypoechoic area posterior to the left brachial artery
and veins
measuring 1.3 x 1.0 cm is incompletely evaluated. Evaluation of
this area
with dedicated ultrasound, when feasible, is recommended
[**2170-5-28**] 05:36AM BLOOD WBC-5.8 RBC-2.70* Hgb-8.0* Hct-26.5*
MCV-98 MCH-29.7 MCHC-30.2* RDW-17.3* Plt Ct-253
[**2170-5-15**] 03:55AM BLOOD PT-11.8 PTT-42.8* INR(PT)-1.1
[**2170-5-28**] 05:36AM BLOOD Glucose-77 UreaN-22* Creat-0.7 Na-137
K-4.1 Cl-97 HCO3-30 AnGap-14
[**Known lastname **] [**Known lastname 1843**],[**Known firstname **] [**Medical Record Number 25335**] F 74 [**2095-7-11**]
Radiology Report CHEST (PA & LAT) Study Date of [**2170-5-24**] 9:27 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2170-5-24**] 9:27 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 25336**]
Reason: eval for effusion/ infiltrate
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman s/p mv repair, decannulated this am
Final Report
INDICATION: 74-year-old woman status post mitral valve repair.
Evaluate for effusion and/or infiltrate.
COMPARISONS: [**4-30**] to [**2170-5-15**].
FINDINGS: Small-to-moderate bilateral pleural effusions are
most apparent on the lateral projections. Heart size is normal.
A right-sided PICC line tip terminates in the mid SVC.
Nasogastric tube extends below the field of view and mitral
valve ring is in unchanged position. Mediastinal clips and
sternal wires are intact. Bibasilar atelectasis has improved
since [**2170-5-15**].
IMPRESSION: Bilateral small to moderate pleural effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: [**Doctor First Name **] [**2170-5-24**] 2:27 PM
Brief Hospital Course:
Ms. [**Known lastname 9464**] [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2170-4-12**] for further
management of her chest pain and myocardial infarction. As she
was having ongoing chest pain, she was taken to the cardiac
catheterization lab. This revealed severe three vessel disease
and significant mitral regurgitation. Persistent hypotension was
noted however an intra-aortic balloon pump was considered
however deferred as the iliac angiography showed severe
occlusive disease. Cardiac surgery was consulted and she was
taken emergently to the operating room. She had a cardiac arrest
when she entered the operating room and was promptly placed on
cardiopulmonary bypass. She then underwent coronary artery
bypass grafting to four vessels and a mitral valve repair.
Please see operative note for details. Postoperatively she was
taken to the intensive care unit on high doses of inotropic
support with an open chest. Of note,Intra-aortic
balloon pump insertion was not attempted because bilateral area
of disease as seen in the cath lab where multiple attempts had
already failed. Over the next 3 days she made grade progress
with weaning of several of the inotropes and maintaining good
hemodynamics. Aggressive diuresis was intiated to optimize
closure. Repeat echocardiogram showed improved ejection fraction
from 5% to 10% to 25%, on [**4-17**] she was taken back to the
operating room for chest closure. The following day she was
found to be neurologically intact, continued to diurese and on
POD#12 she weaned to extubation. Postoperative rapid atrial
fibrillation with associated hypotension was treated with
Amiodarone. This was stopped on [**5-12**] for a prolonged Qtc.
Inotropic and vasopressor support were weaned. Bedside swallow
evaluations were done and nutrition advanced per
recommendations. On [**4-22**] a worsening leukocytosis and secretions
warranted Ms. [**First Name8 (NamePattern2) 5279**] [**Known lastname **] be reintubated. ID was consulted for
evaluation of her leukocytosis and fevers, possibly due to
ventilator-associated pneumonia with transient bacteremia, or
line associated bacteremia with VAP. She completed a full course
of antibiotics for Enterobacter, xanthomonas and Klebsiella,
which ended [**5-18**]. She once again weaned to extubation on [**4-26**]. A
repeat speech and swallow evaluation was performed, and again
her diet advanced per recommendations. [**4-27**] Ms. [**First Name8 (NamePattern2) 5279**] [**Known lastname **] was
reintubated due to respiratory distress. Thoracic surgery was
consulted for failure to wean off ventilatory support and for
tracheostomy and PEG placement. On [**5-3**] she was taken to the
operating room and underwent tracheostomy with Dr. [**First Name (STitle) **]. Please
refer to operative report for further deatils. A PEG was not
placed at that time due to the patients complex history of
previous abdominal surgeries. ACS team was consulted regarding
the possibility of PEG placement. Ms. [**First Name8 (NamePattern2) 5279**] [**Known lastname **] continued to
have waxing and [**Doctor Last Name 688**] leukocytosis and was pan cultured
numerous times. At the time of discharge, she was afebrile and
WBC was normal. Her need for pressor support also waxed and
waned dependent on her infectious state and rhythm issues of
rapid atrial fibrillation that was not well tolerated with
associated hypotension. She was not anticoagulated per Dr.[**First Name (STitle) **]
due to her high risk of falls as well as her history of subdural
hematoma with evacuation. She did progress weaning on the
ventilator via trach collar trials and ultimately with a Passy
Muir Valve. Nutrition was delivered via a dobhoff tube. The
patient refuses a gastric motility study and ACS service has
signed off. Speech and swallow reevaluation has been performed.
She remained on and off pressor support for most of her
hospitalization and ultimately weaned from it with the use of
midodrine. She complained for abdominal pain with normal liver
function tests so an abdominal CT was performed revealing stool
and gas. Her laxatives were increased with good result. She
transferred to the surgical step down floor and calorie counts
were recorded. On POD 19 from tracheostmy, her trach was
downsized to #6 and subsequently cappedd. She tolerated this
well and on POD 21 she was decannulated with oxygen saturation
100% on room air. He oral intake was fair and she continued to
have tube feeds cycled at night to supplement her caloric intake
via Dobhoff tube. She continued to make slow progress and was
discharged to [**Hospital **] rehabilitation on POD #46. All follow up
appointments were advised.
Medications on Admission:
MEDICATIONS: Based on records provided by PCP and confirmed by
patient
-Mirtazapine 15 mg po qhs
-Celexa 10 mg po qday
-[**Hospital **] 100 mg po BID
-Depakote 500 mg po qhs
-Miralax 17g packet po BID
-Prilosec 20 mg po qday
-Synthroid 25 mg po qam
-Wellbutrin 150 mg po BID
-Klor 20 mEq packet po qday
-Pantoprazole 40 mg po qday
-Divalproex 500 mg
-Nasal moisturizing spray 2 drops in each nostil prn
-Potassium chloride 10 mEq qday
-Lasix 40 mg po qday (recently increased from 20 mg)
-Ergocalciferol [**Numeric Identifier 1871**] unit capsule qweek
-Allopurinol 200 mg po qday
-Lorazepam 1 mg po BID
-Tramadol 50 mg po TID prn pain
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
11. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. therapeutic multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days: then reevaluate based on fluid status.
14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
15. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for wheezes.
16. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
17. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
19. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 10 days: Stop when Lasix discontinued.
20. metoclopramide 5 mg/mL Solution Sig: Two (2) Injection Q6H
(every 6 hours) as needed for nausea.
21. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 1 months.
22. valproic acid 250 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p [**2170-4-13**] MVrepair (ring 26) and CABG x4
[**2170-4-17**] chest closure
[**4-30**] tracheostomy
resp failure-reintubation
PMH:
Peptic ulcer disease, Pernicious anemia, peripheral neuropathy,
Hypertension, Frequent falls, Hyperlipidemia, Macular
degeneration, Hyperthyroidism, Migraines, Anxiety, Heart murmur,
Infrarenal AAA, recent subdural hematoma with evacuation and
seizures post head, trauma, s/p Partial gastrectomy with Bilroth
1 for PUD in [**2146**], S/p "Gastric aneurysm" repair in [**2157**], S/p
appendectomy, S/p total hysterectomy, S/p cesarean section x2,
S/p ventral hernia repair with mesh in [**2158**], S/p C5-C6 fusion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol with Codeine
Incisions:
Sternal - healing well, no erythema or drainage
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] [**2170-6-12**] at
1:30 PM
Cardiologist: Dr. [**Last Name (STitle) 171**] [**2170-7-4**], 9:40am
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 5294**] in [**4-12**] 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:[**2170-5-29**]
|
[
"785.52",
"281.0",
"453.86",
"356.9",
"428.0",
"997.31",
"518.0",
"369.4",
"293.0",
"999.31",
"E879.8",
"311",
"038.49",
"560.1",
"785.51",
"V70.7",
"441.4",
"428.23",
"518.51",
"414.01",
"288.60",
"788.5",
"729.92",
"362.50",
"427.41",
"997.49",
"244.9",
"432.1",
"997.5",
"996.74",
"112.0",
"424.0",
"440.8",
"427.31",
"272.4",
"276.3",
"300.00",
"410.71",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"38.97",
"33.24",
"34.79",
"37.23",
"88.47",
"88.56",
"96.6",
"39.61",
"99.62",
"96.72",
"35.33",
"36.14",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
15850, 15923
|
8436, 13134
|
317, 625
|
16617, 16799
|
4968, 7426
|
17723, 18419
|
3813, 3984
|
13822, 15827
|
7466, 8413
|
15944, 16596
|
13160, 13799
|
16823, 17700
|
3999, 4949
|
3112, 3176
|
254, 279
|
653, 2999
|
3207, 3656
|
3021, 3092
|
3672, 3797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,346
| 142,253
|
45735
|
Discharge summary
|
report
|
Admission Date: [**2189-1-8**] Discharge Date: [**2189-1-14**]
Date of Birth: [**2119-10-6**] Sex: F
Service: SURGERY
Allergies:
PEPPERS
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
perforated diverticulum
Major Surgical or Invasive Procedure:
[**2189-1-8**] Sigmoidectomy, end colostomy (Hartmann's)
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
69F w/hx of perforated diverticulitis now presenting for sigmoid
colectomy after undergoing lap washout/abx course.
Past Medical History:
PMH:
- Chronic atrial fibrillation
- Hypertension.
PSH:
- Tonsillectomy.
- Appendectomy.
- D&C.
- Fibroid ablation.
-S/P Right breast lumpectomy for DCIS
-S/P Reexploration R breast for more tissue sampling
Social History:
No alcohol or tobacco.
lives with husband
Family History:
Aunt with breast cancer. Father with lung cancer. Brother with
prostate cancer.
Physical Exam:
Physical examination upon admission: [**2189-1-8**]
FOCUSED PHYSICAL EXAMINATION:
GENERAL: NAD
HEENT: MMM
HEART: RRR
LUNGS: bibasilar decreased breath sounds
ABD: soft, appropriately tender, incisions c/d/i, ostomy site
c/d
GU: deferred
MSK/EXT: warm and perfused with 2+ distal pulses; MAE; able to
flex knees bilaterally; [**6-5**] plantarflexion/dorsiflexion
On discharge [**1-14**]:
97.8 82 130/68 16 97% RA
Gen: NAD, A&O
Chest: CTA bilaterally
Abd: soft, appropriately tender at incisions, incision OTA with
staples, stoma pink, + stool output
Extr: warm, pink, well-perfused, +PP
Pertinent Results:
[**2189-1-13**] 05:17AM BLOOD WBC-6.3 RBC-3.57* Hgb-10.4* Hct-31.7*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.1 Plt Ct-197
[**2189-1-11**] 05:25AM BLOOD WBC-6.0 RBC-3.17* Hgb-9.4* Hct-28.1*
MCV-89 MCH-29.5 MCHC-33.3 RDW-14.7 Plt Ct-141*
[**2189-1-9**] 04:13PM BLOOD WBC-7.5 RBC-3.21* Hgb-9.4*# Hct-27.4*
MCV-85 MCH-29.4 MCHC-34.5 RDW-14.4 Plt Ct-132*
[**2189-1-9**] 05:10AM BLOOD WBC-6.6 RBC-2.59*# Hgb-7.3*# Hct-22.5*
MCV-87 MCH-28.4 MCHC-32.7 RDW-14.7 Plt Ct-171#
[**2189-1-8**] 03:33PM BLOOD Hct-26.1*
[**2189-1-13**] 05:17AM BLOOD Plt Ct-197
[**2189-1-13**] 05:17AM BLOOD PT-51.2* PTT-ERROR* INR(PT)-5.1*
[**2189-1-12**] 05:06AM BLOOD PT-32.1* INR(PT)-3.1*
[**2189-1-8**] 06:35AM BLOOD PT-12.5 PTT-26.4 INR(PT)-1.2*
[**2189-1-13**] 05:17AM BLOOD Glucose-128* UreaN-12 Creat-1.0 Na-142
K-4.2 Cl-106 HCO3-30 AnGap-10
[**2189-1-12**] 05:06AM BLOOD Glucose-159* UreaN-15 Creat-1.1 Na-140
K-4.3 Cl-105 HCO3-29 AnGap-10
[**2189-1-11**] 05:25AM BLOOD Glucose-108* UreaN-17 Creat-1.3* Na-139
K-4.2 Cl-104 HCO3-28 AnGap-11
[**2189-1-9**] 05:10AM BLOOD Glucose-147* UreaN-21* Creat-1.4* Na-141
K-4.3 Cl-107 HCO3-27 AnGap-11
[**2189-1-8**] 03:33PM BLOOD Na-144 K-4.2 Cl-108
[**2189-1-13**] 05:17AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8
[**2189-1-11**] 05:25AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
[**2189-1-9**] 05:10AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.1
[**2189-1-8**] 12:12PM BLOOD Hgb-10.7* calcHCT-32
[**2189-1-8**] 10:36AM BLOOD Hgb-10.6* calcHCT-32
[**2189-1-8**] 12:12PM BLOOD freeCa-1.11*[**2189-1-9**]
[**2189-1-9**]: Chest x-ray:
Moderate cardiomegaly is chronic. Lung volumes are once again
quite low.
There are no areas of consolidation. There is mild residual
edema in the
right lung and plate-like atelectasis at the left base. Pleural
effusions are small if any. No pneumothorax. Nasogastric tube
passes into the upper
stomach. No pneumothorax.
[**2189-1-10**]: chest x-ray:
Greater opacification at the base of the right lung could be due
to worsening atelectasis. Low lung volumes also exaggerate mild
cardiomegaly, probably unchanged. Left upper lung grossly clear.
Pleural effusions are small if any on the right. No
pneumothorax.
Brief Hospital Course:
69 year old female presented for elective sigmoid resection
following episode of [**Last Name (un) 17147**] II diverticulitis requiring
laparoscopic washout. Intra-operatively patient demonstrated
active disease in the pelvis with multiple pockets of purulence
in the pelvis. Presence of this active disease and difficult
dissection precluded primary anastomosis. An epidural catheter
was placed pre-operatively for control of her post-operative
pain. Following surgery, the patient was admitted to the acute
care surgery service on [**1-8**] and had an elective sigmoid
resection with Hartmann's procedure. The patient tolerated the
procedure well and was brought to the PACU in stable condition
before transfer to the floor.
Her post operative course was complicated by hypotension to SBP
60s on floor in setting afib w RVR. Epidural rate decreased and
patient given fluids and IV metoprolol. She also was reported to
have a hematocrit of 22 and required packed red blood cells. Her
blood pressure improved slightly, but she continued in afib
necessitating ICU transfer on POD #1. In the ICU, the patient
was monitored and continued on intravenous lopressor. When
tolerating po's on POD #2, the patient was started on home
medication regimen at half dose. As this proved effective
patient transferred to the surgical floor.
Patient completed post-op course of cephalexin. On POD #3, she
resumed her coumadin, but was reported to have an elevated INR
and her coumadin was held for the remainder of her
hospitalization. On the day of discharge on [**1-14**], INR remained
elevated at 3.5, but stable and downtrending. She was discharged
with instructions to follow up with her PCP and have an INR
recheck on [**1-16**].
Her vital signs remained stable and she was afebrile. She
reported nausea and her flagyl and ciprofloxacin were
discontinued and the nausea resolved. She slowly advanced from
clears to a regular diet. The ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and
provided instruction and supervision in the management of her
ostomy. Her ostomy was functioning well with stool and gas
output.
Vital signs have been stable and she has been afebrile. She has
tolerated a regular diet. Her white blood cell count has
normalized at 6.3 and her hematocrit at 31.7. Her pain is well
controlled with an oral pain regimen and she is out of bed
ambulating independently.
She is preparing for discharge home with follow-up scheduled
with her PCP [**Last Name (NamePattern4) **] [**2189-1-16**] to follow her INR and scheduled follow
up in in [**Hospital 2536**] clinic on [**2189-2-3**].
Medications on Admission:
[**Last Name (un) 1724**]: metoprolol 100mg'', diltiazem ER 120mg', coumadin 5mg
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain: may cause sedation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
diverticulitis
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 to have a part of your colon
resected related to diverticulitis. You had a colostomy as part
of your procedure. Because you had a large fluid requirement
after the procedure, you were transferred to the intensive care
unit where you were closely monitored. Your coumadin was
resumed, but you were found to have an elevated INR, and it has
been held until it returns to baseline. Your blood work and
vital signs are stable and you are preparing for dishcarge home
with the following instructions. You will need to have your INR
monitored and follow up with your PCP at the appointment
scheduled for you below. Do not take your coumadin until your
PCP tells you it is okay to resume it. You are being discharged
with the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Location (un) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
Your staples should be removed by the visiting nurses between
the dates of [**1-19**] and [**1-22**].
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without stool or gas in your ostomy bag, call
your [**Month/Year (2) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Month/Year (2) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2189-1-16**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2189-2-3**] at 2:30 PM
With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2189-1-14**]
|
[
"614.6",
"614.5",
"562.11",
"458.29",
"V58.61",
"427.31",
"584.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"46.13",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
6903, 6962
|
3698, 6331
|
289, 347
|
7021, 7021
|
1538, 3675
|
12705, 13616
|
828, 912
|
6462, 6880
|
6983, 7000
|
6357, 6439
|
7172, 12682
|
927, 950
|
1011, 1519
|
226, 251
|
403, 521
|
965, 989
|
7036, 7148
|
543, 751
|
767, 812
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,609
| 137,406
|
50801
|
Discharge summary
|
report
|
Admission Date: [**2194-1-8**] Discharge Date: [**2194-1-10**]
Date of Birth: [**2144-2-3**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Levaquin / Cephalosporins / Oxycodone /
Percocet
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The patient is a 49-year-old female with PMH of SLE, ESRD on HD,
PE on lovenox, and gallstones with cholagnitis in [**10-23**], now
transferred to [**Hospital1 18**] with septic shock. She had an ERCP earlier
today at [**Hospital1 112**] where a stone was removed from CBD. After ERCP she
presented for scheduled HD, where she had a fever 102.2,
tachycardia and hypotension. She was transferred to [**Hospital 883**]
Hospital ED. She had an SBP in the 60s. A femoral CVL was
placed. Received 2L IVF, stress dose solumedrol 125mg, vanc,
zosyn, and tylenol. Was started on phenylephrine and then
transferred to [**Hospital1 18**] as [**Hospital1 112**] had no ICU beds.
In the ED, VS : 101.8 (rectal) 129 90/50s 20 100%NRB. On exam
she had no crackles or belly pain but she was progressively less
responsive and she was intubated for airway protection in light
of somnolence. Labs revealed elevated WBC of 12.1 with 93% PMNs,
elevated transaminases and alk phosp, but a normal bilirubin.
Amylase and lipase were also elevated. Lactate was 3.0. EKG with
ST depressions II avF V5-6 (no prior). She received ASA 300mg PR
x 1. A CT-A torso was obtained which showed no free air, +
pneumobilia, no PE. She was started on an additional vasopressor
(levophed) for a BP of 80s with improvement in BP to 90s. Blood
cultures were drawn and she was admitted to the [**Hospital Unit Name 153**]. Most
recent VS prior to transfer: 100.0 112 91/45, with vent
settings: 500/14/8/100%.
Past Medical History:
# Lupus c/b: nephritis, antiphospholipid antibody s/p DVT and PE
# ESRD on dialysis
# gallstones with cholangitis and sepsis [**10-23**] s/p ERCP with
stone extraction, sphincterotomy and stent.
# h/o PE on lovenox - despite ESRD, she has been continued on
this due to an apparent resistence to coumadin
# SVC obstruction [**3-18**] HD catheter s/p stenting
# line sepsis (h/o ESBL EColi, actinobacter and klebsiella
bacteremia)...most recent HD line change [**2193-10-28**]
# parathyroidectomy [**2190**]
# gastroparesis
# chronic subdural hematoma s/p burr holes [**2186**]
# utrerine fibroids
# h/o afib (on lovenox)
# chronic pancreatitis
# chronic SOB on home 02 2L NC
# h/o VRE, MRSA
Past Surgical History:
parathyroidectomy
ex-lap removal of 2 large benigh intaabdominal tumors
AV fistulas and HD catheters
Social History:
No sexual activities times years, no risk of pregnancy. The
patient lives with 27-year-old sister and 17- year-old daughter.
The patient works as an administrative assistant at [**Hospital1 11900**]. Born in [**Country 2045**] and raised here. Smoked in high school,
no tobacco currently.
Family History:
Noncontributory.
Physical Exam:
T= 98.9 BP= 113/73 HR= 111 RR= 17 O2= 96% on AC 550/15/5/100%
GENERAL: cushingoid AAF, intubated and sedated
HEENT: b/l injected conjunctiva, b/l chemosis. No scleral
icterus. MM lubricated.
Neck: unable to assess JVP 2/2 habitus. tunneled line in place
CARDIAC: Regular tachycardia, 2/6 systolic murmur across
precordium
LUNGS: coarse breath sounds, no crackles or wheezes
ABDOMEN: obese and surgically scarred abdomen. Minimal BS. NABS.
EXTREMITIES: cool, no edema, dopplerable dorsalis pedis/
posterior tibial pulses. RUE old AV fistula without thrill/bruit
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
Admission Labs:
[**2194-1-7**] 11:05PM WBC-12.1*# RBC-4.44# HGB-13.6# HCT-44.0#
MCV-99*# MCH-30.6# MCHC-30.8* RDW-16.7*
[**2194-1-7**] 11:05PM NEUTS-93* BANDS-0 LYMPHS-2* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2194-1-7**] 11:05PM PLT SMR-LOW PLT COUNT-101*#
[**2194-1-7**] 11:05PM PT-12.6 PTT-26.3 INR(PT)-1.1
[**2194-1-7**] 11:05PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-2+
[**2194-1-7**] 11:05PM GLUCOSE-60* UREA N-39* CREAT-6.8*# SODIUM-144
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-20
[**2194-1-7**] 11:05PM CALCIUM-7.8* PHOSPHATE-4.1 MAGNESIUM-1.3*
[**2194-1-7**] 11:05PM ALT(SGPT)-384* AST(SGOT)-390* CK(CPK)-162*
ALK PHOS-287* AMYLASE-271* TOT BILI-0.6
[**2194-1-7**] 11:05PM LIPASE-411*
[**2194-1-7**] 11:05PM CK-MB-8 cTropnT-0.46*
[**2194-1-7**] 11:12PM LACTATE-3.0* K+-4.5
Discharge Labs:
[**2194-1-9**] 02:29AM BLOOD WBC-8.3 RBC-4.20 Hgb-12.6 Hct-41.5
MCV-99* MCH-30.1 MCHC-30.4* RDW-16.6* Plt Ct-110*
[**2194-1-9**] 02:29AM BLOOD ALT-284* AST-116* AlkPhos-194*
TotBili-0.2
[**2194-1-8**] 11:36PM BLOOD Lipase-66*
[**2194-1-9**] 12:29PM BLOOD Calcium-7.1* Phos-6.7* Mg-1.9
[**2194-1-9**] 06:22PM BLOOD Type-ART Temp-36.7 pO2-186* pCO2-42
pH-7.32* calTCO2-23 Base XS--4 Intubat-INTUBATED
[**2194-1-8**] 11:48PM BLOOD Lactate-2.0
[**2194-1-7**] Chest Xray:
1. Findings consistent with pulmonary edema and small left
pleural effusion. Moderate cardiomegaly, unchanged.
2. Mild overinflation of the ET tube cuff.
3. Please note that evaluation for free air cannot be performed
as chest
radiograph was performed with supine technique.
[**2194-1-7**] CT Chest/Abdomen/Pelvis
CT CHEST: Patient is intubated and an NG tube is also
identified. There is a stent within the right brachiocephalic
vein and superior vena cava. The right brachiocephalic stent is
likely partially occluded. The left brachiocephalic vein is
diminutive in caliber. There is mild cardiomegaly. Scattered
lymph nodes in the mediastinum are noted, none of which meet CT
criteria for pathological enlargement. There is no pericardial
effusion. Dialysis catheter is present. Mitral valve
calcifications are noted. There is no axillary or hilar
lymphadenopathy. There is diffuse ground-glass opacities within
both lungs, with interlobular septal thickening consistent with
pulmonary edema. There are small bilateral pleural effusions.
There is bibasilar atelectasis and patchy opacities could
represent aspiration. Calcification at the left lung base is
noted.
CT OF THE ABDOMEN: There is an extensive amount of pneumobilia
within the
biliary tree. The intrahepatic bile ducts are dilated and there
is marked
dilatation of the common bile duct measuring up to 1.6 cm. Air
and fluid
within the common bile duct is noted. Small amount of air within
the
gallbladder is also identified (2, 65). The adrenal glands are
unremarkable. There is moderate pancreatic ductal dilatation
measuring up to 6 mm (2, 63). The spleen contains large
hypodense lesions which are incompletely characterized. For
example, there is a 3.0 x 3.1 cm hypodense lesion in the spleen
(2, 64). Smaller lesions are also identified. The kidneys
demonstrate multiple hypodense lesions, some of which are too
small to characterize and others which are incompletely
characterized. Scattered mesenteric lymph nodes are noted, none
of which meet CT criteria for pathological enlargement. An NG
tube is seen terminating within the stomach. Small bowel loops
are normal in caliber. There is no free fluid or free air.
CT OF THE PELVIS: The rectum and sigmoid colon are unremarkable.
Large
calcified fibroid within the uterus is noted. A smaller
calcified fibroid is seen slightly superior (2, 97). There is no
pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
IMPRESSION:
1. Diffuse ground-glass opacities in both lungs and small
pleural effusions likely representing pulmonary edema. Patchy
opacities concerning for aspiration.
2. Right brachiocephalic stent is likely partially occluded. The
left
brachiocephalic vein is diminutive in caliber.
2. Extensive pneumobilia with common bile duct and pancreatic
ductal
dilatation. While the pneumobilia could be due to recent ERCP,
the biliary
dilatation and pancreatic ductal dilatation are concerning for
an obstructive process. No definite mass in pancreatic head is
identified, although study was not tailored for evaluation of
pancreas.
3. Multiple renal hypodensities, many of which are too small to
characterize and others which are incompletely characterized.
The number and size of lesions raises the possibility of lithium
use.
4. Large splenic hypodensities which are incompletely
characterized, but
likely congenital.
5. Calcified fibroid uterus.
Brief Hospital Course:
49 year old female with SLE on chronic steroids, ESRD on HD, and
ERCP the day of admission for choledocholithiasis who presented
with sepsis and pancreatitis.
#. Sepsis: She was admitted with sepsis that was thought to be
due to a biliary source, but her HD line was also considered a
possible source of infection. She was initially started on
Vancomycin and Zosyn and was given vasopressors to maintain
blood pressure. OSH blood cultures grew GNR's and she was
switched to Vanc/meropenem. She also has a h/o of VRE sensitive
to linezolid and ESBL sensitive to gentamicin and so her
antibiotics were switched on [**2194-1-8**] to meropenem, linezolid,
and gentamicin. Blood cultures drawn at [**Hospital1 18**] were pending at
the time of discharge. She was weaned off neosynephrine and was
continued on norepinephrine to maintain blood pressure. She was
also continued on stress dose steroids. She was aggressively
volume repleted with IV fluid.
#. Resp Failure - She was intubated for airway protection and
never dropped saturations or demonstrated problems with
oxygenation. She had evidence of volume overload on CXR but was
given aggressive IVF for sepsis and pancreatitis management, but
this may be a barrier to extubation in the future. She was
maintained on fentanyl and midazolam for sedation. On the day
of transfer, she had a favorable RSBI of 74 and may be able to
undergo extubation in the near future.
#. Pancreatitis s/p ERCP - She had no evidence of persistent
obstruction or free air on CT scan. However, her pancreatic
enzymes were elevated, and HCT acutely elevated c/w
pancreatitis. She was given aggressive IV fluids and kept NPO
for bowel rest. Pain control was with IV fentanyl.
#. ESRD: She was seen by the renal team who recommended
bicarbonate to correct her acidosis. She was given 3 amps of
bicarb on [**2194-1-8**] with some improvement. She underwent CVVH on
[**2194-1-9**] for hyperkalemia.
#. SLE: She was placed on stress dose steroids. She was also
continued on Plaquenil and Bactrim at her home doses.
#. H/o PE: Her Lovenox was initially held as her coagulation
history was not known. She was subsequently placed on a heparin
drip for anticoagulation as she has a history of
antiphospholipid antibody syndrome.
#. Hyperglycemia: She was hyperglycemic with blood sugars in the
300's one day after admission and was started on an insulin
sliding.
#. Access: She arrived with a femoral triple lumen catheter.
This was removed after admission and an IR-guided femoral line
was placed on [**2194-1-8**]. She also received a post-pyloric tube
for feeding. She was NPO after intubation but the surgery team
saw her on the day of transfer and recommended possibly starting
tube feeds today.
#. Code Status: She was FULL CODE during this admission
#. Emergency Contact: Was daughter and brother [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 105650**]
Medications on Admission:
ASA 81 daily
Calcium Carbonate 1250 Daily
Lovenox 60 SC Daily
Dilaudid 2mg po q6-8 hours
Plaquenil 200mg daily
Reglan 5mg QID
nephrocaps 1 daily
omeprazole 20mg [**Hospital1 **]
Prednisone 25mg daily
Bactrim SS daily
? vancomycin at HD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig:
One (1) Suspension PO BID (2 times a day).
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: 25-200 mcg/hr
Injection TITRATE TO (titrate to desired clinical effect (please
specify)).
8. Midazolam 5 mg/mL Solution Sig: 0.5-20 mg/hr Injection
TITRATE TO (titrate to desired clinical effect (please
specify)).
9. Norepinephrine Bitartrate 1 mg/mL Solution Sig: 0.03-0.25
mcg/kg/min Intravenous TITRATE TO (titrate to desired clinical
effect (please specify)).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day) as needed for constip.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
13. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day) as needed for rinse.
14. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous ASDIR (AS DIRECTED).
15. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for eyes.
16. MethylPREDNISolone Sodium Succ 80 mg IV Q8H
17. Meropenem 500 mg IV Q24H
18. Gentamicin 100 mg IV QHD
Give after HD and confirmed gentamicin trough < 2.
19. Linezolid 600 mg IV Q12H
Give after HD on HD days.
20. Pantoprazole 40 mg IV Q24H
21. Heparin (Porcine) in NS 10 unit/mL Kit Sig: One (1) Infusion
Intravenous ongoing: Heparin IV infusion per weight-based
protocol.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Sepsis
Respiratory Failure
Secondary Diagnosis:
Pancreatitis
End Stage Renal Disease on Hemodialysis
Discharge Condition:
Critical
Discharge Instructions:
You were admitted to the hospital after an ERCP with sepsis and
hypotension. You were intubated and sedated and received
medications to help support your blood pressure. You are being
transferred to [**Hospital6 **] where you received
your health care in the past.
Followup Instructions:
You are being transferred to [**Hospital6 1708**].
Completed by:[**2194-1-10**]
|
[
"998.59",
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"V12.51",
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"V58.65",
"710.0",
"038.9",
"518.81",
"995.92",
"577.0",
"585.6",
"514"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13678, 13693
|
8534, 11450
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331, 343
|
13858, 13869
|
3658, 3658
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3005, 3023
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2577, 2680
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|
285, 293
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371, 1841
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13782, 13837
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3674, 4585
|
13733, 13761
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1863, 2554
|
2696, 2989
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,014
| 197,589
|
39957
|
Discharge summary
|
report
|
Admission Date: [**2145-10-5**] Discharge Date: [**2145-10-9**]
Date of Birth: [**2088-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
hemetemesis
Major Surgical or Invasive Procedure:
Endoscopic ultrasound with fine needle aspiration
History of Present Illness:
57 y/o M with PMH of polysubstance abuse, [**Doctor First Name 329**]- [**Doctor Last Name **] tear,
pancreatitis transferred from an OSH for further evaluation and
monitoring of hemobilia.
.
In brief, his symptoms started 2 days with chills/ sweats
awakening him the middle of the night. He subsequently had
midepigastric abdominal pain radiating to the left upper
quadrant which was not relieved by pepcid. He felt nausea and
had several episodes of hemetemesis followed by black tarry
stool. + lightheadedness, no syncope, chest pain or shortness
of breath.
.
He presented to an OSH, where he was HD stable throughout stay:
BP 114/64 HR high 90's, RR 16-20 95% RA. His initial Hct was
37.8 which trended down to 31.8 over 12 hrs. He had a
semi-urgent endoscopy which showed blood in the duodenum with
side viewing scope confirming hemobilia. As interventional
radiology was unavailable at the OSH, he was transferred to
[**Hospital1 18**] for further evaluation and treatment.
.
On arrival to [**Hospital1 **], patient complaining of significant epigastric
pain once again radiating to left upper chest.
Past Medical History:
- past history IV heroin use
- hx of alcoholism
- hx of [**Doctor First Name **]-[**Doctor Last Name **] tear
- hx DVT
- hx pancreatitis
- hx seizures related to DT's
- HTN
- HCV
Social History:
Lives at home with his wife, currently unemployed
- drinks pint rum daily, last drink approx 2 day ago
- remote history of IVDA 40 yrs ago
Family History:
mother: deceased from colorectal CA
Physical Exam:
VS: Temp: afebrile BP: 127/83 HR: 78 RR: 13 O2sat 100% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 S2; S3 best heard at apex; no murmurs/ rubs
ABD: nd, +b/s, soft, tenderness in LUQ with voluntary guarding
EXT: no c/c/e
SKIN: no rashes/no jaundice; cap refill < 2 sec
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
Admission labs:
[**2145-10-5**] 08:16PM BLOOD WBC-4.3 RBC-2.77* Hgb-10.4* Hct-30.6*
MCV-110* MCH-37.6* MCHC-34.1 RDW-13.4 Plt Ct-101*
[**2145-10-5**] 08:16PM BLOOD PT-14.1* PTT-31.1 INR(PT)-1.2*
[**2145-10-5**] 08:16PM BLOOD Glucose-83 UreaN-16 Creat-0.8 Na-141
K-3.5 Cl-106 HCO3-26 AnGap-13
[**2145-10-5**] 08:16PM BLOOD ALT-168* AST-383* AlkPhos-63 Amylase-133*
TotBili-1.3
[**2145-10-5**] 08:16PM BLOOD Lipase-73*
[**2145-10-5**] 08:16PM BLOOD CK-MB-1 cTropnT-<0.01
[**2145-10-5**] 08:16PM BLOOD Albumin-3.8 Calcium-8.6 Phos-1.9* Mg-1.9
[**2145-10-6**] 04:24AM BLOOD VitB12-933* Folate-9.1
[**2145-10-6**] 04:24AM BLOOD Triglyc-115
[**2145-10-6**] 09:09AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2145-10-6**] 09:09AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
MICRO:
[**10-6**] Blood culture:
[**10-6**] Urine culture:
STUDIES:
[**10-6**] CT Abd/Pelvis: 1. Nonspecific high-density material noted
in the gallbladder fundus is likely small stones/sludge rather
then blood. No other CT findings of hemobilia.
2. Poorly defined hypoattenuating lesion within the posterior
pancreatic
head, with suggestion of extension to portion of the uncinate
process. The
more focal well-defined component measures 13 x 13 mm.
Differential for this patient includes pancreatic adenocarcinoma
or changes from focal pancreatitis. Suggest correlation with
EUS/FNA to further evaluate.
Scattered peripancreatic and hepatogastric lymph nodes with no
other findings of metastatic disease.
3. Slight dilatation of the intrahepatic biliary tree and
dilated
extra-hepatic biliary tree. This may be secondary to underlying
obstruction with differential including ampullary stenosis or
distal biliary lesion.
4. No CT findings of acute pancreatitis. No secondary
complications
including pseudoaneurysm or pseudocyst identified.
[**10-8**] FNA, Pancreas Head Mass:
NON-DIAGNOSTIC, insufficient glandular cells.
Neutrophils, macrophages, and acellular debris suggesting
acute pancreatitis.
Brief Hospital Course:
57 y/o M with PMH of polysubstance abuse, [**Doctor First Name 329**]- [**Doctor Last Name **] tear,
pancreatitis transferred from an OSH for further evaluation and
monitoring of hemobilia. The patient presented with onset of
epigastric pain, nausea/vomiting and developed hematemesis and
black tarry stools. He went to [**Hospital 2079**] hospital where he
underwent urgent EGD showing hemobilia. Because Southshore does
not have IR and there was concern that the patient may require
intervention he was transferred to [**Hospital1 18**]. The patient remained
hemodynamically stable however required alcohol detox.
Additionally, pancreatic mass was found during imaging and
investigation of potential malignancy was initiated.
.
#. Hematemesis/Hemobilia: Endoscopy at OSH revealed blood from
biliary tree suggesting hemobilia. Imaging was reviewed by ERCP
team at [**Hospital1 18**] and felt consistent with hemobilia. They did not
feel intervention was necessary as the patient was
hemodynamically stable and did not require transfusion during
this admission. They did note that pontaneous hemobilia is rare-
but can occur in the setting of acute/chronic pancreatitis with
vascular damage (hemosuccusvpancreaticus), pancreatic
pseudocyst, pancreatic cancer, gallstones, bile duct tumors, and
vascular anomolies of the liver or biliary tree. A CT revealed a
poorly defined hypoattenuating lesion within the posterior
pancreatic head. Given the patient's extensive drinking history,
epigastric pain and only mild elevations in amylase/lipase, this
was concerning for pancreatic adenocarconima v. changes from
acute pancreatitis. An EUS and FNA was performed on [**2145-10-8**]
which IR felt was concerning for malignancy, however it was
non-diagnostic, showing insufficient glandular cells. CEA is
within normal limits and CA [**53**]-9 was normal. Of note, the
patient did have one episode of fever in the MICU and was
started on cipro/flagyl empirically, however it was later felt
that the fever may have been [**1-19**] withdrawal and the abx were
dced without further elevated temperatures.
.
#. ETOH dependence: The patient presented after hematemesis with
likely etoh induced pancreatitis. Given the patient's extensive
history of heavy ETOH with episodes of withdrawal seizures a few
months prior to presentation, the patient was placed on a CIWA
scale, q2h, managed with valium. The patient continued [**Doctor Last Name **]
on the CIWA scale until [**2145-10-8**]. He experienced anxiety,
tremors, and discomfort but did not experience hallucinations or
seizures. He was also given thiamine, folate, MVI.
.
#. Elevated transaminases: The patient was found to have
elevated transaminases throughout admission. This was felt
likely related to underlying alcoholic hepatitis and HCV.
Pattern of elevation suggests intrahepatic process rather than
obstructive process. Synthetic function was at baseline and the
LFTs were downtrending over the course of the stay. HCV Ab was
confirmed to be positive.
.
#. Elevated amylase/pancreatitis: The patient had mildly
elevated amylase likely [**1-19**] acute on chronic pancreatitis from
ETOH abuse. Though amylase was not three times the upper limit
of normal, given his hx of pancreatitis, it is possible that he
has a partially burned out pancreas and therefore is unable leak
as high levels of amylase. Elevated amylase could also be
related to the pancreatic mass seen on imaging. The patient was
made NPO and treated with morphine and zofran to relieve related
pain and nausea and diet was progressed as tolerated. The
patient was able to tolerate a full meal at time of discharge.
.
#. Thrombocytopenia: likely [**1-19**] cirrhosis
.
#. Anemia: macrocytic anemia likely [**1-19**] HCV vs nutritional
deficiencies with ETOH abuse
.
# Social: The patient's further medical care may be complicated
by the fact the he currently does not have insurance. Appts were
made for him [**Location **]clinic for both PCP and for
financial counseling. He was also scheduled for an appt with Dr.
[**Last Name (STitle) 468**] for further management of pancreatic mass, however as he
is currently self-pay, he was advised to call [**Doctor Last Name **] office
and work with them to find a financially feasible solution. He
has applied to Mass Health but service won't be initiated for a
few weeks, so he may need to delay his appt or see if he can be
billed retroactively. Hopefully his lack of insurance will not
impede his receiving appropriate medical care as an outpatient.
.
Code: Full
Medications on Admission:
Medications at home: none
.
Meds on transfer:
- ativan per CIWA scale
- dilaudid 0.5mg q 3hrs
- zofran 4mg q 4hrs
- protonix gtt
- folic acid
- thiamine 100mg daily
- MVI
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatic mass of unknown etiology
2. Alcohol withdrawal
3. Hemobilia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with epigastric pain, vomiting blood,
and blood from your rectum. You were found to have blood in your
duodenum and biliary tree and a mass in your pancreas. This mass
was biopsied and the results are pending. You will need to
follow up very closely with the appointments we have made for
you.
We also detoxed you from alcohol while you were admitted. You
need to stop drinking alcohol.
New medications:
Oxycodone: this is a pain medication for short term use. do not
drive or operate heavy machinery while taking this medication as
it causes drowsiness.
Please follow-up as indicated below.
Since you do not have health insurance, you have an initial
appointment for financial counseling. You also have an
appointment with Dr. [**Last Name (STitle) 468**] (primary care doctor), which is
listed as self-pay. It is recommended to call Dr.[**Name (NI) 9886**]
office before the appointment and let them know about this
self-pay status so that the office is aware and can try to make
arrangements for you in the interim as you have applied to Mass
Health/other insurance agencies.
It is essential that you follow-up because you have medical
conditions that need to be evaluated on a chronic basis.
Followup Instructions:
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: WEDNESDAY [**2145-10-13**] at 11:00 AM
With: [**First Name8 (NamePattern2) 87876**] [**Last Name (NamePattern1) 87877**] [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
**This appointment is for financial services. Please bring a
picture ID, proof of address and 2 pay stubs or unemployment
benefits**
.
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: MONDAY [**2145-10-18**] at 11:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 8268**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Department: RADIOLOGY
When: MONDAY [**2145-10-25**] at 8:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** currently this appt. is registered as self pay
.
Department: SURGICAL SPECIALTIES
When: MONDAY [**2145-10-25**] at 9:30 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** currently this appt. is registered as self pay
|
[
"577.0",
"291.81",
"070.70",
"577.9",
"285.9",
"287.5",
"303.91",
"V12.51",
"578.0",
"401.9",
"577.1",
"571.5",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.74",
"52.11",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9546, 9552
|
4653, 9183
|
326, 378
|
9670, 9670
|
2559, 2559
|
11086, 12532
|
1895, 1932
|
9404, 9523
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275, 288
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|
2575, 4630
|
9685, 9797
|
1543, 1723
|
1739, 1879
|
9255, 9381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,073
| 132,020
|
34707
|
Discharge summary
|
report
|
Admission Date: [**2144-8-11**] Discharge Date: [**2144-8-14**]
Date of Birth: [**2078-7-10**] Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Alphagan P
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fever, pain in the RUQ
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 year old gentleman with a
history of cholangiocarcinoma s/p CBD excision, CCY, and RnY
hepaticojejunostomy [**2143-8-30**] and adjuvant chemoradiation therapy
which ended [**2143-12-9**]. For the past 2 months, he has been
experiencing cyclical fevers. Every 2.5-3 weeks, he has an
episode of fevers, usually to 100 or 101 degrees which
ultimately
resolve on their own. He was transferred from an OSH on[**2144-8-11**]
where he presented
with complaints of fever to 103 degrees and severe RUQ pain.
Past Medical History:
- CAD s/p MI in [**2111**]
- HTN
- OA
- OSA, wears BiPap at night
- hyperlipidemia
- glaucoma and cataracts
-8/19/009 L segmental PE
-[**2143-12-13**] PE R
Social History:
married. nonsmoker, no illegal drugs
Family History:
negative for malignancy; father and sister with DM
Physical Exam:
GEN - NAD, A&Ox3
HEENT - NCAT, EOMI, MMM
CVS - RRR, nl S1 and S2
PULM - CTAB, no W/R/R
ABD - obese, soft, mild RUQ tenderness to palpation,
nondistended; well-healed right subcostal incision scar;
well-healed open appendectomy scar
EXTREM - warm/dry, no e/c/c
Pertinent Results:
Lab at admission:
[**2144-8-11**] 02:48PM WBC-4.4 RBC-4.07* HGB-13.0* HCT-38.9* MCV-96
MCH-32.0 MCHC-33.5 RDW-16.3*
[**2144-8-11**] 02:48PM PLT COUNT-143*
[**2144-8-11**] 02:48PM PT-16.2* PTT-25.4 INR(PT)-1.4*
[**2144-8-11**] 03:33AM ALT(SGPT)-186* AST(SGOT)-165* ALK PHOS-158*
TOT BILI-2.4*
[**2144-8-11**] 03:33AM LIPASE-12
Brief Hospital Course:
Mr [**Known lastname 79558**] was admitted on [**2054-8-11**] for fever, chills and RUQ pain,
concerns for cholangitis. He was put on broad spectrum
antibiotics (Vancomycin, Ciprofloxacin and Zosyn) but while
receiving his vancomycin infusion, he became hypoxic and
hypotensive and was transeferred to the ICU. His symptoms
remitted, and he was transferred back to the floor. Antibiotics
were continued without any further complications. An MRCP was
done on [**2144-8-12**] which showed heterogeneous non-mass-like
enhancement of the liver parenchyma with peripheral wedge-
shaped areas of increased enhancement. Stably dilated right
biliary duct. Interval resolution of the fluid collection seen
on the previous study dated [**2143-12-8**]. Mr. [**Known lastname 79558**] [**Last Name (Titles) **]
resolution of RUQ pain and did not experience fever or chills
during his hospital stay. Intravenous antibiotics were
discontinued and the patient was discharged home on 500mg Cipro
PO BID.
Medications on Admission:
-albuterol sulfate 90mcg HFA 2puffs q6hrs prn wheeze
-flovent 110mcg HFA 2 puffs [**Hospital1 **] prn wheeze
-atenolol 50mg PO daily
-Gas-X prn
-MVI
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*1*
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic at bedtime: right eye.
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if your symptoms
recur or if you experience any of the danger signs listed below.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern5) 21185**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-8-26**] 1:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2145-9-29**] 11:15
Please call [**Telephone/Fax (1) 673**] to get your appointment time with Dr
[**Last Name (STitle) **] for next week
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2144-8-14**]
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23,483
| 108,568
|
50015
|
Discharge summary
|
report
|
Admission Date: [**2166-3-24**] Discharge Date: [**2166-4-17**]
Date of Birth: [**2106-9-14**] Sex: F
Service: MEDICINE
Allergies:
Biaxin / Erythromycin Base / Amiodarone
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Milrinone Holiday
Major Surgical or Invasive Procedure:
Swan Ganz Catheter
History of Present Illness:
Mrs. [**Known lastname **] is a 59 year old female with h/o ischemic CMP, s/p
CABG with residual EF 15%, & hypothyroid disease c/b amiodarone
induced thyrotoxicosis presents with SOB & cough wks x 3 weeks
and fevers to 101F x 4 days. Pt states that she has been
feeling unwell since her discharge from [**Hospital1 18**] 2 weeks PTA. She
reports decreased energy, SOB, non-productive cough, sore
throat, and sweats x 2-3 weeks. She has also had incr facial,
abdominal, and LE edema despite decr po intake x 5 days. She
has recently been feeling dizzy but has not had syncope or chest
pain. Has PND & 3 pillow orthopnea. She did had a flu shot
this season.
ROS: No HA, no photophobia, no urinary sxs, occ diarrhea & occ
epigastric pain.
Past Medical History:
Ischemic CMP, CHF, EF 15%, dry wt 158-162#, CAD s/p MI '[**39**], s/p
CABG '[**42**] SVT to LAD, severe MR, severe TR, pulm HTN, s/p bivent
pacer/ICD, PAF, hypothyroidism [**1-29**] amiodarone toxicity
Social History:
Smoked for 7 years, currently, not smoking. No alcohol use. The
patient lives alone and is retired.
Family History:
Mother - non-alcoholic liver cirrhosis. Father - DM.
Father deceased of MI at 50.
Sister with SLE.
Physical Exam:
VS: 98.2, 97/70 (86-101/47-70), 80, 18, 96%RA
I/O: poorly recorded, wt 83.8kg (<-84.2kg)
Gen: NAD, mildly ill appearing, sitting in a chair, slightly
tachypnic
HEENT: anicteric, very dry MM
Card: irreg irreg, nl S1 S2, II/VI EM
Resp: few mild wheezes, mild bibasilar crackles
Abd: nl BS, soft, mild RUQ tenderness, no [**Doctor Last Name 515**], no rebound
Exts: mild non-pitting edema, WWP
Neuro: A&O3, MAE
Pertinent Results:
[**2166-3-24**] 10:12PM PT-68.2* PTT-65.3* INR(PT)-29.3
[**2166-3-24**] 08:00PM GLUCOSE-107* UREA N-31* CREAT-1.1 SODIUM-137
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-20* ANION GAP-21*
[**2166-3-24**] 08:00PM ALT(SGPT)-83* AST(SGOT)-159* LD(LDH)-428* ALK
PHOS-150* AMYLASE-64 TOT BILI-1.9*
[**2166-3-24**] 08:00PM LIPASE-26
[**2166-3-24**] 08:00PM ALBUMIN-4.0 CALCIUM-8.4 PHOSPHATE-2.7
MAGNESIUM-1.8
[**2166-3-24**] 08:00PM TSH-17*
[**2166-3-24**] 08:00PM DIGOXIN-1.9
[**2166-3-24**] 08:00PM WBC-7.0 RBC-3.80* HGB-12.4 HCT-40.3# MCV-106*
MCH-32.6* MCHC-30.7* RDW-15.3
[**2166-3-24**] 08:00PM PLT COUNT-210
[**2166-3-24**] 08:00PM PT-75.9* PTT-67.1* INR(PT)-36.3
INR from 36 on admission to 2.7 on HD #2 after vitamin K 10meq
po
.
STUDIES:
Liver U/S [**2166-3-25**]
1. Normal color flow and waveforms within the hepatic arteries,
hepatic veins, and portal veins.
2. Unremarkable abdominal ultrasound.
.
CXR [**2166-3-24**]: Stable appearance of the chest compared with
[**2166-2-16**] with no radiographic evidence of acute cardiopulmonary
process.
.
Rest thallium [**2166-2-17**]: Large, fixed perfusion defect involving
the expected LAD territory, not significantly changed since the
prior study. Markedly dilated left ventricular cavity, stable
since the prior exam.
.
Echo [**7-30**]: EF < 20%, dilated LV, 4+ MR.
Cath [**9-29**]: no sign CAD, EF 15%, 3+MR, mod pulm hypotension,
65/30.
CXR [**2166-3-24**]: Stable c/w [**2166-2-16**], no acute cardiopulmonary
process.
.
MICRO:
[**2166-3-25**] Influenza A/B by DFA negative
[**2166-3-25**] URINE CULTURE negative
[**2166-3-24**] BLOOD CULTURE negative
[**2166-3-24**] BLOOD CULTURE negative
DISCHARGE LABS:
[**2166-4-16**] 06:45AM BLOOD WBC-10.3 RBC-3.19* Hgb-10.1* Hct-31.7*
MCV-99* MCH-31.6 MCHC-31.9 RDW-15.1 Plt Ct-522*
[**2166-4-17**] 06:00AM BLOOD PT-16.0* PTT-34.8 INR(PT)-1.6
[**2166-4-16**] 06:45AM BLOOD Glucose-91 UreaN-4* Creat-0.7 Na-138
K-3.9 Cl-109* HCO3-22 AnGap-11
[**2166-4-15**] 07:08AM BLOOD ALT-33 AST-19 AlkPhos-111 TotBili-0.9
[**2166-4-15**] 07:08AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2166-4-15**] 07:08AM BLOOD HIV Ab-NEGATIVE
[**2166-4-15**] 07:08AM BLOOD HCV Ab-NEGATIVE
[**2166-4-15**] 07:08AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND
[**2166-4-15**] 07:08AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND
Brief Hospital Course:
59 year old female with dilated CM (EF 15%) s/p BiV ICD, s/p
CABG '[**42**] SVG-LAD, Severe MR & TR, PAF, presenting with SOB &
fevers.
1. CV:
A) Pump: The patient presented with a history of CHF/CMP and hx,
sx and exam consistent with failure (SOB, orthopnea, JVD, mild
crackles, non-pitting edema). On admission, she was started on
milrinone and her lasix was increased as her BP tolerated. She
did not diurese well on this regimen and was transferred to the
CCU on [**2166-3-27**] where a a Swan Ganz catheter was placed for
tailored CHF therapy.
In the CCU, she was continued on milrinone gtt and a nipride gtt
was titirated up to achieve a CI of >2.2 and a decreased SVR and
PAP. On this therapy she achieved good diuresis with average 24
hours fluid balance negative 1-2L. After the initial success
with diuresis, the patient was started on valsartan and imdur in
an attempt to wean off drips and convert to oral medication.
With steadily increasing doses of valsartan and imdur, she did
wean off the nipride and the milrinone but developed an episode
of sustained hypotension and decreased urine output when the
milrinone was stopped. From this it was presumed that the
patient required the additional inotropic support of the
milrinone, and after re-starting milrinone her CO and CI
increased sufficiently to maintain MAP >60. On HD#10 ([**2166-4-2**]),
the patient was on a stable dose of aldactone 25mg once daily
(decreased from 50mg po daily as an outpatient), bisoprolol 5mg
once daily, milrinone 0.385mcg/kg/min gtt and was loaded on
digoxin. Her isordil, nipride, valsartan, and lasix were
discontinued. Once on a stable heart failure regimen, the
patient was transferred out of the CCU and sent to the step down
unit. There her ins and outs were not well recorded and
secondary to a foley that was re-inserted on the floor, she
developed a UTI/pyelonephritis confirmed by CT scan which
required re-admission to the CCU for further management. On her
second admission to the CCU, her heart failure regimen was again
altered due to her inability to tolerate milrinone secondary to
development of persistent HA. She was empirically taken off
milrinone with subsequent decompensation and was then started on
low dose dopamine instead. She tolerated the dopamine well with
good urine output and maintenance of pressures. She was able to
regain forward flow and returned to compensated heart failure.
At this point her regimen consisted of Dopamine 2.5mcg/kg/min,
bisoprolol 5mg once daily, and digoxin 0.125mg once daily. She
was taken off the aldactone for persistent hyponatremia.
Initially the plan was to discharge her on home dopamine, but
without right heart catheterization, approval was not granted
for home dopamine infusion. The patient refused another right
heart cath. Upon the patient's insistence, dopamine was
discontinued. She maintained her blood pressures and remained
in compensated CHF during the following day.
She also decided to pursue cardiac transplantation prior to
discharge. The PFT's, carotid studies and panel of serologies
were sent prior to discharge.
B) Coronaries: The patient has had CABG in past but appears most
of her initial CAD was secondary to complications of the cath
from atypical chest pain. The patient is on baby aspirin, and
b-b (bisoprolol), and diuretics. Statins were held temporarily
given her elevated LFTs on admission (which was most likely due
to RHF). This will need to be revisited by her PCP [**Name Initial (PRE) 176**] 6
weeks of discharge for possible re-initiation of statin therapy.
C). Rhythm: The patient was admitted in afib which was thought
to contribute to her decompensated heart failure (with loss of
her atrial kick). She spontaneously converted to NSR after some
diuresis but then continued to go in and out of atrial
fibrillation. The BiV pacer was interrogated on [**2166-3-26**] and was
found to be RV pacing. The capture rate was increased to a HR
of 80 at which point the pacer was pacing both ventricles with
good synchrony. The patient could not be started on ibutilide
or dofetilide due to concerns of torsades while the patient was
on milrinone. The milrinone or dopamine was required to
maintain pressure, and good forward flow as manifested by the
low CO/CI and hypotension when either was stopped, therefore
cardioversion was not considered an option. The patient was
also loaded on amiodarone and continued on her digoxin. If the
patient can remain in sinus rhythm for a few months, then it may
be possible to stop the milrinone or dopamine and start
dofetilide. For anticoagulation she was placed on a heparin gtt
and coumadin PO. The coumadin was loaded slowly as the
amiodarone could elevate the INR. At time of discharge, the
patient was on amiodarone and digoxin for her atrial
fibrillation with evidence of some organized atrial activity.
2. Headache (HA): The patient first reported a HA on return to
the CCU for her second admission. At first the HA was very
concerning for a viral or partially treated bacterial
meningitis. Neurology was consulted and recommended a LP,
however the patient contniued to refuse the procedure. As the
patient had a similar experience with HA on previous admission
where milrinone was used, the possibility of a milrinone induced
vasodilatory migraine type HA was raised. The patient was
empirically taken off the milrinone with some improvement in her
HA. At the same time however, the patient was also given
reduced doses of amiodarone and digoxin as well (dig was held
due to supratherapeutic levels). Also at this time, her
infection (see below) was under better control and the patient
began to respond to abx. Therefore the HA may have been
secondary to any of the above etiologies. Regardless, the
patient was continued on morphine IV for pain control and the
digoxin was held, amiodarone dose was decreased and the pt was
given a milrinone holiday for several days as above with
improvement.
She continued to have morning headaches on and off of dopamine
but this was well-relieved with tylenol.
3. ID:
A). The patient was re-admitted to the CCU with evidence of
urosepsis (fever, elevated WBC, clinical findings and CT scan
consistent with pyelonephritis and blood and urine cultures
positive for E.coli). She was initially started on imipenem,
vanc, and flagyl for empiric coverage of GU, GI and pulm
bacteria. The blood and urine cultures both returned positive
for E.coli with sensitivies to ceftriaxone, ceftaz, gent and
tobramycin and she was swiched over to Ceftriaxone IV 1mg on
[**2166-4-7**]. C. diff returned negative x3 and the flagyl was also
d/c'd. With the ceftriaxone alone, the patient became afebrile
for >48 hours and her WBC count and bands [**Month (only) **].
She was continued on levaquin for a 2wk course and remained
afebrile.
B). The patient had a small 1cm mass that is hard, mobile with
erythema and tenderness at the former RIJ site. US demonstrated
a samll 5x8mm fluid collection which was treated with warm
compresses with some improvement.
C) the patient believed he had a history of hepatitis, although
a full panel of serologies for her pre-transplantation workup
were negative.
4. Elevated LFTs: The patient initially had mild RUQ pain which
resolved during her hospitalization. She had a history of
cholecystectomy, and her LFTs were slightly elevated but stable
during the admission. Causes for liver dysfunction were
explored, and the patient was found to have a negative tylenol
screen, negative hepatitis panel, and a liver ultra sound on
[**2166-3-25**] which was unremarkable and showed normal flow in the
hepatic vasculature. The elevation in LFTs was presumed to be
from hepatic congestion.
5. Chest pain: From description by patient, the chest pain
seemed to be pleuritic in nature. There was no friction rub on
physical exam. The patient was treated with pain medications but
NSAIDs were held in the setting of aggressive diuresis and
concern over renal toxicity. The chest pain did not change over
the course of her hospital stay, and the patient states that she
chronically has this pain.
6. Thyroid: The patient was continued on her home dose of
synthroid. In hospital her TSH was 17 but her free T4 was 1.2.
The problem of starting amiodarone in this patient who has a
istory tyrotoxicosis secondary to amiodarone was discussed with
her endocrinologist, Dr. [**Last Name (STitle) **]. He felt comfortable starting
amiodarone and will follow her closely as a outpatient.
7. Psychiatric: The patient's amitriptyline wean by 25% per week
(decreased from 100->75mg q day on [**2166-3-26**]) with the plan of
starting a antiarrhythmic once she is completely off of the TCA.
She was started on sertraline 50mg PO once daily which was
increased to 100mg once daily on [**2166-4-11**]. She was continued on
her home doses of clonipin and ativan.
8. Renal:
A). Hyponatremia: The patient had significantly worsening
hyponatremia on return to the CCU(132->128->124->121). Given
the [**Month (only) **]. u/o, and [**Month (only) **]. FeNa and FeUrea, as well as the clinical
circumstance of urosepsis, this was thought to be consistent
with hypovolemic hyponatremia. The patient improved with NS as
well as with improved forward flow from milrinone and/ dopamine
as well as dicontinuation of aldactone.
B). Gap metabolic acidosis: The patient developed a gap with
[**Month (only) **]. in HCO3 earlier. This may be secondary to poor flow with
temporary stoppage of milrinone. After re-starting milrinone,
the gap closed to 12 and was no longer an issue.
9. Pulm: The patient had an Abd CT on [**2166-4-6**] that demonstrated
"innumerable non-calcified nodules on RLL". Chest CT confirmed
these findings and the ddx includes septic emboli, mycotic
infection, metastatic CA. During this course of acute
urosepsis, the patient is Not a candidate for bronchoscopy and
we will treat conservatively with repeat chest CT in future. If
patient becomes more symptomatic, we will consider additional
invasive procedure.
---f/u mycotic cultures and Aspergillus Ag
---Age appropriate CA screening when CCU stay is over -
Colonscopy, mammogram, pap.
10. FEN: Low sodium diet, replete potassium and magnessium
.
11. Ppx: Pt was started on a heparin gtt, however has had
elevated coags including PTT and INR. Suspect this may be
secondary to RHF with possible potentiation of coumadin received
on the floor with amiodarone and dig. We will stop all
anticoagulants as she is supratherapeutic. Anticipate
improvement in anticoagulation with improved PO intake and
improved CHF.
12. Access: The patient currently has peripheral IV x1 and PICC
line. PICC line of left arm appears to be somewhat swollen but
without erythema, induration or tenderness. US demonstrates no
thrombus within LUE veins. She was discharged with the PICC in
place.
13. Code Status: The patient was made DNR/DNI on this
admission. The status was discussed with her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 449**] P.
[**Doctor Last Name 2031**]. Prior to discharge, the patient decided to pursue
cardiac transplantation at [**Hospital1 336**] and her code status was changed
to full code.
Medications on Admission:
Aldactone 50mg QD, Ativan 1mg TID, Avaprol 75mg QD, Digoxin
125mcg QOD alternating with 250mcg. Imdur 120mg QD (30mg QD in
recent note from Cardiologist), Klonopin 0.5mg TID, Lasix 20 QD,
Synthriod 137mcg qd (in recent note from cardiologist), Lipitor
10mg QD, Pepcid 40mg QD, Zebeta 5mg QD, Percocet 5/325 TID, and
Coumadin 3mg QD ([**3-11**] INR 2.9).
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:*2*
2. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: per protocol.
Disp:*1 month supply* Refills:*0*
8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Sodium Chloride 0.9 % Syringe Sig: Three (3) ML Injection
DAILY (Daily) as needed: per protocol.
Disp:*1 month supply* Refills:*0*
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Congestive heart failure
Discharge Condition:
fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
.
Please take you medications as prescribed.
Call your doctor or go to the ER if you are having chest pain,
shortness of breath, chest heaviness, light headedness, leg
swelling, weight gain, or any other worrisome symptoms
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2031**] in 1 week. Please call to
schedule an appointment: [**Telephone/Fax (1) 11216**]
1) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2166-5-8**] 2:00
2) Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2166-6-12**] 1:00
3) You will also follow up with the [**Hospital1 336**] transplant service.
4) You will followup with the Heart Failure service for INR
checks
|
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"416.8",
"590.10",
"276.5",
"397.0",
"V45.81",
"790.92",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
17826, 17901
|
4362, 15599
|
318, 338
|
17970, 17976
|
2011, 3672
|
18374, 19015
|
1468, 1568
|
16004, 17803
|
17922, 17949
|
15625, 15981
|
18000, 18351
|
3688, 4339
|
1583, 1992
|
261, 280
|
366, 1110
|
1132, 1335
|
1351, 1452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,825
| 186,430
|
46611
|
Discharge summary
|
report
|
Admission Date: [**2107-12-19**] Discharge Date: [**2107-12-27**]
Service: SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
female with severe coronary artery disease status post MI
admitted with the acute onset of abdominal pain while getting
dressed on the morning of admission. The patient had no
previous history of this kind of pain. The patient was
brought to the emergency room for this pain and while in the
emergency room she had three to four loose bowel movements
with frank red blood. She complained of nausea, but denied
any vomiting. No fevers or chills. No palpitations, chest
pain or diaphoresis.
PAST MEDICAL HISTORY: CAD status post MI in [**2104**]. Status
post cath in [**2103**] with 100% RCA occlusion. Hypertension.
Hypothyroidism. Gout.
MEDICATIONS: Cardizem, Lasix, Synthroid, Prempro, aspirin,
atenolol.
ALLERGIES: Percocet and morphine.
PHYSICAL EXAMINATION: On physical exam temperature is 99.5,
blood pressure 170/69, pulse 79, respirations 20, oxygen
saturation 97% in room air. In general, the patient appears
in moderate distress. On HEENT exam mucous membranes are
dry. Oropharynx clear. Lungs clear bilaterally. Heart
regular rate and rhythm, no murmurs. Abdomen soft, positive
bowel sounds, slight periumbilical tenderness, no suprapubic
tenderness, no masses, no rebound or guarding. On rectal
exam vault empty, no masses or hemorrhoids.
LABORATORY DATA: White count 18.5 with differential of 57
neutrophils, 36 lymphocytes, hematocrit 49.6, platelets 498.
PT 14.6, INR 1.4, PTT 24.3. Electrolytes were remarkable for
BUN of 36, creatinine 1.4. Anion gap was 27. CT of the
abdomen showed numerous cysts in both kidneys which were
unchanged from a previous exam. There was also a region on
the left kidney of poorly perfused cortex with some capsular
retraction consistent with chronic renal infarct which is new
from previous exam. There was aneurysmal dilatation of the
abdominal aorta. The bowel was unremarkable. Cholelithiasis
without evidence of cholecystitis. The patient also
underwent mesenteric angiogram which showed segmental
occlusion at the origin of the ileocolic branch of the
superior mesenteric artery. There were also multiple smaller
filling defects in more distal jejunal branches.
HOSPITAL COURSE: The patient was admitted with multiple
mesenteric emboli. She was started on heparin. She was also
started on IV fluids and IV Cipro and Flagyl. She was
admitted to the SICU and was maintained on heparin.
Hematocrit remained stable at 41.3. On [**2107-12-21**] she was
transferred to the regular floor. She was continued on
heparin until she was therapeutic and was then started on
Coumadin. She was seen by the cardiology service and it was
felt that there was no need for further cardiac workup at
this point. She was started on Coumadin 5 mg q.h.s., but her
INR was supratherapeutic at 6.4 and Coumadin was thus
decreased to 2.5 mg q.h.s. Heparin was discontinued.
Her abdominal pain was much improved and she was tolerating a
regular diet and was discharged on hospital day nine.
Discharge status was stable. She was discharged home. INR
was 2.6 and it was decided to discharge her on a dose of
Coumadin 2.5 mg p.o. q.d. The patient will have her INR
checked three times a week and will follow up with her
primary care doctor, Dr. [**Last Name (STitle) 43672**], for adjustment of her
Coumadin.
DISCHARGE MEDICATIONS: Coumadin 2.5 mg p.o. q.d., Synthroid
100 ??????g p.o. q.d., atenolol 25 mg p.o. q.d., Cardizem, Lasix,
Prempro.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 21942**]
MEDQUIST36
D: [**2107-12-27**] 09:22
T: [**2107-12-27**] 13:38
JOB#: [**Job Number 98984**]
|
[
"401.9",
"414.01",
"272.0",
"574.20",
"578.1",
"441.4",
"244.9",
"557.0",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
3454, 3832
|
2318, 3430
|
929, 2300
|
122, 646
|
669, 906
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,270
| 164,425
|
40530
|
Discharge summary
|
report
|
Admission Date: [**2118-11-17**] Discharge Date: [**2118-11-29**]
Date of Birth: [**2089-6-13**] Sex: F
Service: MEDICINE
Allergies:
cefepime
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
mechanical intubation and ventilation
History of Present Illness:
The patient is a 29 y/o female w/ PMHx AML diagnosed in [**Month (only) **] s/p
7+3 followed by 5+2 induction, now day 18 of 4th cycle of HiDAC
consolidation who presents with febrile neutropenia. Today, pt
went for routine countcheck/eval, day 18 following 4th cycle of
HIDAC. Noted nasal congestion and drainage with sore throat.
Tmax at home this AM 100.1. Endorses fatigue, dry cough. Normal
PO intake. Denies Denies any nausea, vomiting, diarrhea or
constipation. Denies any abdominal pain or cramping. Denies any
shortness of breath, chest pain, chills or night sweats,
lightheadedness, or rashes.
Vital signs in the office today were:
BP: 101/66. HR: 109. W: 98. BMI: 18.5. T: 100.5, 100.1. RR: 18
O2sat 100%
Past Medical History:
Past Oncologic History:
Ms. [**Known lastname 88752**] is a 29-year-old female with history of AML. She
was in her usual state of health until about a month prior to
initial presentation, which was in [**Month (only) **] when she started to note
some increased bruising. She then had developed some daily
fevers and felt more fatigued and then ultimately had a syncopal
episode. She went to [**Hospital **] Hospital and then ultimately was
transferred to [**Hospital3 **] and upon review of her peripheral
smear was found to have blasts.
She had a bone marrow biopsy on [**5-26**], which reveals AML-M2 with
approximately 23% blasts. Her blast expressed HLA-DR, CD33,
CD117, CD11c subset M. In terms of her presenting cytogenetics,
she did not have any abnormal cytogenetics and she was with FLT3
and NPM negative. When she presented, she had a white count of
3.4, hemoglobin of 7.1, hematocrit of 18.9 and a platelet count
of 23,000 with approximately 60% circulating blasts. She
proceeded with 7 and 3 (Cytarabine and Daunorubicin). On her
day 14 marrow, which was done on [**6-9**] unfortunately, it
revealed a hypocellular marrow with increased blasts, some
left-shifted myelopoiesis. As a result of her persistent
disease, she proceeded with 5 and 2 regimen with daunorubicin
and cytarabine. Her treatment course was complicated by fever
and no clear source was identified. There was question as to
whether it was related to her chemotherapy. She ultimately was
discharged from the hospital on [**7-10**]. Had a bone marrow bx and
aspirate on [**7-14**] which did not reveal any morphologic or
cytogenetic evidence of disease.
.
[**2118-7-25**]: Cycle #1 high-dose ARA-C, complicated by fever, most
likely due to ARA-C as had similar symptoms during induction.
[**2118-8-10**] to [**2118-8-19**]: Hospitalized for neutropenic fever and
typhlitis.
[**2118-8-29**] to [**2118-9-5**]: Cycle #2 HIDAC.
[**2118-9-29**] to [**2118-10-4**]: Cycle #3 HIDAC.
[**2118-10-31**] to [**2118-11-5**]: Cycle #4 HIDAC.
.
OTHER PAST MEDICAL HISTORY: Reveals an admission to [**Hospital1 2025**] around
[**2110**] which by her report was for 2 days for low blood counts,
admission to [**Hospital **] Hospital for gastroenteritis.
Social History:
Originally from [**Country 4194**], she has been in the US for 16 years.
Not currently working, but was previously a housekeeper. She is
single, has an 8yo son, and they live with her twin sister
[**Doctor First Name 88753**] [**Telephone/Fax (1) 88754**]). Parents remain in [**Country 4194**]. No
tobacco, alcohol or drugs.
Family History:
Mother--possible transfusion-dependent MDS.
Father--healthy.
No other major medical problems.
Physical Exam:
ON ADMISSION:
Vitals - T: 100.1 BP 96/54 HR 85 RR 16 99% on RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
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
.
AT DISCHARGE:
Pertinent Results:
ADMISSION LABS:
[**2118-11-17**] 09:55AM BLOOD WBC-0.5* RBC-2.93* Hgb-9.5* Hct-24.8*
MCV-85 MCH-32.5* MCHC-38.3* RDW-15.4 Plt Ct-17*#
[**2118-11-17**] 09:55AM BLOOD Neuts-8 Bands-0 Lymphs-72 Monos-17 Eos-0
Baso-0 Atyps-3 Metas-0 Myelos-0
[**2118-11-17**] 09:55AM BLOOD Gran Ct-8*
[**2118-11-17**] 09:55AM BLOOD UreaN-9 Creat-0.7 Na-134 K-4.2 Cl-97
HCO3-26 AnGap-15
[**2118-11-17**] 09:55AM BLOOD ALT-51* AST-30 AlkPhos-132* TotBili-1.1
CXR [**2118-11-15**]
IMPRESSION: PA and lateral chest compared to [**8-18**] through
[**9-1**]:
Normal heart, lungs, hila, mediastinum and pleural surfaces.
.
CXR [**2118-11-17**]
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal appearance of the lung parenchyma, no pleural
effusions.
Normal size and shape of the mediastinal structures and the
cardiac
silhouette. No pneumonia.
.
CXR [**2118-11-19**]
Overall, the cardiac and mediastinal contours are stable. The
interstitium appears slightly prominent throughout both lungs
but when
compared to multiple previous studies given differences in
technique, this is not likely significantly changed. No focal
airspace consolidation is seen to suggest pneumonia. No pleural
effusions or pneumothorax. If the patient's symptoms persist,
followup imaging should be considered. No acute bony
abnormality.
.
CXR [**2118-11-19**]
FINDINGS: As compared to the previous radiograph, the
inspiratory volume has decreased. In addition, there is a
relatively ill-defined bilateral pattern of parenchymal
opacities with air bronchograms and minimal bronchial cuffing.
Given the patient's clinical presentation, this change would be
consistent with pneumonia. Otherwise, there is no relevant
change. Borderline size of the cardiac silhouette. No evidence
of pleural effusions. Normal appearance of the hilar and
mediastinal contours.
chest CT [**2118-11-21**]:
IMPRESSION:
1. Multifocal lung consolidations and small nodular opacities
rapidly
appearing over few days and given the clinical history is
concerning for lung infection, likely bacterial. Fungal
infection though less likely, cannot be ruled out.
Alternatively, recent leukocytosis in immune challenged patient
as reflected from online medical records, may cause similar
appearance.
2. Mild pulmonary artery hypertension.
ECHO [**2118-11-25**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate global left ventricular hypokinesis (LVEF = 35-40%).
Systolic function of apical segments is relatively preserved.
Right ventricular chamber size is normal with mild global free
wall hypokinesis. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with mild-moderate
global left ventricular hypokinesis and mild right ventricular
free wall hypokinesis c/w diffuse process (toxin, metabolic,
etc. - less suggestive of multivessel CAD, but cannot fully
exclude).
Compared with the prior study (images reviewed) of [**2118-6-16**],
global biventricular systolic function is now depressed.
ADMISSION LABS:
MICROBIOLOGY:
Blood cultures 12/1- negative
Blood cultures [**11-18**]- negative
Throat culture [**11-17**]-
GRAM STAIN- R/O THRUSH (Final [**2118-11-17**]):
NEGATIVE FOR YEAST.
NO [**Doctor Last Name **] ORGANISMS SEEN.
R/O Beta Strep Group A (Final [**2118-11-19**]):
NO BETA STREPTOCOCCUS GROUP A FOUND.
Rapid respiratory viral culture [**11-18**]- negative
Blood cultures 12/3- negative
Urine culture [**11-19**]- negative
Urine culture [**11-20**]- negative
Expectorated sputum [**11-20**]- gram stain >25 PMNs and >10
epithelials/100x field, no acid fast bacilli on smear, culture
pending
Blood culture for mycolytics- NGTD, pending
Urine culture [**11-21**]- negative for urinary legionella antigen
Fungal culture pending
Bronchoalveolar lavage [**11-21**]-
RML- GRAM STAIN (Final [**2118-11-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
Culture- no legionella, no acid fast bacilli on smear, no
PCP, >6000 commensal respiratory flora, no fungus
Lingula- GRAM STAIN (Final [**2118-11-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
CULTURE- no legionella, no acid fast bacilli on smear,
culture showing >5000 commensal respiratory flora, no fungus
Rapid Respiratory Viral Screen & Culture- negative for HSV, CMV,
VZV
Stool- c.diff negative
CMV viral load ?????? no CMV DNA detected
Aspergillus antigen- 0.1
Beta-glucan- <31
Histoplasma antigen - urine - negative
..........................
Mycoplasma pneumonia PCR- pending
Aspergillus antigen from BAL- pending
[**Location (un) **] virus B antibodies - pending
PERTINENT LABS THROUGHOUT HOSPITAL COURSE
CBC:
[**2118-11-23**] 03:20PM BLOOD WBC-10.4# RBC-2.94* Hgb-9.4* Hct-25.2*
MCV-86 MCH-31.9 MCHC-37.2* RDW-14.9 Plt Ct-55*
[**2118-11-29**] 06:28AM BLOOD WBC-3.3* RBC-3.23* Hgb-10.3* Hct-29.0*
MCV-90 MCH-31.8 MCHC-35.3* RDW-17.7* Plt Ct-104*
DIFF:
[**2118-11-21**] 06:05AM BLOOD Neuts-67 Bands-1 Lymphs-13* Monos-18*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2118-11-23**] 03:24AM BLOOD Neuts-90.4* Lymphs-5.0* Monos-4.3 Eos-0.2
Baso-0.1
[**2118-11-26**] 12:00AM BLOOD Neuts-79.4* Lymphs-10.2* Monos-10.0
Eos-0.1 Baso-0.3
ANC:
[**2118-11-18**] 05:55AM BLOOD Gran Ct-144*
[**2118-11-19**] 06:00AM BLOOD Gran Ct-710*
[**2118-11-20**] 07:25AM BLOOD Gran Ct-1748*
[**2118-11-21**] 06:05AM BLOOD Gran Ct-2584
[**2118-11-26**] 12:00AM BLOOD Gran Ct-3260
LFTs:
[**2118-11-21**] 06:30AM BLOOD ALT-30 AST-30 LD(LDH)-299* AlkPhos-97
TotBili-0.8
[**2118-11-24**] 07:14AM BLOOD ALT-101* AST-110* AlkPhos-107*
TotBili-0.4
[**2118-11-29**] 06:28AM BLOOD ALT-48* AST-45* AlkPhos-105 TotBili-0.5
OTHER:
[**2118-11-21**] 06:30AM BLOOD proBNP-[**Numeric Identifier 45977**]*
[**2118-11-26**] 08:21AM BLOOD CK-MB-1 cTropnT-<0.01
[**2118-11-26**] 12:00AM BLOOD cTropnT-<0.01
[**2118-11-23**] 08:08AM BLOOD Hapto-310*
[**2118-11-29**] 06:28AM BLOOD TSH-2.8
[**2118-11-29**] 06:28AM BLOOD Cortsol-26.6*
[**2118-11-23**] 08:08AM BLOOD Fibrino-688*#
Brief Hospital Course:
The patient is a 29 y/o female w/ PMHx AML diagnosed in [**Month (only) **] s/p
7+3 followed by 5+2 induction, s/p 4th cycle of HiDAC
consolidation who presents with febrile neutropenia, fevers to
104, and bilateral pulmonary infiltrates.
# Febrile neutropenia- pt s/p 4 cycles HiDAC consolidation,
presented at 18 days from last cycle. P/w cough, rhinorrhea,
nasal congestion, fatigue, and fever of 100.5 suggestive of
viral infection. CXR, UA, cultures, viral swabs were all
negative. On presentation her ANC was 8. Aztreonam and
vancomycin were started. Pt had been taking home cipro and
acyclovir prophylactically. Cipro was discontinued. Pt continued
to spike with fevers of 102-104. Additionally, she developed a
new O2 requirement. Ambisome was added. CT chest showed
bilateral extensive opacities, concerning for multifocal
bacterial pneumonia, less likely fungal infection. Other
etiologies considered include DAH, TRALI vs TACO (1 pRBCs had
been administered on her 3rd day of hospitalization), drug
pneumonitis given recent high dose ARA-c. In the setting of
potential pulmonary infection, Levaquin was started, aztreonam
switched to meropenem to cover for ESBL, Bactrim and prednisone
started for PCP. [**Name10 (NameIs) **] transferred to the ICU, electively
intubated for bronchoscopy, which showed 1+ GPC and 1+ GNR, and
negative PCP, [**Name10 (NameIs) **] which point Bactrim and prednisone were
discontinued. B-glucan and galactomannan were negative, urine
Legionella and Histo Ab negative. Negative mycoplasma PCR and
coccidiomycosis. [**Location (un) **] virus antibodies still pending at
time of discharge. Ambisome was discontinued after patient
clinically improved and fungal markers negative. BAL cultures
did not grow any organisms. Pt defervesced and was extubated and
transferred to the floor. Pt remained afebrile with
non-neutropenic counts throughout the rest of the hospital stay.
# Hypoxic respiratory failure- Patient developed respiratory
distress in the setting of fevers. CT chest showed extensive
bilateral opacities concerning for multifocal bacterial
pneumonia, viral infection vs fluid overload with multiple
transfusions. Patient electively intubated for bronchoscopy,
initially difficult to extubate [**1-19**] tachypnea and high FiO2/PaO2
ratio. Antibiotics treatment per above. CXR began to clear
after diuresis with lasix and auto-diuresis, and patient was
extubated without complications. Testing for fungal wall
elements, histo, legionella, CMV, crypto, coccidio, and
mycoplasma negative. Unclear etiology of infection. [**Location (un) **]
virus antibodies pending. Pt also with elevated BNP, c/f heart
failure. TTE showed newly decreased EF of 35-40% (see
cardiomyopathy, below).
# Cardiomyopathy- In the setting of respiratory failure
responsive to diuresis, a repeat ECHO was obtained with showed
biventricular and global hypokinesis (new compared to [**5-/2118**])
and EF 35-40%. This is likely [**1-19**] recent chemotherapy as pt
received daunorubicin, exacerbated in the setting of sepsis and
increased demands on the heart. Pt started on carvedilol 3.125mg
[**Hospital1 **], to have follow up with cardiology in 2 weeks at which time
most likely repeat of TTE. On the floor, pt's blood pressure ran
in the high 70s and 80s systolic. Her first day out on the floor
her SBPs were in the high 70s and pt required two 250cc boluses
to maintain SBP in the 80s, likely combination of dehydration
(decreased PO intake) in setting of decreased myocardial
function. Pt was started on low dose carvedilol, however she
remained slighly hypotensive so this was switched to metoprolol.
#hypotension - on admission, pt had SBP from high 80s to 120s.
In the past it appears her SBPs have run in the 90s. After pt
was called out to the floor she had SBP in the high 70s. She
reported some diarrhea, having just started her period, and
decreased PO intake in this setting, all likely compounding the
effects of underlying cardiomyopathy with decreased EF and
contributing to hypotension. Pt was also started on carvedilol
in the setting of CHF. Pt was monitored on telemetry without
arrhythmia or other events, HR initially fluctuated between 60
and low 100s and then stabilized to remain in roughly the 80s
range. Carvedilol was switched to metoprolol for its decreased
alpha blocking effects. Pt went home on metoprolol XL 50mg
daily.
# AML/Pancytopenia - S/p 4 cycles of consolidation. Continue
therapy per primary oncologist. Patient counts recovering.
Supportive transfusion with threshold Hct<21, and plt<10.
Patient required a total of 2 units pRBC during this
hospitalization.
# Transaminitis: Mild, likely due to chemo. transaminase levels
peaked towards the end of [**Month (only) **] and trendeding back to
baseline. During her stay in the ICU, transaminitis recurred and
was thought to be direct toxicity from one of the broad spectrum
drugs she was receiving, likely ambisome. Acyclovir was held in
this setting. LFTs trended down as antibiotic and fungal
coverage narrowed.
TRANSITIONAL ISSUES:
Pt had TSH and AM cortisol sent for evaluation of hypotension.
These results were not back at the time of discharge. Since then
they have come back showing TSH of 2.8 and cortisol of 26.6,
slightly elevated.
Also, [**Location (un) **] virus antibodies pending at time of discharge.
Medications on Admission:
Acyclovir 400mg TID
Ciprofloxacin 500mg [**Hospital1 **]
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
3. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
febrile neutropenia
multifocal pneumonia
Acute systolic heart failure
SECONDARY:
hypotension
acute myeloid leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 88752**],
It was a pleasure taking care of you during your recent
hospitalization. You were admitted with a fever in the setting
of very low white blood cell counts because of your recent
chemotherapy. These are the cells needed to fight infection, so
we started you on some very strong antibiotics. Even so, you
continued to have fevers and then developed low oxygen levels. A
CT scan of your chest showed a pneumonia located in multiple
different areas, and because of that it became more and more
difficult for you to breathe. Accordingly you were sent to the
ICU and placed on a breathing machine (intubated) while the
infection cleared up. After several days you improved and you
were able to come off the ventilator. During your stay in the
ICU your white blood cell counts recovered and were back to
normal. You came back to the floor and continued to recover,
however your blood pressure was low. An echocardiogram of your
heart showed that your heart was not functioning as well as it
had been the last time we looked at this in [**Month (only) **]. We started a
medication called metoprolol which has been shown to be very
helpful in situations of decreased heart function. We think the
[**Last Name **] problem is possibly related to one of the chemotherapy
drugs, in addition to the serious infection. We think your low
blood pressures were due to a combination of the heart function
and being dehydrated. Your blood pressure remained stable
although on the low side, and you were able to walk around and
drink enough fluids on your own to keep it in the normal range.
We sent you home with an appointment to follow up with
cardiology for the heart issue. You will also follow up in the
bone [**Hospital6 **].
The following CHANGES were made to your medications:
START metoprolol succinate 50mg daily
STOP ciprofloxacin
START fluconazole (for mouth infection) take for 7 more days
Continue your acyclovir as you had been taking it before you
were admitted to the hospital (400mg tablet three times a day)
Followup Instructions:
Please follow up with the appointments below.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2118-12-6**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2118-12-6**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Department: CARDIAC SERVICES
When: WEDNESDAY [**2118-12-14**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2118-12-23**] at 2:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr [**Last Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. She works closely with Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care. Please call
your insurance and name Dr. [**Last Name (STitle) **] as your PCP. [**Name10 (NameIs) **] MUST BE DONE
BEFORE YOUR APPOINTMENT.
|
[
"428.23",
"205.00",
"425.4",
"780.61",
"288.03",
"790.4",
"276.2",
"284.19",
"428.0",
"E933.1",
"458.9",
"276.8",
"799.02",
"518.81",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"33.24",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
17055, 17061
|
11181, 16225
|
285, 324
|
17231, 17231
|
4397, 4397
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19447, 21096
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3684, 3779
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16637, 17032
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17082, 17210
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16555, 16614
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|
240, 247
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352, 1070
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7945, 11158
|
3808, 4362
|
17246, 17358
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3141, 3321
|
3337, 3668
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,078
| 180,553
|
4517+55585
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-8-7**] Discharge Date: [**2195-8-12**]
Date of Birth: [**2150-11-14**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
right flank pain and redness
Major Surgical or Invasive Procedure:
Removal of spinal cord stimulator and debridement
History of Present Illness:
This 44 year old female with a history of RLL sympathetic
dystrophy/chronic pain s/p placement of spinal cord stimulator
with good result. Presented to the ED on [**2195-8-7**] with right
flank pain and redness. She also had an increased WBC count,
fever, and tachycardia. She was taken to the OR where she was
found to have severe cellulites with a pocket of pus surrounding
the cord stimulator. The stimulator was removed. Cultures grew
gram + cocci in pairs and clusters. She was treated with 1gm
Vanco, 1gm Ceftriaxone, and Oxacillin. She also had occasional
cough productive of yellow sputum, negative CXR. She is now
being treated with Vanco for incision infection and ? of
pulmonary infection. She was initially admitted from the ED to
CC7 but transferred to the MICU after having SBPs in the 60s to
70s. Patients baseline SBP is in the 90s. She is now stable
and transferred back to cc7.
Past Medical History:
1. Chronic lower back pain s/p implanted stimulator,
parasthesias
Social History:
Lives with husband, no EtOH, no tobacco
Family History:
Non-contributory
Physical Exam:
Temp 98.9
BP 100/60
Pulse 84
Resp 20
O2 sat 97% on RA
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Respiratory wheezes and coughing on deep inhalation
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - Dressing on right flank C/D/I, wound 3 by 1 inch, clean,
with good granulation tissue and no evidence of abscess
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-19**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Pertinent Results:
[**2195-8-7**] 04:25PM WBC-21.5*# RBC-4.10* HGB-13.0 HCT-36.1 MCV-88
MCH-31.7 MCHC-36.1* RDW-12.3
[**2195-8-7**] 04:25PM GLUCOSE-96 UREA N-9 CREAT-0.8 SODIUM-135
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
Brief Hospital Course:
Please see Dr.[**Name (NI) 19275**] discharge summary for further
details of her hospital course.
Mrs. [**Known lastname 19276**] was admitted to the MICU after removal of the cord
stimulator due to SBPs in the 60s to 70s. Upon stabilization of
her SBP back to her baseline of 90 she was transfered from the
MICU to the floor. On the floor she was treated for the
following issues.
1. Pain control - She suffers from both chronic pain in her
right leg and the acute pain of the opperation. We discontinued
her morphine PCA and started her on a regimen of long acting
morphine with short acting morphine for breakthrough pain. She
was also given doses of morphine for her dressing changes. We
also continued to give her Tylenol, Advil, and Neurontin for her
pain.
2. Right flank abscess - The cultures obtained in the OR of the
abscess site grew MSSA. We stopped the Vancomycin and started
her on Oxacillin IV to treat the MSSA. She remained afebrile
and her WBC count resolved. In the setting of an infection with
a decreased blood pressure consitent with sepsis we plan to
obtain an Echo to rule out endocarditis. All blood cultures
show no growth to date.
3. Pulmonary - She continued to have a cough and wheezes. She
stated that she had had the cough for a month so we started her
on Protonix, Nasal steroids, and Albuterol inhaler as treatment
for her chronic cough. A repeat CXR showed a "left pleural
effusion appears to be loculated; it is not free flowing on the
left lateral decubitus view. Because it is loculated, it is
possible to visualize the lung underneath this effusion.
Possible infiltrate cannot be assessed." She is being worked up
for causes of this.
4. Heme - Her HCT remained stable while in my care 28.9 from
29.0.
5. Prophylaxis - She was maintained on normal diet and was
ambulating while in my care. She was given Lactulose for
constipation.
Medications on Admission:
1. Nortriptyline 100mg qHS2.
2. Neurontin 1400mg TID
3. MS Contin 45mg TID4.
4. Actonel 35mg qWeek
5. Percocet prn
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
See Dr.[**Name (NI) 19275**] discharge
Discharge Condition:
See Dr.[**Name (NI) 19275**] discharge
Discharge Instructions:
See Dr.[**Name (NI) 19275**] discharge
Followup Instructions:
See Dr.[**Name (NI) 19275**] discharge
Name: [**Known lastname 3141**],[**Known firstname 153**] Unit No: [**Numeric Identifier 3142**]
Admission Date: [**2195-8-7**] Discharge Date: [**2195-8-12**]
Date of Birth: [**2150-11-14**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1852**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Removal of spinal cord stimulator
History of Present Illness:
see Dr.[**Name (NI) 3143**] d/c note
Past Medical History:
1. Chronic lower back pain s/p implanted stimulator,
parasthesias
Social History:
Lives with husband, no EtOH, no tobacco
Family History:
Non-contributory
Physical Exam:
98.3 110/60 80 16 95% RA
Gen: alert and oriented, sitting up in bed in NAD
HEENT: pupils pinpoint, OP clr without lesion, neck supple, no
meningismus
Lungs: CTA bilaterally, no wheezes/crackles/rhonchi
CV: RRR, no m/r/g
Back: wounds dressed, c/d/i
Abd: soft, nt/nd. +bs.
Ext: RLE exquisitely tender per baseline, 2+ dp pulses, no c/c/e
Pertinent Results:
[**2195-8-11**] 05:55AM BLOOD WBC-4.5 RBC-3.49* Hgb-11.1* Hct-31.2*
MCV-90 MCH-31.8 MCHC-35.5* RDW-12.3 Plt Ct-297
[**2195-8-11**] 05:55AM BLOOD Ret Aut-0.9*
[**2195-8-11**] 05:55AM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-141
K-4.0 Cl-105 HCO3-28 AnGap-12
[**2195-8-11**] 05:55AM BLOOD Iron-94
[**2195-8-11**] 05:55AM BLOOD calTIBC-152* VitB12-1518* Folate-GREATER
TH Ferritn-PND TRF-117*
Brief Hospital Course:
Please see d/c summary from Dr. [**Last Name (STitle) **] for hospital course
until [**2195-8-11**]. This hospital course covers [**Date range (1) 3144**].
1. Pulmonary: Pt was seen to have a L-sided pleural effusion by
CXR in left lateral decub. Appeared as though it was loculated,
so f/u CT revealed a tiny L sided effusion. As this was
asymptomatic and felt by Interventional Pulmonology to be
trivial, a thoracentesis was not performed. It was felt this
was secondary to the large amount of IVFs she received over the
weekend. Her O2 saturation remained over 95% and she did not
experience any SOB. Will need CXR repeated in one month.
2. Pain control: Pt was switched to po pain medications with
good control. She was scheduled for f/u the day after d/c with
her Pain Clinic. She was receiving MS SR 75 mg q8h with MS IR
30 mg q1-2 hrs breakthrough.
3. ID: She remained afebrile over the last 2 days. Her abx
regimen was changed from Oxacillin to Cefazolin in order to
lessen the number of times she would need the visiting nurse to
give abx through her PICC. She was discharged with a
prescription for Cefazolin to complete a total of 14 days of
abx. She had a negative TTE and negative blood cultures.
4. Anemia: Pt was found to be anemic. Her transferrin was low
and TIBC were low, possibly anemia of chronic disease.
Recommend f/u as outpt.
5. GI: Pt was nauseated with morphine, but this was relatively
relieved with compazine. Pt also experienced some constipation
which was relieved with Lactulose.
Medications on Admission:
as per Dr.[**Name (NI) 3143**] note
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Nortriptyline HCl 50 mg Capsule Sig: Two (2) Capsule PO HS
(at bedtime).
3. Gabapentin 300 mg Capsule Sig: Six (6) Capsule PO QAM (once a
day (in the morning)).
4. Gabapentin 300 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
6. Morphine Sulfate 15 mg Tablet Sig: Two (2) Tablet PO Q1-2H ()
as needed for breakthrough pain.
7. MS Contin 30 mg Tablet Sustained Release Sig: 2.5 Tablet
Sustained Releases PO every eight (8) hours.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
8. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
9. Cefazolin Sodium 1 g Piggyback Sig: One (1) Piggyback
Intravenous Q8H (every 8 hours) for 10 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3145**] Healthcare
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Good
Discharge Instructions:
Please call your PCP with increased pain at wound site,
increased redness or swelling at wound site, numbness or
tingling in legs, urinary or fecal incontinence, increasing
productive cough, shortness of breath, or headache.
Please obtain a f/u CXR in one month.
Followup Instructions:
Provider: [**Name Initial (NameIs) 3146**] PAIN MANAGEMENT CENTER Where: PAIN MANAGEMENT
CENTER Date/Time:[**2195-8-13**] 8:40
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**]
Completed by:[**2195-8-12**]
|
[
"E878.1",
"V09.0",
"511.9",
"285.9",
"996.63",
"337.29",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.94"
] |
icd9pcs
|
[
[
[]
]
] |
8886, 8947
|
6387, 7919
|
5314, 5351
|
9002, 9008
|
5975, 6364
|
9320, 9606
|
5580, 5599
|
8005, 8863
|
8968, 8981
|
7945, 7982
|
9032, 9297
|
5614, 5956
|
5265, 5276
|
5379, 5417
|
5439, 5507
|
5523, 5564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,172
| 153,138
|
29327
|
Discharge summary
|
report
|
Admission Date: [**2146-11-28**] Discharge Date: [**2146-12-5**]
Date of Birth: [**2061-4-9**] Sex: M
Service: SURGERY
Allergies:
Bactrim DS
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2146-11-29**]
1. Total laminectomies of T10, T11, L1, and L2.
2. Extra cavitary decompression of T12.
3. Fusion of T10 to L2.
4. Instrumentation of T10 to L2.
5. Autograft.
History of Present Illness:
85M s/p MVC vs pole, then veered into a tree. Does not remember
losing control of the car, ? LOC. Notes low back pain on
arrival to ED. Found to have C4 spinous process, C7 left
transverse process, T12 vertebral body and spinous process
fractures. Taken to OR for thoracic/lumber fusion. Was
neurologically normal until pt was flipped prone. Now have b/l
LE paralysis (although pt is able to move left toes).
Significant blood loss in OR of ~ 3.5L. Transferred to TICU from
OR intubated with levophed and phenylephrine GTT.
Past Medical History:
PMH: CAD, HTN, HL, BPH, BPPV, spinal stenosis, pacemaker
,tinnitus, renal insufficiency (lasix recently stopped for Cr
2.2, new baseline since [**2145**] 2.1-2.3)
PSH: pacemaker implantation, CABG x 4 [**2145**], AVR with St.[**Male First Name (un) 923**]
Epic Tissue Valve [**2145**], TURP, back surgery for spinal stenosis,
bilateral knee replacement
Social History:
-Tobacco history: never
-ETOH: never
-Illicit drugs: never
Pt is a former [**University/College **] design and land development professor.
Lives in [**Location **] with grandson and a close friend. His friend
helps out with cooking, and he bathes himself. Pt is still
active in planning an intergenerational apartment complex in
[**Hospital1 8**].
Family History:
Father died at [**Age over 90 **] yo of CHF. Mother had a "[**Last Name **] problem" since
her youth but died at [**Age over 90 **] yo of complications after hip fx. Two
sisters both 80 and 82 yo with hx of colon cancer.
Physical Exam:
On arrival to the ED at [**Hospital1 18**]:
HR: 104 BP: 169/98 Resp: 16 O(2)Sat: 100 Normal
Constitutional: Uncomfortable
HEENT: Pupils equal, round and reactive to light
Tympanic membranes clear, no tenderness in back of neck
Chest: Airways intact, bilateral breath sounds, no
crepitus, chest stable
Cardiovascular: 2+ radial and pedal pulses bilaterally
Abdominal: Soft
Extr/Back: Upper and lower extremities stable bilaterally,
2+ radial and 2+ pedal pulses bilaterally
Skin: Warm and dry
Neuro: Speech fluent
Upon discharge:
HR: 97 BP: 118/70 Resp: 18 O2 sat: 95% on RA Temp:97.8
Neuro: Alert and oriented x 3, follows commands, speech fluent
and clear, + sensation bilateral LE, + movement bilat LE
strength 2-3/5, PERRLA
Chest: CTA bilaterally, normal S1S2
Abd: soft, nondistended, nontender, +BS, +flatus
GI: foley in place, clear yellow urine
Ext: +PP, warm and pink
Pertinent Results:
CT head ([**2146-11-28**]) - no acute process
CT cspine ([**2146-11-28**]) 1. Acute fracture of C4 spinous process, C7
left transverse process, and bilateral first ribs.
2. Hematoma in the paraspinal muscles posterior to C2 through
C5. Consider MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for ligamentous injury if not
contraindicated. 3. Multilevel degenerative changes with
bilateral moderate to severe neural foraminal narrowing at
multiple levels and mild to moderate central canal narrowing,
most prominent at C3-C4.
CT torso ([**2146-11-28**]) 1. No acute intraabdominal process.
2. Unstable transverse fracture through the T12 vertebral body
with anterior distraction and extension through the posterior
elements, highly concerning for cord and ligamentous injury.
3. Fracture of the left first, second, and third ribs with
associated chest wall hematoma. Fracture of the right first rib
and the fourth anterior costochondral junction.
4. Fracture of the sternum with associated mediastinal hematoma.
5. Stable pancreatic and renal cysts.
6. 2-mm right lower lobe pulmonary nodule. Follow chest CT in 1
year is recommended if the patient has a history of smoking or
prior malignancy; otherwise no further follow up is required.
CT T spine [**12-1**]: 1. T12 fracture, status post fusion of T10
through L2. No evidence of hardware loosening.
2. Limited evaluation of spinal canal due to a CT modality and
streak
artifacts from hardware. If there is continued concern for
significant spinal canal stenosis, CT myelography is
recommended.
CT L spine [**12-1**]: 1. Limited study due to streak artifact from
hardware and subcutaneous attenuation from prior surgeries. If
there is continued concern for cord impingement, recommend
correlation with a CT myelogram. 2. Post-surgical changes from
T10-L2 fusion and L3-S2 fusion
CXR [**12-2**]: Stable position of support and monitoring devices.
Unchanged effusions. No evidence of pneumonia or new vascular
congestion
[**2146-11-28**] 10:28AM WBC-10.0 RBC-3.71* HGB-11.2* HCT-33.1* MCV-89
MCH-30.3 MCHC-34.0 RDW-14.9
[**2146-11-28**] 10:28AM NEUTS-59.7 LYMPHS-36.0 MONOS-3.3 EOS-0.9
BASOS-0.1
[**2146-11-28**] 10:28AM PLT COUNT-258
[**2146-11-28**] 10:28AM PT-12.5 PTT-25.3 INR(PT)-1.1
[**2146-11-28**] 10:28AM GLUCOSE-123* UREA N-25* CREAT-1.6* SODIUM-142
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-20* ANION GAP-16
[**2146-11-28**] 02:52PM CK-MB-16* MB INDX-2.2 cTropnT-0.02*
[**2146-11-28**] 02:52PM CK(CPK)-720*
[**2146-11-28**] 10:07PM CK-MB-22* MB INDX-1.6
[**2146-11-28**] 10:07PM CK(CPK)-1380*
Brief Hospital Course:
TSICU course:
Mr. [**Known lastname 6164**] was admitted to the trauma ICU on [**11-28**]. Ortho spine
was consulted for is cervical and T12 fractures, and he was
taken to the operating room on [**11-29**] for T10-L2 spinal fusion.
When flipped prone the patient was shown to have no motor
function seen in the lower extremities. (please see operative
report from Dr. [**Last Name (STitle) 363**] for details). Also during the operation
there was significant blood loss requiring TXA infusion and
massive transfusion. He was transferred out of the OR with
Levophed and Neo GTT. Transfused rest of 200ml cell-[**Doctor Last Name 10105**] blood.
The patient came with noticable leak from 6.5 ETT and cuff
maximally inflated. DL with glidescope showed significant soft
tissue redundancy, edematous airway/tongue, and herniation of
cuff outside of the vocal cords. Fiberoptic bronch placed inside
ETT until carina visualized to confirm placement within airway.
ETT advanced and cuff distal to vocal cords.
On [**11-30**] he was noted to be moving all extremities when sedation
off. He received 500cc NS bolus for low UOP, as well as 1U PRBC
in AM. FeNa suggests pre-renal. When The ICU team attempted to
wean pressors but was unable to get past 0.06. 1U PRBC given
overnight. Also of note, his creatinine bumped to 2.4. On
[**12-1**], he was started on a lasix gtt. Thrombocytopenia, no signs
of bleeding, coags and fibrinogen within normal limits. He also
received PRBCX1 for mild hypotension. On [**12-2**] he was extubated
extubated and the lasix GTT off. He was advanced to a regular
diet and betablockers were restarted (started labetolol instead
of atenolol because atenolol renally cleared). He was on all PO
medications and began to autodiurese. On [**12-3**] the surgical
drain was removed by Dr. [**Last Name (STitle) 363**] and his urine output continued
to improve. He remained hemodynamically stable and was
transferred to the floor from the ICU.
Floor course:
On [**11-24**] Mr. [**Known lastname 6164**] was transferred to the surgical floor. His
vital signs were routinely monitored and he remained afebrile
and hemodynamically stable. His oxygen saturation was monitored
with vital signs and remained in the mid to upper 90's on room
air. Incentive spirometry and pulmonary toileting were
encouraged. His pain was well controlled with oral pain
medication. He continued to have improved mobility and sensation
in his lower extremities. At the time of discharge he was able
to move both lower extremites, but had decreased strength 2-3/5,
worse in the right than the left. He remained alert and oriented
and was following commands appopriately.
On [**12-5**] in the morning he became nauseated when getting out of
bed and had one episode of emesis. Of note, the patient had not
had a bowel movement since prior to admission. He had previously
been started on a bowel regimen of miralax and colace, and was
also given a dulcolax suppository on [**12-5**]. His abdomen remained
soft, nondistended and nontender. He had + bowel sounds and
reported passing flatus at the time of discharge. Aside from the
one episode of vomiting, he was tolerating a regular diet. He
failed a void trial on [**12-4**], and on [**12-5**] his foley was
replaced. He was voiding adequate amounts of clear yellow urine
at the time of discharge via the foley. His creatinine continued
to trend downward to his baseline and 1.4 at the time of
discharge. He remained afebrile with a normal WBC count of 7.4
upon discharge. He was on SC heparin for DVT prophylaxis.
Physical therapy was consulted who recommended discharge to an
extended care facility when medically stable for continued PT
needs. He remained in a TLSO brace when the head of the bed was
greater than 45 degrees or when out of bed. He remained in the
cervical collar at all times. On [**12-5**], he was discharged to an
extended care facility with plans to return the following week
for an anterior fusion with Dr. [**Last Name (STitle) 363**] for further stabilization
of the spine.
Medications on Admission:
tylenol 2 tabs prn pain, calcium carbonate 1250', colace 100'',
finasteride 5', folic acid 1', toprol xl 25', omeprazole 20',
zocor 40', flomax .4', vitamin D 1000', miralax daily, meclizine
25', multivitamin
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. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
s/p MVC
Injuries:
C4 spinous process fracture
C7 left transverse process fracture
Left first and second rib fracture
Right first rib fracture
T12 vertebral body/spinous process fracture
Fracture of sternum with small associated mediastinal hematoma
Fracture of anterior costochondral junction of 4th rib
Right lower lobe contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2146-12-5**]
|
[
"285.1",
"V45.01",
"584.5",
"V42.2",
"805.04",
"787.01",
"E816.0",
"V43.65",
"478.6",
"276.69",
"272.4",
"806.29",
"807.04",
"861.21",
"805.07",
"585.9",
"564.09",
"V45.81",
"403.90",
"807.2",
"958.4",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"81.63",
"03.53",
"03.09",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
11094, 11190
|
5519, 9563
|
278, 456
|
11565, 11565
|
2912, 5496
|
1774, 1996
|
9825, 11071
|
11211, 11544
|
9589, 9800
|
2011, 2527
|
230, 240
|
2544, 2893
|
484, 1012
|
11580, 11853
|
1034, 1390
|
1406, 1758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,273
| 164,660
|
6643
|
Discharge summary
|
report
|
Admission Date: [**2131-12-12**] Discharge Date: [**2131-12-20**]
Date of Birth: [**2065-12-31**] Sex: M
Service: PLASTIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Left lateral abdominal wound, open
wound and exposure of mesh.
Major Surgical or Invasive Procedure:
1. Incisional hernia repair with AlloDerm bioprosthetic
mesh 12 x 12 cm.
2. Local tissue rearrangement via 2 bipedicled flaps.
3. Split-thickness skin grafting, meshed 1.5:1. Size is 10
x 25 cm.
History of Present Illness:
This patient is a 65-year-old male who has undergone liver
transplantation in the past. He has presented with a lateral
incisional hernia repaired
previously with Prolene mesh and subsequently has had an open
wound on the left side with exposure of mesh. Risks,benefits of
the procedure were explained. This included the risks of
bleeding, infection, additional surgery, flap loss,
graft loss, asymmetry, delayed wound healing, open wound
healing, need for revisional procedures and repeat or revisional
skin grafting and recurrent hernia. He also is a current smoker
and this also is a contributing factor to
delayed wound healing. All of his questions were answered and he
wished to proceed.
Past Medical History:
OLT [**2127-4-23**]
EtOH cirrhosis
DM type II - resolved, occurred after OLT in setting of steroids
splenorenal shunt
obstructive sleep apnea - not on CPAP
asthma
L ventral hernia repair [**2127-4-23**] and [**2127**] as well
Social History:
Lives in [**Hospital1 **]. Former bank president. He is a smoker. He has a
h/o heavy etoh use, and currently drinks 1 drink/week. No drug
use.
Family History:
Many family members died from cirrhosis.
Physical Exam:
VS: Afebrile, VSS
Gen: NAD
CV: RRR, no murmurs
Resp: CTAB, no wheezes or crackles
Abd: Soft obese abd with wounds with good granulatpon well
medially,
but still some fibrinopurulent debris laterally.
Pertinent Results:
[**2131-12-18**] 06:41AM BLOOD WBC-5.1 RBC-3.46* Hgb-10.3* Hct-29.0*
MCV-84 MCH-29.7 MCHC-35.5* RDW-16.0* Plt Ct-122*
[**2131-12-17**] 06:30AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.5* Hct-29.7*
MCV-82 MCH-29.0 MCHC-35.4* RDW-15.8* Plt Ct-122*
[**2131-12-16**] 03:26AM BLOOD WBC-4.2 RBC-3.54* Hgb-10.3* Hct-29.2*
MCV-83 MCH-29.1 MCHC-35.3* RDW-15.4 Plt Ct-94*
[**2131-12-15**] 02:52AM BLOOD WBC-4.8 RBC-3.62* Hgb-11.0* Hct-30.4*
MCV-84 MCH-30.3 MCHC-36.1* RDW-15.6* Plt Ct-92*
[**2131-12-14**] 08:00AM BLOOD WBC-7.4 RBC-4.04* Hgb-11.9* Hct-35.6*
MCV-88 MCH-29.5 MCHC-33.5 RDW-15.7* Plt Ct-98*
[**2131-12-18**] 06:41AM BLOOD Plt Ct-122*
[**2131-12-17**] 06:30AM BLOOD Plt Ct-122*
[**2131-12-16**] 03:26AM BLOOD Plt Ct-94*
[**2131-12-15**] 02:52AM BLOOD Plt Ct-92*
[**2131-12-18**] 06:41AM BLOOD Glucose-92 UreaN-17 Creat-1.6* Na-139
K-3.6 Cl-104 HCO3-29 AnGap-10
[**2131-12-17**] 06:30AM BLOOD Glucose-112* UreaN-16 Creat-1.5* Na-137
K-3.4 Cl-103 HCO3-29 AnGap-8
[**2131-12-16**] 03:26AM BLOOD Glucose-95 UreaN-19 Creat-1.5* Na-139
K-3.5 Cl-104 HCO3-29 AnGap-10
[**2131-12-15**] 02:52AM BLOOD Glucose-102 UreaN-24* Creat-1.6* Na-138
K-4.2 Cl-106 HCO3-28 AnGap-8
[**2131-12-14**] 08:49AM BLOOD Glucose-101 UreaN-23* Creat-1.6* Na-139
K-4.7 Cl-107 HCO3-25 AnGap-12
[**2131-12-14**] 08:00AM BLOOD Creat-1.5*
[**2131-12-14**] 06:40AM BLOOD Glucose-94 UreaN-23* Creat-1.6* Na-139
K-4.9 Cl-108 HCO3-25 AnGap-11
[**2131-12-16**] 03:26AM BLOOD ALT-34 AST-57* AlkPhos-134* TotBili-1.4
[**2131-12-15**] 02:52AM BLOOD ALT-60* AST-105* AlkPhos-157*
TotBili-3.5*
[**2131-12-14**] 08:49AM BLOOD ALT-47* AST-61*
[**2131-12-14**] 08:00AM BLOOD CK-MB-4 cTropnT-0.02* proBNP-1071*
[**2131-12-18**] 06:41AM BLOOD Calcium-9.1 Phos-3.0# Mg-1.9
[**2131-12-17**] 06:30AM BLOOD Calcium-8.0* Phos-1.4*
[**2131-12-16**] 03:26AM BLOOD Albumin-2.7* Calcium-8.1* Phos-1.9*
Mg-1.7
[**2131-12-15**] 02:52AM BLOOD Calcium-8.2* Phos-2.5*
[**2131-12-14**] 08:49AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.9
[**2131-12-19**] 06:33AM BLOOD Cyclspr-90*
[**2131-12-18**] 06:41AM BLOOD Cyclspr-126
[**2131-12-17**] 06:30AM BLOOD Cyclspr-94*
[**2131-12-16**] 03:26AM BLOOD Cyclspr-146
[**2131-12-15**] 02:52AM BLOOD Cyclspr-119
[**2131-12-13**] 04:20PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
Brief Hospital Course:
The patient was admitted to the plastic surgery service on [**12-11**]
and had a incisional hernia repair with AlloDerm bioprosthetic
mesh 12 x 12 cm, local tissue rearrangement via 2 bipedicled
flapsl, split-thickness skin grafting, meshed 1.5:1. Size is 10x
25 cm. The patient tolerated the procedure well. The patients
hospital course was complicated by hypoxia in the AM of POD 1.
Patient was noted in the AM to have O2sat 60%, he was placed on
NRB with good improvement. Later in the morning he was noted to
be confused with increased WOB. He was transferred to the ICU
and a CXR showed likely PNA in the RLL, possible from
aspiration. He was given aggressive chest PT, zosyn
antibiotics, lasix and improved, although patient was difficult
to motivate throughout his entire hospital course to participate
in his own medical care and therapy. He was transferred out of
the ICU and improved on the floor without new issues. His
oxygen sat remained stable and there were no further respiratory
issues. He was instructed to use CPAP at night which he did.
He worked intermittently with PT.
Neuro: Post-operatively, the patient received a PCA with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: See hospital course above. Serial chest x-rays
showed a stable small effusion/consolidation.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His/Her diet was advanced when
appropriate, which was tolerated well. He/She was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: Post-operatively, the patient was started on zosyn and
bactrim prophylaxis after the aspiration event. He will complete
a full 14d course of zosyn at home.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#8, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
cyclosporine 100 mg po qd
CellCept [**Pager number **] mg po bid
Osteo-Biflex
Bactrim one po qd
Os-Cal 500 plus D one tab po bid
multivitamin one po qd.
Discharge Medications:
1. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
8. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) bag Intravenous Q8H (every 8 hours) for 10 days.
Disp:*30 bags* Refills:*0*
9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous DAILY (Daily) as needed for PICC line use.
Disp:*100 ML(s)* Refills:*0*
10. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ml
Injection three times a day as needed for PICC line use.
Disp:*qs syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Left lateral abdominal wound, open wound and exposure of mesh.
Discharge Condition:
Good
Discharge Instructions:
You need to wear your CPAP every night while you sleep. Your
wounds will need to be dressed with xeroform dressing with fluff
gauze on top of the xeroform with an abdominal pad
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
You are being discharged with drains in place.
Drain care is a clean procedure. Wash your hands thoroughly with
soap and warm water before performing drain care. Perform
drainage care twice a day. Try to empty the drain at the same
time each day. Pull the stopper out of the drainage bottle and
empty the drainage fluid into the measuring cup. Record the
amount of drainage fluid on the record sheet. Reestablish drain
suction.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] next week. Call his office at ([**Telephone/Fax (1) 25379**] for an appointment.
Follow-up with Dr. [**Last Name (STitle) **] in the next week after discharge. Call
his office at ([**Telephone/Fax (1) 16915**] for an appointment
|
[
"V42.7",
"998.83",
"998.32",
"553.21",
"327.23",
"507.0",
"585.9",
"568.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"86.69",
"86.74",
"53.61",
"54.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7988, 8040
|
4227, 6482
|
337, 542
|
8147, 8154
|
1971, 4204
|
9595, 9876
|
1693, 1735
|
6686, 7965
|
8061, 8126
|
6508, 6663
|
8178, 9572
|
1750, 1952
|
234, 299
|
570, 1267
|
1289, 1516
|
1532, 1677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,619
| 108,160
|
12971
|
Discharge summary
|
report
|
Admission Date: [**2134-7-27**] Discharge Date: [**2134-8-12**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transferred from OSH for managment of renal failure
Major Surgical or Invasive Procedure:
Repair of abdominal wound dehiscence
History of Present Illness:
87yo M with a h/o CAD s/p [**2124**] cath, HTN, and asthma, s/p recent
TKNR, who presented on [**2134-7-18**] to [**Hospital3 **] Hospital with abd
pain. Hospital course included unsuccessful ERCP on [**2134-7-21**]
which showed hemorrhage and stricture of posterior bulbar
duodenum. Given increasing bili, jaundice, with persistent WBC
and fevers, pt had laparotomy on [**2134-7-21**], where was noted to
have inflamed GB with necrosis over the pancreas. Patient had
CCY and removal of portion of biliary tree, but due to
inflammation, CBD exploration was not possible. Post-op
percutaneous cholangiography showed a beaded appearance of
intra-hepatic bile ducts. After operation, patient was left
intubated. Other post-op course: 1) afib, managed with
lopressor, 2) renal failure (baseline Cr 1.8). With worsening
RF, began renal dose dopamine and lasix drip. Pt was transferred
to [**Hospital1 **] for mgmt of worsening oliguric renal failure.
Past Medical History:
HTN, CAD s/p angina with [**2124**] cath (no pain since cath), lactose
intolerance, episode of syncope when when 11 yrs ago
Brief Hospital Course:
1. Gallstone pancreatitis, cholangitis.
a. GI was consulted and felt that in the absence of ductal
dilatation, with bili >> alk phos, the pt's elevated LFT's most
likely represented cholestasis (multifactorial), +/- and
underlying primary sclerosing cholangitis. A RUQ u/s showed no
intra/extra hepatic ductal dilitations. Surgery followed
throughout hospitalization and felt there was no role for
surgical intervention.
b. Abx: Pt completed 3 week course of imipenem for pancreatic
necrosis.
c. Patient began tube feeds on [**8-4**].
d. Patient was placed on ursodiol, with slowly decreasing T
Bili.
e. Abdominal wound dehiscence surgically repaired [**8-9**].
2. Renal failure - ATN felt secondary to prerenal state.
a. Pt had Quintin catheter placed and was placed on CVVH, with
decreasing Cr. On [**2134-8-2**], pt began significant autodiuresis and
on [**8-3**] catheter was d/c'ed.
b. Pt developed severe metabolic acidosis. Urine pH on [**8-10**]
revealed no RTA and etiology was thought to be from output from
JP drain but could not be resolved.
3. Hypotension.
a. On admission pt was hypotensive, felt secondary to sepsis,
and required levophed pressor support, which was slowly weaned
over the course of a week. Steroids were started on admission
for adrenal insufficiency, and were tapered over a 10 day
course. On [**8-8**], hydrocort taper was completed and insulin drip
was d/c'ed.
b. Pt had episode of hypotension after suctioning on [**8-4**] and
was re-started on levofed and received IVF with good response.
At that time, TWI seen on EKG and enzymes were rechecked.
Patient was taken off levophed on [**8-6**] and on [**8-8**] became
hypertensive.
c. On [**8-10**], pt became hypotensive. [**Last Name (un) **] stim was rechecked,
blood cultures resent. It was felt that pt may have been preload
dependent, and was given fluid with resolution of hypotension.
4. ID.
a. Pt was maintained on imipenem for a total of a 3 week course.
b. Patient completed a 2 week course of vancomycin for gram
positive cocci in blood, etiology presumed to be line sepsis.
c. On [**8-10**] began Zosyn for stenotrophomonas infection.
d. In setting of increasing tachypnea on [**8-9**], abdomen was
reimaged, without evident source of infection.
5. Respiratory.
Patient was admitted intubated and was continued on ventilatory
support -- respiratory failure was felt most likely d/t
combination of fluid overload and abdominal ascites. On [**8-8**] pt
self-extubated and afterwards was persistently tachypneic around
29. On [**8-9**] pt was re-intubated due to increasing tachypnea to
30's. Abdominal wound dehiscence was noted and pt underwent
surgery [**8-9**]; tachypnea felt to be secondary to dehiscence.
However, tachypnea continued to worsen despite intubation, with
a respiratory rate in 40's and patient's breathing not aligned
with ventilator despite many changes in vent settings and
attempts at heavy sedation. Blood gas showed a non-gap acidosis,
and on [**8-10**] respiratory rate was mildly improved with bicarb. On
[**8-10**], stanotrophomonous grew out from sputum and pt was placed
on Zosyn.
6. Altered MS. Despite minimal sedation, pt was unresponsive.
Head CT on [**8-3**] showed only old lacunar infarcts. Neuro thinks
that AMS was related to use of long-acting fentanyl vs
toxic/metabolic, and fentanyl was weaned. On [**8-8**] MS improved;
pt spoke minimally (1 word responses) and was a/o to
person/place. Had mild slurred speech. On [**8-9**] pt was
reintubated, with sedation and tachypnea, and MS [**First Name (Titles) **] [**Last Name (Titles) 39778**].
7. Melena began [**8-7**], etiology thought to be likely [**1-25**]
gastritis. Protonix increased to [**Hospital1 **]. Hcts were checked q12 with
slow decreased. Received 1 unit on [**8-10**].
8. Afib after surgery at OSH. Anticoagulation was held given
risk of bleed.
9. FEN. Amylase and lipase were WNL and TPN was started on [**8-3**],
per surgery. TF's were continued. During autodiuresis phase of
ATN, electrolytes were checked and repleted every 6hrs.
7. Massive scrotal edema on admission. Scrotal U/S showed no
epididymits/torsion. Urology consult felt that edema was [**1-25**]
edematous state, and scrotum was elevated with skin care. Edema
resolved with CVVH and autodiuresis.
8. Access
a. Central line - R quintin was d/c'd; L subclavian in placed
b. A-line - L radial
9. Prophylaxis
a. PPI
b. SQ heparin
***
10. Code status. The hospital team stayed in close contact with
the family throughout the hospitalization and multiple
conversations about pt's code status took place. Pt was
initially full code at family's request, but with the patient's
worsening ventilatory status on the week of [**8-10**], the family's
goals shifted to the patient's comfort. On [**8-12**] the pt was made
CMO and was extubated with the goal of comfort and pain control.
He passed away approximately 45 minutes after extubation.
Discharge Disposition:
Home with Service
Facility:
Deceased
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"584.5",
"570",
"996.62",
"518.81",
"576.1",
"577.0",
"785.52",
"995.92",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.61",
"96.6",
"39.95",
"38.93",
"38.95",
"96.72",
"96.04",
"99.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6434, 6473
|
1492, 6411
|
309, 347
|
6536, 6673
|
6494, 6515
|
218, 271
|
375, 1322
|
1344, 1469
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,431
| 135,188
|
12935
|
Discharge summary
|
report
|
Admission Date: [**2173-5-5**] Discharge Date: [**2173-5-18**]
Date of Birth: [**2096-3-1**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient was transferred from
[**Hospital3 **] for an upper GI bleed. The patient was
originally admitted on [**4-23**] with cellulitis of her left
hand. She underwent an irrigation and debridement of her hand
for treatment of this abscess versus cellulitis. However, a
few days ago the patient began complaining of some abdominal
pain and the right upper quadrant ultrasound subsequently
demonstrated the presence of stones, but no evidence of acute
cholecystitis. The patient was also noted to have some black,
loose, tarry appearing stools. Her hematocrit on the day of
transfer was noted to drop from 31 to 25. Endoscopy that was
performed showed a duodenal ulcer with a fresh blood clot.
The patient was subsequently transferred to [**Hospital1 346**] for further evaluation and
treatment. In addition, is that the patient had elevated
creatinines upon discharge and is at the time of discharge
noted to be anuric.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for coronary artery disease, including a cardiac
catheterization in [**2171-9-23**] that showed moderate
diastolic ventricular dysfunction and 1 vessel coronary
artery disease and an ejection fraction of 63%. The patient
also has a history of congestive heart failure, hypertension,
pericarditis and is status post a pericardial window and
endometrial cancer.
PAST SURGICAL HISTORY: Past surgical history is significant
for coronary artery bypass graft in [**2164-6-23**]. She had
dilatation and curettage. A pericardial window in [**2164**] and a
hysterectomy in [**2171**].
MEDICATIONS: Her meds at home were Lasix 40 mg once a day,
Toprol XL 50 mg once a day, Diovan 80 mg once a day, Digoxin
0.125 mg once a day, Lipitor 20 mg once a day, Omeprazole 20
mg once a day, Dolobid one 3 times a day, potassium, aspirin
81 mg once a day, as well as some creams.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: The patient had a temperature of 97.4,
heart rate of 82, blood pressure 133/50, respiratory rate of
20 and a saturation of 97% on 2 liters. In general she was
alert and oriented and in no acute distress with mild pallor
and obese. Her chest had bilateral crackles. Her
cardiovascular exam had a holosystolic murmur of [**3-28**]. Her
abdomen was obese and soft with positive epigastric and left
upper quadrant pain.
LABORATORY DATA: Pertinent initial laboratory included an
initial sodium of 135, potassium 4.6, chloride 104,
bicarbonate 19, BUN 93, creatinine 3.0. Blood glucose is 78.
An initial CBC significant for a white blood cell count of
20.7, hematocrit 38.6 and a platelet count of 108,000. The
patient's LFTs were an ALT of 15, an AST of 78 and alkaline
phosphatase of 77. Amylase 113, T-bilirubin 0.6, and a lipase
of 152.
The patient's first blood gas on [**5-6**] had a pH of 7.2, an
O2 of 81, a CO2 of 41, bicarbonate 17 and a base excess with
negative 11.
HOSPITAL COURSE: In brief, the patient was noted to be in
anuric acute renal failure likely secondary to hypoperfusion
from this lower GI bleed. Subsequently her hospitalization
was complicated by sepsis, respiratory failure ultimately
requiring intubation, and the sepsis requiring several
antibiotics and several pressors. While the patient did make
some progress on all these fronts, the patient ultimately
decided on a consultation with multiple attending surgeons,
as well as social work to become comfort measures only and
was placed on a morphine drip and ultimately expired early on
the morning of [**5-18**].
Problems by systems, briefly in terms of cardiovascular, the
patient had an echo that showed an ejection fraction of 65%.
No atrial stenosis initially on admission. However, likely
because of her septic shock and GI bleeding, the patient
required Levophed to maintain her systolic blood pressure. In
addition, because of her complicated hemodynamic status, she
initially required monitoring with a Swan Ganz catheter,
which was ultimately changed to a triple lumen catheter on
hospital day 6. Early on multiple attempts were made to wean
the Levophed, which was found to be extremely difficult. Her
urine output was often dependent upon the presence of
Levophed. The patient was ultimately discontinued on Levophed
on [**2173-5-12**]. However, her blood pressures remained
intermittently low. Following this the cardiology service was
ultimately consulted in search of another pressor [**Doctor Last Name 360**],
which they were unable to determine. The patient's Levophed
was now discontinued for good until the day prior to the
patient's death on [**2173-5-17**].
From a respiratory standpoint the patient was initially not
intubated and was able to maintain her oxygenation. However,
she developed a right lower lung opacity and a pneumonia, as
well as a pleural effusion and became obtunded. On hospital
day 6 she ultimately required intubation. The patient
remained intubated until hospital day 10, at which time she
was made do not intubate and was extubated. The patient
remained extubated until the time of her death.
From a GI perspective the patient was given high doses of IV
Protonix for her duodenal ulcer. This high dose of Protonix
was maintained for the majority of the patient's admission.
The patient was also noted at some point to have evidence of
cirrhosis.
From a fluid, electrolyte and nutrition perspective, the
patient was given TPN during the admission and was
intermittently bolused and then diuresed depending on her
volume status.
From a renal perspective the patient's anuria ultimately
resolved and her creatinine slowly drifted down once better
renal perfusion was achieved with the use of Levophed and IV
fluids, and the patient began making urine several days after
admission. Her creatinine on admission as stated previously
was 3.0 and ultimately trended down to 1.0. However, in the
final days of the patient's life the creatinine trended back
up to 1.3 at the time of her death. It was believed that thus
her renal failure was secondary to hyperperfusion as a renal
ultrasound on admission was within normal limits. The renal
service followed the patient throughout the patient's
admission.
From an ID perspective, the patient was initially admitted on
oxacillin for her cellulitis. However, because of the
development of right lower lobe pneumonia the patient was
switched to levofloxacin and vancomycin. Flagyl was
subsequently added to her regimen. Fluconazole was
subsequently added. The fluconazole was added for the
presence of yeast in her urine. The yeast was subsequently
changed to voriconazole and at the time of the patient's
death she was noted to be on Vancomycin, Levophed,
fluconazole, erythromycin and amoxicillin.
CONDITION ON DISCHARGE: The patient's condition on discharge
was deceased. Her discharge status was deceased.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Acute renal failure.
3. Pneumonia.
4. Sepsis.
5. Respiratory failure.
6. Urinary tract infection.
7. Cellulitis.
DISCHARGE MEDICATIONS: No discharge medications and
obviously no follow up plans.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 23293**]
Dictated By:[**Last Name (NamePattern1) 39725**]
MEDQUIST36
D: [**2173-5-18**] 12:19:26
T: [**2173-5-18**] 13:50:59
Job#: [**Job Number 39726**]
|
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icd9cm
|
[
[
[]
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[
"89.64",
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icd9pcs
|
[
[
[]
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7025, 7176
|
7200, 7497
|
3114, 6892
|
1563, 2097
|
2120, 3096
|
181, 1105
|
1128, 1539
|
6917, 7004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,409
| 161,287
|
54150
|
Discharge summary
|
report
|
Admission Date: [**2117-4-12**] Discharge Date: [**2117-4-28**]
Service: CARDIOTHORACIC
Allergies:
Trazodone
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent left pleural effusion.
Major Surgical or Invasive Procedure:
[**2117-4-16**] Thoracoscopic left partial pulmonary decortication
with parietal pleurectomy.
[**2117-4-16**] Flexible bronchoscopy with therapeutic aspiration
of secretions.
[**2117-4-19**] Flexible bronchoscopy with therapeutic aspiration of
secretions.
[**2117-4-20**] Flexible bronchoscopy with therapeutic aspiration
of secretions.
[**2117-4-23**] Flexible bronchoscopy. Therapeutic aspiration of
secretions.
Bronchial alveolar lavage of the right upper lobe.
[**2117-4-22**] percutaneous placement of a 12 Fr Wills-Ogelsby G-tube.
History of Present Illness:
The patient is an 88M with a history of CAD, CHF, COPD, and
recurrent left sided pleural effusions. He states that he had a
chest xray done in his rehabd center recently, which showed
recurrent left pleural effusion, and was
taken to the ED for care. At the ED, a thoracentesis was
attempted - he says that this was not not successful, as the
physician [**Name Initial (PRE) **] "pockets" and blood, and the procedure was
stopped. At this point, the patient says he was transferred to
[**Hospital1 18**] for further evaluation for possible surgical treatment.
The patient states that he was recently hospitalized for feeling
weak. He is unsure if he was diagnosed with any disease process
of illness, though he believes that he may have been diagnosed
with pneumonia. Available records indicated that he had been
started on levaquin and fluconazole, as well as a prednisone
taper. The patient has a L cephalic PICC line in place, that he
says was placed while he was at [**Hospital 1562**] Hospital because he
needed blood draws and IV fluids/medications.
Past Medical History:
Coronary Artery Disease s/p CABGx2 & MV repair
COPD
CHF Diastolic
Atrial Fibrillation no coumadin risk for falls & bleed
HTN
Anxiety
s/p B/L THR
s/p C-spine and L-spine laminectomies [**2103**]
s/p open ccy
s/p removal of RLE hematoma and skin grafting
Social History:
Former smoker, quit 10 years ago. Drinks two glasses of scotch
per day. No exposures. retired ownere of manufacturing plant
of aerospace materials and offshore oil rig. Lives with wife on
[**Name2 (NI) **].
Family History:
Mother - died at 39y of [**First Name9 (NamePattern2) 110976**] [**Last Name (un) 2902**]
Father - dies of a heart condition
Siblings - healthy older brother
Offspring - healthy son
Physical Exam:
VS: T: 96.0 HR: 79 AFib SBP: 116/47 Sats: 96% 4L nasal
cannula
General: lying in bed no apparent distress
HEENT: normocephalic. mucus membranes dry
Neck: supple
Card: irregular
Resp: decreased breath sounds with scattered crackles
GI: G-tube in place
Extr: warm
Skin: multiple skin tears and ecchymosis
Incision: L VATs site clean dry, steri-strips at chest tube
site
Neuro: awake alert needs re-orienting
Pertinent Results:
Labs on admission:
[**4-13**]/WBC-14.0*# RBC-3.15* Hgb-10.3* Hct-32.0* Plt Ct-114*
[**2117-4-13**] PT-53.5* PTT-34.4 INR(PT)-6.2*
[**2117-4-13**] Glucose-88 UreaN-56* Creat-1.8* Na-142 K-3.8 Cl-103
HCO3-30
[**2117-4-13**] CK(CPK)-11 CK-MB-NotDone cTropnT-0.04*
[**2117-4-17**] CK-MB-NotDone cTropnT-0.05* CK-MB-NotDone cTropnT-0.05*
[**2117-4-13**] Calcium-10.2 Phos-3.2 Mg-2.2 Iron-23*
[**2117-4-13**] calTIBC-147* VitB12-1033* Folate-GREATER TH
Ferritn-1321* TRF-113*
[**2117-4-13**] TSH-2.0
Labs prior to discharge:
[**2117-4-28**] WBC-5.8 RBC-3.06* Hgb-9.5* Hct-28.6 Plt Ct-101*
[**2117-4-27**] WBC-5.1 RBC-2.64* Hgb-8.5* Hct-24.9* Plt Ct-100*
[**2117-4-26**] WBC-5.1 RBC-2.94* Hgb-8.9* Hct-27.2* Plt Ct-104*
[**2117-4-28**] Glucose-129* UreaN-69* Creat-2.3* Na-143 K-3.8 Cl-102
HCO3-33
[**2117-4-27**] Glucose-121* UreaN-64* Creat-2.1* Na-143 K-3.7 Cl-105
HCO3-33*
[**2117-4-26**] Glucose-110* UreaN-59* Creat-2.1* Na-143 K-3.8 Cl-104
HCO3-32
Cultures: [**2117-4-26**] MRSA SCREEN (Final [**2117-4-28**]): No MRSA
isolated.
GRAM STAIN (Final [**2117-4-25**]): 2+ PMns, 2+ GPC in pairs, 1+ GPRs
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2117-4-16**] 1:50 pm PLEURAL FLUID
GRAM STAIN (Final [**2117-4-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2117-4-19**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2117-4-22**]): NO GROWTH.
ACID FAST SMEAR (Final [**2117-4-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Blood cultures x 6 no growth
Urine cultures no growth
Imaging:
CHEST (PA & LAT) Study Date of [**2117-4-13**] 1:17 AM:
As compared to the previous radiograph, there is now a severe
left-sided pleural effusion that occupies more than half of the
left
hemithorax. Subsequent left basal atelectasis and blunting of
the
cardiopulmonary interface. At the left lung bases, the
pre-existing opacities have minimally increased in extent. Newly
appeared is a subtle opacity blunting the costophrenic sinus.
This opacity suggests a parenchymal than a pleural origin. The
right hilus and the right paramediastinal contours are
unremarkable.
CHEST PORT. LINE PLACEMENT Study Date of [**2117-4-16**] 4:36 PM:
The left hemithorax is not completely opacified with complete
collapse of the left lung and likely adjacent pleural effusion.
CHEST (PORTABLE AP) Study Date of [**2117-4-16**] 5:17 PM:
Compared with earlier the same day, there is considerably
improved aeration in the left upper and mid zones.
CT ABDOMEN W/O CONTRAST Study Date of [**2117-4-22**] 11:06 AM:
1. Completely collapsed stomach, with loop of transverse colon
interposed
between the greater curvature and the anterior abdominal wall.
2. Dense consolidation at the left lung base, incompletely
imaged. Small
right pleural effusion with atelectasis.
3. Infrarenal abdominal aortic aneurysm measuring up to 4 cm,
and spanning
approximately 5.7 cm craniocaudal.
4. Atrophic kidneys.
5. Marked degenerative changes in the lumbar spine.
G TUBE PLACMENT, ALL INCL. Study Date of [**2117-4-22**] 1:48 PM
Uncomplicated percutaneous placement of a 12 Fr Wills-Ogelsby
G-tube. Feedings may be started through the tube in the morning
of [**4-23**].
CHEST PORT. LINE PLACEMENT Study Date of [**2117-4-27**] 10:14 AM
In comparison with earlier study of this date, the PICC line has
been pulled back to the subclavian vein, just to the right of
the junction
with the superior vena cava.
CHEST (PORTABLE AP) Study Date of [**2117-4-27**] 4:29 AM:
In comparison with study of [**4-26**], there is little overall
change.
Again there is opacification on the left consistent with pleural
fluid. In
addition, there is substantial volume loss with some shift of
the mediastinum to the left. Some of this apparent shift may be
due to the combination of scoliosis and mild obliquity of the
patient
Brief Hospital Course:
Patient was admitted from OSH with recurrent left pleural
effusions s/p thoracentesis showing hemothorax. GS showed
2+PMNs, no micros, and culture was negative at OSH. Patient was
given vitamin k for an INR of 6 (on coumadin for afib) in
preparation of surgery. We continued levoflox which was started
at the OSH for likely CAP. He was cleared by cardiology for
surgery. Geriatrics c/s also obtained. Patient underwent left
VATS partial pulmonary decortication with parietal pleurectomy
on [**2117-4-16**]. An old clotted hemothorax was removed and a
fibrinous rind was noted on the visceral and parietal pleura.
Two left chest tubes were placed. Please see Dr.[**Name (NI) 2347**]
operative note for details. Patient tolerated the procedure
well and was transferred to the PACU in stable condition. Post
op CXR showed a complete white out of his left hemithorax c/w
proximal mucous plug. Patient's vital signs were stable with
good oxygenation. Patient was emergently reintubated in the
PACU. Subsequent flex bronchoscopy showed mucous plugging in
multiple left lobes. Patient tolerated the procedure well
without bradycardia or desat. Post bronch CXR showed
reexpansion of left lung. He was then transferred to the SICU
intubated in stable condition. The rest of the hospital course
is summarized by systems below:
Neuro: Patient was initially given IV narcotics post op but
then quickly transitioned to standing PO tylenol. His pain was
well controlled during most of his hospital stay. Patient did
not show any significant signs of delirium despite his prolonged
SICU stay and multiple medical problems.
Respiratory: Patient was extubated on POD1 without events.
Patient was kept NPO for concern of aspiration. He failed a
subsequent speech and swallow eval and was kept NPO (see GI).
He completed a full course of levoflox, which was discontinued
on POD2. Patient was started on nebs, mucomyst, and aggressive
pulmonary toilet with nasopharyngeal suctioning. It was quite
obvious that he had difficulty clearing his secretion giving his
overall nutritional and functional poor status. On POD3 patient
had worsening aeration on CXR, particularly on the left, with
increasing supp O2 requirement. Underwent a bedside bronch
showing thick mucous plugging bilat. BAL was sent. Post bronch
CXR again showed improved aeration bilat. BAL ultimately grew
OP flora and therefore was nondiagnostic. CT#1 output had
decreased to <200 per day and was pulled. Post pull cxr was
stable. Two interrupted stitches were placed over CT wound. On
POD4 patient continued to have difficulty clearing excessive
secretions, and again had consolidated L lower lobe. Multiple
thick mucous plugs were removed by bedside bronch. POD6 and 7,
same story. Mucous plugs again were removed by bronch. On POD7,
Vanc and zosyn were started despite previous negative cultures
given high probability of LLL aspiration PNA. CT#2 output had
decreased to <200cc per day and was pulled that evening.
Subsequent CXRs showed mild worsening of LLL consolidation quite
similar to pre bronch imaging during the prior week. He
continued to have difficulty clearing his airway, requiring
excessive nasopharyngeal suctioning with 1:1 nursing care. At
this point it was quite clear that his poor respiratory status
was not going to improve quickly. We recommended a
tracheostomy, but patient and family wanted to defer at the time
and give him a chance to recover.
CV: Patient was HD stable during the entire hospital course.
He was in rate-controlled afib. Patient did require lasix
intermittently for mild volume overload as evidenced by exam and
pulmonary edema on CXRs.
GI: Patient failed a speech and swallow eval post op. Made
NPO. Dobhoff placed by IR on POD4 and TFs were started. A
nutrition consult was obtained. Gtube was placed by IR on POD6.
TFs were restarted. Patient tolerating tube feeds with low
residuals.
Renal: Patient has CRI with baseline Cr 1.8-2. Cr was stable
throughout hospital course, although his BUN disproportionally
trended up by POD10.
ID: Patient continued on levoflox on admission for CAP.
Levoflox was stopped on POD2. Patient was started on vanc/zosyn
POD7 given persistent LLL consolidation concerning for
aspiration PNA despite prior negative BALs. He will need a full
14 day course (through [**4-30**]). Patient did intermittently spike
a temperature. Cultures were taken during these episodes and
were all negative on culture. His WBC was normal. His
incisions were without erythema or significant drainage.
Heme: Patient required vit k preop for an INR of 6 on
admission. He received FFP and platelets perioperatively. Post
op patient continued to have elevated INR requiring vit k
supplementation. A hematology c/s was obtained for
thrombocytopenia and coagulopathy. SICU teamed was concerned
about HITT. HITT antibodies were negative. hematology did not
believe he had HITT. His thrombocytopenia is from a chronic
myelodysplasia (prior BM bx at OSH) currently followed by his
outpatient hematologist. No new recs. They agreed that his
elevated INR was likely related to severe nutritional deficiency
requiring vit k supplements and TFs. He received 2u platelets
and 1uPRBCs POD9 given anemia and a small amount of hemoptysis
following suctioning. Patient received an additional 1upRBCs on
POD2 and POD11. His stools were guiac positive.
FEN: See GI. Patient had severe nutritional deficiency with FTT
prior to presentation. This continued during his stay. He was
given TFs via dobhoff then Gtube. His electrolytes were
replenished daily, particularly phosphate postoperatively. He
did have mild hypernatremia post op successfully managed by D5W
and late free H20 boluses via the gtube. His Na prior to
discharge was 129.
Dispo: He was discharged to [**Hospital1 **] Hopistal in
[**Location (un) 701**].
Medications on Admission:
albuterol nebs [**Hospital1 **], ipratropium nebs [**Hospital1 **], dorzaolamide-timolol 1
drop right eye [**Hospital1 **], colace 100 po bid, folic acid 1mg po daily,
magnesium oxide 400mg po bid, prednisone taper ([**4-5**]- ) 30x3,
20x1, 10x6, 5x6, oxazepam 15mg po qhs, metoprolol succ 25 po
daily lasix 40 by mouth daily OR every other day, vitamin C
500mg po daily allopurinol 300mg po daily, coumadin 4 or 5mg
daily, mvi
zinc 220 po daily ([**Date range (1) 110977**]), iron 325 po daily, perforomist
20mcg/2ml 1U [**Doctor First Name **] [**Hospital1 **], fluconazole 200mg po daily ([**Date range (1) 91452**]),
levaquin 500 po daily x7 days, nystatin 500 000U TID x5d
([**Date range (1) 109592**]) alvesco 160mcg inhaler 2puff po bid - start on [**4-13**]
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): Right eye.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at
bedtime)): Give at 8 pm, may repeat x 1 if no effect after 1 hr,
do not give after 2 am .
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q 12H (Every 12 Hours): mix w/albuterol to prevent
bronchial spasm.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) Inhalation Q12H (every 12 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Acetaminophen 160 mg/5 mL Solution Sig: Ten (10) ML PO Q6H
(every 6 hours) as needed for fever.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 2-8 Puffs
Inhalation Q6H (every 6 hours).
13. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 3 days: through
[**4-30**].
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous Q48H (every 48 hours) as needed for PNA for 3
days: through [**4-30**].
15. Regular Insulin Sliding Scale
Insulin SC Sliding Scale Q6H
Glucose Insulin Dose
0-70 mg/dL [**12-18**] amp D50
71-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
Discharge Disposition:
Expired
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Recurrent left pleural effusion with clotted hemothorax.
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] in experience
increased shortness of breath, cough or sputum production
Followup Instructions:
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 110978**]
Follow-up with Dr. [**Last Name (STitle) **] [**5-11**] 9:00am in the [**Hospital Ward Name 121**]
Building Chest Disease Center [**Hospital1 **] I [**Location (un) 453**]
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology
for a Chest X-Ray 45 minutes before your appointment.
Completed by:[**2117-6-3**]
|
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icd9cm
|
[
[
[]
]
] |
[
"43.11",
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"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
15680, 15746
|
7183, 13071
|
257, 798
|
15847, 15863
|
3039, 3044
|
16049, 16509
|
2406, 2590
|
13888, 15657
|
15767, 15826
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13097, 13865
|
15887, 16026
|
2605, 3020
|
4766, 4766
|
4799, 7160
|
4184, 4237
|
184, 219
|
826, 1885
|
3058, 4143
|
1907, 2162
|
2178, 2390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
279
| 192,224
|
18929
|
Discharge summary
|
report
|
Admission Date: [**2164-6-14**] Discharge Date: [**2164-6-18**]
Date of Birth: [**2090-2-27**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
gentleman with a history of type 2 diabetes, coronary artery
disease (status post myocardial infarction), and
cerebrovascular accident who originally presented on [**6-11**]
from [**Hospital 1562**] Hospital with painless jaundice and a 55-pounds
weight over the past year here for endoscopic retrograde
cholangiopancreatography.
The patient noticed gradual jaundice since [**2164-5-25**]. No
abdominal pain, nausea, vomiting, fevers, or chills.
Positive dark urine, and light stools, pruritus, and fatigue.
An abdominal computed tomography on [**2164-5-31**] from the
outside hospital was reported to have shown moderate ascites,
a large liver and spleen, and dilation of the biliary tree,
with a question of intrahepatic malignancy.
An abdominal ultrasound at the outside hospital on [**2164-6-1**] showed splenomegaly, ascites, gallbladder wall
thickening, and dilated ducts in the liver.
A magnetic resonance imaging on [**2164-6-2**] at the outside
hospital showed dilation of the biliary tree and a 4-cm
lesion in the left lobe of the liver.
Endoscopic retrograde cholangiopancreatography on [**6-11**]
performed at [**Hospital1 69**] showed an
intraductal mass, and plastic stent placed. The mass was
brushed and cells were sent to cytology which were positive
for adenocarcinoma.
Additionally, the patient was found to have an increased
creatinine while admitted. Creatinine in [**2163-12-24**]
was noted to be 0.9. Then on [**6-5**], creatinine was noted
to be 2 after a computed tomography scan at the outside
hospital. On admission to the hospital on [**6-11**],
creatinine was noted to be 8.1. The patient was treated
multiple times with Kayexalate for a high potassium. A
paracentesis was performed on [**6-13**] which showed no
evidence of spontaneous bacterial peritonitis.
On [**6-14**], a Quinton catheter was placed in the right
femoral vein, and the patient underwent hemodialysis. During
the course of hemodialysis the patient became hypotensive in
the 80s/40s, and was subsequently volume resuscitated with
2.2 liters of fluids. His blood pressure did not increase,
and the patient began to experience shortness of breath. The
patient was originally saturating 96% on room air but then
desaturated to 93% on 2 liters of oxygen and then 95% on 4
liters of oxygen. Additionally, the patient was wheezing.
Thus, the patient was transferred to the Medical Intensive
Care Unit.
An arterial blood gas was taken and showed a pH of 7.41, a
PCO2 of 28, and a PO2 of 72. Once the patient was
transferred to the Medical Intensive Care Unit, his blood
pressures dropped to the 60s. A right internal jugular was
placed, and the patient was started on Levophed. Fresh
frozen plasma was given prior to line placement as the
patient's INR was 1.7. Additionally, the patient was started
on ampicillin, gentamicin, and Flagyl for presume
cholangitis.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease; status post myocardial
infarction. A catheterization performed in [**2162-5-23**]
showed no significant coronary artery disease.
2. An echocardiogram performed in [**2162-5-23**] showed
diastolic dysfunction without systolic dysfunction and left
atrial enlargement.
3. Non-insulin-dependent diabetes mellitus.
4. Cerebrovascular accident with a right facial droop.
5. Left hydronephrosis; chronic ?
6. Mild spinal stenosis at L4-L5.
7. Left anterior temporal lobe small arachnoid cyst.
MEDICATIONS ON ADMISSION: Spironolactone.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Alcohol once per month. Tobacco times 20
years; quit four years ago. No intravenous drug abuse. One
to two cups of coffee once per day. A retired truck driver.
FAMILY HISTORY: Family history was not significant for
gastrointestinal problems or [**Name2 (NI) 499**] cancer.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Medical Intensive Care Unit revealed
vital signs of 93/29, heart rate was 83, respiratory rate was
10, and oxygen saturation was 96% oxygen saturation on 4
liters nasal cannula. Temperature was 95.8 (hypothermic).
In general, the patient was markedly jaundiced and
appropriately conversational. Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Pupils were equal, round, and reactive to light. Scleral
icterus. A jaundiced oropharynx. Spider angiomas on the
face. Chest examination revealed crackles at the bases
bilaterally/anteriorly. Mild expiratory wheezes.
Cardiovascular examination revealed a regular rate and
rhythm. A [**1-26**] holosystolic murmur heard at the left fifth
intercostal space midclavicular line. The abdomen was soft
and nontender. Distended. Positive fluid wave. Unable to
assess organ size. A right femoral Quinton catheter.
Extremity examination revealed no edema. Dorsalis pedis
pulses were 2+ bilaterally. Positive asterixis bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission to the Medical Intensive Care Unit revealed white
blood cell count was 7 (down from 10.2), hematocrit was 28.6,
and platelets were 90. Prothrombin time was 15.9, partial
thromboplastin time was 37.1, and INR was 1.7. Urinalysis
revealed brown/cloudy. Specific gravity was 1.016, large
blood, 100 protein, moderate bilirubin, trace leukocytes,
greater than 50 red blood cells, 6 to 10 white blood cells,
few bacteria, and amorphous crystals. Sodium was 137,
potassium was 4.5, chloride was 100, bicarbonate was 16,
blood urea nitrogen was 86, creatinine was 7.9, and blood
glucose was 105. Lipase was 72 and amylase was 25. Calcium
was 7.8, phosphate was 6.9, and magnesium was 2.1. Albumin
was 3. ALT was 47, AST was 82, total bilirubin was 27.2, and
alkaline phosphatase was 145. Microscopic examination from
ascites taken from [**6-13**] revealed no growth, no
polymorphonuclear leukocytes, no organisms seen on Gram
stain, 55 white blood cells, and 3045 red blood cells.
Cytology from ascites taken from [**6-13**] was negative for
malignant cells. Brush on endoscopic retrograde
cholangiopancreatography taken from [**6-11**] was positive for
malignancy cells adenocarcinoma. Urine cultures from [**6-12**]
and [**6-13**] revealed no growth.
PERTINENT RADIOLOGY/IMAGING PERFORMED AT [**Hospital1 **]:
1. Endoscopic retrograde cholangiopancreatography performed
on [**6-11**] revealed intraductal mass, stent placed.
2. Abdominal ultrasound on [**6-12**] revealed sludge in the
gallbladder, negative [**Doctor Last Name **] sign, liver shrunken with
increased echogenicity, enlarged spleen, and portal vein was
patent.
3. Magnetic resonance imaging of the abdomen performed on
[**6-11**] (although limited by the patient's claustrophobia),
revealed massive ascites, left greater than right small
bilateral pleural effusions, liver nodularity (consistent
with cirrhosis), 3.6-cm X 4.8-cm mass with increased signal
in segment 4A liver, spleen mildly enlarged, varices along
the stomach (portal hypertension), gallbladder with no stones
and no ductal dilatation.
4. A chest x-ray on [**6-14**] revealed right internal jugular
in place and pulmonary edema. No infiltrate. No
pneumothorax.
HOSPITAL COURSE BY ISSUE/SYSTEM: In summary, the patient is
a 74-year-old gentleman with diabetes, coronary artery
disease, and cerebrovascular accident who presented with
painless jaundice and a 55-pound weight loss, status post
endoscopic retrograde cholangiopancreatography with stent,
now with cirrhosis and acute renal failure and probable
cholangiocarcinoma. The patient was transferred to the
Medical Intensive Care Unit with hypotension and shortness of
breath.
1. HYPOTENSION ISSUES: Hypotension was treated with
pressors (Levophed). The patient was weaned off Levophed
with gentle fluid boluses. Mean arterial pressure remained
in the 50s to 60s, and the patient mentated well throughout
his hospital course in the Medical Intensive Care Unit.
Hypotension was most likely secondary to sepsis.
2. PULMONARY ISSUES: The patient remained stable on 4
liters nasal cannula and was saturating well. The patient's
pulmonary status was monitored closely while receiving fluid
boluses for blood pressure so as to prevent a flare of
pulmonary edema. Albuterol nebulizers were given for
wheezing.
Shortness of breath differential diagnoses included
cirrhosis, renal failure, ascites (atelectasis), possible
congestive heart failure or fluid overload.
3. CORONARY ARTERY DISEASE/CONGESTIVE HEART FAILURE ISSUES:
No aspirin was given at this time as the patient was
coagulopathic with an increased INR. No beta blocker were
given during this time as the patient was hypotensive. Mild
congestive heart failure was seen on chest x-ray on [**6-11**].
The patient received an echocardiogram on [**6-15**] which
revealed an ejection fraction of 75% to 80%; although the
patient was on Levophed at the time of this echocardiogram.
Findings included left atrium was mildly dilated, left
ventricular wall thickness and cavity size were normal,
hyperdynamic, right ventricular size and motion were normal,
aortic valve leaflets were thickened, no regurgitation,
trivial tricuspid regurgitation, and borderline pulmonary
artery systolic hypertension. No effusions.
4. GASTROENTEROLOGY ISSUES: Intraductal mass was positive
for adenocarcinoma by cytology. Palliative care for this
patient. The patient's treatment options and prognosis were
discussed at length with the patient and his family.
Total bilirubin and liver function tests were checked daily
to assess for obstruction. If these values were to increase
significantly, could possibly replace stent with a more
permanent stent via endoscopic retrograde
cholangiopancreatography to relieve obstruction. Total
bilirubin tended to decrease throughout his hospital stay.
The patient also has cirrhosis of unclear etiology.
5. RENAL ISSUES: Acute renal failure; question as to
etiology - acute tubular necrosis; status post contrast for
computed tomography versus hepatorenal syndrome.
The patient received three days of hemodialysis. No fluid
was removed in hemodialysis. Renal consultation team is
following the patient. Fractional excretion of sodium was
1%.
6. INFECTIOUS DISEASE ISSUES: The patient was originally
started on ampicillin, gentamicin, and Flagyl for presumed
cholangitis causing a septic picture with increased white
blood cells, hypotension, and hypothermia. This antibiotic
regimen was changed to vancomycin, ceftazidime, and Flagyl so
as to provide more protection for the kidneys.
Cultures were negative or pending to date. Blood cultures
from [**6-15**] were pending. Urine cultures from [**6-12**] and
[**6-13**] showed no growth. Ascites from [**6-13**] showed no
growth.
7. HEMATOLOGIC ISSUES: The patient remained coagulopathic
secondary to liver disease. The patient was oozing from
intravenous site. Thus, the patient was given three days of
subcutaneous vitamin K to correct for the increased INR.
The patient received two units of packed red blood cells
while in the Medical Intensive Care Unit for a hematocrit of
less than 30. The patient also received one unit of fresh
frozen plasma prior to internal jugular central vein line
placement on [**6-14**].
8. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient
received fluid boluses for a decreased blood pressure; yet
remained saturating well on 4 liters nasal cannula oxygen and
had no complaints of chest discomfort. Electrolytes were
repleted as needed. The patient was given a full diet upon
his request.
9. ACCESS ISSUES: The patient has a right internal jugular
central line which was placed on [**6-15**], and a right femoral
Quinton catheter which was placed on [**6-14**], as well as two
peripheral intravenous lines.
10. CODE STATUS: The patient's code status was changed from
full code to do not resuscitate/do not intubate. The patient
and the patient's family expressed a wish to not be started
on pressors if the patient's blood pressure were to fall.
11. SOCIAL ISSUES: Multiple family meetings were held with
the patient and his family. His son [**Doctor Last Name **] is the main
contact person. Additionally, the patient's brother flew in
from [**Name (NI) **] and was able to meet with the patient and spend
time with him.
DISCHARGE DISPOSITION: Currently, the patient is in the
Medical Intensive Care Unit awaiting a private bed on the
floor. The patient will most likely either be discharged to
the floor in a private bed or go home soon with some kind of
hospice care or visiting nurse assistance; pending Social
Work evaluation and discussions with the family and the
patient.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE STATUS: The patient was to be discharged pending a
private room on the floor, or the patient and his family wish
for care at home.
DISCHARGE DIAGNOSES:
1. Cirrhosis.
2. Probably cholangiocarcinoma.
3. Acute renal failure.
4. Diabetes.
5. Coronary artery disease/congestive heart failure.
MEDICATIONS ON DISCHARGE: Have yet to be decided. The
patient will most likely go home with antibiotics for
presumed cholangitis and other comfort medications.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with his primary care doctor
if needed.
2. The patient was also to follow up with Social Work for
home hospice care if desired.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 21075**]
Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36
D: [**2164-6-17**] 22:36
T: [**2164-6-17**] 22:51
JOB#: [**Job Number 51753**]
cc:[**Last Name (NamePattern4) 51754**]
|
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icd9cm
|
[
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icd9pcs
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|
3761, 3926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,492
| 179,219
|
27537
|
Discharge summary
|
report
|
Admission Date: [**2143-4-13**] Discharge Date: [**2143-4-29**]
Date of Birth: [**2077-4-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Severe gallstone pancreatitis
Major Surgical or Invasive Procedure:
Tracheostomy
History of Present Illness:
This is a 66 year old male, transferred from [**Hospital3 7569**]
with pancreatitis, respiratory failure, ?pna, and NSVT. Pt
initially presented to [**Hospital3 7569**] on [**4-7**]; by report, he
had sudden onset of bdominal/epigastric pain with associated
nausea (no vomiting). He was initially afebrile, hypertensive,
tachycardic; amylase was 1851, lipase was >6000.
Past Medical History:
PNA, Schizophrenia, Syncope
Pertinent Results:
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2143-4-13**] 11:00 PM
LIVER OR GALLBLADDER US (SINGL
Reason: evaluate gallbladder, duct; please measure CBD
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with gallstone pancreatitis, fevers, ?dilation
of CBD
REASON FOR THIS EXAMINATION:
evaluate gallbladder, duct; please measure CBD
INDICATION: 66-year-old male with gallstone pancreatitis and
concern for common bile duct dilatation.
RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates a 1.8 x
1.6 x 1.5 cm well circumscribed echogenic focus of the posterior
right hepatic lobe compatible with a hemangioma. The gallbladder
is contracted and contains sludge and a few small stones. There
is no pericholecystic fluid. The contracted state of the
gallbladder causes apparent wall thickening. There is no intra-
or extrahepatic biliary ductal dilatation. The common bile duct
measures 3-4 mm. There is no ascites. Incompletely visualized is
a right pleural effusion. The pancreas is not well seen due to
overlying bowel gas. There is appropriate hepatopetal portal
venous flow. The right kidney is unremarkable.
IMPRESSION:
1. Contracted gallbladder with small stones and sludge.
2. No intra- or extrahepatic biliary ductal dilatation, with the
common duct measuring 3-4 mm.
3. 1.8 cm well circumscribed echogenic focus of the posterior
right hepatic lobe is consistent with an hemangioma.
4. Limited evaluation of the pancreas due to overlying bowel
gas.
Cardiology Report ECHO Study Date of [**2143-4-15**]
PATIENT/TEST INFORMATION:
Indication: Atrial/ventricular ectopy. Left ventricular
function.
Height: (in) 69
Weight (lb): 165
BSA (m2): 1.91 m2
BP (mm Hg): 96/51
HR (bpm): 115
Status: Inpatient
Date/Time: [**2143-4-15**] at 11:00
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W022-0:20
Test Location: West MICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.88
Mitral Valve - E Wave Deceleration Time: 183 msec
TR Gradient (+ RA = PASP): *32 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous
hypertrophy of the
interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Suboptimal technical quality, a focal LV wall motion
abnormality
cannot be fully excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic root.
AORTIC VALVE: Normal aortic valve leaflets. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - ventilator. Based on [**2133**] AHA endocarditis
prophylaxis
recommendations, the echo findings indicate a low risk
(prophylaxis not
recommended). Clinical decisions regarding the need for
prophylaxis should be
based on clinical and echocardiographic data.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic root is
mildly dilated. The aortic valve leaflets appear structurally
normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely
represents a fat pad.
IMPRESSION: Preserved global biventricular systolic function.
Mild pulmonary
artery systolic hypertension.
Based on [**2133**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
CHEST (PORTABLE AP) [**2143-4-19**] 6:00 AM
CHEST (PORTABLE AP)
Reason: interval changes in lung volumes, infiltrate
[**Hospital 93**] MEDICAL CONDITION:
66 year old man new transfer from OSH with pancreatitis,
Elevated Peak Pressures, abd distention
REASON FOR THIS EXAMINATION:
interval changes in lung volumes, infiltrate
AP CHEST, 6:07 A.M., [**2143-4-19**].
HISTORY: Pancreatitis.
IMPRESSION: AP chest compared to [**4-14**] and 24.
Left lower lobe collapse has not improved. Lung volumes are low
normal. Small bilateral pleural effusions unchanged. No
pneumothorax. Heart size normal and mediastinum midline. ET tube
and left subclavian line, and nasogastric tube are in standard
placements respectively.
CT HEAD W/O CONTRAST [**2143-4-22**] 9:49 AM
CT HEAD W/O CONTRAST
Reason: Intracranial process causing sedation and coma
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with pancreatitis, Off all sedation but not
responding neurologically
REASON FOR THIS EXAMINATION:
Intracranial process causing sedation and coma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 66-year-old male with history of pancreatitis. The
patient is now off all sedation but not responding.
COMPARISONS: No comparisons are available.
TECHNIQUE: CT of the head without IV contrast.
FINDINGS: There are very severe periventricular hypodensities.
These are more severe in the bilateral frontal lobes where there
is loss of the [**Doctor Last Name 352**]- white matter differentiation at some point.
There is also encephalomalacia and atrophy involving
predominantly the right temporal lobe. There is a lacunar
infarct within the left thalamus. The ventricles are prominent.
The above findings are most likely secondary to chronic ischemic
changes and chronic infarcts. There are calcifications in the
falx. There is no evidence of herniation. There is no evidence
of hemorrhage, shift of normally midline structures. No evidence
of mass effect. There is mild opacification of the bilateral
maxillary sinus, ethmoid sinuses, and sphenoid sinuses. There is
severe septal deviation to the right side. The NG tube is coiled
in the nasopharynx. There is mild opacification of the external
auditory canal bilaterally (left greater than right), correlate
with physical examination. There is mild opacification of the
bilateral mastoid air cells.
IMPRESSION:
1. No evidence of hemorrhage.
2. Chronic encephalomalacic changes likely representing chronic
infarcts and chronic ischemia.
3. Mild opacification of the paranasal sinus, and mastoid air
cells as was described above. The feeding tube is coiled within
the nasopharynx.
If indicated, MRI could be performed for further evaluation.
OBJECT: PANCREATITIS. R/O SEIZURE.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: Brief polymorphic bursts of moderate to, at
times,
moderately high voltage mixed frequency slower theta were seen
bifrontally, without clear laterality at times in a somewhat
bursting
character. No associated sharp or spike activity was seen.
BACKGROUND: Well-formed and moderately well-sustained moderate
voltage
10 Hz activity was seen biposteriorly present without
significant
asymmetry. The anterior-posterior voltage gradient was
preserved.
HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: Not performed.
CARDIAC MONITOR: No arrhythmias noted.
IMPRESSION: Normal EEG due to some bifrontal slow bursts.
Whether this
represents increased cortical hyperreactivity related to
subcortical or
deeper midline structures increased irritability is uncertain.
No
definitive spike discharges were seen. No persistent slowing
suggestive
of a destructive or structural process could be seen.
CHEST (PORTABLE AP) [**2143-4-27**] 12:08 PM
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
Reason: dobhoff placement?
[**Hospital 93**] MEDICAL CONDITION:
66 year old pancreatitis w/ new Dobhoff placement.
REASON FOR THIS EXAMINATION:
dobhoff placement?
AP CHEST, 1:12 P.M. ON [**4-27**].
HISTORY: Pancreatitis. New Dobbhoff tube placement.
IMPRESSION: AP chest compared to 11:21 a.m.:
New feeding tube, with wire stylet in place passes through the
distal stomach and out of view. Nasogastric tube ends in the
upper stomach. ET tube and right subclavian line in standard
placements. Moderate left pleural effusion has increased. Left
lower lobe atelectasis is stable. Atelectasis at the medial
aspect of the right lung is worsening. Mediastinal venous
engorgement and upper lobe vascular dilatation have worsened
indicating cardiac decompensation or volume overload although
heart size remains normal. No pneumothorax.
CHEST (PORTABLE AP) [**2143-4-29**] 4:42 AM
CHEST (PORTABLE AP)
Reason: ETT placement
[**Hospital 93**] MEDICAL CONDITION:
66 year old pancreatitis w/ new Dobhoff placement.
REASON FOR THIS EXAMINATION:
ETT placement
The findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] at 11 a.m.,
[**2143-4-29**].
REASON FOR EXAMINATION: Evaluation of the ET tube placement and
Dobbhoff placement.
Portable AP chest radiograph compared to [**2143-4-27**].
The ET tube is low at the level of the carina. There is no
Dobbhoff tube inserted demonstrated on the current film.
The right subclavian line tip is in mid portion of superior vena
cava.
The heart size is markedly decreased as well as there is
prominent improvement of bilateral pulmonary edema with
decreased bilateral, mostly on the left, pleural effusion.
IMPRESSION:
1. Low position of the ET tube.
2. Marked improvement with almost complete resolution of
pulmonary edema and decrease in left pleural effusion.
Brief Hospital Course:
1. Pancreatitis: Amylase and lipase were very elevated on
admission to [**Location (un) **] (AST and ALT mildly elevated). US and CT
were suspicious for gallstones in cystic duct with dilation of
CBD. Persistent fevers are concerning for necrotic pancreas, and
most recent CT had findings suspicious for phlegmon. He was
started on meropenem, and vancomycin was added when he continued
to have fevers. Cultures have been negative, but he is growing
klebsiella from sputum.
- will continue meropenem (d6)/vanco (d2)
- continue IVF with goal CVP>12, MAP>65
- will review OSH radiology (CT scans)
- ERCP consult given concern for stones in duct
- repeat cultures
- TPN for now given ileus
- insulin gtt for tight control
- protonix daily
.
2. ?PNA: CXR concerning for pna at left base, with klebsiella in
sputum
- continue meropenem/ vanco
- repeat sputum culture
- repeat CXR (?tappable effusion)
.
3. Respiratory failure: hypercarbic, ?in setting of sepsis
- will ck ABG, wean vent as tolerated
- treat PNA, may need to tap effusion
- fentanyl and versed for sedation
- [**4-25**] trach'ed
.
4. Ileus: will repeat KUB, NGT to suction if necessary, NPO with
TPN
.
5. NSVT: will continue amio gtt, is currently hemodynamically
stable, will shock if unstable rhythm
- t/c cards input if ectopy persists
- replete lytes as needed
.
6. Hypotension: now stable, was requiring pressors, will give
IVF, keep MAP>65, A-line in place
.
7. PPX: SQ hep, PPI, bowel meds
.
8. FEN: NPO for now, IVF, replete lytes as above
.
9. Code: Full, confirmed with power of attorney
.
10. Access: R IJ (will need to resite), R A-line ([**4-13**])
.
11. Contact: power of attorney: [**Name (NI) 8513**] [**Name (NI) 67329**] ([**Telephone/Fax (1) 67330**],
[**Telephone/Fax (1) 67331**])
.
12. Dispo: ICU care.
.
MICRO: [**4-25**] cath tip: no growth; [**4-21**] CDiff +; [**4-20**] sputum: yeast
[**4-20**] urine - [**4-20**] blood:P [**4-15**] Sputum: 3+ yeast, Cx Mod yeast,
OP flora; blood:NGTD; Urine:Neg; C.Diff:Neg; [**4-14**] blood:NGTD;
Cath tip:Neg; [**4-13**] sputum:Cx=yeast, Klebsiella (pan-[**Last Name (un) 36**]);
blood:NGTD; Urine: Neg
[**4-12**] Sputum from outside hosp Klebsiella resist to Amp(otherwise
sensitive)
RADS: [**4-23**] EEG nonspecific; [**4-23**] CXR: no change; [**4-22**] CT head:
chronic ischemic changes [**4-17**] CXR: improved LLL consolidation,
borderline pulm edema; [**4-14**] CXR: L effusion, mild CHF; CXR [**4-13**]:
Left effusion, [**4-13**] US: no intra/extra hepatic dilatation, some
gallstones/sludge
Mr. [**First Name (Titles) 25408**] [**Last Name (Titles) **] on [**2143-4-29**].
Medications on Admission:
Wellbutrin, Buspar, Neurontin
.
Discharge Disposition:
[**Date Range **]
Discharge Diagnosis:
severe gallstone pancreatitis
Discharge Condition:
deceased
Completed by:[**2143-7-18**]
|
[
"560.1",
"482.0",
"427.31",
"577.0",
"427.69",
"008.45",
"519.1",
"285.9",
"295.90",
"427.1",
"574.90",
"348.39",
"458.9",
"492.8",
"518.81",
"311",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"96.72",
"00.17",
"33.23",
"99.04",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14249, 14268
|
11557, 13839
|
344, 358
|
14341, 14380
|
827, 986
|
10638, 10689
|
14289, 14320
|
14192, 14226
|
2378, 5930
|
275, 306
|
10718, 11534
|
386, 757
|
13848, 14166
|
779, 808
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,687
| 179,109
|
6143
|
Discharge summary
|
report
|
Admission Date: [**2177-8-21**] Discharge Date: [**2177-8-22**]
Date of Birth: [**2112-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Fatigue, shortness of breath, edema
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This patient is a 65 year old male with history of type 1
diabetes melltius for 35 years (A1c 6.7), kidney transplant in
[**2165**], who was transferred from [**Hospital3 24012**] ED where he
presented with fatigue x5 days, worsening edema and mild dyspnea
on exertion. He was was in the ER to have acute on chronic renal
failure with a creatinine of 5.6, hyponatremia to 113 and
question of PNA on chest Xray.
Patient reports feeling extremely week for the past 5 days. He
complaints of extreme fatigue preventing him from getting up on
his own. he denies fevers, chills. he complains of some
difficulty breathing and orthopnea for the past week. He has
been nauseated with dry heave for the past 5 days. He has also
noticed increased scrotal edema x1 month and periorbital edema
occassionally for the past month. He has had worsening LE edema
since [**Month (only) **] and was started on lasix in the beginning of
[**Month (only) 462**]. He reports no change in his urination, denies
frequency or burning. No changed in the color. His stool has
changed, as he goes about 3 times a day now, and previously he
was constipated. He also reports decreased PO intake
His issues started around last [**Month (only) 547**] when he had an epsidode of
vomitting in the setting of 4 days of constipation. This
resolved, but he remained weak since then. He went to [**State **]
for a week at the end of [**Month (only) 116**] and that is when he first noticed
swelling in his feet. He recalls that the swelling has been
getting worse slowly since then. He finally called his
nephrologist Dr. [**First Name (STitle) **] in the middle of [**Month (only) **] who scheduled an
ECHO and requested him to have his labs drawn. He also adjusted
the dosages of his Tacro.
The patient went to [**Hospital3 24012**] [**7-22**] or low blood sugar and
again [**2177-7-28**] because he was feeling very weak. At that time he
was found to have low sodium and chloride and low blood count
and was given 2 units of blood and 2 bags of NS (according to
wife). He felt much better after this admission, was able to
take long walks with his wife, and his appetite returned. This
last until 5 days ago when he started with the above symptoms.
In the ED his blood pressure ranged from 151-208/77-106, T 97,
HR 65-79, RR 16 sat 100% RA. He was fiven LEvaquin 750mg IV,
Lasix 80mg IV, labetolol 10mg IV, Compazine 10mg IV. He put out
1300 cc lasix after a foley was placed.
Past Medical History:
- Diabetes type 1 x34 years Last Hb A1c 6.7 [**8-4**]
- s/p living related kidney transplant [**1-/2166**]
- gastroparesis
- neuropathy
- retinopathy with microaneurysms, s/p surgery [**2155**]
- GERD
- Hypercholesterolemia
- Gastroparesis
- Osteopenia
Social History:
Patient denies smoking, drinking, or ilicit drug use. He is a
retired teacher. lives in [**Location 24013**] with his wife. [**Name (NI) **] has 2
grown children, one in [**State **] one in [**Location (un) **].
Family History:
His mother's sister has type two diabetes, and a paternal aunt
also has type two diabetes mellitus. There is no family history
of heart disease.
Physical Exam:
On admission:
Vitals: T: 97.5 BP: 142/79 P: 80 RR: 16 O2Sat 92% RA
Gen: no acute distress
HEENT: Clear OP, MMM, periorbital edema
NECK: Supple, No LAD, JVD about 7 cm
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: 3+ pitting edema. Upper extremity edema. Anasarcic
Scrotum: edematous
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-27**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2177-8-21**] 11:13PM GLUCOSE-313* UREA N-50* CREAT-5.6*
SODIUM-112* POTASSIUM-3.9 CHLORIDE-82* TOTAL CO2-16* ANION
GAP-18
[**2177-8-21**] 06:30PM URINE HOURS-RANDOM UREA N-169 CREAT-33
SODIUM-30
[**2177-8-21**] 06:30PM URINE OSMOLAL-196
[**2177-8-21**] 06:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2177-8-21**] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2177-8-21**] 06:30PM URINE RBC-0-2 WBC-[**1-29**] BACTERIA-FEW YEAST-NONE
EPI-[**1-29**]
[**2177-8-21**] 06:30PM URINE AMORPH-FEW
[**2177-8-21**] 04:54PM CYCLSPRN-43* tacroFK-LESS THAN
[**2177-8-21**] 03:50PM GLUCOSE-273* UREA N-45* CREAT-5.6*#
SODIUM-113* POTASSIUM-3.8 CHLORIDE-79* TOTAL CO2-18* ANION
GAP-20
[**2177-8-21**] 03:50PM estGFR-Using this
[**2177-8-21**] 03:50PM proBNP-[**Numeric Identifier 24014**]*
[**2177-8-21**] 03:50PM CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.3
[**2177-8-21**] 03:50PM WBC-8.6 RBC-3.27* HGB-10.3* HCT-28.7* MCV-88#
MCH-31.5 MCHC-35.8* RDW-14.6
[**2177-8-21**] 03:50PM PLT COUNT-351#
[**2177-8-21**] 03:50PM PT-12.8 PTT-30.2 INR(PT)-1.1
Chest x-ray [**2177-8-21**]:
CONCLUSION:
Pulmonary edema, likely cardiogenic. Bibasal effusions.
Increased density at right lung base, confluent edema versus
pneumonia. Followup post diuresis is recomended.
The study and the report were reviewed by the staff radiologist.
Renal Ultrasound [**2177-8-21**]:
IMPRESSION:
1. Interval development of mild-to-moderate hydronephrosis
within the
transplanted kidney.
2. Slight broadening of the waveform of the mid pole renal
artery,
hoever resistive indices within normal range
Transthoracic Echo [**2177-8-22**]:
Conclusions
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 70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. There is no left
ventricular outflow obstruction at rest or with Valsalva. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior report (images
unavailable for review) of [**2170-10-1**], concentric left
ventricular hypertrophy and moderate diastolic dysfunction now
evident.
IMPRESSION: moderate diastolic dysfunction of the left ventricle
with normal ejection fraction
Brief Hospital Course:
Patient is a 65 year old male with type one diabetes mellitus,
renal transplant in [**2165**], gastroparesis, who presented with
fatigue, hyponatremia, worsening edema, dyspnea on exertion, and
worsening renal insufficiency who was transferred from an
outside hospital for further management.
Patient was admitted to the medical intensive care unit. The
nephrology team was consulted and discussed dialysis with the
patient. He refused dialysis, and was able to state the risks
associated with doing so. He understood what dialysis entailed,
and was also not interested in temporary dialysis. It was
recommended that he be treated with trial hypertonic saline to
see if there was improvement in his hyponatremia and energy
level. He refused to stay as an inpatient and declined a PICC
line for administration of hypertonic saline. He was evaluated
by the psychiatry team to help assess whether there was a
component of depression, and to ensure that his mental status
was not clouded by his low sodium. The psychiatry team felt that
the patient was competent and had the capacity to make medical
decisions and fully understood the implications of refusing
dialysis and other treatments. His primary nephrologist
confirmed that this was in accordance with prior discussions
regarding the goals of his care.
The patient stated that his goals were to return home and spend
time with his wife. Social work, palliative care, and case
management were then involved to assist with arranging home
Hospice services to meet the patient's wishes. A Hospice bed was
available for the next day and would be arranged for him in his
home. Per his and his wife's wishes, he was discharged home. A
regimen of salt tabs and lasix was initiated for his
hyponatremia after discussion with the renal team.
His code status is DNR/DNI, and paperwork was completed for his
ambulance ride home for this order.
Medications on Admission:
Fosamax 70mg qweek
Azathioprine 50mg once a day
Calcium 600mg daily
Cyclosporine 50mg twice a day
Fludrocortisone Acetate 0.1mg once a day
Glyburide 5mg once a day
Lipitor 10mg
Lantus 5-6 units before breakfast. Novolog [**11-27**] units before
each meal
Midodrine 5mg three times a day
Protonix 40mg daily
Prednisone 1mg 3 3 tablets once a day
lasix 20mg twice daily
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
3. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: 5-6 units
Subcutaneous QAM: Resume your home dosing.
7. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours: As
needed for seizure, discomfort.
Disp:*30 Tablet(s)* Refills:*0*
8. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO q1
hour PRN: PRN shortness of breath, discomfort.
9. Insulin Aspart 100 unit/mL Solution Sig: [**11-27**] units
Subcutaneous before meals: Please resume your home dosing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary diagnoses:
- Acute on chronic renal failure
- Hyponatremia
Secondary diagnoses:
- Diabetes Mellitus
- Renal transplant
- Gastroparesis
- Neuropathy
- Retinopathy
- GERD
Discharge Condition:
Fair, alert, oriented.
Discharge Instructions:
You were admitted from an outside hospital for management of
your renal failure, low sodium, mild shortness of breath,
fatigue, and swelling of your extremities. It was recommended
that you undergo dialysis or have other treatments for your low
sodium, however you declined these treatments. The psychiatry
team helped evaluate you, and they were in agreement that you
understood the risks and benefits of this decision. The
palliative care team and case management helped to arrange for a
discharge home with Hospice services.
.
Please call your primary care physician if you have any pain,
worsening shortness of breath, or other concerns that need
attention.
.
You should take 80 mg of lasix three times a day in addition to
[**11-27**] salt tabs 3 times a day. Please continue all of your other
medications as directed or appropriate. A foley catheter has
been placed for comfort and should be left in unless otherwise
directed.
Followup Instructions:
You decided that you wanted to go home with Hospice. Please
contact your primary care physician or other providers for any
needs you may have outside of Hospice services.
|
[
"357.2",
"530.81",
"272.0",
"996.81",
"536.3",
"584.9",
"591",
"583.81",
"285.21",
"733.90",
"250.51",
"250.41",
"362.01",
"276.1",
"E878.0",
"250.61",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10493, 10561
|
7255, 9144
|
351, 358
|
10783, 10808
|
4152, 7232
|
11789, 11963
|
3356, 3503
|
9575, 10470
|
10582, 10650
|
9171, 9552
|
10832, 11766
|
3518, 3518
|
10671, 10762
|
276, 313
|
386, 2832
|
3533, 4133
|
2854, 3110
|
3126, 3340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,611
| 157,336
|
29182
|
Discharge summary
|
report
|
Admission Date: [**2122-10-3**] Discharge Date: [**2122-10-21**]
Date of Birth: [**2056-4-30**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
IR-guided PICC placement
Post-pyloric nasogastric tube placement.
History of Present Illness:
66 y.o. woman with complicated PMH including SLE, ESRD on HD,
PVD, chronic atypical chest pain, and CVA, recently worked up
for tachypnea and electrolyte abnormalities and discharged on
[**2122-10-1**]. Subsequently went to HD the day after discharge, and
was found to be tachypneic again on route and sent to ED again.
No CP, no subjective SOB. Breathing slows down when asked to
calm down.
.
ED course: VS 95.8, HR 92, BP 138/100, RR 30, 90%RA. ABG with
similar respiratory alkalosis as during recent admission. CXR
with persistent moderate-sized right-sided pleural effusion with
compression atelectasis. No evidence of fluid overload. Labs
significant again for hypophosphatemia, also Hct of 20 and
Lactate 4.0 (repeat down to 2.2). INR 6.2 (?on coumadin for IJ
clot but not listed on DC summary med list). Pt was admitted for
repeat workup of tachypnea.
Past Medical History:
1. s/ p CVA ([**5-3**], with left facial drop)
2. HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin,
PF4+ in [**4-4**])
3. TTP (s/p plasmapheresis *10)
4. ESRD on HD (first HD, [**2121-9-5**], HD three days/week), s/p
5. VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid)
6. C. difficile colitis with h/o failed flagyl
7. SLE (diagnosed [**2119**])
8. HTN
9. ACD (baseline Hct from [**Date range (1) 70208**], 26---37)
10. Bowel and bladder incontinence
11. Peripheral vascular disease
12. Diverticulosis
13. Peptic ulcer disease
14. s/p Billroth II gastrectomy ([**2118**])
15. Gout
16. ETOH abuse
17. Depression
18. s/p hysterectomy
Social History:
She lives in a nursing home. Prior to going to the nursing home
she was living alone. Her husband died 3 years ago. she has a
son and [**Name2 (NI) **]. Her son lives locally with his wife. they are
supportive. used to work as [**Name8 (MD) **] RN. Smoked for 8 years about [**1-31**]
cig a day. quit about 40 years ago. Alcohol states quit 1 year
ago, previous heavy use. Her daughter is her HCP.
Family History:
Unknown
Physical Exam:
Physical Exam:
VS: Temp: 97.1 BP: 122 / 90 HR: 93 RR: 36 (decreases when
sleeping to RR of 12) O2sat: could not be obtained by RNs (ABG
in ED with pO2 of 114, repeat ABG on floor showed pO2 of 132)
general: Somnolent but responsive, tachypneic but seems
comfortable, NAD, complaining of being cold
HEENT: PERLLA, EOMI, anicteric, no scleral icterus,
lungs: CTA, decreased BS at bases
heart: RR, S1 and S2 wnl, [**3-3**] holosystolic murmur at left
sternal border, no rubs or gallops
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis. Left lower extremity edema up to the
knee - no tenderness.
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Persistant left side weakness -> residual from
stroke. Sensation equal bilaterally. Lower extremity weakness
bilaterally. Upper extremity weakness L>R. Able to MAE
.
Physical Exam on transfer to MICU:
VS: t 96.9 oral, HR 84, BP 130/88, RR 18-32, sat 94% RA, FS 57
General: sleepy but responsive, intermittently tachypneic during
interview but seems comfortable, complaining of being cold, also
with periodic lip-smacking
HEENT: PERLLA, EOMI, anicteric, no scleral icterus,
lungs: CTA, decreased BS at bases
heart: reg, S1 and S2 wnl, 3/6 systolic murmur
abdomen: +b/s, soft, non-tender, no hsm
extremities: DP 1+ b/l, 1+ left lower extremity edema up to the
knee skin: no rash
neuro: AAOx3. Persistant left side weakness -> residual from CVA
Pertinent Results:
[**2122-10-3**] 02:59PM BLOOD WBC-2.9* RBC-2.41*# Hgb-7.9*# Hct-25.7*#
MCV-107* MCH-32.7* MCHC-30.6* RDW-24.2* Plt Ct-PND
[**2122-10-3**] 12:45AM BLOOD WBC-3.8* RBC-1.89* Hgb-6.2* Hct-20.4*
MCV-108* MCH-33.0* MCHC-30.6* RDW-25.1* Plt Ct-111*
[**2122-10-3**] 12:45AM BLOOD Neuts-60.6 Bands-0 Lymphs-34.8 Monos-3.5
Eos-0.7 Baso-0.3
[**2122-10-3**] 12:45AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-3+
Macrocy-2+ Microcy-1+ Polychr-1+
[**2122-10-3**] 12:45AM BLOOD PT-51.9* PTT-50.5* INR(PT)-6.2*
[**2122-10-3**] 12:45AM BLOOD Glucose-74 UreaN-12 Creat-3.1* Na-131*
K-4.4 Cl-107 HCO3-14* AnGap-14
[**2122-10-3**] 12:45AM BLOOD Albumin-1.6* Calcium-7.4* Phos-1.2*
Mg-1.5*
[**2122-10-3**] 08:42AM BLOOD Type-ART pO2-160* pCO2-34* pH-7.39
calTCO2-21 Base XS--3
[**2122-10-3**] 04:04AM BLOOD Type-ART pO2-132* pCO2-14* pH-7.71*
calTCO2-18* Base XS-1
[**2122-10-2**] 05:17PM BLOOD Type-ART Temp-36 pO2-114* pCO2-12*
pH-7.67* calTCO2-14* Base XS--2 Intubat-NOT INTUBA
[**2122-10-3**] 04:04AM BLOOD Lactate-2.2*
[**2122-10-2**] 05:17PM BLOOD Glucose-98 Lactate-4.0* Na-128* K-4.4
Cl-107
[**2122-10-2**] 05:17PM BLOOD Hgb-9.2* calcHCT-28 O2 Sat-98
[**2122-10-2**] 05:17PM BLOOD freeCa-1.12
.
Results:
CXR [**2122-10-2**]:
1. Persistent moderate-sized right-sided pleural effusion with
compression atelectasis. Underlying consolidation cannot be
excluded.
2. No evidence of fluid overload.
.
LE U/S [**2122-10-3**]:
Occlusive left-sided DVT involving the left common femoral,
superficial femoral and popliteal veins. Non-occlusive thrombus
seen within the right common femoral vein, in the region of the
junction with the greater saphenous vein.
.
CTA chest [**2122-10-3**]:
1. Non-occlusive pulmonary embolus within the right upper lobe
pulmonary artery, without associated findings to suggest
infarct. .
2. Small left and moderate right pleural effusions.
3. 2-mm right upper lobe pulmonary nodule, for which no
additional followup is required in a patient without a history
of malignancy or increased risk for lung cancer.
4. Anasarca.
5. Ascending thoracic aorta diameter at upper limits of normal
at 4 cm.
.
MRI/A Brain w/o contrast [**2122-10-4**]
Limited examination secondary to motion artifact, however there
is evidence of vascular signal in both internal carotids as well
as the
vertebrobasilar system, the distal branches are not completely
visualized likely secondary to motion artifact and combination
of atherosclerotic disease in the distal vascular branches.
.
Abdominal U/s complete [**2122-10-6**]
1. Markedly improved appearance in gallbladder wall edema from
prior study of [**12-3**].
2. Interval development of fatty infiltration of the liver.
Other forms of diffuse liver disease including cirrhosis,
fibrosis, and possible long-term steroid use can result in this
appearance.
3. Echogenic, atrophic kidneys.
4. Large right pleural effusion.
.
CT abdomen/pelvis [**2122-10-15**]
1. No evidence of retroperitoneal bleed.
2. Stable left renal hypodensity, which is too small to further
characterize but likely a cyst.
3. Moderate right and small left pleural effusions which
measure simple fluid density. No evidence of pneumonia.
.
U/s RUE venous ultrasound [**2122-10-20**]
Duplex and color Doppler demonstrate no right upper extremity
DVT.
Note of an occluded AV fistula within the right antecubital
fossa.
.
Brief Hospital Course:
66F h/o SLE, ESRD on HD, PVD, chronic atypical chest pain, and
CVA, recently worked up for tachypnea and electrolyte
abnormalities, admitted for tachypnea, and found to have PE/DVTs
and coagulopathy.
.
# Hypoglycemia: During her inpatient stay she has had
hypoglycemia in 20s and 40s. Hypoglycemia is likely
multifactorial due to ESRD, s/p gatrectomy, and possible
cirrhosis due to hx of ETOH abuse and poor oral intake.
Insulinoma, although unlikely, was ruled out with normal insulin
levels. Patient was also treated with TPN and her hypoglycemia
subsequently improved. TPN was discontinued on [**2122-10-19**] with
the placement of a post-pyloric NGT for continued feeding. She
additionally has had an increased appetite the last several days
with the addtion of Megace. No hypoglycemic events for some
time prior to discharge. Thus, will discharge on continued tube
feeding and a regular diet with continued nutrition evaluation
via qweek albumen levels. Does not need fingersticks at this
time, but would recommend checking one if patient becomes
lethargic or somnolent for unclear reason.
.
# Tachypnea/Respiratory alkalosis: The patient was admitted for
episodes of tachypnea, which was also the cause of a recent
admission from which the patient had been recently discharged
and worked up for possible etiologies. During her previous
hospitalization, it was believed that her tachypnea was most
likely of central origin, but a head CT did not reveal a cause.
When the patient was admitted, her respiratory rate reached 30,
and an ABG demonstrated a pH of 7.67 with pCO2 of 12, a pO2 of
114 on oxygen by NC and a bicarb of 14. The patient's
respiratory rate decreased when the patient was sleeping an a
repeat ABG demonstrated pH 7.39 pCO2 34 pO2 160 HCO3 21. As
anxiety was thought to be contributing to the patient's
tachypnea, the patient was given ativan, and the respiratory
rate remained normal during the remainder of her
hospitalization. The patient's ativan dose was decreased to PRN
as the patient became somnolent when taking the medication on a
regular schedule. During the course of the patient's
hospitalization, a head MRI/MRA and a repeat CT head did not
suggest any other etiologies for the patient's repeated
tachypnea. The patient was found to have a small PE (see below),
which may have contributed to the initial tachypnea, but as the
patient's O2 sats and HR were normal it was unclear why
tachypnea caused by the PE would resolve with sleep. Neuro
suggested to consider long term EEG study to evaluate for
central cause of tachypnea if further workup was wanted that
revealed encephalopathy. Tachypnea may be related to anxiety.
Evidence in support of this is that the patient becomes less
tachypneic when asked to breath slowly. She was treated
symptomatically with benzos at low dose prn for anxiety to
prevent severe respiratory alkalosis from tachypnea. Her
electrolytes were additionally monitored on a daily to twice
daily frequency without progression of her alkalosis. On
discharge will send with lorazepam low dose PRN. We
additionally started her on Megace as an appetite stimulant but
would recommend discontinuing this if her respiratory alkalosis
worsens.
.
# Coagulopathy: The patient was admitted with an INR of 6.2, PT
of 51.9 and a PTT of 50.5. She has a history of coumadin use,
but her coumadin was reportedly discontinued during a
hospitalization [**2122-8-21**] for a chronic (>8month) septic
thrombophlebitis of the left IJ vein, although it was restarted
briefly during the patient's previous hospitalization in
[**2122-9-24**]. The patient had a RUQ ultrasound that demonstrated new
fatty infiltration of the liver. DIC labs did not show any
evidence for DIC. Heme-onc was consulted and believed that the
patient's coagulopathy could have been the result of the
treatment with coumadin given during the patient's previous
hospitalization, vancomycin dosing, nutritional deficiency (see
below) or liver failure. Thus, coumadin was held until patient
was therapeutic and was ultimately restarted prior to discharge.
No etiology mixed with coumadin in the setting of vancomycin
and poor diet, with possible mild synthetic dysfunction of her
liver.
.
# PE/DVT: The patient was found to have an enlarged left leg on
admission. Ultrasound of the lower extremities revealed clots in
both the left and the right leg and a CT chest revealed a PE.
Because the patient's INR was already supratherapeutic (see
above) treatment was not initiated, and the patient's tachypnea
resolved spontaneously. INR supratherapeutic, although clots
developed in setting of supratherapeutic INR. Anti-coagulation
will be an issue given HIT. Heme-onc is following, will follow
recs as to anticoagulation when INR decreases. Heme/Onc agrees
with the possibility of an IVC filter given failure with
therapeutic INR. Pt received single-lumen midline for IV
access; IR also placed an IVC filter. Current hematology
recommendations for anticoagulation is low dose heparin 1mg
Qday. Goal INR [**1-31**]. Started on low dose coumadin with
titration per facility protocol.
.
# Nutritional deficiency: The patient was found to have an
albumin of 1.3. Nutrition was consulted and recommended
supplementation that was added to the patient's diet. The
patient was maintained on a normal diet and her diet was
supplemented with thiamine. At the time of transfer, the patient
and family agreed a feeding tube is needed and appropriate
consultation is requried. Patient was evaluated by surgery, who
felt she was a poor surgical candidate due to her nutritional
status. It was recommended that she get a post-pyloric NGT
placed and that surgery be considered when albumin was greater
than 2. Thus, IR placed a feeding tube on [**2122-10-19**] and
tubefeeding was started per Nutrition recs. She should
continued to have her albumen monitored weekly while at rehab
and bring this information to her follow-up surgical appointment
in approximately 3 weeks to determine if a PEG is needed & if
she would heal properly. She should additionally continue a
regular renal diet and Megace. If she takes adequate oral
intake and meets a caloric goal of 1800 calories/day, would
consider removing feeding tube sooner than at scheduled
follow-up appointments.
.
# Hypophosphatemia: In the setting her of respiratory alkalosis,
hypophosphatemia is likely due to transcellular shift. However,
phos improved with TPN. Original concern was that she may not
be absorbing neutraphos from gut. Thus, she was continued on
phosphate supplementation with holding parameters. Will be
discharged to rehab with daily eletrolyte checks given concern
for refeeding syndrome with continued nuetraphos with holding
parameters.
.
# Anemia: Baseline hematocrit is 21-26. Hct on admission 20. Hct
stable post 2U transfusion on [**10-14**]. Anemia studies suggest
anemia of chronic disease plus element of hemolysis. Unclear
why patient would be hemolyzing. Hct was slowly decreasing
towards discharge, likely related to both continued blood draws
and poor production [**1-30**] ESRD. In the past has been fairly Epo
resistant. Followed by Renal throughout inpatient stay who
suggested reinitiating epo at 10-15kU/rx so she does not become
transfusion dependent. The day of discharge iron studies were
again checked and remained consistent with anemia of chronic
disease with decrease iron and TIBC and elevated ferritin. Will
discharge with epo as suggested by Renal. Should continue with
TIweek HD and Hct monitoring at those sessions. Would transfuse
for Hct < 21.
.
# DVT in left brachial vein and subclavian vein & PE: Per last
DC summary, a LUE U/S showed a subclavian and brachial DVT that
possibly extends to the IJ. As there was evidence of clot as far
back as [**2120**] (on a neck CT), it was felt that it did not need to
be treated. Patient has history of HIT, so is on coumadin for
PE. Started on low dose as described above.
.
# Hyponatremia: The patient was hyponatremic on admission, she
was given IL NS and her hyponatremia resolved. Her electrolytes
were monitored during the hospitalization but she had no futher
sodium abnormalities.
.
# Renal failure: She has known chronic renal failure secondary
to SLE, on HD M/W/F. She was continued on hemodialysis while
inpatient and followed by the renal team. Initially thought to
be epo resistant, she was not continued on this - especially
given concern for SLE related thrombophilia. Given risk for
transfusion-dependence, she was restarted on epo with her
continued coumadin dosing.
.
# FEN: Regular diet with tubefeeding supplementation.
Tubefeedins is Nutren Pulmonary per Nutrition. Note, her
tubefeeding doesn't need to be on Nutren Renal given that she is
an HD pt and gets extra electrolytes dialyzed off.
.
# Code: full - daughter [**Name (NI) 18945**] HCP
.
Communication: daughter [**Name (NI) 18945**] [**Name (NI) **] [**Telephone/Fax (1) 70209**](home);
[**Telephone/Fax (1) 70210**](husband cell)
Medications on Admission:
Discharge Medications from [**2122-10-1**]:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for prn constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): please take every six hours for the next 4 days, then
take twice a day for one week, then take once a day for one
week, then take every other day for one week, then take every
third day for two weeks.
.
Medications on transfer to MICU:
Metoprolol 25 mg PO TID
Ascorbic Acid 500 mg PO BID
Neutra-Phos 2 PKT PO TID
Fluoxetine 20 mg PO DAILY
Pantoprazole 40 mg PO Q24H
FoLIC Acid 1 mg PO DAILY
Senna 1 TAB PO BID:PRN
Glucagon 1 mg IV ONCE Duration: 1 Doses, GIVE IM [**10-11**]
Thiamine HCl 100 mg PO DAILY
Lactulose 30 ml PO TID
Vancomycin Oral Liquid 125 mg PO Q6H
Lorazepam 0.25 mg PO BID
.
All: Heparin --> HIT
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses:
Pulmonary embolism
Deep vein thrombosis
hypophosphatemia
.
Secondary dianoses:
end stage renal disease
septic thrombophlebitis
c.difficil colitis
systemic lupus
hypertension
peripheral vascular disease
peptic ulcer disease
Discharge Condition:
Stable
|
[
"008.45",
"453.41",
"443.9",
"585.6",
"285.21",
"276.1",
"451.89",
"274.9",
"V45.1",
"403.91",
"415.19",
"518.0",
"263.9",
"251.2",
"571.8",
"511.8",
"276.3",
"275.3",
"286.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
17655, 17734
|
7198, 16200
|
285, 353
|
18020, 18030
|
3846, 7175
|
2369, 2378
|
17755, 17999
|
16226, 17632
|
2408, 3827
|
236, 247
|
381, 1243
|
1265, 1936
|
1952, 2353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,216
| 150,661
|
40997
|
Discharge summary
|
report
|
Admission Date: [**2165-5-8**] Discharge Date: [**2165-5-19**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Upperg gastrointestinal bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Right Femoral CVL placement with attempted trauma line
replacement
Left IJ Trauma CVL placement
History of Present Illness:
[**Age over 90 **]F with history of cryptogenic cirrhosis c/b distal esophageal
varices, duodenal ulcers and submucosal gastric neoplasm arrives
from NH with massive hempotysis, and blood pressures 70s/30s.
Per son was her usual self this morning.
.
In the ED initial vs were: T97.7 P100 BP60/palp. NGT was placed
with 500-600 cc BRB out OGT. Started on Octreotide and
Protonix. Admission HCT noted to be 19.5. Received 4 units of
PRBC's and massive transfusion protocol was initiated. A L
femoal Cordis was placed. BP's noted to be 130s/60s. Patient
was intubated for airway protection. Sedated with propofol with
resultant hypotension, so propofol was weaned.
.
Of note, d/c'd 3 days ago for UGIB. EGD on [**5-2**] showed 3 cord
grade I esophageal varices, 2 cm submucosal mass in stomach, and
superficial non-bleeding ulcers at the duodenum.
.
On the floor, VS HR 103, BP 126/58, 100% on RA, nonsedated on
the vent. Actively vomiting BRB with massive transfusion
protocol activated.
.
Review of systems: Unable to obtain.
Past Medical History:
-Cryptogenic cirrhosis
-Gastric tumor: Per [**Month/Day (4) 2287**] records, [**2160**] EGD notable for 1.5cm
submucosal lesion in the proximal stomach c/w GIST tumor with
associated ulceration/bleeding. Bleedings site clipped with
endoclips. EGD on [**2165-5-2**] confirmed presence of fundic mass.
- Myelodysplastic syndrome
- Hyponatremia
- s/p Cataract surgery
- Radial/ulnar fracture s/p surgical repair [**2165-4-25**]
Social History:
Born in [**State 4565**]. Lives at home alone, though son [**Name (NI) **] and
daughter-in-law [**Name (NI) **] live nearby.
- Tobacco: Never
- Alcohol: None
- Illicits: None
Family History:
No contributing family history.
Physical Exam:
General: Intubated, sedated, lying flat, profuse BRB per NG tube
HEENT: Sclera anicteric, pupils equal, pinpoint and reactive
Lungs: Diffuse rhonchi with air movement bilaterally
CV: Tachycardic, distant
Abdomen: initially distended but soft, however on repeat exam 30
minutes later, abdomen more rigid
GU: foley in place
Ext: Left wrist in cast from recent fracture. No peripheral
edema. 2+ peripheral pulses.
Pertinent Results:
Admission Labs:
==================
[**2165-5-8**] 11:46PM TYPE-ART PO2-129* PCO2-45 PH-7.26* TOTAL
CO2-21 BASE XS--6
[**2165-5-8**] 11:46PM LACTATE-1.9
[**2165-5-8**] 08:57PM GLUCOSE-112* UREA N-29* CREAT-1.4* SODIUM-142
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-21* ANION GAP-14
[**2165-5-8**] 08:57PM CALCIUM-6.9* PHOSPHATE-5.1* MAGNESIUM-2.0
[**2165-5-8**] 08:57PM WBC-11.0 RBC-4.25 HGB-12.8 HCT-34.6* MCV-81*
MCH-30.1 MCHC-37.1* RDW-16.7*
[**2165-5-8**] 08:57PM NEUTS-77* BANDS-11* LYMPHS-5* MONOS-5 EOS-1
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2165-5-8**] 08:57PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL BURR-1+
BITE-OCCASIONAL ACANTHOCY-1+
[**2165-5-8**] 08:57PM PLT COUNT-155
[**2165-5-8**] 08:57PM PT-15.5* PTT-36.6* INR(PT)-1.4*
[**2165-5-8**] 08:57PM FIBRINOGE-196
[**2165-5-8**] 07:34PM TYPE-ART PO2-118* PCO2-37 PH-7.33* TOTAL
CO2-20* BASE XS--5
[**2165-5-8**] 07:34PM LACTATE-2.3*
[**2165-5-8**] 07:34PM freeCa-0.95*
[**2165-5-8**] 05:55PM TYPE-ART TEMP-35.9 RATES-/30 TIDAL VOL-280
PEEP-5 O2-60 PO2-61* PCO2-29* PH-7.43 TOTAL CO2-20* BASE XS--3
-ASSIST/CON INTUBATED-INTUBATED
[**2165-5-8**] 05:55PM LACTATE-2.3*
[**2165-5-8**] 05:55PM freeCa-0.85*
[**2165-5-8**] 03:20PM GLUCOSE-139* UREA N-28* CREAT-1.3* SODIUM-142
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-21* ANION GAP-18
[**2165-5-8**] 03:20PM CK(CPK)-164
[**2165-5-8**] 03:20PM CK-MB-7 cTropnT-0.05*
[**2165-5-8**] 03:20PM CALCIUM-6.1* PHOSPHATE-6.4*# MAGNESIUM-1.5*
[**2165-5-8**] 03:20PM WBC-11.1* RBC-4.06*# HGB-12.1# HCT-33.6*#
MCV-83 MCH-29.9 MCHC-36.1* RDW-16.0*
[**2165-5-8**] 03:20PM PLT COUNT-169
[**2165-5-8**] 03:20PM PT-16.6* PTT-38.6* INR(PT)-1.5*
[**2165-5-8**] 03:20PM FIBRINOGE-159
[**2165-5-8**] 11:28AM PO2-415* PCO2-49* PH-7.21* TOTAL CO2-21 BASE
XS--8
[**2165-5-8**] 11:28AM LACTATE-3.2*
[**2165-5-8**] 11:28AM HGB-9.0* calcHCT-27
[**2165-5-8**] 11:28AM freeCa-0.7*
[**2165-5-8**] 11:20AM WBC-12.6* RBC-3.07*# HGB-9.3*# HCT-25.9*#
MCV-84# MCH-30.3 MCHC-35.9* RDW-15.7*
[**2165-5-8**] 11:20AM PLT COUNT-173#
[**2165-5-8**] 11:20AM PT-17.9* INR(PT)-1.6*
[**2165-5-8**] 07:32AM TYPE-MIX TEMP-35.4 RATES-/33 TIDAL VOL-220
PEEP-5 O2-100 PO2-125* PCO2-47* PH-7.18* TOTAL CO2-18* BASE
XS--10 AADO2-554 REQ O2-90 -ASSIST/CON INTUBATED-INTUBATED
COMMENTS-GREEN TOP
[**2165-5-8**] 07:32AM LACTATE-4.7*
[**2165-5-8**] 07:32AM HGB-10.7* calcHCT-32
[**2165-5-8**] 04:59AM LACTATE-5.6*
[**2165-5-8**] 04:55AM GLUCOSE-204* UREA N-29* CREAT-1.3* SODIUM-138
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-16* ANION GAP-22*
[**2165-5-8**] 04:55AM ALT(SGPT)-16 AST(SGOT)-29 LD(LDH)-199 ALK
PHOS-80 TOT BILI-1.1
[**2165-5-8**] 04:55AM CK-MB-5 cTropnT-0.02*
[**2165-5-8**] 04:55AM ALBUMIN-1.7* CALCIUM-6.1* PHOSPHATE-8.2*#
MAGNESIUM-1.6
[**2165-5-8**] 04:55AM WBC-13.1* RBC-4.88# HGB-15.3# HCT-44.3#
MCV-91# MCH-31.4 MCHC-34.6 RDW-15.2
[**2165-5-8**] 04:55AM NEUTS-69 BANDS-12* LYMPHS-5* MONOS-5 EOS-2
BASOS-0 ATYPS-0 METAS-4* MYELOS-3*
[**2165-5-8**] 04:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2165-5-8**] 04:55AM PLT SMR-VERY LOW PLT COUNT-50*#
[**2165-5-8**] 04:55AM PT-21.1* PTT-76.9* INR(PT)-1.9*
[**2165-5-8**] 03:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2165-5-8**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2165-5-8**] 03:00AM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2165-5-8**] 03:00AM URINE HYALINE-9*
[**2165-5-8**] 03:00AM URINE MUCOUS-FEW
[**2165-5-8**] 02:40AM WBC-9.5 RBC-1.94*# HGB-6.5*# HCT-19.5*#
MCV-101*# MCH-33.6* MCHC-33.3 RDW-19.4*
[**2165-5-8**] 02:40AM NEUTS-74.0* BANDS-0 LYMPHS-17.6* MONOS-5.2
EOS-2.8 BASOS-0.3
[**2165-5-8**] 02:40AM PLT COUNT-137*
[**2165-5-8**] 02:40AM PT-17.6* PTT-42.4* INR(PT)-1.6*
Brief Hospital Course:
Respiratory failure: Intubated in face of massive GIB. CXR
initally showed right sided effussion with possible opacity
concerning for traumatic hemothorax vs simple effusion vs
aspiration. Progressed to bilateral opacities and large right
pleural effusion, c/w ARDS/cardiogenic pulmonary
edema/aspiration pneumonitis/pneumonia. Initated treatment for
HCAP given fever spikes in presence of CXR findings.
Aggressively diuresed with lasix drip with moderate improvement
of effusions. However, despite continuing to treat for HCAP, the
patient remained very difficult to wean from the vent. Goals of
care were discussed with her son and daughter in law. They felt
that she would not want prolonged respiratory support. With that
in mind, the decision was made to attempt to optimize her
respiratory status and extubate her, with the understanding that
if she did not tolerate extubation, she would be made
comfortable and would be comfort measures only. After
extubation, she did not tolerate a face mask very well and was
repeatedly taking it off her face. She was kept on nasal cannula
alone. Her oxygenation progressively worsened, and she began
having signs of respiratory distress. She was started on IV
morphine to relieve symptoms of respiratory distress. She never
fully regained consciousness. She became progressively hypoxic
and passed away peacefully soon after. Her son declined an
autopsy.
Right sided effusion: Per above noted on CXR consistently since
admission. Given tenuous clinical status, have differed
thoracentesis as high risk. Concern for a parapneumonic
effusion was low, as patient continued to improve without fevers
on HCAP treatment. Initially held off on thoracentesis given
high risk in intubated supine patient. However, with the goal of
extubation in mind, the patient had a successful thoracentesis.
Unfortunately, the effusion recurred soon after, likely from
severe total-body fluid overload.
Upper GI bleed from GIST tumor: Presented with massive UGIB
from GIST tumor. Received massive transfusion protocol
resusucitation. Endoscopy confirmed GIST tumor in fundus of the
stomach. Inability to achieve hemostasis during EGD lead to
interventional raidoloyg performing a splenic artery
embolization to stop the bleeding with good effect. Had
sporadic small drops in HCT requiring occsassional transfusions,
as well as episodes of bloody ouput from NGT. Surgery deferred
based on goals of care from HCP. Eventually, the bleeding
slowed, but the patient continued to have respiratory failure
described above and eventually passed away from difficulty
breathing.
[**Last Name (un) **]: Likely pre-renal/hypvolemia induced in presence of massive
GIB and later diuresis in presence of massive fluid overload
post resuscitative efforts Her creatinine stabilized around 1.5
to 1.7 but never returned to her baseline.
Left radius fracture: Trauma occurred prior to hospitalization.
Ortho consulted who removed her sutures and placed a splint,
with a plant to keep the splint in place for four weeks.
Medications on Admission:
APAP 650 mg po q6hrs pain/fever
Calcium carbonate 200 mg calcium (500 mg) Tablet 3 tablets po
qday
Cholecalciferol (vitamin D3) 800 unit po qday
Pantoprazole 40 mg Tablet 1 tablet PO Q12H
Furosemide 20 mg Tablet 1 PO daily
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
Docusate sodium 100 mg Tablet 1 Tablet PO BID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Crytogenic Cirrhosis
Upper GI bleed
GIST tumor
respiratory failure
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2165-7-16**]
|
[
"276.0",
"285.1",
"276.69",
"584.9",
"785.59",
"456.1",
"V66.7",
"518.81",
"532.90",
"V54.12",
"238.1",
"572.2",
"571.5",
"537.9",
"286.6",
"276.2",
"578.0",
"511.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"44.43",
"96.6",
"44.44",
"96.04",
"88.47",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10000, 10009
|
6560, 9606
|
280, 404
|
10119, 10129
|
2609, 2609
|
10181, 10344
|
2129, 2162
|
9972, 9977
|
10030, 10098
|
9632, 9949
|
10153, 10158
|
2177, 2590
|
1449, 1469
|
211, 242
|
432, 1429
|
2625, 6537
|
1491, 1920
|
1936, 2113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,453
| 115,130
|
19694
|
Discharge summary
|
report
|
Admission Date: [**2188-10-17**] Discharge Date: [**2188-10-23**]
Date of Birth: [**2134-7-25**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
intubation, mechanical ventilation
History of Present Illness:
54 yo male with Hepatitis C cirrhosis and mult admissions for
encephalopathy now with admission s/p increasing confusion,
?fall, AMS and intubation for desaturations in the field. Pt
found down by sister in home holding onto a door in basement
with bruise on head, likely s/p fall. Sister had noticed he had
been increasingly confused over the previous few days after
having been doing quite well since discharge from [**Hospital1 18**] [**9-26**] (?)
s/p hepatic encephalopathy; currently compliant on home meds
regimen. Pt transfered to OSH, during transfer pt with acute
desaturations and was intubated in the field, requiring ativan
and pancuronium. Head CT, neck CT neg for acute pathology.
Transfered to [**Hospital1 18**] for further management. On admission to
MICU, pt hemodynamically stable on ventilator and responsive to
verbal and physical stimuli with ativan on board from OSH.
Past Medical History:
1. HCV cirrhosis (hx portal htn/ ascites/ arices/
encephalopathy/ sbp)
2. Chronic Renal Insufficiency (baseline Cr = 1.6)
3. Diabetes Type II
4. Pancytopenia likely d/t hypersplenism
5. chronic hyperkalemia
6. HTN
Social History:
lives with sister, current 22 [**Name2 (NI) 53278**] tobacco, h/o IVDU quit 12yrs
ago on methadone, h/o alcohol quit [**2166**]
Family History:
Father died at 55 CAD, Mother died at 82 lung cancer
Physical Exam:
97.3, 153/90, 71, 14, 100% (on AC 600/14/40%/5)
Gen sedated, responsive to verbal stimuli and pain
HEENT PERRL, anicteric, abrasion on forehead with L periorbital
edema
Neck supple without deformity
Lungs coarse BS b/l
CVS RRR
Abd soft nt nd, BS wnl, no hsm, fluid wave not appreciated
Ext 1+ pitting edema of ankles, petechiae on b/l LE, 2+DPs
Neuro exam limited by sedation, moving all extremities and opens
eyes
Pertinent Results:
ECG([**10-17**]):Sinus arrhythmia
Ant/septal+lateral ST-T changes may be due to myocardial
ischemia
ST-T wave changes in those leads less pronounced than previous
----
Abd U/S([**10-18**]):1. No portal vein thrombosis.
2. Persistent small amount of ascites.
----
LLE doppler:There is no evidence of DVT.
----
p-MIBI:1) Normal myocardial perfusion. 2) Normal left
ventricular cavity
size and systolic function.
----
Chemical cardiac stress: No angina with no ischemic ECG changes.
Nuclear report
will be sent separately.
----
[**2188-10-17**] 10:37PM BLOOD WBC-2.8* RBC-2.95* Hgb-9.0* Hct-26.4*
MCV-90 MCH-30.6 MCHC-34.2 RDW-18.0* Plt Ct-65*
[**2188-10-23**] 06:50AM BLOOD WBC-2.2* RBC-3.27* Hgb-10.0* Hct-29.9*
MCV-92 MCH-30.6 MCHC-33.4 RDW-16.9* Plt Ct-60*
----
[**2188-10-17**] 10:37PM BLOOD PT-15.1* PTT-27.8 INR(PT)-1.4
[**2188-10-19**] 02:24AM BLOOD Gran Ct-1160*
----
[**2188-10-17**] 10:37PM BLOOD Glucose-177* UreaN-40* Creat-1.2 Na-147*
K-4.5 Cl-114* HCO3-24 AnGap-14
[**2188-10-17**] 10:37PM BLOOD ALT-20 AST-42* LD(LDH)-271* CK(CPK)-97
AlkPhos-127* Amylase-39 TotBili-0.6
[**2188-10-17**] 10:37PM BLOOD Lipase-29
-----
[**2188-10-17**] 10:37PM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2188-10-18**] 06:32AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2188-10-19**] 02:24AM BLOOD CK-MB-4 cTropnT-0.05*
[**2188-10-18**] 06:32AM BLOOD ALT-19 AST-42* LD(LDH)-256* CK(CPK)-77
AlkPhos-121* Amylase-37 TotBili-1.4
[**2188-10-19**] 02:24AM BLOOD ALT-19 AST-42* LD(LDH)-207 CK(CPK)-47
AlkPhos-105 Amylase-37 TotBili-0.7
[**2188-10-17**] 10:37PM BLOOD ALT-20 AST-42* LD(LDH)-271* CK(CPK)-97
AlkPhos-127* Amylase-39 TotBili-0.6
----
[**2188-10-17**] 10:37PM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.0 Mg-1.5*
[**2188-10-20**] 06:40AM BLOOD Albumin-2.4* Calcium-7.6* Phos-2.6*
Mg-2.0
----
[**2188-10-18**] 06:10PM BLOOD Ammonia-49*
[**2188-10-17**] 09:52PM BLOOD Lactate-1.5
----
[**2188-10-17**] 10:42PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2188-10-17**] 10:42PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2188-10-17**] 10:42PM URINE RBC-14* WBC-0 Bacteri-FEW Yeast-NONE
Epi-0
----
Blood and urine cultures negative
Brief Hospital Course:
Mr [**Known lastname 23657**] is a 54 yo with Hep C cirrhosis and a history of
hepatic encephalopathy who presented with another apparent bout
of encephalopathy and also s/p a fall and ? resp distress
requiring intubation. He was intially in the ICU and then
extubated and transferred to the floor.
1. Mental status changes/encephalopathy: This was again likely
hepatic encephalopathy from worsening liver fxn. The reason he
continues to have these episodes in unclear, although infectious
cause must be ruled out. He is afebrile and has no evidence of
infection. Abd U/S showed again only a small amt of untappable
ascites. Not changed from previous admit. A CT of his head was
neg, and despite a low Hct, his levels were stable and stol
guaiac was negative. This suggests he is not having a GI bleed.
Cultures were drawn from blood and urine and were negative for
growth. He was continued on a high dose of lactulose with a
goal of 5 BMs/day, but was initially having closer to 10. His
dose was dropped to get him to an appropriate range, andhe was
sent out on this dose.
Again, his methaodne was considered to be a possible factor
in his mental status alterations. It was initially held in the
ICU, but restarted on the floor, and eventually, the team and
the patient agreed on a dose of 15 [**Hospital1 **]. The patient was to
eventually get off of it all together and can hopefully do this
as an outpt. His Cipro and Flagyl were continued as well.
2. Hypoxic respiratory failure: Initially had hypoxia in the
field and was intubated. Question of whether this was true
hypoxia, or intubation was more for airway protection. It
resolved in the ICU and he was extubated. He may have been
sedated due to his encephalopathy, causing him respiratory
problems. For the remainder of his stay, he had no hypoxia or
DOE or other pulmonary issues.
3. Cirrhosis: We continued his propranolol and cipro/flagyl as
above. He was sent out on [**Hospital1 **] dosing of propranolol after his
last admit, but was apparently coming back in on tid dosing.
This was continued here, and his PCP can hopefully work to
decrease this as an outpt if his BP will not becoem too
elevated. This medicine will prevent some portal flow and
impair his liver even further if not managed appropriately. His
lactulose was given with a goal of 5 BMs/day. He was achieving
this, so he was sent out on the hospital dose. Again, no
tappable ascites or reason to worry about SBP. Also, no
hemoptysis or Hct drop that would suggest varices.
4.Methadone: Initially continued 20 [**Hospital1 **], and after much
resistance, pt agreed to 15 [**Hospital1 **]. Would like to eventually get
him off of this all together, but his psychological dependence
is strong. Can work on this as an outpt.
5. HTN: Continued his propranolol at outpt tid dose. Adequate
control, but could probably go down to [**Hospital1 **].
6. DM2: His outpt regimen is unclear as some records indicate he
takes glargine while other say glipizide. He was covered here
with SSI alone and maintained blood glucoses in the high
100s(covered with insulin for these). Although glipizide not
that good a drug for people in liver failure, pt and his sister
both state he does not take insulin shots now, but does take
glipizide every day. This could not be confirmed with his PCP.
[**Name10 (NameIs) **] was sent out on a low dose of glipizide for the short term to
help control his blood glucose and asked to see his PCP [**Name Initial (PRE) 176**] 1
week to get on a better regimen long term. Unfortunately
insulin amnagement may be too difficult for him due to his
mental capacity.
7. EKG changes: He had questionable changes at an OSH, and an
ECG read here was also showing possible ischemia. His cardiac
enzymes were cycled and he did have a troponin bump, but flat
CKs/CK-MBs. This was likely demand ischemia and not an MI. He
had a stress in [**Month (only) **] but it wasn't an adequate study, so we
performed a p-MIBI here. It was normal, with no evidence of
ischemia or perfusion defects. The study was adequate.
8.LLE swelling: Thought to be chronic, but got LLE doppler that
was neg for DVT.
9.Foley removal:Pt at one point pulled out his own foley with
the bulb inflated. He had bleeding from his penis afterwards
that was controlled by pressure. He was monitored closely for
clots/bladder outlet obstruction. This did not occur. He had
one additional episode of gross hematuria, but then reported no
blood in his urine. He also reported no additional
dysuria/pain. He was urinating noramlly and without blood on
discharge. No Hct drop as a result.
10.Pancytopenia:His blood counts were all low, but monitored
daily. He never became neutropenic. Also, his Hct was low, but
asymptomatic and stable. He was not transfused. His platelets
also stayed low, but stable and no dangerous bleeding was
observed. He did not require platelets to stop his penile
bleeding episode after the folwy removal.
He was discharged with close follow-up by his PCP to put him on
a good insulin/diabetes regimen, and with Dr [**Last Name (STitle) 497**].
Medications on Admission:
methadone 30 [**Hospital1 **], protonix 40 mg, aspranolol 20 tid, cipro 250
qd, flagyl 250 tid, lactulose 45cc tid, lasix 40 qd, nicotine
patch, procrit 40K QW, kayexalate 30cc QW, glargine 20u Qpm
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
2. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO TID (3 times
a day).
6. Methadone HCl 10 mg Tablet Sig: 1.5 Tablets PO twice a day.
Tablet(s)
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO qam.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
Hepatic encephalopathy
HCV cirrhosis
CRI
Type II diabetes
Pancytopenia
HTN
Discharge Condition:
Good. Pt was mentating normally. Walking around without issue.
He was at his baseline per pt.
Discharge Instructions:
Please call your PCP or return to the hospital if you have more
confusion, trouble with your thinking, falls, or you are overly
sleepy. Also call if you have any other symptoms that concern
you, such as fever or chills.
We changed your methadone dose to 15 mg twice a day.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-11-5**] 11:00
Provider: [**Name10 (NameIs) **] TRANSPLANT,ORIENTATION TRANSPLANT
CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE
Date/Time:[**2188-11-13**] 3:00
Provider: [**Name10 (NameIs) 970**],[**Name11 (NameIs) 971**] TRANSPLANT CENTER-MEDICINE Where:
TRANSPLANT CENTER-MEDICINE Date/Time:[**2188-12-9**] 2:00
Please call your PCP and make an appointment to follow-up within
1 week to discuss your diabetes management and to follow-up
after your hospital stay
|
[
"571.2",
"070.44",
"284.8",
"572.2",
"401.9",
"276.7",
"789.5",
"599.7",
"289.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10427, 10488
|
4415, 9539
|
330, 366
|
10607, 10702
|
2197, 4392
|
11024, 11642
|
1692, 1747
|
9787, 10404
|
10509, 10586
|
9565, 9764
|
10726, 11001
|
1762, 2178
|
272, 292
|
394, 1293
|
1315, 1531
|
1547, 1676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,561
| 141,211
|
19585+19586
|
Discharge summary
|
report+report
|
Admission Date: [**2166-5-16**] Discharge Date: [**2166-5-22**]
Service: Vascular Surgery
CHIEF COMPLAINT: Asymptomatic 5.2-cm abdominal aortic
aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old
nondiabetic white male who was found to have a abdominal
aortic aneurysm while undergoing an ultrasound study of his
prostate in [**2165**]. Initial abdominal ultrasound showed the
aneurysm to be 4.5 cm. A follow-up ultrasound in [**2166-1-16**] showed a 5.2-cm abdominal aortic aneurysm.
The patient was referred to Dr. [**Last Name (STitle) **] for evaluation for
surgery. The patient underwent a CTA of his abdomen on
[**2166-2-13**]; which showed that the patient was not a
candidate for endovascular abdominal aortic resection due to
small iliac arteries.
The patient denied any new onset of abdominal or back pain or
new onset of claudication. He was scheduled for an elective
open repair of his abdominal aortic aneurysm with a tube
graft.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation postoperatively in [**2165-1-16**].
2. Colon cancer, right hemicolectomy.
3. Chronic obstructive pulmonary disease.
4. Benign prostatic hypertrophy.
5. Pneumonia postoperatively in [**2165-6-16**].
6. Peptic ulcer disease; Helicobacter pylori infection.
7. Kidney stones.
8. Hypertension.
PAST SURGICAL HISTORY:
1. Transurethral resection of prostate in [**2162**].
2. Right total knee replacement.
3. Perirectal abscess.
4. Right hemicolectomy in [**2165-6-16**] by Dr. [**Last Name (STitle) 53103**] at
[**Hospital3 **].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient has been a widower for 20 years.
He lives alone. He has two daughters and a son who live
locally. He has been smoking one pack of cigarettes per day
for the last 60 years. He does not drink alcohol. He
ambulates independently.
ALLERGIES:
1. DIAZEPAM (causes nausea, vomiting, and diarrhea).
2. CEPHALEXIN (causes nausea, vomiting, and diarrhea).
3. TETANUS (causes arm swelling and pruritus).
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg by mouth once per day.
2. Norvasc 5 mg by mouth once per day.
3. Protonix 40 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
pulse was 60, respirations were 12, and blood pressure was
126/77. Head, eyes, ears, nose, and throat examination
revealed no jugular venous distention. Carotids palpable.
No bruits. Chest revealed heart with a regular rate and
rhythm without murmurs. The lungs were clear bilaterally.
The abdomen was soft and nontender. Pulse examination
revealed femoral pulses were 2+ bilaterally with bruits.
Distal pulses were all 2+ bilaterally. Neurological
examination was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 8.3, hemoglobin was 12.6, hematocrit was 39.6,
and platelets 272,000. Prothrombin time was 13.1, partial
thromboplastin time was 22.4, and INR was 1.1. Sodium was
141, potassium was 3.6, chloride was 105, bicarbonate was 23,
blood urea nitrogen was 21, creatinine was 1.1, and blood
glucose was 143.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on [**2166-5-9**] showed a normal sinus rhythm with a rate of 63. Normal
electrocardiogram.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2166-5-16**] following an open abdominal aortic resection
with tube graft.
Postoperatively, after extubation, the patient developed
inspiratory stridor and required reintubation. He was
successfully extubated on postoperative day one.
Postoperative pain was managed with a Dilaudid epidural. A
nasogastric tube remained until postoperative day two. The
patient was then started on sips. He was ordered to begin
ambulation.
The patient self removed his left cordis leading to bleeding in
the neck controlled with manula pressure. On the evening on
postoperative day two, the patient
developed aphasia. The rest of his neurological examination
was normal. The Neurology/Stroke Service was consulted. A
magnetic resonance imaging showed multiple small
embolic-looking infarctions in the left hemisphere. An
ultrasound of the carotids showed bilateral 40% to 59%
internal carotid artery stenosis.
A portable transthoracic echocardiogram done on [**2166-5-19**]
and [**2166-5-20**] showed no source for a cardiac source of
embolus. Ejection fraction was normal. The Stroke Service
recommended starting Plavix and aspirin. Over the next 48
hours, the patient's aphasia improved considerably.
A bedside swallow study on [**2166-5-19**] showed no evidence of
aspiration or dysphagia. His aphasia was evaluated as being
mild-to-moderate expressive/nonconfluent aphasia with
decreased sentence formulation, occasional agrammatic
productions, mild impaired naming, and paraphasic errors. He
was felt to be a good candidate for speech therapy for
aphasia remediation.
Physical Therapy evaluated the patient. The patient was able
to ambulate independently without difficulty on a flat
surface as well as on stairs. He was felt to be safe for
discharge home on [**2166-5-22**]. Home physical therapy, speech
therapy, and occupational therapy at home was recommended.
The patient's atenolol was stopped, and his blood pressure
was controlled with Lopressor 100 mg by mouth twice per day.
The patient will follow up with Dr. [**Last Name (STitle) **] in one week for
abdominal staple removal or for further instructions at the
time of discharge.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg by mouth once per day.
2. Ecotrin 325 mg by mouth once per day.
3. Lopressor 100 mg by mouth twice per day (hold for a
systolic blood pressure of less than 130, heart rate of less
65).
4. Amlodipine 5 mg by mouth once per day.
5. Lipitor 10 mg by mouth once per day.
6. Protonix 40 mg by mouth once per day.
7. Tylenol 325 mg to 650 mg by mouth q.4-6h. as needed.
8. Percocet one to two tablets by mouth q.4-6h. as needed
(for pain).
DISCHARGE DISPOSITION: Home with services.
CONDITION AT DISCHARGE: Satisfactory.
PRIMARY DISCHARGE DIAGNOSES:
1. Asymptomatic 5.2-cm abdominal aortic aneurysm.
2. Abdominal aortic aneurysm resection with tube graft on
[**2166-5-16**].
SECONDARY DISCHARGE DIAGNOSES:
1. Postoperative left cerebrovascular accident with aphasia;
resolving.
2. Hypertension.
3. Chronic obstructive pulmonary disease.
4. Benign prostatic hypertrophy, transurethral resection of
prostate in [**2162**].
5. History of paroxysmal atrial fibrillation postoperatively
in [**2165-6-16**].
6. Pneumonia postoperatively in [**2165-6-16**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2166-5-21**] 16:17
T: [**2166-5-21**] 16:08
JOB#: [**Job Number 53104**]
Admission Date: [**2166-5-16**] Discharge Date: [**2166-5-22**]
Service: VASCULAR S
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 79 year old white male
with known abdominal aortic aneurysm found on abdominal
ultrasound for work-up of prostate and he has had several
ultrasounds since the initial evaluation. The most recent
one was done in [**Month (only) 956**] of this year which showed an
increase in size. The patient was referred to Dr. [**Last Name (STitle) **] and
underwent an arteriogram which showed an abdominal aortic
infrarenal aorta and a CT angiogram to determine whether the
patient could be an endovascular repair. The patient returns
now for aortic aneurysm repair.
REVIEW OF SYSTEMS: Review of systems is negative for back
pain, no bowel changes, groin or flank pain, weight changes,
appetite changes.
PAST MEDICAL HISTORY:
1. Include paroxysmal atrial fibrillation after his
colectomy.
2. Benign prostatic hypertrophy.
3. Colon carcinoma.
4. Pneumonia status post his colon surgery.
5. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY:
1. Right hemicolectomy in [**2165-6-16**].
2. Perirectal abscess, remote.
3. Colonoscopy in [**4-19**], which was negative.
ALLERGIES: The patient has allergies to tetanus which
causes arm swelling and pruritus; diazepam causes nausea,
vomiting and diarrhea; Cephalexin causes nausea, vomiting and
diarrhea.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg q. day.
2. Lipitor 10 mg q. day.
3. Norvasc 5 mg q. day.
4. Atenolol 25 mg q. day.
SOCIAL HISTORY: He is widowed for 20 years. He owns his own
home. He is a retired telephone repairman. Habit wise - he
has a sixty pack year history of smoking and he has not had
alcohol in 30 years.
PHYSICAL EXAMINATION: Vital signs 126/70; 60; 12. HEENT
examination with no jugular venous distention, no carotid
bruits, two plus palpable carotid pulses bilaterally. Lungs
are clear to auscultation. Heart is a regular rate and
rhythm with no murmur, gallop or rubs. Abdominal examination
is prominent, wide abdominal aorta on palpation. There are
no bruits or masses. The bowel sounds are active times four.
Peripheral vascular examination shows bilateral femoral
bruits with pulses two plus symmetrically bilaterally
femorals to pedal pulses. Neurological examination: He is
oriented times three and is grossly intact.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2166-5-16**] where he underwent
DICTATION ENDS
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2166-5-21**] 18:55
T: [**2166-5-21**] 18:58
JOB#: [**Job Number 53105**]
|
[
"530.81",
"427.31",
"997.1",
"V10.05",
"997.02",
"441.4",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
6013, 6044
|
1583, 1601
|
6262, 6987
|
5529, 5988
|
8360, 8466
|
9321, 9710
|
8019, 8334
|
8694, 9303
|
6059, 6082
|
7653, 7772
|
7006, 7034
|
7063, 7633
|
7794, 7996
|
8483, 8671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,472
| 184,486
|
24
|
Discharge summary
|
report
|
Admission Date: [**2179-4-12**] Discharge Date: [**2179-4-15**]
Date of Birth: [**2114-2-8**] Sex: M
Service: MEDICINE
Allergies:
Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
altered mental status and hypotension
Major Surgical or Invasive Procedure:
picc line and central access
History of Present Illness:
65 year-old gentleman with multiple medical problem including
history of lung cancer post right pneumonectomy in [**2174**], severe
COPD, post tracheostomy and [**Year (4 digits) 282**] placement(respiratory failure
due to pneumonia) recently admitted to [**Hospital1 18**] for urosepsis, now
presenting yet again with hypotension and altered mental status.
Patient unable to give a history at this time so obtained from
records. Pt was admitted to [**Hospital1 **] on [**3-26**] after an admission
at [**Hospital1 18**] for a Klebsiella UTI and hypotension. Since his
admission there, the pt has been alert and getting out of bed to
the commode with assistance. On [**4-11**], the pt became lethargic
and then gradually unresponsive. On [**4-12**], his BP decreased to
60 over palp and the pt was noted to be diaphoretic. He received
a 500 cc bolus with an increase in his BP to 90/40. He remained
unresponsive during this time. ABG showed 7.265/92.7/82 on an
FiO2 of 0.50 with a temperature of 99.4. Of note, pt's triple
lumen was placed [**2179-3-21**].
.
Wife later arrived at the hospital and was able to provide
additional history. She reports that he had been doing very well
until Friday. They were working on weaning him and he was able
to be on the trach mask for 1-2 hours at a time. However, on
Friday, the pt felt mildly more SOB per his report. He was
maintained exclusively on the vent over the rest of the weekend.
Yesterday, the pt's wife reports that he looked "very scared"
and would often stare at the ceiling. He also had periods of his
eyes "rolling back in his head". He was occasionally responsive
to her. She reports that they had been checking ABGs over the
last 24 hours and his CO2 had been elevated. When they changed
the vent settings to decrease the CO2, she felt that he was
slightly less confused. She also notes that he was very
diaphoretic yesterday and his faced appeared red and swollen.
The pt's BP has always been very low in his left arm and she
reports that they just starting taking his pressure there due to
a skin tear on the right.
.
In the ED, the pt's VS were, 99.8 85 80/60-L 150/80-R 20 100% AC
400/20/100%/PEEP 5. He received vancomyicin and zosyn. Pt was
initially started on levophed for hypotension. However, after
learning that his BP has always been considered to be abnormally
low in the left arm, it was checked in the right and has been
stable in the 120s off of pressors. No new consolidation on CXR.
Normal lactate.
Currently getting a liter of NS
.
Past Medical History:
1. Squamous cell lung carcinoma, status post right
pneumonectomy in [**2174**].
2. Prostate cancer, status post radical prostatectomy.
3. Perioperative pulmonary embolus [**2174**].
4. Type 2 diabetes mellitus.
5. Chronic obstructive pulmonary disease.
6. Atrial fibrillation.
7. Transient ischemic attack in [**2165**].
8. Gout.
9. Atypical chest pain since [**2164**].
10. Gastroesophageal reflux disease.
11. Obstructive sleep apnea. unable to tolerate BiPAP.
12. Hypertension.
13. Colonic polyps.
14. Hypercholesterolemia.
15. Basal cell carcinoma on his back.
16. Anxiety.
17. Sciatica.
18. History of herpes zoster.
19. multiple admissions for pneumonia (including pseudomonas)
and bronchitis, last in [**10-31**] resulting in ventilator
dependence, trach and [**Date Range 282**] placement
20. vitamin B12 deficiency.
21. Diastolic heart failure. Echo [**7-31**]: LVEF>55%
21. Cataracts
22. bradycardia on amiodarone
Social History:
Recently discharged to [**Hospital **] rehab s/p trach and [**Hospital 282**]. He has
a 3-pack-per-day tobacco history but quit in [**2174**] and an overall
160-pack-per-year history. No recent history of alcohol use.
Family History:
Mother with coronary artery disease.
Physical Exam:
99.8 85 80/60-L 150/80-R 20 100% AC 400/20/100%/PEEP 5
Gen- Lethargic appearing man on strecher. Will occasionally look
in your dirrection to his name. Does not follow simple commands.
Does not answer any questions.
HEENT- NC AT. Trach in place. Pinpoint pupils that are minimally
reactive to light. Anicteric sclera. Right subcalvian triple
lumen without erythema or other signs of infection.
Cardiac- RRR.
Pulm- Coarse breath sounds throughout. Difficult to detect
decreased breath sounds on the left.
Abdomen- Soft. Does not respond to palpation. ND. Minimal bowel
sounds. [**Year (4 digits) 282**] in place with no erythema or discharge.
Extremities- No c/c/e. 2+ DP pulses bilaterally. Feet are warm.
[**Name (NI) 298**] Pt [**Last Name (un) 299**] frequent twiching. Moderate rigidity with
movement of his limbs. Positive clonus. Downgoing toes
bilaterally.
Pertinent Results:
[**2179-4-12**] 09:35PM TYPE-ART TEMP-37.8 RATES-25/ TIDAL VOL-450
PEEP-5 O2-40 PO2-98 PCO2-54* PH-7.43 TOTAL CO2-37* BASE XS-9
-ASSIST/CON INTUBATED-INTUBATED
[**2179-4-12**] 09:35PM K+-3.8
[**2179-4-12**] 09:17PM CK(CPK)-33*
[**2179-4-12**] 09:17PM CK-MB-4 cTropnT-0.13*
[**2179-4-12**] 06:45PM TYPE-ART TEMP-38.5 RATES-25/0 TIDAL VOL-450
PEEP-5 O2-40 PO2-66* PCO2-68* PH-7.35 TOTAL CO2-39* BASE XS-8
-ASSIST/CON INTUBATED-INTUBATED
[**2179-4-12**] 02:44PM TYPE-ART TEMP-38.3 RATES-25/ TIDAL VOL-485
PEEP-5 O2-100 PO2-68* PCO2-71* PH-7.36 TOTAL CO2-42* BASE XS-10
AADO2-589 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED
[**2179-4-12**] 11:54AM GLUCOSE-77 UREA N-28* CREAT-0.6 SODIUM-148*
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-37* ANION GAP-11
[**2179-4-12**] 11:54AM CK-MB-4 cTropnT-0.16*
[**2179-4-12**] 09:05AM TYPE-ART RATES-/24 PO2-401* PCO2-88* PH-7.25*
TOTAL CO2-40* BASE XS-7 -ASSIST/CON INTUBATED-INTUBATED
[**2179-4-12**] 07:07AM TYPE-ART O2-100 PO2-439* PCO2-107* PH-7.21*
TOTAL CO2-45* BASE XS-10 AADO2-186 REQ O2-39 INTUBATED-INTUBATED
[**2179-4-12**] 06:20AM URINE HOURS-RANDOM
[**2179-4-12**] 06:20AM URINE UHOLD-HOLD
[**2179-4-12**] 06:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2179-4-12**] 06:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2179-4-12**] 06:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2179-4-12**] 05:36AM O2 SAT-84
[**2179-4-12**] 05:34AM GLUCOSE-186* UREA N-28* CREAT-0.5 SODIUM-148*
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-40* ANION GAP-8
[**2179-4-12**] 05:34AM ALT(SGPT)-73* AST(SGOT)-50* CK(CPK)-32* ALK
PHOS-328* AMYLASE-42 TOT BILI-0.6
[**2179-4-12**] 05:34AM LIPASE-18
[**2179-4-12**] 05:34AM CK-MB-NotDone cTropnT-0.08*
[**2179-4-12**] 05:34AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.1
MAGNESIUM-2.2
[**2179-4-12**] 05:34AM WBC-14.2*# RBC-3.23* HGB-8.7* HCT-29.1*
MCV-90 MCH-26.8* MCHC-29.8* RDW-14.3
[**2179-4-12**] 05:34AM NEUTS-93.2* BANDS-0 LYMPHS-2.4* MONOS-4.1
EOS-0.1 BASOS-0.1
[**2179-4-12**] 05:34AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-3+ STIPPLED-OCCASIONAL
ENVELOP-2+
[**2179-4-12**] 05:34AM PLT COUNT-332
[**2179-4-12**] 05:34AM PT-16.0* PTT-28.5 INR(PT)-1.7
[**2179-4-12**] 05:30AM LACTATE-1.3
studies:
ECG- Sinus rhythm at 72 beats per minute. Nonspecific ST-T wave
changes but no major changes since previous studies.
.
CXR- Stent projecting over the right brachiocephalic vein. Right
lung remains opacified with shift of the cardiac and mediastinal
contours toward the right consistent with previous
pneumonectomy. There is blunting of the left costophrenic angle
which could represent pleural thickening or small left pleural
effusion. Slightly increased interstitial markings int he left
lung which appear stable. No new left pneumo or focal
consolidation.
.
Head CT (WET READ)- No hemorrhage, shift, mass effect, or
evidence of hydrocephalus. No evidence of a major CVA.
US upper extremity:IMPRESSION:
1) Nonocclusive thrombus in the left cephalic vein.
2) Nonocclusive thrombus in the distal left brachial veins
Transabdominal ultrasound examination was performed. The
gallbladder is not distended. There is an 8-9 mm stone located
at the neck of the gallbladder. The gallbladder wall is
thickened. There are possible crystal or tiny cholesterol polyps
located at the fundus of the gallbladder. No intra or
extrahepatic biliary ductal dilatation is identified. The common
duct is not dilated and measures 3 mm. Flow in the portal vein
is anterograde. Limited evaluation of the liver demonstrates no
focal abnormality.
IMPRESSION: Thickened gallbladder wall with a stone in the
gallbladder neck in a nondistended gallbladder. In the proper
clinical setting, these findings may be consistent with
cholecystitis. They are not completely typical for acute
cholecystitis. Gallbladder wall thickening may also be produced
by third spacing of fluids. If there is continued clinical
concern for cholecystitis, a HIDA scan may be performed for
further evaluation.
TECHNIQUE: CT images of the chest without the administration of
IV contrast.
COMPARISON: [**2176-9-11**] and [**2179-3-21**].
FINDINGS:
Soft tissue window images demonstrate changes of prior right
pneumonectomy and mediastinal shift towards the right. There is
no pathologic axillary, mediastinal, or hilar lymphadenopathy.
There is a left pleural effusion. The patient is intubated with
a tracheostomy tube. A stent is again identified within the
right brachiocephalic vein. The heart demonstrates coronary
calcifications, but is normal in size. The main pulmonary artery
appears prominent measuring 3.5 cm.
Lung window images demonstrate multifocal nodular opacities seen
scattered throughout the left lung. No specific areas of
cavitation are identified within these nodules. Atelectasis is
also seen at the left lung base. There is no focal consolidation
or pneumothorax. Septal thickening is seen throughout the left
lung field. A small 3-mm nodule seen on the prior studies is
again seen, though slightly difficult to discern given the
surrounding septal thickening and nodular opacities. However, on
the study from [**2179-3-21**], this nodule was clearly seen and appears
stable dating back to [**2176-9-11**]. The bronchi appear patent to the
segmental level within the left lung.
Images of the upper abdomen demonstrate high-density material
within dependent portion of the gallbladder, probably relating
to sludge. A percutaneous gastrostomy tube is seen within the
stomach. The remainder of the visualized portion of the upper
abdomen is unremarkable other than arterial calcifications. The
soft tissues are unremarkable. Degenerative changes are seen
throughout the thoracic spine.
IMPRESSION:
1) Multifocal nodular opacities seen scattered throughout the
entire left lung. These most likely represent aspiration
pneumonia. Septic emboli are considered less likely based on the
CT appearance.
2) Mild CHF.
3) Left upper lobe nodule seen on the prior study of [**2179-3-21**]
demonstrates stability dating back to [**2176-9-11**].
4) Probable sludge within the gallbladder.
5) Findings suggestive of underlying pulmonary arterial
hypertension.
Brief Hospital Course:
65 y/o man with PMH significant for squamous cell lung CA, type
2 DM, atrial fib, and multiple past pneumonias admitted from
[**Hospital1 **] with mental status change and hypotension.
#ID/sepsis
Patient had fever and leukocytosis initially with fluctuating
blood pressure, lactate 1.3. His blood pressure in the ED was
measured on the left arm (which is typically much lower). His
blood pressure on the right was found to be normal and pressors
were off. Sputum culture was sent(colonized with pseudomonas),
blood culture, urine culture and cath tip culture negative on
discharge. His decubitus ulcer looks clean. His line was resited
line to the right femoral. Chest CT was consistent with
aspiration pneumonia. He will be continued on zosyn for 14 days.
He remained afebrile and no pressors required throughout the
rest of his hospital stay.
#Mental status changes:
His mental status improved with decreasing CO2 and also with
narcan. His CO2 remained well controlled in the hospital and was
at baseline in 70s. CT head was negative. Narcotics was taken
into consideration as possible cause of mental status changes.
Patient's duragesic patch was removed in the ED.
#anemia/coagulation
Patient has history of deep venous thrombosis with IVC filter
and SVC clot and also atrial fibrillation for which he was on
coumadin. COumadin was taken off 3 days prior to hospital
admission because he had blood oozing from his trach and foley.
In hospital, central line was attempted intially on the right
subclavian but the artery was puctured. His right femoral artery
was also punctured and he did lose a signifcant amount of blood.
The 2 arterial puncture was tamponaded and there was no
hematoma. He also got an ultrasound of uppper extremity which
revealed DVT in left arm for which he was started on heparin
drip. He then had mild guiac negative stool and oozing from
arterial line site. Heparin drip was then stopped and he was
given 2 unit of transfusion. His hematocrit had been stable
since then. On discharge, coumadin was not restarted. It should
be restarted in 1-2days time if the hematocrit remain stable.
.
#transaminitis
He presented intially with transaminitis likely from
hypotension. LFTS trended down on discharge. RUQ ultrasound was
done which showed gallstone at neck of GB, no distension,
thickened gallbladder. He remained afebrile and has no abdominal
tenderness
#respiratory:
Patient has squamous cell lung CA post right pneumonectomy and
post tracheostomy. During his past admission there was concern
about cuff leak and possible tracheomalacia. Dr. [**Last Name (STitle) **]
recommended keeping the cuff pressures low with a cuff leak to
prevent further tracheamalacia. Possible change the trach to a
foam-filled trach ([**Last Name (un) 295**] tube) in the future if the cuff leak
is interfering with the ability to ventilate. He remained on
assist control ventilation.
.
# [**Name (NI) 300**] Pt with mildly elevated Na at 148. This is most
likely due to water deficit as he can not drink to replace his
needs. He recieved free water through G tube.
.
# Cardiac
Patient has long history of atypical chest pain but has no such
complain during this hospitalization. Cardiac enzymes were
unremarkable. He was continued on aspirin and also amiodarone
for atrial fibrillation. He is to avoid beta blockers and
calcium channel blockers because of profound bradycardia.
.
#Type 2 diabetes mellitus
Patient was continued on standing 8U glargine and sliding scale
while in hospital.
#Anxiety/pain
Patient's family reports that he is extemely anxious at
baseline. He was continues on his outpatient doses of Haldol for
anxiety 5mg hs, 2mg 8am/2pm, 1mg tid/prn, and paxil. His pain is
from his scaral decubitus ulcer and back pain. Anxiety has been
severely worsened in the past with ativan. Would avoid further
ativan. Fentanyl patch was discontinued since there was a
concern regarding narcotic overdose. He was on prn morphine.
THis should be adjusted in [**Hospital1 **].
# Sacral Decubitus:
He had Kinair bed
# FEN
Tube feeds was continued with no residual
#access
He had picc line on discharge
#code
OK with pressor, do not resuscitate(confirmed again with family
meeting)
Medications on Admission:
1. Xopenex 1.2 mg inhaled Q4H
2. Atrovent neb Q6H PRN
3. Haldol 1 mg 0800 and 1400
4. Haldol 5 mg QHS
5. Casec powder 2 tablespoons TID
6. Lantus insulin 8 units QHS
7. Ambien 5 mg QHS
8. Flovent 110 mcg 2 puffs Q12H
9. Lactulose 20 gm daily
10. Glycerin suppository daily
Allergies:
1. Doxepin
2. Levofloxacin
3. Oxycontin
4. Benzodiazepines
5. Ativan
11. Colace 100 mg [**Hospital1 **]
12. Dulcolax 10 mg suppository daily
13. Theravite liquid 5 ml daily
14. MOM 30 ml daily
15. Paxil 20 mg daily
16. Vitamin C 500 mg daily
17. Vitamin D 800 units daily
18. Zinc 220 mg daily
19. ASA 325 mg daily
20. Prevacid 30 mg daily
21. Humulin SS
22. Atrovent nebs Q4H PRN
23. Xopenex 1.25 mg Q4H PRN
24. Tylenol 650 mg Q4H PRN
25. Haldol 1 mg Q8H PRN
26. Duragesic patch 75 mcg Q72H
27. Amiodarone 400 mg daily
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
3. Glycerin (Adult) 3 g Suppository [**Hospital1 **]: One (1) Suppository
Rectal PRN (as needed).
4. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Paroxetine HCl 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Amiodarone HCl 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
11. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q4H (every 4 hours).
12. Ipratropium Bromide 18 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
13. Haloperidol Lactate 2 mg/mL Concentrate [**Hospital1 **]: Five (5) mg PO
HS (at bedtime).
14. Haloperidol Lactate 2 mg/mL Concentrate [**Hospital1 **]: One (1) mg PO
BID (2 times a day): at 8AM and 2PM.
15. Heparin Sodium (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
ml [**Hospital1 **] TID (3 times a day).
16. Zolpidem Tartrate 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
17. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
18. Morphine Sulfate 10 mg/5 mL Solution [**Hospital1 **]: Five (5) mg PO Q6H
(every 6 hours) as needed for pain.
19. Piperacillin-Tazobactam 4.5 g Recon Soln [**Hospital1 **]: 4.5 gm
Intravenous Q8H (every 8 hours) for 10 days.
20. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Eight (8) unit
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
hypotension and altered mental status likely from narcotic
overdose +/- aspiration pneumonia
Discharge Condition:
stable
Discharge Instructions:
please return to the hospital or call your doctor if you have
more shortness of breath, confusion, hypotension, chest pain,
fever or if there are any concerns at all.
Please take all prescribed medication
Followup Instructions:
PLease follow up with doctors [**First Name (Titles) **] [**Last Name (Titles) **].
Coumadin has been discontinued because you had significnant
bleeding from arterial punctures from attempted central line
insertion. This should be restarted at a lower dose in [**11-29**] days
time given the history of DVT and also atrial fibrillation
Fentanyl patch has been discontinued due to concern about
narcotic overdose. Morphine IV prn has been used. Total morphine
use should be calculated and patient can be started on standing
morphine if necessary
Patient should continue zosyn for a total of 14 days(started on
[**2179-4-12**])
Completed by:[**2179-4-15**]
|
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115
| 114,585
|
28391
|
Discharge summary
|
report
|
Admission Date: [**2194-10-16**] Discharge Date: [**2194-11-13**]
Date of Birth: [**2119-1-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Right adrenal tumor
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right adrenalectomy and right segment 6
resection
History of Present Illness:
The patient is a 75 y/o female who presents with a right adrenal
mass. The patient has been progressively feeling unwell since
[**Month (only) 116**]. After sustaining a fall, the patient started to have
worsening weakness and fatigue that she needed to start using a
walker to ambulate and had difficulty getting out of chairs.
She also reports increased facial hair in the past six months.
On imaging, the patient had a 10 x 7 cm right adrenal mass.
Further workup revealed that the patient had hypercortisolism.
On review of systems, the patient complains of pain and
increased difficulty in performing her activities of daily
living. The patient denies weight loss or weight gain.
Although, her obesity has become more central in nature and she
has had loss of hair on her scalp, while having increased facial
hair. She also reports increased bruising along her
extremities, some shortness of breath on exertion, thinning of
her skin, and decreased energy. The patient denies fever,
chills, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, constipation, or dysuria.
Past Medical History:
colon Ca s/p partial colectomy and adjuvant chemo - 8y ago
HTN
CCY [**2184**]
adrenal mass
mitral valve prolapse
Social History:
Lives alone in NJ, here living with daughter while undergoes
further evaluation and mgmt. Denies tobacco (<100 lifetime
cigarettes), social EtOH, no IVDU. Has 3 daughters and 2 sons
Family History:
DM in both brothers and both parents; F - prostate and liver Ca;
uncle - gastric Ca
Physical Exam:
T 96.3 P 66 BP 176/90 R 20 SaO2 95% RA
Gen - no acute distress, well-appearing, upper lip hirsutism
Heent - facial hirsutism, no scleral icterus, moist mucous
membranes
Lungs - clear to auscultation bilaterally
heart - regular rate and rhythm
abd - obese, soft, nontender, nondistended
Pertinent Results:
[**2194-10-16**] 08:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2194-10-16**] 08:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2194-10-16**] 08:08PM URINE RBC-0-2 WBC-1 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2194-10-16**] 08:08PM URINE AMORPH-FEW
[**2194-10-16**] 05:30PM GLUCOSE-124* UREA N-19 CREAT-0.4 SODIUM-142
POTASSIUM-2.9* CHLORIDE-98 TOTAL CO2-33* ANION GAP-14
[**2194-10-16**] 05:30PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2194-10-16**] 05:30PM WBC-7.3 RBC-3.63* HGB-11.8* HCT-33.6* MCV-93
MCH-32.5* MCHC-35.0 RDW-16.4*
[**2194-10-16**] 05:30PM PLT COUNT-231
[**2194-10-16**] 05:30PM PT-10.8 PTT-19.1* INR(PT)-0.9
Brief Hospital Course:
She was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for exploratory
laparotomy, right
adrenalectomy and right hepatic segment 6 resection. Please see
operative report for details. EBL was 3 liters. An introp U/S
revealed- liver echogenicity appeared unremarkable. Within the
posterior segment of the right lobe of the liver, there was s a
5.5 x 3.3 cm well- circumscribed, slightly hypoechoic lesion
that contained a degree of increased through transmission
suggesting at least some cystic components. The relationship of
this to the surrounding vasculature, particularly the posterior
branch of the right portal vein was demonstrated. No other
additional lesions were found.Two [**Doctor Last Name **] drains were removed by
postop day 5. Pathology returned positive for 1. Right adrenal
mass, excision (A-F):
Malignant neoplasm most consistent with adrenal cortical
carcinoma, see note.
2. Liver segment six, resection (G-O):
Malignant neoplasm most consistent with adrenal cortical
carcinoma, see note. Endocrinology was to follow and the plan
was to use ________ as an outpatient.
Postop she was in the SICU for fluid management and ATN.
Baseline creatinine was 0.6. Nephrology was consulted.
Creatinine trended down to 1.1 by POD 8. Renal u/s was normal.
Stress dose steroids were given preop and postop per
Endocrinology. Endocrinology preferred a slow 6 month steroid
taper. Dr. [**First Name (STitle) **] tapered prednisone after one week as she
developed an incision infection necessitating opening the
incision and using a wound vac. A CT of the abd was done on
which demonstrated Two ill-defined fluid collections
post-surgical site that were extrahepatic and could represent
postoperative seromas, bilomas, or less likely abscesses.
Multiple scattered foci of air, likely postoperative. 2.
Increased stranding about the head of the pancreas, possibly
pancreatitis. 3. Bibasilar atelectasis and small right pleural
effusion. Amylase and lipase were normal. LFTs preop were ast
1298, alt 1308, alk phos 64 and tbili 0.7. These trended down
postop with the exception of the alk phos which increased to as
high as 806 on HD 20. Subsequently, this has decreased some to
504 as of [**11-13**].
She required PICC line placement for IV antibiotics and TPN as
her kcals were insufficient. Her appetite was diminished. She
appeared apathetic on many days and expressed feelings of
sadness. Psychiatry saw her and agreed with the team that she
was experiencing intermittent delerium. There was concern that
she was experiencing the effects of less cortisol. Neurology
recommended a CT and EEG. A head CT was done for waxing/[**Doctor Last Name 688**]
mental status. This was negative for bleed/mass on [**10-29**]. An EEG
was performed which demonstrated mild encephalopathy. TSH was
3.4. Psychiatry did not recommend antidepressents or stimulants
at the time.
On CT a right pleural effusion was noted. She experienced desats
and sob. Pleuracentesis was performed on [**11-6**] (HD 20)with a
negative culture. A f/u cxr was improved and without
pneumothorax.
She developed a Klebsiella uti which was treated with Cipro and
Flagyl for the wound x 4 days. These antibiotics were switched
to Vanco and Meropenum when a wound culture identified strep
veridans, sparse yeast, Klebsiella which was pan sensitive and
staph coag positive resistent to levo/oxicillin/penicillin and
sensitive to vanco. Vanco levels were monitored. Creatinine
remained stable. She developed a 2nd UTI,yeast which was treated
with a GU Ampho bladder irrigant x3 days. This was due to finish
on [**11-13**] pm. Repeat u/a and cx were sent on [**11-13**].
A repeat abd CT revealed stable appearance of hepatic fluid
collections with some debris and air in the surgical bed.
Bibasilar atelectasis with stable right pleural effusion.
Stable appearance of right abdominal wall defect overlying
surgical site. Interval development of nonocclusive thrombus
within the intrahepatic inferior vena cava. She was started on
coumadin and IV heparin until she was therapeutic. INR Goal was
[**1-31**]. INR on [**11-13**] was 2.6
On [**11-12**] after taking off the vac and reviewing the CT, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**]
drain was inserted thru the wound into a peri-hepatic collection
and placed to bulb suction. Water soluble contrast was
administered at the bedside through this catheter. Contrast was
administered. Contrast was seen surrounding this wound and
draining along the right lateral aspect of the wound into
dressing, however, no definite communication into the abdominal
cavity noted. Midline chevron scar and multiple clips scattered
across the abdomen were seen. Remainder of abdomen was gasless.
Small amount of oral contrast seen in the rectum. She then
underwent successful drainage catheter placement in collection
in the subhepatic and hepatic areas on [**2194-11-12**].
The plan is for her to go to [**Hospital 100**] Rehab on TPN via a R picc
with a RUQ incision wound vac. She has 2 hepatic drains to
gravity drainage and meropenum/vanco will continue until next
week. She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-17**] and
with endocrinology as an outpatient.
Please schedule GYN follow up of postmenopausal bleeding noted
on POD #5.Pelvic U/S (prelim report) - Study v. limited as
patient was not able to achieve proper positioning; uterus 8.0 x
4.4 x 4.5 cm; endometrium is not well visualized; ovaries not
visualized. She experienced minimal spotting while hospitalized.
Medications on Admission:
hydralazine 25q8, HCTZ 25, KCl 40"
Discharge Medications:
1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold for sbp <140.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 doses.
6. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous every six (6) hours.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic DAILY
(Daily).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): peri area.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
check INR twice weekly. goal [**1-31**].
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): check vanco level twice
weekly.
14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: per picc line
protocol.
16. Outpatient Lab Work
Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili, albumin and inr. Fax to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], RN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
R adrenal mass
Hepatic collections
IVC thrombus
malnutrition
UTI,yeast
pleural effusion
ARF, resolved
post menopausal bleeding
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, incision red/bleeding or draining pus, wound drain
dislodges, foul smelling wound or increased wound drainage,
increased shortness of breath.
Followup Instructions:
weekProvider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2194-11-17**] 11:30
please schedule follow up with Dr [**Last Name (STitle) 574**] [**Telephone/Fax (1) 6468**]
(Endocrinology) in 1 week. Attempt Monday appointment
GYN follow up [**Telephone/Fax (1) 2664**] & schedule TVU/S as outpt prior to
apt.
Completed by:[**2194-11-13**]
|
[
"V58.65",
"251.8",
"041.3",
"511.9",
"998.59",
"V10.00",
"349.82",
"424.0",
"E932.0",
"584.5",
"401.9",
"682.2",
"255.3",
"V45.3",
"194.0",
"428.0",
"197.7",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"07.22",
"93.59",
"34.91",
"96.49",
"38.93",
"50.22",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
10438, 10504
|
3061, 8676
|
335, 411
|
10675, 10682
|
2300, 3038
|
10973, 11391
|
1890, 1975
|
8761, 10415
|
10525, 10654
|
8702, 8738
|
10706, 10950
|
1990, 2281
|
276, 297
|
439, 1536
|
1558, 1672
|
1688, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,424
| 191,932
|
30816
|
Discharge summary
|
report
|
Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-6**]
Date of Birth: [**2101-8-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Drug overdose
Major Surgical or Invasive Procedure:
Endotrachael Intubation
History of Present Illness:
This is a 46 year-old man with history of IVDA, now on methadone
who presents to the [**Hospital1 18**] after being found down on the "T." His
initial vitals were HR 48, BP 110/palp, RR 18, 92% with pinpoint
pupils. He was given 2 mg IV narcan and became awake and alert,
reported taking methadone. Foley was placed at which time the
patient reportedly had HR drop to the 30s. EKG demonstrated
sinus rhythm. He was intubated due to mental status changes
(agitation and somnolence) with etomidate and succinylcholine
and started on propofol. He also received charcoal and glucagon
and subsequently vomitted charcoal. Per notes, did not appear to
aspirate. He had a head CT which had no abnormalities. His labs
in the ED were negative for serum EtOH, and negative for serum
benzos but positive for urine benzos and urine methadone. Urine
was negative for opiates, cocaine and amphetamines. The patient
was transferred to the [**Hospital Unit Name 153**] intubated on settings of AC, FiO2
0.6, Tv 600, RR 14, PEEP 5.
Past Medical History:
chronic low back pain from MVA
lung ca with current mass - gets care at [**Hospital1 2177**]
asthma
LBP
Hep C
Social History:
Homeless, lives in shelter.
Attends a methadone program.
Family History:
Not contributory
Physical Exam:
S: Temp: 97 oral BP: 121/64 HR:76 RR:14 O2sat 99
general: pleasant, comfortable, NAD
HEENT: Pupils 3 mm, equal, round, reactive, vestibuloocular
reflex not intact, black staining around lips and mouth,
anicteric, MMM,, no supraclavicular or cervical lymphadenopathy,
no jvd, no carotid bruits, no thyromegaly or thyroid nodules
lungs: coarse lung sounds b/l with good air movement throughout
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: no rashes/no jaundice/no splinters
Pertinent Results:
[**2148-5-6**] 05:55AM BLOOD WBC-9.9 RBC-4.05* Hgb-11.9* Hct-37.0*
MCV-92 MCH-29.5 MCHC-32.2 RDW-14.9 Plt Ct-348
[**2148-4-29**] 09:00PM BLOOD WBC-10.9 RBC-4.17* Hgb-12.7* Hct-38.3*
MCV-92 MCH-30.5 MCHC-33.1 RDW-14.7 Plt Ct-362
[**2148-4-29**] 09:00PM BLOOD Neuts-55 Bands-1 Lymphs-33 Monos-6 Eos-2
Baso-2 Atyps-1* Metas-0 Myelos-0
[**2148-4-29**] 09:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+
[**2148-4-30**] 04:47AM BLOOD PT-11.8 PTT-29.8 INR(PT)-1.0
[**2148-5-4**] 06:50AM BLOOD UreaN-8 Creat-0.7 Na-141 K-3.8 Cl-104
HCO3-32 AnGap-9
[**2148-4-29**] 09:00PM BLOOD Glucose-89 UreaN-15 Creat-1.6* Na-149*
K-4.9 Cl-112* HCO3-33* AnGap-9
[**2148-5-1**] 05:01AM BLOOD ALT-61* AST-51*
[**2148-4-29**] 09:00PM BLOOD ALT-67* AST-54* LD(LDH)-274* CK(CPK)-179*
AlkPhos-82 Amylase-32 TotBili-0.2
[**2148-5-2**] 06:10AM BLOOD Mg-1.9
[**2148-5-1**] 05:01AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
[**2148-4-30**] 04:47AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4
[**2148-4-29**] 09:00PM BLOOD Digoxin-<0.2*
[**2148-4-29**] 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-4-29**] 10:24PM BLOOD Rates-/20 O2 Flow-100 pO2-420* pCO2-46*
pH-7.39 calTCO2-29 Base XS-2 -ASSIST/CON Intubat-INTUBATED
[**2148-5-5**] 03:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2148-5-5**] 03:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2148-4-30**] 04:34AM URINE RBC-46* WBC-6* Bacteri-MANY Yeast-NONE
Epi-<1
[**2148-4-29**] 09:00PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass
effect, shift of normally midline structures, or major vascular
territorial infarct is apparent. The density values of the brain
parenchyma appear within normal limits. Size of ventricles,
sulci, and cisterns is within normal limits. Mucosal thickening
is seen in several ethmoid air cells, one of which contains an
air-fluid level. The mastoid air cells are clear. Bony
structures and surrounding soft tissue structures appear
unremarkable.
IMPRESSION: No evidence of acute intracranial hemorrhage.
[**2148-5-5**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2148-5-5**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2148-4-30**] URINE URINE CULTURE-FINAL INPATIENT
PORTABLE SUPINE CHEST 5:01 A.M. [**4-30**]
INDICATION: ETT placement. Pneumonia.
FINDINGS: Compared with [**2148-4-29**], the tip of the ETT remains 4.5
cm above the carina. Allowing for lower lung volumes and the
supine position no overt CHF.
Some linear retrocardiac atelectasis is now present, but no
confluent infiltrates are appreciated.
Brief Hospital Course:
Drug overdose - Pt reports starting to use opiates (heroin) 7
yrs ago [**1-5**] chronic
low back pain. After several yrs, he lost his house and
commercial truck. While being homeless, pt started to attend
methadone clinic and reports being on 120 mg of methadone
(confirmed by calling them). Pt continued to experience pain and
felt that methadone was not sufficiently covering his pain.
That's why, he started to add
benzodiazepines (Xanax, [**12-5**] bar shaped, unknown dose) which
hewas buying on the streets. Day before admission, pt bought
small blue pills. He believed that those Xanax pills have lower
dose and took between 5 or 10 pills. Pt denied suicidal intent.
Additionally, pt reported being increasingly depressed x at
least2 yrs (after loosing his truck): he was increasingly
tearful,sad, anxious, worried about future. +decreased sleep,
decrease ofappetite and loosing weight (from to 230 to 187 lbs).
He admits
feeling helpless and hopeless. Month ago, he was told THough, he
denies any direct thoughts to kill himself, he admitted to not
caring about his life. He also says, "I will be dead if they
(BAyCove) kick me out". Pt denies aver seeing psychiatrist or
being admitted to psychiatric hospital. He tried to go to [**Hospital1 1680**]
but was not
admitted and did not see psychiatrist. He denies any hx of
suicide attempts.
He was in acute resp failure from the drug overdose. Tolerated
extubation well and then was transferred to the floor. He was
alert and oriented but depressed. Psych did not feel he needed
any sitter. They offered him dual diagnosis Rx but he did not
accept this. On initial EG - QTc interval was prolonged. This
was likely from the drug effect esp methadone. Pain service was
involed and the regimen was changed with decreasing dose of
methadone and starting other pain meds to counteract the pain
and to minimize dose of methadone. His pain was well controlled
at discharge, he was given enough Rx till he sees his new PCP at
[**Name9 (PRE) 191**] and he was advised to go back to the methadone program. They
were informed of the change in dose of methadone.
He had low grade fevre a day before dc, no clear inf source
found.
He was advised to continue to either follow at [**Hospital1 2177**] for h/o lung
cancer or talk to his new PCP here at [**Hospital1 18**] for transferring
care.
Medications on Admission:
methadone 120mg daily (from program)
xanax - (non-prescription)
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 * Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*35 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*70 Capsule(s)* Refills:*0*
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*35 Adhesive Patch, Medicated(s)* Refills:*0*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*100 Capsule(s)* Refills:*0*
8. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
Disp:*50 Tablet(s)* Refills:*0*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 * Refills:*0*
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*70 Tablet(s)* Refills:*2*
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical ONCE DAILY ().
Disp:*35 Adhesive Patch, Medicated(s)* Refills:*0*
13. Methadone
Return to your methadone program to continue to take the
methadone as prescribed. (60 mg daily in morning)
Discharge Disposition:
Home
Discharge Diagnosis:
Drug overdose
Acute respiratory failure requiring intubation - resolved
Prolonged QT interval - resolved
Depression
h/o lung cancer - per patient
Discharge Condition:
Stable. Not suicidal or homicidal.
Discharge Instructions:
Return to the hospital if you have fevers, chills, dizziness,
chest pain, pain or any other symptoms of concern to you.
You have an appointment scheduled for primary care at this
hospital. Please keep your appointments. The primary doctor will
be caring you for further medicine and health care needs. Talk
to your new doctor about further testing or followup for the
lung cancer.
Return to your methadone program - Bay cove for continuing the
methodone. The dose has been reduced as the higher dose was
having an ill-effect on your heart. You are being given a letter
that you should give to your counsellor at the program stating
the new dosing.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2148-6-11**]
1:30
at [**Hospital6 **].
Return to your methadone program - Bay cove for continuing the
methodone.
|
[
"965.02",
"969.4",
"518.81",
"311",
"493.90",
"794.31",
"162.8",
"E980.3",
"070.54",
"724.2",
"304.71",
"E980.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9148, 9154
|
5103, 7443
|
327, 353
|
9345, 9382
|
2282, 5080
|
10080, 10297
|
1619, 1637
|
7558, 9125
|
9175, 9324
|
7469, 7535
|
9406, 10057
|
1652, 2263
|
274, 289
|
381, 1396
|
1418, 1529
|
1545, 1603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,263
| 107,910
|
14351
|
Discharge summary
|
report
|
Admission Date: [**2161-10-27**] Discharge Date: [**2161-10-30**]
Date of Birth: [**2089-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Sulfamethoxazole/Trimethoprim
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2161-10-27**] Redo-sternotomy x 3, replacement of ascending aorta and
aortic arch reimplantation of the arch vessels, repair of the
main pulmonary and right and left pulmonary arteries with bovine
pericardial patch and replacement of the mitral valve with a
size 25 [**Company 1543**] Mosaic tissue valve
History of Present Illness:
72 y/o female with extensive past medical history (see below)
who has been c/o progressively worsening dyspnea on exertion
over the past six months. Most recent cardiac cath and echo
revealed severe MR along with moderate AI.
Past Medical History:
Mitral Regurgitation and Aortic Insufficiency
Aortic Dissection s/p Aortic Root Replacement [**2153**]
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
[**2155**], s/p Stents to left main and POBA of OM1 [**2155**]
Complete Heart Block s/p PPM [**2160**]
Hypertension
Hyperlipidemia
s/p Appendectomy
s/p Tonsillectomy
Social History:
Retired. Quit smoking [**2152**]. Denies ETOH.
Family History:
Mother with hypertension. Father died from brain tumor/cancer.
Physical Exam:
VS: 62 130/69 5'3" 136#
Gen: WDWN elderly female in NAD
HEENT: EOMI, PERRL, NCAT, OP benign
Neck: Supple, FROM, -JVD, -bruit
Chest: CTAB -w/r/r, well-healed MSI
Heart: RRR 3/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused -Edema, well-healed right EVH incision
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**10-27**] Echo: PRE-BYPASS: 1. The left atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
2. 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%). 3. Right
ventricular chamber size and free wall motion are normal. 4. An
ascending aortic graft is noted consistent with previous
replacement surgery. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. 5. There are three aortic valve leaflets. There is no
aortic valve stenosis. Moderate(2+) aortic regurgitation is
seen. 6. The mitral valve leaflets are moderately thickened.
There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Moderate (2+) mitral regurgitation is seen. POST-BYPASS: For the
post-bypass study, the patient was receiving vasoactive
infusions including epinephrine and phenylephrine. 1. A
well-seated bioprosthetic valve is seen in the mitral position
with normal leaflet motion and gradients. No mitral
regurgitation is seen. 2. An ascending aortic and arch graft is
also seen. 3. Biventricular function is unchanged, AI is
unchanged. 4. Other findings are unchanged
[**10-29**] Head CT: There is diffuse cerebral edema identified with
compression of the ventricles. There is obliteration of the
basal cisterns identified with deformity of the brain stem
indicating central herniation. At the foramen magnum, downward
displacement of the cerebellar tonsils indicates tonsillar
herniation. There are multiple infarcts identified bilaterally
involving the posterior cerebral and anterior cerebral arteries
as well as the right superior cerebellar artery as well as the
watershed distribution. There is no hemorrhage identified.
[**2161-10-27**] 03:24PM BLOOD WBC-13.2*# RBC-3.02*# Hgb-9.6*#
Hct-27.5*# MCV-91 MCH-31.7 MCHC-34.7 RDW-14.3 Plt Ct-101*
[**2161-10-30**] 02:53AM BLOOD WBC-12.1* RBC-3.34* Hgb-10.5* Hct-31.3*
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.9 Plt Ct-76*
[**2161-10-27**] 03:24PM BLOOD PT-18.2* PTT-69.9* INR(PT)-1.7*
[**2161-10-29**] 02:37AM BLOOD PT-13.3* PTT-35.1* INR(PT)-1.2*
[**2161-10-27**] 04:58PM BLOOD UreaN-11 Creat-0.6 Cl-114* HCO3-24
[**2161-10-30**] 02:53AM BLOOD Glucose-145* UreaN-12 Creat-0.5 Na-141
K-3.8 Cl-106 HCO3-26 AnGap-13
[**2161-10-30**] 02:53AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
Brief Hospital Course:
Mrs. [**Known lastname 5719**] was admitted and taken directly to the operating
room with plans for a redo-sternotomy, along with aortic and
mitral valve replacements. Unfortunately due to a very fragile
and heavily calcified aorta along with adherent scar tissue,
aortic valve replacement could not be performed. Mitral valve
replacement was performed along with an unplanned replacement of
her ascending aorta and total arch with reimplantation of the
head vessels which required circulatory arrest for 24 minutes.
For additional surgical details, please see seperate dictated
operative note. Following the operation, she was brought to the
CVICU in critical condition. Due to the heavily calcified aorta
and unplanned circulatory arrest, there was much concern for
neurologic injury. Over 48 hours, she remained unreponsive. A
head CT scan on postoperative day two showed diffuse cerebral
edema with deformity of the brain stem indicating central
herniation. There was also downward displacement of the
cerebellar tonsils indicating tonsillar herniation. The CT scan
also showed multiple infarcts involving the posterior cerebral
and anterior cerebral arteries as well as the right superior
cerebellar artery as well as the watershed distribution. No
hemorrhage was identified. The neurology service was consulted
and brain death examination was performed on [**10-30**]. After
declaration of brain death, a family meeting was held, and the
patient was withdrawn from ventilatory support. She expired
soon after. The medical examiner was notified, and post mortem
was refused.
Medications on Admission:
Lisinopril 20mg qd, Lopressor 50mg [**Hospital1 **], Lasix 20mg qd, Crestor
10mg qd, Norvasc 5mg qd, Aspirin 81mg qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Mitral Regurgitation and Aortic Insufficiency
Aortic Dissection s/p Aortic Root Replacement [**2153**]
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
[**2155**], s/p Stents to left main and POBA of OM1 [**2155**]
Complete Heart Block s/p PPM [**2160**]
Hypertension
Hyperlipidemia
s/p Appendectomy
s/p Tonsillectomy
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"272.4",
"V45.01",
"434.91",
"440.0",
"401.9",
"441.01",
"V45.81",
"414.01",
"E878.2",
"348.1",
"396.3",
"997.02",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.56",
"35.23",
"39.61",
"38.45",
"39.59"
] |
icd9pcs
|
[
[
[]
]
] |
5935, 5944
|
4155, 5739
|
342, 651
|
6317, 6327
|
1735, 2994
|
6380, 6388
|
1339, 1403
|
5906, 5912
|
5965, 6296
|
5765, 5883
|
6351, 6357
|
1418, 1716
|
283, 304
|
679, 906
|
3003, 4132
|
928, 1259
|
1275, 1323
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,274
| 138,969
|
4578
|
Discharge summary
|
report
|
Admission Date: [**2133-7-3**] Discharge Date: [**2133-7-7**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
EGD and Colonoscopy
History of Present Illness:
HPI: 81 yo female with past medical history of mild CAD s/p
stenting [**3-16**], atrial fibrillation on chronic Coumadin therapy
who presented with BRBRP, fatigue and dizziness.
.
Ms. [**Known lastname 19461**] who was in her usual state of health until
approximately 2-3 months prior to this admission. At that time,
she began to notice a progressive decline in her exercise
tolerance. She reports that she did not notice any change in
her stool color until approximately 2-3 weeks ago when she began
to notice increasingly dark stools with passage of red blood in
the toilet bowl yesterday. Her last bowel movement was a dark
brown color with a small amount of blood on the toilet paper and
in the toilet bowl. Additionally in the last 2-3 days, she
complains of dizziness, occasional lightheadedness and severe
fatigue making it difficult for her to participate in her
activities of daily living, prompting her to seek care today.
.
She denies nausea, vomiting, hematemesis. She denies recent
NSAID use. Patient reports that she had a colonoscopy
approximately 3 years ago at an OSH that was normal but has had
polyps removed in former colonoscopies.
.
Upon admission to the [**Hospital1 18**] ED, patient was found to have a
large drop in her Hct from 40 ([**3-16**]) to 30 ([**2133-6-16**]) to 19
([**2133-7-3**]) over a [**3-14**] month period. She was guiac positive by ED
report and received one unit.
Past Medical History:
Past Med Hx:
1. Hx of CAD with cardiac cath [**2133-4-3**]: One vessel CAD with
normal LV function and successful stenting of ostial LAD lesion
2. Chronic A-Fib
3. HTN
4. Hyperlipidemia
5. Appendectomy
6. ? Prior TIAs
7. Hx of cholecystectomy
8. Hemorrhoids
9. [**Month/Day/Year **] polyps
Social History:
Lives alone; No tobacco use.
Family History:
Father with MI at age 81, Sister with [**Name2 (NI) 499**] cancer
Physical Exam:
PE:
Vitals: T98, P 65, BP 130/54, RR 14, O2 Sat 100%RA
HEENT: Appears somewhat pale, PERRLA
CV: Regular, rate and rhythm, No mrg
Resp: Clear to auscultation bilaterally
Abdomen: Soft, Nontender, Nondistended; Diminished bowel sounds
Extremities: Trace pitting edema
Rectal: Deferred; Melena per heme note and patient history
Pertinent Results:
[**2133-7-3**] 10:10PM HCT-22.4*
[**2133-7-3**] 01:00PM PT-27.4* PTT-29.2 INR(PT)-2.8*
[**2133-7-3**] 01:00PM PLT COUNT-281
[**2133-7-3**] 01:00PM NEUTS-70 BANDS-1 LYMPHS-18 MONOS-6 EOS-4
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-2*
[**2133-7-3**] 01:00PM WBC-6.1 RBC-2.15*# HGB-6.5*# HCT-19.5*#
MCV-91 MCH-30.2 MCHC-33.2 RDW-16.3*
[**2133-7-3**] 01:00PM CK-MB-3
[**2133-7-3**] 01:00PM cTropnT-<0.01
[**2133-7-3**] 01:00PM CK(CPK)-109
[**2133-7-3**] 01:00PM GLUCOSE-120* UREA N-24* CREAT-1.1 SODIUM-137
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-23 ANION GAP-15
[**2133-7-3**] 04:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
Ms. [**Known lastname 19461**] is an 81 yo female with past medical history of mild
CAD s/p stenting [**3-16**], HTN, and atrial fibrillation on chronic
Coumadin therapy who presented with BRBRP, fatigue and
dizziness. In the ED, she was found to have a hematocrit of 19
with a drop over the last 3-4 months from 40 ([**3-16**]) to 30
([**2133-6-16**]) to 19 ([**2133-7-3**]). She was admitted to the medicine
service for further evaluation and treatment.
.
#GIB: Ms. [**Known lastname 19461**] was admitted to medicine with plans made by
the GI team to perform [**Last Name (un) **] and EGD after the patient had been
transfused with red blood cells and prepped for colonoscopy.
She received packed red blood cells to maintain a Hct > 30 was
started on a proton pump inhibitor. Her Coumadin was stopped
and she received FFP and Vitamin K to reverse an INR of 2.8.
Shortly after she was admitted, she passed a large amount of
dark red blood per rectum and was transferred into the MICU for
stabilization. An NG tube was passed without evidence of blood
in the stomach. She was stabilized in the MICU with blood
transfusions and IV fluids. She was then transferred out of the
MICU when her hematocrit stabilized and was prepped for
colonoscopy. She received a total of 6 units of blood during her
hospitalization.
.
Her colonocopy performed revealed a cecal dieulafoy's
malformation which was clipped and treated with thermal therapy.
She tolerated the procedure well and showed no evidence of
rebleeding the following day. She was restarted on PO intake
and tolerated this well.
.
#Atrial Fibrillation: Her atrial fibrillation was stable this
admission. She was continued on her digoxin and carvedilol for
rate control, and was monitored on telemetry.
.
#HTN/CAD: Stable during this admission. She was continued on
Coreg, Cozaar and Lasix. She was continued on Lipitor and
sublingual nitro PRN.
Medications on Admission:
Digoxin 0.125mg daily
Coreg 3.125mg twice a day
Lipitor 20mg daily every morning
Cozaar 100mg daily
Furosemide 40mg every morning
Coumadin 2.5mg M/W/F, 5mg T/TH/S/[**Doctor First Name **], last dose [**2133-3-30**]
SL nitroglycerin
Aricept 5mg daily every evening
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Pantoprazole 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*
6. Cozaar 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: To
start on [**7-14**].
Disp:*30 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual prn angina: one tab every 5 minutes until relief;
then report to Emergency Room.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Lower GI Bleed
Discharge Condition:
Good
Discharge Instructions:
Please restart your Coumadin 1mg PO daily on Tuesday, [**7-14**].
You will follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3065**]
[**Last Name (NamePattern1) 16258**], on [**7-23**] at 3:00pm at which time he will make
adjustments as necessary.
.
If you experience blood in your stool or very dark colored
stools, please call your doctor immediately or report to the
Emergency Room.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 3065**]
[**Last Name (NamePattern1) 16258**], on [**2133-7-23**] at 3:00pm.
Completed by:[**2133-7-12**]
|
[
"V58.61",
"211.3",
"414.01",
"285.1",
"569.85",
"V45.82",
"427.31",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.07",
"45.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6310, 6367
|
3233, 5142
|
229, 251
|
6426, 6433
|
2502, 3210
|
6924, 7113
|
2074, 2141
|
5457, 6287
|
6388, 6405
|
5168, 5434
|
6457, 6901
|
2156, 2483
|
175, 191
|
279, 1698
|
1720, 2012
|
2028, 2058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,440
| 139,904
|
12944
|
Discharge summary
|
report
|
Admission Date: [**2139-8-31**] Discharge Date: [**2139-9-4**]
Date of Birth: [**2061-5-30**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
CODE STROKE, speech disturbance
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 yo woman with vascular rf's including cad, htn, dm, high
chol, former smoker, early family hx, who presents five days
after a lap ccy and ercp (for abd pain and nausea), with
post-operative confusion for several days per notes, with acute
onset "dysarthria and aphasia" at 11:45 AM according to note by
neurologist at [**Hospital **] Hosp, where she had presented. She had
apparently c/o headaches for several days prior to admission.
Neuro exam revealed decreased level of consciousness, inability
to follow complex commands, ? R visual field cut (decr blink to
threat), ? R decreased sensation to pain, and speech with
frequent paraphasic errors, that was intermittently fluent, per
notes. The GI MD [**First Name (Titles) **] [**Name (NI) 653**] about risks of TPA, and
benefits would outweigh risks, despite recent surgery, thus IV
TPA given at 2PM, for possible L MCA infarct. Head CT at the
time was neg, and BP at osh initially was 181/82, HR 84, INR 1,
gluc 127. IV tpa was given, but soon into infusion, pt c/o
severe bifrontal HA. TPA was stopped, and head CT was repeated,
neg for bleed apparently. TPA was restarted, and soon after, pt
c/o abd pain. TPA was again stopped, and pt transferred to
[**Hospital1 18**] for further w/u. Unfortunately, we do not have records of
how much TPA was given before onset of abd pain, but we have
bottle of remaining TPA, which is [**12-16**] full. Pt is quite
inattentive and unable to provide further hx.
Regarding nocturnal confusional states, these were thought to be
related to nightmares. On OSH record from [**8-28**], patient reported
to have nightmare and prior to admission falling out of bed
after a similar episode. At that point, all narcotics (including
morphine, percocet, also ambien) were discontinued. Unclear if
an EEG was performed. Per OSH neurologist rec'd 8mg bolus then
infused [**Date range (1) 8642**] of bottle totaling approximately 50mg IV TPA.
Past Medical History:
1. CHF
2. High chol
3. CAD s/p LAD stent, last stress [**6-18**], now off plavix
4. HTN
5. DM
6. CRI
7. Hypothyroid
8. s/p ccy and ERCP 5 d ago (had p/w incr lft's and abd pain)
9. migraines with confusion and temporary aphasia
10. Memory loss s/p PET neg for AD
11. Melanoma s/p resection L arm with lymph node dissection
12. TAH for bleeding
13. GERD with schatzi ring
14. bilat stapedectomy
15. removal benign breast tumors
16. s/p mva
Social History:
Lives with husband, no [**Name2 (NI) **] and no etoh now, but formerly smoked
for 30 yrs, quit 20 yrs ago. Former kitchen/bath designer.
Family History:
No strokes; father had MI at age 59
Physical Exam:
T- 101.2 BP- 166/44 HR- 76 RR- 24 96% O2Sat RA
Gen: Lying in bed, left hand to forehead in mod distress
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, 2/6 SEM LSB murmurs, no gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, diffuse tenderness, no exudate or pus from
incisions which are c/d/i
ext: no edema
Neurologic examination:
Mental status: Drowsy, cooperative but inconsistent with effort
during exam and slight distress from headache. Oriented to
person, place and not to date. Attentive. Speech is fluent
with normal comprehension and repetition; naming intact. No
dysarthria. [**Location (un) **] partially intact. Registers [**2-13**], recalls
[**2-13**] in 5 minutes. No right left confusion. No evidence of
apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Hearing
intact to finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch intact throughout.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal.
Gait: deferred
Discharge exam: unchanged
Pertinent Results:
Admission labs:
Na 136 Cl 97 BUN 21 Glc 144 AGap=15
K 4.7 CO2 29 Cr 1.5
CK: 36 MB: Notdone Trop-*T*: <0.01
Ca: 9.8 Mg: 2.1 P: 3.7
ALT: 86 AP: 178 AST: 68 [**Doctor First Name **]: 39
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
WBC 7.1 D HGB 10.8 PLT 313 HCT 30.6
N:78.8 L:15.9 M:3.9 E:0.9 Bas:0.5
UA Color Yellow Appear Clear SpecGr 1.016 pH 8.0 Urobil 8
Bili Neg Leuk Neg Bld Neg Nitr Neg Prot Neg Glu Neg Ket Tr
Imaging:
CXR: No evidence for acute cardiopulmonary abnormality including
infiltrate or congestive heart failure.
ABD CT: IMPRESSION:
1. Status post cholecystectomy with stranding in the
gallbladder fossa and right paracolic gutter, but no fluid
collection. This appearance is likely consistent with
postoperative change.
2. No hematoma.
3. Vascular calcifications.
4. Hypoattenuating foci in the liver and spleen which are not
fully characterized here. Following acute illness, when
clinically feasible, these findings should be evaluated with
multiphasic post-contrast imaging, namely MR [**First Name (Titles) **] [**Last Name (Titles) **], to
characterize them further.
HCT: No hemorrhage.
Carotid u/s: No stenosis of the right or left ICA.
EEG:
ABNORMALITY #1: Brief multisecond bursts of moderate voltage
polymorphic delta was seen from the left mid to posterior
temporal
region in waking. Some admixed slow wave theta of similar
voltage
amplitude was seen.
ABNORMALITY #2: Independent polymorphic slow wave theta was seen
in
brief bursts from the right mid to posterior temporal region.
Rare
associated delta was seen in conjunction.
ABNORMALITY #3: Brief several-second bursts of moderate to
moderately,
at times, high voltage polymorphic delta and theta were seen
with, at
times, a bifrontal voltage predominance.
ABNORMALITY #4: A slowed posterior background was seen with
maximal 6
Hz activity seen bioccipitally.
BACKGROUND: The anterior-posterior voltage gradient was poorly
preserved. No frank epileptiform discharges were seen.
HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: No activation of the record.
SLEEP: Not obtained.
CARDIAC MONITOR: No arrhythmias noted.
IMPRESSION: Abnormal EEG due to bursts of slowing occurring
independently from the L>R mid to posterior temporal regions
along with
bursts of slowing occurring in a generalized fashion with, at
times, a
bifrontal voltage predominance and a slowed posterior
background. The
record, overall, suggests a mild encephalopathy with
superimposed
increased irritability involving left and right posterior
quadrants
independently with some involvement as well as subcortical and
deeper
midline structures. No frank epileptiform discharges were,
however,
seen.
TTE: 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 aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened, without prolapse. There is
trivial mitral regurgitation. There is an anterior space which
most likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
Abd u/s: 1. Small amount of echogenic material in the
gallbladder fossa, reflecting either a small hematoma,
comparable to findings on the prior CT, as limited by
differences in technique.
2. No intra- or extrahepatic biliary ductal dilatation. Please
note that this study cannot exclude cholangitis.
3. No ascites in the right upper quadrant.
CTA head: Unremarkable CTA of the head.
Brief Hospital Course:
78yo womam with multiple vascular risk factors and recent lap
ccy, ERCP presented with acute dysarthria and aphasia per OSH
and s/p IV TPA within 3 hr window. Given her persistent headache
and exacerbation of head and abdominal pain, head and abdominal
CT were performed which were negative for bleed. Head CT was
also negative for signs of acute ischemia. Patient's exam
improved from reports from outside hospital. She was following
commands and no longer had dysarthria or aphasia. She apparently
received 50mg of TPA a fraction of the wgt based dose she was
supposed to receive due to worsening headache. It is possible
that she may have been experiencing a migraine which is
associated with transient aphasia. She had several episodes of
confusion, mostly at night, accompanied by visual
hallucinations, which spontaneously resolved. She was evaluated
with carotid u/s (no stenosis), CTA (normal), TTE (good LVEF),
and EEG (see report as above). She was monitored with HCTs which
were repeatedly normal. She was initially observed in the ICU,
where her course was complicated only by the confusion mentioned
above and by brief episodes of chest pain, resolving
spontaneously, without changes in EKG or cardiac enzymes.
Otherwise, she was also followed by the ERCP team, and had a RUQ
u/s which was unremarkable. Per their recs, she was treated with
levofloxacin and flagyl for empiric GI coverage. For her neuro
status, she was started on ASA and lipitor. She and her husband
refused for her to be discharged to rehab, so she was sent home
with services.
Medications on Admission:
Diovan 160 mg
Tricor 160 mg
Atenolol 25 mg
ASA 325 mg
Levothyroxine 117 mcg
Dyrenium 50 mg
Nexium
Insulin sliding scale
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
transient ischemic attack
diabetes
high cholesterol
Discharge Condition:
stable, walking steadily
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appoiments. Please return to the nearest ED if
symptoms worsen.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 4023**]
Date/Time:[**2140-6-29**] 3:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"250.00",
"V45.82",
"272.0",
"435.9",
"346.90",
"414.01",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
11440, 11497
|
8442, 10003
|
306, 312
|
11593, 11620
|
4713, 4713
|
11803, 12067
|
2909, 2947
|
10175, 11417
|
11518, 11572
|
10029, 10152
|
11644, 11780
|
2962, 3380
|
4683, 4694
|
234, 268
|
340, 2276
|
3834, 4667
|
4729, 8419
|
3419, 3818
|
3404, 3404
|
2298, 2738
|
2754, 2893
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,199
| 115,922
|
21677
|
Discharge summary
|
report
|
Admission Date: [**2122-8-21**] Discharge Date: [**2122-8-27**]
Date of Birth: [**2053-7-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Transfer from OSH for management of STEMI.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1140**] is a 69 year old man with a past medical history of
diabetes, hypertension, hyperlipidemia, peripheral [**Known lastname 1106**]
disease s/p lower extremity percutaneous revascularization, CVA
secondary to left carotid stenosis s/p endovascular stenting,
presenting from [**Hospital 882**] hospital after developing chest pain
this morning. He initially presented to [**Hospital1 882**] with a
complaint of nausea, decreased oral intake and dark tarry stools
x5 days. His hematocrit at presentation was 23.7 and he was
given 2U PRBC. He underwent colonoscopy and endoscopy that
showed multiple polyps and ulcerations; 3 esophageal ulcers, 5
gastric ulcers, 2 sessile polyps in ascending colon, 2 in the
transverse colon and two in the splenic flexure and three just
distal to the anus, with multiple biopsies obtained.
.
This morning, he acutely developed substernal chest pain, rated
[**7-5**], worsened with inspiration and non radiating, not
associated with nausea or diaphoresis. He also desaturated to
88%, developed pallor and malaise. Temp 98, HR 132, BP 147/93,
92% on 2L NC. No complaints of arm, neck or jaw pain. He was
given sublingual nitroglycerin, aspirin, atorvastatin 80mg. Labs
revealed CK of 25, TropI 0.36, ABG 7.41/31/113. Second set of
cardiac enzymes revealed CPK 36 Tn 1.32. Cardiology was
consulted and Dr [**Last Name (STitle) **] recommended transfer to tertiary center
given ongoing GI bleeding and likely ACS.
.
On arrival, he reported his pain had resolved and he was only
experiencing some numbness of his left superior foot. Denied any
active chest pain, nausea, shortness of breath, dizziness or any
other symptoms.
.
On review of systems, he reports a prior history of stroke
(residual mild left sided deficits), denies prior deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, hemoptysis. Cough for the last 3 days. As
per HPI patient with black tarry stools. He denies recent
fevers, chills or rigors. Denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for dyspnea on exertion
with less than one block of walking, denies paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension, Hyperlipidemia
2. CARDIAC HISTORY: NONE
3. OTHER PAST MEDICAL HISTORY:
*CVA: In [**5-/2122**], RMCA territory
*s/p right carotid stent
*History of percutaneous revascularization of bilateral lower
extremies in [**6-/2122**]
-- Balloon angioplasty and Stent placement of right external
iliac artery.
-- Balloon angioplasty and Stent of left common iliac and left
external iliac artery
*COPD
*ETOH abuse: (prior) complicated by cardiomyopathy and
pancreatitis, no hx of withdrawal seizures, last drink >1 year
ago
*HTN
*COPD
Social History:
History of ETOH abuse. Smokes 1.5ppd--90pky smoking hx, denies
illicit drug use. Retired security guard. He is divorced and has
8 estranged children. He currently lives with an 82yo roommate
in an apartment complex named [**Name (NI) 9700**] Estate. Uses walker.
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
VS: Heart rate 91, oxygen saturation of 100%, blood pressure
106/56.
GENERAL: Well appearing thin elderly male, Oriented x3 (although
with wrong age). Mood, affect slightly innappropriate.
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 sternal angle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, distant heart sounds with 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. (+) rhonchi at the
bases, no crackles, wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. Soft left femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+, warm foot
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+, warm foot
..
PHYSICAL EXAM AT DISCHARGE:
Pertinent Results:
LABS AT ADMISSION:
.
[**2122-8-21**] 11:34PM TYPE-CENTRAL VE PH-7.38 COMMENTS-GREEN TOP
[**2122-8-21**] 11:34PM GLUCOSE-100 K+-3.5
[**2122-8-21**] 11:34PM freeCa-1.18
[**2122-8-21**] 11:24PM PTT-32.8
[**2122-8-21**] 07:53PM CK(CPK)-41
[**2122-8-21**] 07:53PM CK-MB-NotDone cTropnT-0.09*
[**2122-8-21**] 07:53PM HCT-31.1*
[**2122-8-21**] 02:31PM GLUCOSE-88 UREA N-6 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-11
[**2122-8-21**] 02:31PM estGFR-Using this
[**2122-8-21**] 02:31PM CK(CPK)-43
[**2122-8-21**] 02:31PM CK-MB-NotDone cTropnT-0.16*
[**2122-8-21**] 02:31PM CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.1*
[**2122-8-21**] 02:31PM WBC-8.1 RBC-3.06* HGB-9.4* HCT-27.2* MCV-89
MCH-30.9 MCHC-34.7 RDW-14.9
[**2122-8-21**] 02:31PM PLT COUNT-316
[**2122-8-21**] 02:31PM PT-14.6* PTT-28.0 INR(PT)-1.3*
..
STUDIES:
.
EKG ([**2122-8-21**] 4:57am, 8/10 chest pain)
Normal sinus rhythm at 130, with anteroseptal 1-2mm ST
elevations involving V1 to V4, with reciprocal inferior ST
depressions in leads II, III and aVF.
.
EKG ([**2122-8-21**] 5:06 am, 2/10 chest pain)
Normal sinus rhythm at rate of 116, with 1mm ST elevationss
involving V1 ot V4, with reciprocal inferior ST depressions in
leads II, III and aVF.
.
EKG ([**2122-8-21**] 14:18, 0/10 chest pain)
Normal sinus rhythm at rate of 90, resolved ST elevations, low
voltage and T wave flattening on precordial leads. No Q waves,
normal axis.
..
CXR ([**2122-8-21**]):
FINDINGS: Small bilateral pleural effusions are new. There is
increased
opacity at the lung bases bilaterally which may represent lower
lobe
distribution of pulmonary edema in this patient with upper lobe
emphysema.
However, imaging alone cannot exclude bilateral infectious
process. The lungs are otherwise clear. Cardiomediastinal and
hilar contours are normal. There is a new left internal jugular
central venous line ending in the upper SVC. There is no
pneumothorax. Visualized soft tissue structures and bony thorax
are normal.
IMPRESSION:
1. Probable dependent distribution of edema in setting of upper
lobe
emphysema and less likely infection or aspiration.
2. New left IJ central line in good position with no
pneumothorax.
.
Stress Test [**2122-8-25**]
The patient was infused with 0.142 mg/kg/min of dipyridamole
over 4
mintues. The patient had no back, neck, arm, or chest pain
during
infusion or in recovery. The baseline STT wave abnormalities did
not
change during infusion or during recovery. The rhythm was sinus
with
frequent isolated apc's. There was appropriate hemodynamic
response. The
dipyridamole was reversed with 125mg of aminophylline. No
anginal type symptoms and no signficant ST segment changes from
baseline. Nuclear report to be sent separately.
INTERPRETATION:
Left ventricular cavity size is normal. Rest and stress
perfusion images reveal uniform tracer uptake throughout the
left ventricular myocardium. There is a soft tissue attenuation
in the distal anterior wall, but no definite perfusion defect.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 54%.
Compared with the study of [**2120-9-4**], there is no significant
change.
IMPRESSION: Soft tissue attenuation in the distal anterior wall,
but no
definite perfusion defects are seen. Normal cavity size and
function.
Brief Hospital Course:
In summary, this is a 69 year old man with a history of
hypertension, hyperlipidemia, diabetes, severe [**Year (4 digits) 1106**] disease
and acute GI bleed, presenting with acute onset of chest pain
and ST changes, now resolved. Stress test showed no perfusion
defect. No PCI pursued. Hospital course c/b c.diff colitis
which is responding to flagyl by time of discharge.
..
# CORONARY ARTERY DISEASE / ISCHEMIA: ECG at admission was
concerning for left anterior descending disease, likely
symptomatic in the setting of ongoing blood loss and anemia.
Differential diagnosis included PE, aortic dissection,
esophageal rupture, but these seemed less likely given the ST
elevations. STEMI was believed to be unlikely given the
complete resolution of ST changes without reperfusion therapy.
Troponins were mildly elevated with flat CKs. There may have
been a mild troponin leak in the setting of demand on day of
admission. There was no coronary intervention, although it is
very likely that he has coronary artery disease given his
history of peripheral [**Year (4 digits) 1106**] disease and his multiple coronary
risk factors.
.
Nuclear stress test (report attached) showed no perfusion defect
c/w prospect of diffuse 3 vessel dz. We continued Aspirin at a
lower dose and d/c'ed [**Year (4 digits) 4532**] (carotid and iliac stents placed 3+
months ago). Metoprolol dose was increased. We increased his
statin to 80 mg qd, a dose which he should contiinue
indefinitely if his LFTs permit.
..
# CARDIOMYOPATHY: There was question of prior cardiomyopathy,
although he had a normal echo one month ago. Echo at OSH showed
depressed EF, but nuclear stress reveled EF=54%. His volume
status was monitored closely; there was no indication for
diuresis.
..
# RHYTHM: He was in normal sinus rhythm throughout admission.
..
# C.diff colitis: Pt started on Flagyl 500mg po tid on [**8-25**] for
2 week course to treat c.diff. Diarrhea began to subside before
time of discharge. WBC trending down. Abdominal tenderness
decreased.
.
#Hypomagnesemia: likely secondary to wasting during previous
(now resolved) alcohol abuse. Mg was 1.8 at time of discharge
despite standing oral supplementation and repeated IV
supplementation. Pt given 4g IV on day of discharge.
.
# PUD WITH ACUTE GI BLEED: This was recently worked up at
[**Hospital 882**] hospital. The findings are provided above in HPI. We
discussed with radiology a recent CT angiogram of his abdominal
and pelic vasculature; although he has superior mesenteric
artery narrowing, there is no stenosis of his celiac plexus or
[**Female First Name (un) 899**] that would cause significant mesenteric ischemia to account
for his GI ulcers. The biopsy reports from his recent
endoscopies are being followed at [**Hospital1 882**] and he should have
close follow-up there. Biopsies were negative for ischemia and
malignancy--further work-up is necessary.
..
# DIABETES: He had a hemoglobin A1C of 5.8 in [**Month (only) 205**], indicating
excellent glycemic control. We held his metformin and kept him
on an insulin sliding scale while in house.
..
# HYPERTENSION: He was not hypertensive during this admission.
His metoprolol was uptitrated mainly for the benefits to be had
in the setting of probable coronary artery disease.
..
# HYPERLIPIDEMIA: We continued his home statin (higher dose).
..
# COPD: We continued his home inhalers, but discontinued his
theophylline given risk for toxicity. Spiriva was added. 02 sat
maintained in the 93-100% range.
..
# PERIPHERAL [**Month (only) **] DISEASE: As above, we continued his home
aspirin (lower dose 162mg) and discontinued [**Month (only) 4532**]. His foot
ulcer was followed by wound care and the pt was seen and
examined by [**Month (only) 1106**] surgery who determined that there was no
active surgical issue.
..
During the hospitalization, pneumoboots (and later, SQH) were
used for DVT prophylaxis. He was given a cardiac, heart healthy
diet and continued on PPI d/t his history of GI bleed. His code
status remained full.
.
Dispo: Physical therapy reccommended that the patient complete
Short term rehab b/c of his difficulty with ambulation. Pt
refused and was deemed competent to make his own decisions
regarding this issue. At the time of discharge, he was
medically stable for discharge from the hospital, but went
against our advice in choosing to go home over physical rehab.
======================================
Issues requiring immediate follow-up:
-Hypomagnesemia: to be checked by his VNA
-LFTs in six weeks b/c of increased statin dose: to be checked
by his VNA/PCP
[**Name10 (NameIs) 57003**] care for his foot
-further work-up of his multiple GI ulcers: etiology currently
unknown
Medications on Admission:
DARIFENACIN 7.5mg daily
DIGOXIN 125 mcg daily
FENOFIBRATE 145mg daily
LISINOPRIL 10 mg daily
METFORMIN 500mg daily
THEOPHYLLINE 300mg [**Hospital1 **]
Albuterol nebs prn
Aspirin 325 mg daily
Montelukast 10 mg daily
Escitalopram 10 mg daily
Omeprazole 20 mg daily
Clopidogrel 75 mg daily
Simvastatin 80 mg daily
Niacin 500 mg daily
Oxycodone 5 mg q4h prn
Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **]
Tiotropium Bromide 18 mcg Capsule daily
Ipratropium Bromide nebs q6h
Ferrous Sulfate 325 mg daily
Brimonidine 0.15 % 1gtt daily each eye
Dorzolamide 2 % Drops one gtt TID
Latanoprost 0.005 % Drops one drop each eye qhs
Folic Acid 1 mg daily
Discharge Disposition:
Home With Service
Facility:
Family Care Extended
Discharge Diagnosis:
Acute coronary syndrome/Coronary Artery Disease
C. difficile colitis
Acute Blood Loss Anemia secondary to Peptic Ulcer Disease
Peripheral [**Hospital1 **] Disease
Left Great Toe Lesion: followed by [**Hospital1 1106**] surgeon
Diabetes Mellitus
Chronic Obstructive Pulmonary disease
Hypertriglyceridemia
Discharge Condition:
stable,
Hct 28.2
WBC 8.9
BUN 8
creat 0.7
Mg 1.8
Discharge Instructions:
You had some heart strain that may be due to some narrowing in
your coronary arteries. We did a stress test that showed no
acute blockages and a mostly normal heart function. We started
you on a beta blocker called metoprolol that decreases your
heart rate and helps to prevent heart attacks, we also started
you on Atorvastatin for your cholesterol. You need to have your
liver function checked in 6 weeks. You also had a
gastrointestinal bleed from stomach ulcers that made you anemic.
You had an infection in your bowel and antibiotics were started.
New medicines:
1. Metoprolol: to help you heart rate and prevent a heart
attack.
2. Spiriva: to help you breathe
3. Nitroglycerin: to take if you have pain in your chest
4. Flagyl: an antibiotic to treat the infection in your bowel.
5. We increased your magnesium
We stopped the following medicines: [**Hospital1 **], Lisinopril,
Theophylline, and digoxin.
Please call your doctor if you have any chest pain, increasing
diarrhea, nausea, inablility to eat or drink, dizziness, trouble
breathing, dark or bloody stools.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2122-11-12**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2122-11-12**] 4:15
Primary Care:
[**Last Name (LF) 11139**], [**Name8 (MD) 449**], MD Phone: [**Telephone/Fax (1) 11144**]. Date/time: Thursday
[**9-10**] at 1:30pm.
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Address: [**Hospital 882**] Hospital [**Apartment Address(1) 57004**],
[**Location (un) 86**]. Phone:[**Telephone/Fax (1) 57005**] Date/Time: Friday [**9-11**] at
9am.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2122-8-31**]
|
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"530.21",
"531.40",
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"414.01",
"401.9",
"250.00",
"496",
"008.45",
"V12.72",
"411.1",
"285.1",
"425.4",
"V12.54",
"440.23",
"440.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13501, 13552
|
8076, 12795
|
315, 321
|
13900, 13950
|
4725, 8053
|
15165, 16072
|
3574, 3634
|
13573, 13879
|
12821, 13478
|
13974, 15142
|
3649, 4690
|
2787, 2792
|
4706, 4706
|
233, 277
|
349, 2658
|
2823, 3276
|
2702, 2767
|
3292, 3558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,010
| 138,576
|
19972
|
Discharge summary
|
report
|
Admission Date: [**2160-11-10**] Discharge Date: [**2160-11-16**]
Date of Birth: [**2084-1-23**] Sex: M
Service: CARDIAC SURGERY
[**Last Name (un) 53846**] COMPLAINT: Mr. [**Known lastname 53847**] is a 76 year-old male with
recent increase in his chest pain who was recently admitted
to [**Hospital 1474**] Hospital for rule out myocardial infarction. At
that hospital he had a positive exercise tolerance test
Cardiac catheterization on [**2160-10-30**] revealed a good left
ejection fraction of 67 percent, 90 percent stenosis of the
right coronary artery and a left anterior descending artery
to 70 to 100 percent. He was evaluated as an outpatient for
a coronary artery bypass graft procedure. He presents today
for an elective procedure. He denies any cough, wheezing or
asthma, any heartburn, any dysuria, any nocturia, any history
of syncope, seizures or strokes. Denies any claudication but
acknowledges that he does have leg cramps sometime when he
wakes up.
PRIOR MEDICAL HISTORY: Chronic lower extremity edema,
hypertension, degenerative joint disease, glaucoma, sleep
apnea, history of gastric ulcers, gastroesophageal reflux
disease, status post multiple orthopedic surgeries including
a left hand, left knee and bilateral hip replacement. He has
no known drug allergies. His medicines at home include
aspirin once a day, Cardizem 240 mg once a day, Imdur 30 mg
once a day, Terazosin 2 mg q.h.s., Alphagan eye drops b.i.d.,
Betimol eye drops b.i.d. and Dexol eye drops q A.M. He also
takes a multivitamin.
SOCIAL HISTORY: HE is a pike smoker. He uses occasional
alcohol. He is married and lives with his wife. [**Name (NI) **] is a
retired either plumber or contractor, I'm not sure.
LABORATORY DATA: His pre-admission laboratories - white
count 7.5, hematocrit 36.1, platelet 196, INR 1.1. Sodium
137, potassium 3.9, chloride 104, bicarb 23, BUN 15,
creatinine 0.7, glucose 126.
PHYSICAL EXAMINATION: He is 76 years old. He appears his
stated age. In no apparent distress. Neurologic is grossly
intact. Neurologic examination: he is alert and oriented
times three in no apparent distress. Mucous membranes are
moist. His neck is supple without any carotid bruits noted.
His heart is regular rate and rhythm, S1, S2, no murmurs.
Lungs clear to auscultation bilaterally. Abdomen: he is an
obese man but his abdomen is soft, firm, nontender.
Extremities are warm with good bilateral pulses. He has 2+
bilateral leg edema which he acknowledges has been there
since his hip replacement. His preoperative cardiac
catheterization showed two vessel heart disease and Dr.
[**Last Name (STitle) 70**] and he has consented for an elective coronary
artery bypass graft on [**2160-11-10**].
After consent was obtained the patient was taken to the
operating room on the morning of [**2160-11-10**]. Please refer to
the previously dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
of that day. In brief, a three graft coronary artery bypass
graft was performed. The left internal mammary artery was
connected to the distal left anterior descending artery and
two saphenous vein grafts were used to bypass stenoses in the
diagonal artery and the right coronary artery. The patient
tolerated this procedure well and was taken back to the
cardiac recovery unit intubated on propofol and Neosynephrine
drip. Patient did well postoperatively and on the night of
surgery he was extubated and his drip were weakened. The
rest of his Cardiac Surgery Recovery Unit course was not
significant and on postoperative day two he was transferred
to the floor in good condition. Like other patients he was
diuresed and beta blocked while on the floor. His pacer
wires, chest tubes and Foley were also discontinued once he
was on the floor. Mr. [**Known lastname 53848**] course was significant for
two major thing. Number one, postoperatively Mr. [**Known lastname 53847**]'
blood sugars were elevated up to the mid 200s. A [**Hospital1 **]
consult was obtained on postoperative day two. The [**Hospital1 **]
team felt that Mr. [**Known lastname 53847**] could be managed on Glucophage
rather than instructing him how to use insulin. This worked
well and for several days prior to discharge MR. [**Known lastname 53848**]
blood sugars were very well controlled. On postoperative day
five Mr. [**Known lastname 53847**] [**Last Name (Titles) 5058**] in the morning with slurred speech.
In addition, his wife noted that Mr. [**Known lastname 53848**] language
seemed more garbled than usual. A neurology consult was
obtained and it was felt that this confusion postoperatively
was secondary to opiate use rather than an acute stroke. Mr.
[**Known lastname 53848**] opiate pain medication were discontinued and
patient's confusion/dysarthria improved markedly. So on
[**11-16**], postoperative day six, Mr. [**Known lastname 53847**] was
discharged home in good condition.
DISCHARGE DIAGNOSES:
Coronary artery disease.
Hypertension.
Diabetes mellitus.
Gout.
Glaucoma.
Gastroesophageal reflux disease.
Degenerative joint disease.
Osteoarthritis.
Chronic lower extremity edema.
DISCHARGE MEDICATIONS: Lasix 20 mg p.o. b.i.d. for two
weeks, K-Ciel 20 mg p.o. b.i.d. for two weeks, aspirin 325 mg
p.o. q.d., metoprolol 50 mg p.o. b.i.d., Glucophage 500 mg
p.o. b.i.d., Terazosin 2 mg p.o. q.h.., Zantac 150 mg p.o.
b.i.d. and he also recommended to take his eye drops as prior
to admission and also to use Tylenol or Motrin as needed for
pain. He is also recommended to follow his blood sugars
q.i.d. and to record those results and follow them up with
[**Hospital1 **]. He should have followup appointments with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29041**], the [**Hospital1 **] Diabetes
doctors, Wound Care Clinic and Dr. [**Last Name (STitle) 70**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2160-11-16**] 06:18
T: [**2160-11-16**] 18:29
JOB#: [**Job Number 53849**]
|
[
"250.00",
"414.01",
"401.9",
"530.81",
"293.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4996, 5179
|
5203, 6210
|
1958, 2064
|
2089, 4975
|
1571, 1935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,751
| 190,485
|
8788
|
Discharge summary
|
report
|
Admission Date: [**2111-1-22**] Discharge Date: [**2111-2-6**]
Date of Birth: [**2082-8-18**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain accompanied by Nausea and vomiting
Major Surgical or Invasive Procedure:
Dental Abscess Debridement
Tooth Extraction Procedure
Central line placement due to poor peripheral access.
IR-guided PICC line placement in R arm
History of Present Illness:
HPI: 28 year old type I and type II diabetic with right
mandibular abscess recently treated with 14-day course of
clindamycin, presents claiming to be in DKA, with blood sugars
at home [**Location (un) 1131**] greater than 600 mg/dL. Pt initially refused
central access. Multiple IV attempts were made, and patient was
found to have anion gap acidosis with elevated lactate and urine
ketones. Pt was started on insulin gtt at 10 U/hr and admitted
to the MICU.
.
In the MICU, insulin regimen was closely monitored by [**Last Name (un) **]
staff, and anion gap was closed. Pt was seen by oral surgeons,
and abscess was debrided and cultured on [**2111-1-24**], growing out
GPC, GPR, and GNR. Pt started on clindamycin and levofloxacin.
Pt had very poor peripheral access, and after much discussion
with patient and psychiatry consult, pt agreed to have central
line access for blood draws and medications. Central line was
successfully placed in R IJ and placement confirmed in SVC by
CXR. On morning of transfer at 8AM, pt was given full dose of
insulin although pt was not taking PO due to pain/nausea. Pt has
continued to refuse to take PO, and fingersticks have ranged
from 60-120 since the insulin dose. Insulin gtt was stopped and
all further insulin doses have been held. Pt was transferred to
medicine team in stable condition. Pt has had low urine output,
but is refusing Foley. Pt also has had no bowel movements in one
week.
Past Medical History:
Type I and II diabetes mellitus, c/b previous episodes of DKA
chronic sinusitis
Irritable bowel syndrome
Gerd
asthma
Social History:
works as preschool teacher, lives with her husband, no children
at this time,
occasional EtOH, denies tob, illicits
Family History:
type II DM in materanal grandmother, paternal grandmother, and
one uncle, also
CAD
Physical Exam:
on Admission:
Fatigued-appearing
VS: 97.9 117 130/106 20 100% ra
HEENT:ROMI PERRL Face symmetric, MMM
JVP: Flat
CHEST: CTAB
CV: Tachy, reg, no MRG
ABD: S/NT/ND/BS+, obese
EXT: No edema or rash, obese
Gait and Station: Not evaluated
Pertinent Results:
Labs on Admission to MICU:
[**2111-1-23**] 05:08AM BLOOD WBC-8.3# RBC-4.38 Hgb-12.1 Hct-33.8*
MCV-77* MCH-27.6 MCHC-35.9* RDW-14.2 Plt Ct-318
[**2111-1-23**] 05:08AM BLOOD Neuts-63 Bands-4 Lymphs-27 Monos-1* Eos-1
Baso-3* Atyps-1* Metas-0 Myelos-0
[**2111-1-23**] 05:08AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1
[**2111-1-23**] 05:08AM BLOOD Glucose-161* UreaN-12 Creat-0.9 Na-139
K-3.5 Cl-108 HCO3-17* AnGap-18
[**2111-1-23**] 05:08AM BLOOD ALT-12 AST-14 LD(LDH)-123 AlkPhos-132*
Amylase-47 TotBili-0.2
[**2111-1-23**] 05:08AM BLOOD Albumin-4.0 Calcium-8.6 Phos-2.1*#
Iron-23*
[**2111-1-23**] 06:30PM BLOOD Calcium-8.6 Phos-1.1* Mg-1.7
[**2111-1-23**] 05:08AM BLOOD calTIBC-278 Ferritn-139 TRF-214
[**2111-1-22**] 01:42PM BLOOD Type-[**Last Name (un) **] pO2-36* pCO2-32* pH-7.17*
calHCO3-12* Base XS--16
[**2111-1-22**] 01:42PM BLOOD Glucose-459* Lactate-2.1* Na-136 K-5.3
Cl-98*
.
Labs on Admission to Medicine floor:
[**2111-1-25**] 05:15AM BLOOD WBC-5.6 RBC-3.99* Hgb-11.3* Hct-30.9*
MCV-78* MCH-28.3 MCHC-36.6* RDW-14.1 Plt Ct-264
[**2111-1-28**] 05:54AM BLOOD ESR-63*
[**2111-1-31**] 05:30AM BLOOD Ret Aut-2.1
[**2111-1-25**] 12:15AM BLOOD Glucose-111* UreaN-3* Creat-0.6 Na-138
K-3.6 Cl-107 HCO3-22 AnGap-13
[**2111-1-25**] 12:15AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.4*
[**2111-1-31**] 05:30AM BLOOD VitB12-467 Folate-12.8
[**2111-1-24**] 01:12AM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-74* pCO2-35
pH-7.36 calHCO3-21 Base XS--4
.
Labs on Discharge:
[**2111-2-6**] 10:15AM BLOOD WBC-4.4 RBC-3.51* Hgb-9.5* Hct-28.1*
MCV-80* MCH-27.0 MCHC-33.7 RDW-14.1 Plt Ct-296
[**2111-2-4**] 07:26AM BLOOD Glucose-239* UreaN-5* Creat-0.7 Na-137
K-4.5 Cl-102 HCO3-28 AnGap-12
[**2111-2-4**] 07:26AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.1
.
Cultures:
1. [**2111-1-24**] 12:55 pm TISSUE #29 TOOTH GRANULATION.
GRAM STAIN (Final [**2111-1-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
TISSUE (Final [**2111-1-27**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
ANAEROBIC CULTURE (Final [**2111-1-30**]): NO ANAEROBES ISOLATED.
.
2. [**2111-1-24**] 3:00 pm TISSUE Site: BONE #29 TOOTH BONE.
GRAM STAIN (Final [**2111-1-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
TISSUE (Final [**2111-1-27**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 203-0534S
[**2111-1-24**].
ANAEROBIC CULTURE (Final [**2111-1-30**]): NO ANAEROBES ISOLATED.
.
3. [**2111-1-24**] 2:55 pm TISSUE #31 TOOTH GRANULATION.
GRAM STAIN (Final [**2111-1-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
TISSUE (Final [**2111-1-31**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 203-533S [**2111-1-24**].
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITES REQUESTED BY DR. [**Last Name (STitle) **] [**Numeric Identifier 30694**] [**2111-1-29**].
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. UNASYN (AMPICILLIN/SULBACTAM) PER ID
[**2111-2-1**].
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
STAPH AUREUS COAG +
|
AMPICILLIN/SULBACTAM-- <=2 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ 0.25 R
ANAEROBIC CULTURE (Final [**2111-1-30**]): NO ANAEROBES ISOLATED.
.
4. [**2111-1-24**] 3:00 pm TISSUE Site: BONE #31 TOOTH-BONE.
GRAM STAIN (Final [**2111-1-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2111-1-27**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 203-0533S
[**2111-1-24**].
ANAEROBIC CULTURE (Final [**2111-1-30**]): NO ANAEROBES ISOLATED.
.
Imaging:
[**2111-1-22**] - CXR: IMPRESSION: No acute cardiopulmonary process.
[**2111-1-22**] - CT Orbits/Sella: IMPRESSION: 1. No evidence of
abscess or acute sinusitis. 2. Right maxillary mucus retention
cyst, with possible adjacent small fluid level.
[**2111-2-1**] - CT Neck: IMPRESSION: 1. No definite evidence of
abscess within the soft tissues of the neck or within the region
of the mandible. Interval extraction of three molars since
[**2111-1-22**]. 2. Stable right maxillary mucous retention cyst
versus polyp.
[**2111-2-5**] - Bilateral LE U/S: IMPRESSION: No evidence of DVT.
.
Pathology:
[**2111-1-24**] - 1. Bone and tooth, "#29", extraction (A):
Fragments of tooth, bone and fibrous tissue with no evidence of
acute osteomyelitis.
2. Bone and tooth, "#31", extraction (B,C):
Fragments of tooth and fibrous tissue with no evidence of acute
osteomyelitis.
Brief Hospital Course:
IMPRESSION: 28 year old brittle diabetic admitted in DKA and
with dental abscess.
.
1. DKA: Patient was started on insulin gtt and IV fluids and
monitored in the ICU until her DKA had resolved. A central line
was placed in the MICU due to poor peripheral access, and the
central line was discontinued 4 days later after an IR-guided
PICC line was placed. At that point, she was transferred to the
medical floor on her home regimen of NPH insulin [**Hospital1 **] and humalog
SS. The [**Last Name (un) **] Diabetes Center followed her closely during her
stay. Her glucose levels were very difficult to manage
initially, likely [**1-15**] her ongoing infection, and were
complicated by the patient's inability to tolerate po intake.
The patient was unable to eat very much, and was also refusing
to have an NG tube placed or parenteral nutrition. Her insulin
regimen was continuously adjusted to avoid large fluctuations in
her sugars. Her diabetic control was also complicated by the
patient's inability to sense episodes of hypoglycemia. On
discharge, the patient's sugars were maintained in the
100's-200's on 45 units of NPH qAM and 50 units of NPH qPM, with
a Humalog sliding scale. The patient was discharged on this
regimen, and will followup with the [**Last Name (un) **] Diabetes Center on
Tuesday, [**2-10**], for further management.
.
2. Mandibular Dental abscess:
Her R mandibular dental abscess was debrided on [**2111-1-24**] by Dr.
[**Last Name (STitle) 2866**] from Oral Maxillofacial Surgery. Micro data from bone
and tooth granulation tissue cultures were suggestive of
osteomyelitis, with multiple gram-positives and gram-negative
rods, as well as MSSA and [**Female First Name (un) **] albicans. The patient was
treated with IV antibiotics during her admission, and the ID
service was consulted. The patient continued to have significant
jaw pain unrelieved by high doses of morphine and tramadol, and
the pain clinic was also consulted for her management. CT
imaging of her jaw showed no evidence of osteomyelitis, and her
bone pathology was also negative for signs of acute
osteomyelitis. A panoramic X-ray of her teeth indicated possible
involvement of tooth #28, and this tooth was extracted on
[**2111-2-5**] by Dr. [**Last Name (STitle) 2866**]. On discharge, the patient's pain was
relatively controlled, although still requiring high dose
narcotics. The patient was discharged with a PICC line in place
for IV clindamycin at home, as well as po levafloxacin and
fluconazole, for 5 weeks for presumptive osteomyelitis. Although
ID felt that po clindamycin would likely be sufficient, the
patient was extremely anxious about going home without IV
treatent, as she had had poor response to oral antibiotic
therapy in the past. The patient was also discharged on MSContin
and morphine sulfate IR as needed, along with neurontin for
neuropathic pain, per the pain clinic evaluation. The patient
was instructed to follow up with her PCP [**Name Initial (PRE) 176**] 2 weeks, and she
will also followup with the post-op Trauma Clinic in 1 week. In
addition, the efficacy of her antibiotic treatment will be
evaluated by ID in 3 weeks. ID will also check her LFTs at that
time.
.
3. Urinary Retention: During her admission, the patient also was
complaining of very low urine output despite adequate fluid
intake, and difficulty voiding. Bedside bladder scans indicated
bladder retention of volumes ranging from 500-900 cc of urine.
However, the patient refused any catheter intervention, and
preferred to continue to attempt to void on her own. Her renal
function was monitored closely, and she never showed signs of
renal failure or urinary tract infection. Her urine output
remained low at several hundred cc/day throughout her admission.
She was encouraged to followup with her PCP regarding this
issue.
.
4. Asthma: The patient also demonstrated increased wheezing from
her baseline asthma during her admission. She attributed it
initially to being put on amoxacillin-sulbactam, as she claims
to have had this reaction to ampicillin in the past. However,
her symptoms did not resolve upon discontinuing the ampacillin.
Her wheezing was relieved by albuterol nebs. The patient was
discharged on low-dose Advair diskus in addition to her
albuterol, and was encouraged to followup with her PCP should
her symptoms continue.
.
5. Lower extremity edema: The patient began to complain of lower
extremity swelling and tenderness 2 days prior to discharge. The
patient had refused all subcutaneous heparin DVT prophylaxis.
Bilateral lower extremity ultrasound was performed and showed no
evidence of DVT. Urinalysis had all been negative. On discharge,
her edema had improved somewhat, but the etiology of her mild
edema remained unclear.
.
6. Chronic sinusitis: The patient was concerned about her
chronic problems with sinusitis. A head CT was evaluated by [**First Name8 (NamePattern2) 26247**]
[**Last Name (NamePattern1) **] from ENT. It was deemed to be significant only for a benign
mucus retention cyst. No acute issues. ENT recommended follow-up
for long-term management as outpatient after resolution of
current infection.
.
7. Psychosocial: The patient throughout her admission
demonstrated an inability to cope with many issues surrounding
her illness. She was at times refusing interventions that were
deemed to be necessary for preventing life-threatening
complications. Psychiatry and social work closely followed the
patient. Her medical team focused on being non confrontational,
bargaining with the patient and trying to present options for
her management. Clear and consistent communication with the
patient was encouraged. The patient eventually complied with
most issues surrounding her treatment, although she remained
resistant to certain interventions as well as attempts to
increase her po nutrition intake. Her nortryptiline was
increased to 75mg qhs during admission, and benzodiazepines were
used as needed for anxiety. The patient was transitioned back to
her home dose of nortryptiline prior to discharge.
.
8. Anemia: The patient also developed a mild iron-deficiency
anemia that was stable for most of her hospital stay, likely [**1-15**]
poor nutrition. She was maintained on po iron supplementation,
and discharged on daily ferrous sulfate.
.
9. GI: Patient refused bowel regimen despite ongoing
constipation. She did have one episode of watery diarrhea, and
her stool was negative for C. Diff. Protonix was continued
prophylactically throughout admission.
Medications on Admission:
* Humalin 75U qam, qhs
* Humalog 75U qam, qhs
* Humalog 20U with meals if BS>300
* Protonix 40mg qd
* Nortriptyline 50mg qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 weeks.
Disp:*35 Tablet(s)* Refills:*0*
5. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours) for 10 days: Please
taper use of this medication as your pain subsides.
Disp:*40 Tablet Sustained Release(s)* Refills:*0*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day: Please take twice a day for 3 days, then increase to
three times a day.
Disp:*63 Capsule(s)* Refills:*1*
7. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*0*
8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 10 days: Please decrease use of
this medication as pain becomes manageable.
Disp:*60 Tablet(s)* Refills:*0*
9. Clindamycin Phosphate 150 mg/mL Solution Sig: Six (6) mL
Injection Q8H (every 8 hours) for 5 weeks: Please administer
through R arm PICC line.
Disp:*qs solution* Refills:*0*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing:
Please continue to use your albuterol inhalers as needed.
Disp:*qs inhaler* Refills:*2*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 days: Please decrease use of
this medication as tolerated as pain decreases.
Disp:*40 Tablet(s)* Refills:*0*
12. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 Disk* Refills:*2*
13. Glucometer
Please provide patient with glucometer.
14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 weeks.
Disp:*35 Tablet(s)* Refills:*0*
15. NPH
sig: 45U qAM, 50U qPM
Disp: qs
Refills:2
16. Humalog
sig: Please follow insulin sliding scale
disp: qs
refills: 2
17. Glucagon Emergency 1 mg Kit Sig: One (1) Injection For
Emergency: For emergency use.
Disp:*2 kits* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis
Diabetic Ketoacidosis
Dental Abscess
Poorly controlled Type I/Type II DM
.
Secondary Diagnoses
Type I Diabetes
Chronic sinusitis
Irritable Bowel Syndrome
Depression
GERD
Asthma
Discharge Condition:
Good, vitals stable.
Discharge Instructions:
Please seek medical services immediatly if you experience
fevers, chills, or really low/ high blood sugars. Please return
to the ED if you suspect that you may be experiencing any signs
of DKA, whichn include but are not limited to the following -
nausea, vomiting, abdominal pain, or any other concerning
symptoms.
.
Please keep all your scheduled follow up appointments.
.
Please take all medications as directed.
.
You have been provided with a copy of your insulin regimen.
.
On [**2111-3-2**] you will see Dr. [**First Name (STitle) **] [**Name (STitle) **] in Infectious
Disease to have your liver enzymes checked. During that time
another appointment needs to be scheduled for you to see her in
three weeks to check liver enzymes, esr and crp.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17181**],
to schedule followup appointments in 2 weeks from discharge. We
have attempted to contact his office to schedule this
appointment. We left a message with the answering service.
.
Infectious Disease
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2111-3-2**]
10:00
.
You will need followup at the trauma surgical clinic for your
debridement. The number is [**Telephone/Fax (1) 6439**].
.
You have a scheduled appointment at [**Last Name (un) **] Diabetes Center with
teaching nurse [**First Name8 (NamePattern2) 30695**] [**Last Name (Titles) **], on Tuesday, [**2-10**], at 3:00PM.
Please call [**Telephone/Fax (1) 2378**] with any questions.
.
Please contact ENT - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**] - at [**Hospital1 18**]
([**Telephone/Fax (1) 2349**]), to schedule outpatient appointment for followup
for chronic sinusitis.
Completed by:[**2111-2-9**]
|
[
"112.89",
"493.90",
"041.11",
"300.00",
"473.9",
"278.01",
"788.20",
"250.83",
"280.9",
"250.13",
"276.51",
"522.5",
"E932.3",
"V15.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"24.4",
"23.19",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18636, 18688
|
9570, 16080
|
329, 478
|
18927, 18950
|
2589, 4029
|
19751, 20855
|
2231, 2315
|
16254, 18613
|
18709, 18906
|
16106, 16231
|
18974, 19728
|
2330, 2330
|
240, 291
|
4048, 9547
|
506, 1941
|
2344, 2570
|
1963, 2081
|
2097, 2215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,115
| 164,952
|
8513
|
Discharge summary
|
report
|
Admission Date: [**2140-2-16**] Discharge Date: [**2140-2-20**]
Date of Birth: [**2098-3-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Renal transplant recipient
Major Surgical or Invasive Procedure:
Living unrelated renal transplant
History of Present Illness:
The patient is a 41-year-old gentleman with end-stage renal
disease secondary to diabetes mellitus who underwent a pancreas
and kidney transplant in the past.
Kidney has now failed, and he presents for retransplantation.
Past Medical History:
1. Pancreas/kidney transplant (kidney [**7-/2132**], pancreas [**6-28**])
2. Multiple ventral hernia repairs
3. Hx of CHF although ECHO normal in [**2135**]
4. Status post appendectomy
5. CAD s/p Pixel stent to LAD in [**1-30**]
6. ASD s/p repair at age 3
7. Pulmonary hypertension (2L home O2 at night)
8. Hypertension
9. History of Guillian-[**Location (un) **]
Social History:
Works as a landscaper part time. Lives in [**Location 942**] with his
wife and 2 children. Denies EtOH or IVDU. 2pk/yr smoker quit
13yrs ago.
Family History:
Brother w/ ASD.
Physical Exam:
General: WN man in NAD
Heart RRR
Lungs Clear to Auscultation (sl diminished post bases)
Abdomen soft, nontender, well healed midline incision, kidney in
RLE
Extremities nonfunctioning AV graft in LUE; no pedal edema
Other anicteric, neck supple
Pertinent Results:
[**2140-2-16**] 08:19PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2140-2-16**] 08:19PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-2-16**] 08:19PM URINE RBC-[**11-17**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
[**2140-2-16**] 08:19PM URINE AMORPH-OCC
[**2140-2-16**] 08:19PM URINE MUCOUS-FEW
[**2140-2-16**] 12:36PM GLUCOSE-134* UREA N-97* CREAT-6.1*#
SODIUM-141 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-19* ANION GAP-20
[**2140-2-16**] 12:36PM CALCIUM-7.7* PHOSPHATE-5.4* MAGNESIUM-1.8
[**2140-2-16**] 12:36PM WBC-4.1# RBC-4.10* HGB-11.5* HCT-33.3*
MCV-81* MCH-28.0 MCHC-34.5 RDW-14.1
[**2140-2-16**] 12:36PM PLT COUNT-189
[**2140-2-16**] 11:07AM TYPE-ART RATES-/8 TIDAL VOL-555 O2-50
PO2-294* PCO2-39 PH-7.33* TOTAL CO2-21 BASE XS--4
INTUBATED-INTUBATED VENT-CONTROLLED
[**2140-2-16**] 11:07AM GLUCOSE-126* LACTATE-0.6 NA+-138 K+-3.8
CL--103
[**2140-2-16**] 11:07AM HGB-12.1* calcHCT-36
[**2140-2-16**] 11:07AM freeCa-0.98*
Brief Hospital Course:
41yM admitted to Transplant surgery s/p LURT. Pt tolerated the
procedure well with no complications. The patient was
transfered to the SICU post operatively secondary to his
concominant pulmonary hypertension. A swan was placed in the OR
so postop PA pressure measurements could be taken. He was placed
on his home regimen of anti pulmonary hypertension meds, but in
the evening of POD#0, the patient developed hypertension to SBP
>200 and tachycardia. Nifedipine prn was added to his regimen,
and he was stabilized on 90mg TID which he often takes at home.
That same night, he spiked to 102.6 and was cultured. The
patient's creatinine showed good functioning of the transplanted
kidney by falling from 6 to 1.5 in 3 days. Otherwise, the
hospital course was uncomplicated, he was transfered to the
floor on [**2-18**] and remained afebrile with all vitals stable.
Upon discharge, the patient was tolerating po food, ambulating
well, and with pain controlled on po pain medication.
Medications on Admission:
ASA, Bosentan 125", calcitriol 0.25 mcg', PhosLo 2 tab''',
Aranesp 40 mcg q2wk, Fe 325mg', Lasix 80mg", metolazone 5 mg',
metoprolol 25 mg", nifedipine 90 mg' and 30 mg', prednisone
2.5', Rapamune 5mg', Prograf 1mg", Bactrim.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. 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*
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Tracleer 125 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Revatio 20 mg Tablet Sig: One (1) Tablet PO tid ().
Disp:*90 Tablet(s)* Refills:*2*
12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
13. Tacrolimus 1 mg Capsule Sig: per level Capsule PO Q12H
(every 12 hours).
Disp:*100 Capsule(s)* Refills:*2*
14. Tacrolimus 5 mg Capsule Sig: per level Capsule PO every
twelve (12) hours.
Disp:*30 Capsule(s)* Refills:*2*
15. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Failed transplanted kidney
Discharge Condition:
Good
Discharge Instructions:
Please call the Transplant office for any of the following:
- Fever > 101 or chills
- Inability to urinate
- Inability to tolerate food
- Discharge or blood from your surgical incisions
- Redness or swelling of your surgical incisions
- Anything else of concern.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-2-25**] 1:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-3-1**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2140-3-1**] 10:30
|
[
"250.40",
"V45.82",
"V42.83",
"996.81",
"414.01",
"585.6",
"403.91",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.91",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
5551, 5557
|
2549, 3538
|
339, 375
|
5627, 5634
|
1487, 2526
|
5945, 6360
|
1190, 1207
|
3815, 5528
|
5578, 5606
|
3564, 3792
|
5658, 5922
|
1222, 1468
|
273, 301
|
403, 626
|
648, 1014
|
1030, 1174
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,742
| 136,870
|
37794
|
Discharge summary
|
report
|
Admission Date: [**2108-10-16**] Discharge Date: [**2108-11-13**]
Date of Birth: [**2039-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Benzodiazepines
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
[**2108-11-8**] Coronary artery Bypass GRAFTING X 3 (lEFT INTERNAL
MAMMARY ARTERY GRAFTED TO THE lEFT ANTERIOR DESCENDING.SAPHENOUS
VEIN GRAFTED TO RAMUS/POSTERIOR DESCENDING ARTERY)/AORTIC VALVE
REPLACEMENT (#27mm [**Company 1543**] Ultra Porcine)
[**2108-10-26**] right popliteal thrombectomy/ resect. [**Doctor Last Name **]. aneursym and
fem-[**Doctor Last Name **] BPG
[**2108-10-25**] AAA endovascular stent-grafting
History of Present Illness:
This 69 white male presented to [**Hospital3 3583**] on [**2108-10-16**] with
severe back and flank pain. He became hypotensive and hypoxic
and was life flighted to [**Hospital1 18**].
He was transferred to the MICU intubated and a CTA of the torso
showed a 7 cm infrarenal AAA without evidence of leak or
rupture. He ruled in for an MI with a troponin of 2.68 and a
CK of 1099. Cardiac cath on [**10-16**] revealed 90% LMCA lesion,
occluded LCX, and 80% RCA. His EF is 35-40%. Cardiac surgery
was consulted. Vascular surgery took Mr.[**Known lastname 84604**] for exploration
of below-knee popliteal artery with popliteal and tibial
thrombectomies, repair of thrombosed popliteal aneurysm with
reversed saphenous vein graft, and angioscopy and valve
lysis.Once recovered from this procedure, Cardiac surgery
prepared him for surgical coronary artery revascularization and
Aortic Valve Replacement.
Past Medical History:
1.Aortic stenosis.
2. Severe 3-vessel coronary artery disease.
3. Status post recent myocardial infarction.
4. History of ruptured abdominal aortic aneurysm in the
setting of an acute myocardial infarction.
5. Status post Endo AAA repair
6. Chronic obstructive pulmonary disease
7. HTN
8. hyperlipidemia
9. A Fib
Social History:
Race: Caucasian
Last Dental Exam: years
Lives with: alone
Occupation: retired
Tobacco: never
ETOH: none
Family History:
Noncontributory
Physical Exam:
Pulse: 80 Resp: 16 O2 sat: 95%
B/P Right: 123/75 Left:
Height: 5'[**09**]" Weight: 92 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Disoriented to place, but knows year and president.
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: tr Left: tr
PT [**Name (NI) 167**]: tr Left: tr
Radial Right: 1+ Left: 1+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2108-11-11**] 02:13AM BLOOD WBC-10.5 RBC-3.37* Hgb-9.9* Hct-29.0*
MCV-86 MCH-29.3 MCHC-34.0 RDW-17.0* Plt Ct-131*
[**2108-10-16**] 12:35AM BLOOD WBC-13.5* RBC-3.38* Hgb-10.1* Hct-30.5*
MCV-90 MCH-29.8 MCHC-33.1 RDW-16.0* Plt Ct-193
[**2108-11-12**] 11:45AM BLOOD PT-24.7* INR(PT)-2.4*
[**2108-10-16**] 12:35AM BLOOD PT-14.4* PTT-20.4* INR(PT)-1.3*
[**2108-11-11**] 02:13AM BLOOD Glucose-110* UreaN-33* Creat-1.6* Na-134
K-4.2 Cl-101 HCO3-23 AnGap-14
[**2108-10-16**] 04:36AM BLOOD Glucose-167* UreaN-38* Creat-1.6* Na-138
K-7.3* Cl-110* HCO3-20* AnGap-15
[**2108-10-31**] 03:37AM BLOOD ALT-74* AST-65* CK(CPK)-105 AlkPhos-74
Amylase-39 TotBili-0.6
[**2108-10-16**] 04:36AM BLOOD ALT-170* AST-348* LD(LDH)-601*
CK(CPK)-1099* AlkPhos-58 TotBili-0.6
[**2108-11-13**] 05:35AM BLOOD WBC-9.8 RBC-3.78* Hgb-11.1* Hct-32.9*
MCV-87 MCH-29.5 MCHC-33.9 RDW-17.3* Plt Ct-155
[**2108-11-13**] 05:35AM BLOOD Plt Ct-155
[**2108-11-13**] 05:35AM BLOOD PT-28.6* INR(PT)-2.8*
[**2108-11-13**] 05:35AM BLOOD Glucose-83 UreaN-34* Creat-1.3* Na-137
K-4.0 Cl-100 HCO3-29 AnGap-12
[**2108-11-7**] 07:25AM BLOOD %HbA1c-5.6
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84605**] (Complete)
Done
DOB: [**2039-1-3**]
Indication: Aortic valve disease. Atrial fibrillation. Coronary
artery disease. Left ventricular function. Mitral valve disease.
Pericardial effusion. Prosthetic valve function. Valvular heart
disease.
ICD-9 Codes: 427.31, 440.0, V43.3, 424.1, 424.0
Test Information
Date/Time: [**2108-11-8**] at 13:49 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18397**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
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 - Ejection Fraction: 30% to 40% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *55 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 27 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Elongated LA. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD or PFO by 2D, color
Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Top normal/borderline dilated LV cavity
size. Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta tube graft. Simple atheroma in
ascending aorta. Mildly dilated descending aorta. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Small to moderate pericardial effusion. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Suboptimal image quality - poor echo windows.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is elongated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is moderately depressed (LVEF= 3040 %). Right
ventricular chamber size and free wall motion are normal. The
appearance of the ascending aorta is consistent with a normal
tube graft. There are simple atheroma in the ascending aorta.
The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Mild (1+) mitral regurgitation is seen.
There is a small to moderate sized pericardial effusion. There
are no echocardiographic signs of tamponade.
POST CPB:
1. LV systolic function is mildly improved EF = 45-50 % (No
inotropic support)
2. Preserved RV systolci function
3. Trileafllet bioprosthesis in aortic position. Mechanically
stable and well seated with good leaflet excursion.
4. Trace AI.Peak gradient 18 mm Hg.
5. No other change.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2108-11-8**] 13:55
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-11-13**] 7:55
AM
[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p avr/cabg and ct removal
Final Report CHEST RADIOGRAPH
INDICATION: Status post CABG and chest tube removal, rule out
pneumothorax.
FINDINGS: As compared to the previous examination, the chest
tubes have been removed. On today's examination, several
millimeters left apical lateral pneumothorax is visible. There
are no signs of tension.
No changes in the appearance of the right lung parenchyma and of
the cardiac and mediastinal silhouette.
A repeat chest film revealed a partially resolved left apical
pneumothorax.
Brief Hospital Course:
The patient is a 69-year-old gentleman who presented with acute
back pain and hypotension which was thought to be due to
contained ruptured abdominal aortic
aneurysm. The patient was resuscitated but in the process of
being resuscitated had suffered an acute myocardial infarction.
The patient was resuscitated appropriately,
treated for his myocardial infarction. Cardiac cath showed
severe left main disease as well as high-grade LAD, circumflex
marginal and right coronary artery disease.
However, due to the patient's acuity and anatomy, he was not
felt to be either a percutaneous interventional candidate nor a
cardiac surgical candidate at that point in time. He did
recover with medical therapy and it was felt that he should
proceed with Endo AAA repair prior to cardiac surgical repair.
He underwent endo AAA repair on [**10-25**] with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], with
right popliteal rescue/revisions on [**10-26**].
[**11-8**] Mr.[**Known lastname 84604**] was taken to the operating room and underwent
an Aortic valve replacement(#27 mm [**Company 1543**] mosaic ultra
bioprosthesis)/Coronary bypass grafting x3 with left internal
mammary artery to the left anterior descending coronary artery;
reversed saphenous vein single graft from the aorta to the
posterior left ventricular coronary artery; as well as reversed
saphenous vein single graft from the aorta to the ramus
intermedius coronary artery. Please refer to Dr[**Last Name (STitle) 5305**]
operative report for further details. Cardipulmonary Bypass
Time=140 minutes. Cross Clamp Time= 117 minutes. Postoperatively
he was transferred to the CVICU intibated and sedated in stable
but critical condition requiring pressors to optimize cardiac
hemodynamics. He awoke neurologically intact and was extubated
on POD#1 without incident. He was weaned off pressors and all
lines and drains were discontinued in a timely fashion with
criteria met. Beta-Blocker, Amiodarone for new preop atrial
fibrillation was resumed, along with ASA/statin and gentle
diuresis was initiated. He continued to progress and was
transferred to the step down unit for further monitoring on
POD#3. Anticoagulation was started with Coumadin for his
paroxysmal AFib. Amiodarone was discontinued due to HR in the
50-60 range, but then restarted laterfor adequate rate. Physical
therapy was consulted for evaluation of strength and increased
mobility. It was their recommendation that Mr.[**Known lastname 84604**] go to
rehab for further improvement in strength and activities of
daily living. The remainder of his postoperative course was
essentially uneventful. He was cleared for discharge to rehab by
CSURG attending on POD5 .Target INR for A Fib is 2.5-3.0. All
follow up appointments were advised. As per patient request,
prior to discharge a new PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 50871**] [**Name (STitle) **] was arranged for
follow up. Dr.[**Last Name (STitle) **] follow up per Vascular surgery.
Medications on Admission:
MEDICATIONS (obtained from [**Company 4916**] Pharmacy):
Simvastatin 20 mg daily
Captopril 100 mg po bid
Amlodipine 5 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain/temp.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily)
as needed for AFib: adjust dose to target INR of 2.5-3.
[**11-13**] dose 1mg.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x1 week then 200mg QD.
13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous Q 24H (Every 24 Hours): thru [**11-16**].
14. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
Q12H (every 12 hours): x1 week then change to oral dosing.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
-Aortic stenosis, Severe 3-vessel coronary artery disease- - s/p
CABG x3/AVR.
s/p rt side Exploration of below-knee popliteal artery with
popliteal and tibial thrombectomies.
Repair of thrombosed popliteal aneurysm with reversed saphenous
vein graft
-Status post recent myocardial infarction.
-history of ruptured abdominal aortic aneurysm in the setting of
an acute myocardial infarction.
Status post Endo AAA repair
Chronic obstructive pulmonary disease
HTN
Hyperlipidemia
RIJ/cephalic vein thrombus
A Fib
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
target INR 2.5-3.0 for A Fib and lower extremity thrombus/w
bypass graft
Followup Instructions:
-Dr. [**First Name (STitle) 50871**] [**Name (STitle) **], *new PCP, [**Name10 (NameIs) 648**] [**Name11 (NameIs) **]. [**11-20**] at 2:15pm,
[**Hospital6 733**], [**Location (un) **], South Suite [**Hospital Ward Name 23**]
Building-[**Hospital1 18**]
-Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in 4 weeks, [**Telephone/Fax (1) **] please call for
[**Telephone/Fax (1) 648**]
-Dr.[**Last Name (STitle) **] follow up [**Last Name (STitle) 648**] in 2 weeks# [**Telephone/Fax (1) 2395**]
Wound check [**Telephone/Fax (1) 648**] [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
- see Dr. [**Last Name (STitle) **] in [**2-28**] weeks
Completed by:[**2108-11-13**]
|
[
"997.2",
"276.2",
"584.9",
"453.81",
"507.0",
"428.0",
"441.02",
"041.11",
"442.3",
"276.7",
"424.1",
"785.51",
"453.86",
"E878.2",
"272.4",
"414.01",
"287.5",
"518.81",
"401.9",
"428.41",
"410.71",
"427.31",
"790.7",
"276.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"39.50",
"88.56",
"00.47",
"88.42",
"00.41",
"38.18",
"88.52",
"36.15",
"37.23",
"39.71",
"36.12",
"96.72",
"39.90",
"00.40",
"35.21",
"39.29",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14023, 14095
|
9277, 12291
|
294, 719
|
14648, 14655
|
2840, 6940
|
15268, 15998
|
2133, 2150
|
12469, 14000
|
8712, 9254
|
14116, 14627
|
12317, 12446
|
14679, 15245
|
6984, 8134
|
2165, 2821
|
243, 256
|
747, 1654
|
1676, 1995
|
2011, 2117
|
8144, 8672
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,575
| 177,153
|
47925
|
Discharge summary
|
report
|
Admission Date: [**2164-12-12**] Discharge Date: [**2164-12-19**]
Date of Birth: [**2104-5-17**] Sex: F
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
female who is admitted for elective total hip replacement.
She has a history of hypertrophic obstructive cardiomyopathy,
hypertension and multiple psychiatric disorders, and was
admitted to [**Hospital1 69**] in [**2164-7-23**], status post fracture of her left hip. At that point,
she underwent open reduction and internal fixation which has
since failed to completely heal and she returns now for an
elective total hip replacement. Of note, during her [**Month (only) 205**]
admission, she had a complicated hospital course spending
several months in the Intensive Care Unit following a bout of
congestive heart failure and hypoxemia believed to be related
to her hypertrophic obstructive cardiomyopathy. She has a
left ventricular ejection fraction of greater than 55% by her
echocardiogram of [**2164-7-23**], but is extremely sensitive to
fluid balance. Since her discharge from [**Hospital1 346**] in [**Month (only) 216**]/[**2164-9-23**], the
patient has apparently been nonweight-bearing on the left
lower extremity secondary to pain in the left hip with
movement or weight bearing. She also relates feeling
extremely anxious recently regarding both her upcoming
surgery and the fact that she has no place to live following
surgery as her brother is selling the apartment that she has
been living in. She says that she has felt several times
that "life is not worth living" but denies any active
suicidal ideation, homicidal ideation or suicidal plan. She
also denies any recent auditory or visual hallucinations.
PAST MEDICAL HISTORY:
1. Hypertrophic obstructive cardiomyopathy diagnosed in
[**2162**], sensitive to fluid overload and diuresis.
Echocardiogram of [**2164-8-14**], also demonstrated elongated left
atrium, mildly dilated right atrium, symmetric left
ventricular hypertrophy, however, there is severe resting
left ventricular outflow obstruction.
2. Hypertension.
3. Schizo-affective disorder.
4. Depression.
5. Anxiety.
6. Basal cell carcinoma on her breast.
7. Questionable neuroleptic malignant syndrome secondary to
Zyprexa but she is currently taking without difficulty.
PAST SURGICAL HISTORY:
1. Status post left hip open reduction and internal fixation
in [**2164-7-23**].
2. Status post total abdominal hysterectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Tylenol p.r.n. pain.
2. Zyprexa 5 mg p.o. q.a.m. and 20 mg p.o. q.h.s.
3. Trazodone 25 mg p.o. twice a day.
4. Combivent inhaler MDI two puffs four times a day p.r.n.
Shortness of breath.
5. Bumetanide 1 mg p.o. once daily.
6. Metoprolol 50 mg p.o. once daily.
7. Protonix 40 mg p.o. once daily.
8. Celexa 60 mg p.o. once daily.
9. Calcium Carbonate 1250 mg p.o. three times a day.
SOCIAL HISTORY: The patient is currently living at a nursing
home where she has been since her discharge from [**Hospital1 346**]. She denies any tobacco, alcohol or
drug use.
PHYSICAL EXAMINATION: Upon admission, the patient's vital
signs are temperature 97.1, blood pressure 90/60, heart rate
60 and regular, respiratory rate 18, oxygen saturation 96% in
room air. In general, she was an obese female, anxious but
not in any acute distress. Head, eyes, ears, nose and throat
- She is normocephalic and atraumatic. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. The oropharynx is clear and moist.
Neck is supple, no jugular venous distention, no
lymphadenopathy. Chest - The chest is clear to auscultation
bilaterally. Cardiovascular - The patient has regular rate
and rhythm, but she has a harsh IV/VI early systolic murmur
heard diffusely across her precordium radiating towards the
neck, heard loudest at the left sternal border. There were
no rubs, gallops or heaves. Abdomen is obese, soft,
nontender, nondistended, normal bowel sounds. Back - There
was no costovertebral angle tenderness. Extremities - There
is a well healed scar in her left hip with limited range of
active and passive motion of the left hip. The left leg was
held in midflexion and external rotation. There was 1+
bilateral lower extremity edema, no calf tenderness on either
side. Neurologically, she was alert and oriented times
three. Cranial nerves II through XII are grossly intact.
Motor was [**5-27**] upper extremities bilaterally and in the right
leg it was [**5-27**] as well as the left leg was 2 to [**3-27**] hip
flexion. Sensation was intact in both extremities upper and
lower. Reflexes were 2+ throughout. Psychiatry - she had
questionable suicidal ideation as mentioned above and no plan
and no homicidal ideation, no hallucinations and her mood was
appropriate at the time of physical examination.
LABORATORY DATA: Her complete blood count on admission was
as follows: White blood cell count 5.9, hematocrit 32.7,
platelet count 199,000. Chem7 was sodium 144, potassium 3.8,
chloride 104, bicarbonate 27, blood urea nitrogen 22,
creatinine 1.1. Her sugar was 89. Her calcium was 10.6,
magnesium 2.0 and her phosphate was 4.0.
Electrocardiogram showed normal sinus rhythm with left
ventricular hypertrophy, but no significant changes from
[**2164-8-23**].
The patient had a portable chest x-ray to rule out congestive
heart failure on [**2164-12-14**]. The pulmonary vascularity was
minimally indistinct suggesting mild congestive heart
failure. There were low lung volumes but no pleural
effusions or focal consolidations.
On the day prior to discharge, the patient had the following
laboratory values: White blood cell count was 4.7,
hematocrit 34.2 and her platelet count was 129,000, MCV 88.
Prothrombin time was 17.8, partial thromboplastin time 38.6
and her INR was 2.1. Sodium was 143, potassium 3.8, chloride
107, bicarbonate 29, blood urea nitrogen 15, creatinine 0.8,
and glucose 117. Calcium 9.0, magnesium 1.7, phosphorus 2.6.
She had blood cultures from [**2164-12-15**], that were negative at
the date of discharge.
HOSPITAL COURSE:
1. Orthopedic - The patient underwent left total hip
replacement without significant orthopedic complications. She
was discharged to the floor on postoperative day number four
and did well from the orthopedic standpoint. She was able to
get out of bed to chair without difficulty. She had
difficulty continuing to move her left lower extremity but
this was not surprising given the extent of the surgery. She
also developed a pressure ulcer on the lateral malleolus of
the left leg that was likely due to the persistent position
of external rotation. The ulcer was without active bleeding
or discharge and no surrounding erythema. There were no
other evidence of infection of this ulcer and wet to dry
dressings were applied twice a day and a heel pad was put in
place to minimize further pressure on the site. She received
physical therapy and deemed a good candidate for
rehabilitation at this time.
2. Cardiovascular - The patient has a history of
hypertrophic obstructive cardiomyopathy with a complicated
hospital course in the past. She was sent to the Surgical
Intensive Care Unit after her total hip replacement as
planned prior to the operation for hemodynamic monitoring.
She developed mild hypotension in the Post Anesthesia Care
Unit and required less than 24 hours of Neo-Synephrine for
blood pressure support. She was weaned from the
Neo-Synephrine within 24 hours of entering the Surgical
Intensive Care Unit and did well from a cardiovascular
standpoint thereafter. Her blood pressure was mildly
elevated to systolic of 160 but she was completely
asymptomatic with no chest pain, shortness of breath or
palpitations. She was well controlled below 90 during her
stay on the floor. She continued to receive her Lopressor
and Bumetanide in order to optimize her cardiovascular
performance. She was exquisitely sensitive to fluids on her
previous admission and she was attempted to keep euvolemic
during the hospitalization stay to prevent recurrence of her
congestive heart failure.
3. Psychiatric - The patient has an extensive psychiatric
history including schizo-affective disorder, depression,
anxiety. She related some chronic suicidal ideation but
without a plan but no homicidal ideation, auditory or visual
hallucinations during the hospital stay. She was continued
on her Celexa, Trazodone and Seroquil during her hospital
stay. There were no changes in her psychiatric status.
4. Hematologic - The patient was treated with Coumadin for
anticoagulation and with a goal INR of 1.5. She is to be
anticoagulated for a three to six week course or she can be
switched to 30 mg twice a day of subcutaneous Lovenox once in
the rehabilitation facility setting. She had a mild drop in
her hematocrit which corrected prior to discharge. She also
had a mild drop in her platelets which also corrected the day
prior to discharge. These were deemed most likely due to
mild blood loss in the Emergency Department and taking the
dilution from the intravenous fluid she received.
CONDITION ON DISCHARGE: The patient was in good condition at
discharge.
DISCHARGE STATUS: The patient will be discharged to the
[**Hospital **] Rehabilitation facility where she is applying for
long term residency.
DISCHARGE DIAGNOSES:
1. Status post elective total hip replacement on the left.
2. Hypertrophic obstructive cardiomyopathy and mitral
regurgitation.
3. Hypertension.
4. Schizo-affective disorder.
5. Depression.
6. Anxiety.
7. Left heel pressure ulcer.
8. History of basal cell carcinoma on the breast.
MEDICATIONS ON DISCHARGE:
1. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
2. Zyprexa 5 mg p.o. q.a.m. and 20 mg p.o. q.h.s.
3. Trazodone 25 mg p.o. twice a day.
4. Combivent MDI two puffs four times a day p.r.n. shortness
of breath.
5. Bumetanide 1 mg p.o. once daily.
6. Lopressor 50 mg p.o. once daily.
7. Protonix 40 mg p.o. once daily.
8. Celexa 60 mg p.o. once daily.
9. Calcium Carbonate 1250 mg p.o. three times a day.
10. Coumadin 2.5 mg p.o. once daily for a goal INR of 1.5 to
2.0, the last dose of her Coumadin should be [**2165-1-12**].
11. Iron Sulfate 325 mg p.o. once daily.
12. Colace 100 mg p.o. twice a day.
FOLLOW-UP PLANS: The patient is to follow-up with Orthopedic
surgeon, Dr. [**First Name (STitle) 1022**], two weeks following discharge. She is also
to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2204**], one to two weeks after discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2164-12-18**] 18:41
T: [**2164-12-18**] 20:05
JOB#: [**Job Number **]
|
[
"733.82",
"425.1",
"V10.83",
"287.5",
"401.9",
"707.0",
"295.72",
"300.4",
"905.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"78.65"
] |
icd9pcs
|
[
[
[]
]
] |
9428, 9718
|
9744, 10365
|
2545, 2940
|
6175, 9188
|
2352, 2519
|
3142, 6158
|
10383, 10945
|
183, 1744
|
1766, 2329
|
2957, 3119
|
9213, 9407
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,919
| 162,579
|
26523
|
Discharge summary
|
report
|
Admission Date: [**2186-2-9**] Discharge Date: [**2186-2-13**]
Date of Birth: [**2133-9-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Gadolinium-Containing Agents
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Benzodiazepine overdose
Major Surgical or Invasive Procedure:
endotracheal intubation (intubated [**2186-2-8**], extubated [**2186-2-9**])
History of Present Illness:
Ms. [**Known lastname **] is a 52 year-old woman with a history of
depression/anxiety who was brought to the ED after taking a
"handfull" of Xanax following an argument with her partner.
[**Name (NI) 65507**] to him, they were home at his apartment where she has
also been staying for the last few months. They had a few beers
before dinner, ate dinner around 5 pm, and were later preparing
to go to bed and watch [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] when they began to argue over
"something stupid." The partner suggested she just go back to
her own house (where she has not stayed in several weeks), at
which point she became upset. She told him she was taking
several pills (he thinks maybe [**5-10**] Xanax, though it may have
been more) though he did not actually see exactly what she took.
She then went to the kitchen and took a knife and began trying
to cut her wrists. He went to her and was able to wrestle the
knife away. He held her wrists and maneuvered her to the sofa;
after several minutes of holding her still, she began to
"weaken" and then became somnolent, at which time he called 911.
He states there was never any trauma or injury other than that
self-inflicted to her wrists.
She is followed by Dr. [**First Name (STitle) 4135**] (prescribing psychiatrist) and
therapist [**Doctor First Name **] at [**Hospital1 **] for mental health issues. As far as
her partner is aware, she has never been hospitalized for
psychiatric reasons or had a prior suicide attempt. She is seen
approximately monthly as an outpatient.
Partner is not aware of any recent physical complaints or
symptoms though does note that since her bypass surgery she is
only able to eat very small amounts at a time and occasionally
has stomach problems including cramping.
Vitals on arrival to the ED were not recorded on ED dash but per
verbal signout she had normal BP, HR and RR of [**9-13**]. She was
found to be obtunded and was intubated for airway protection.
She received a dose of Narcan after which she was mildly roused,
but then became somnolent again. She received activated charcoal
x 1 dose through OG tube. She received Td shot given wrist
injury, and lacerations to left wrist were sutured. She received
IVF (on 2nd L NS). She was started on propofol after intubation.
Vitals prior to transfer to the MICU were: t 97.8, BP 120/71, HR
80, RR 20, 100% on ventillator.
REVIEW OF SYSTEMS: Could not be obtained as patient intubated,
somnolent.
* * * * *
Additional history obtained post-extubation: Patient now reports
that she was not intending to kill herself by taking the pills
or using a knife on her wrists. She says that her depression has
generally been under fair to good control, but on the night of
admission she was very upset and felt like she "just snapped."
She now reports two prior hospitalizations approximately 10
yaers ago for depression.
Past Medical History:
- History of DM2 prior to gastric bypass (now off meds)
- History of HTN prior to gastric bypass (now off meds)
- Allergic rhinitis
- Asthma
- Possible urticaria (seeing allergist [**1-/2186**])
- Chronic LBP for which she has been getting injections
- Gastric bypass in [**2179**] for obesity
- Hysterectomy [**2158**]
- Depression, anxiety (followed by Dr. [**First Name (STitle) 4135**] [psych] and
therapist [**Doctor First Name **] at [**Hospital1 **])
- G4P1S3 with stable simple right adnexal cyst
- Osteoarthritis
- Small right insula meningioma and a pineal cyst
Social History:
Has been with her partner for 5 years and living in his
apartment for the past several months, though she maintains her
own separate address.
TOBACCO: 1.5 ppd
ETOH: Occasional; typically beers on weekends
ILLLICTS: None
Family History:
Non-obtainable
Physical Exam:
ADMISSION:
VS: T 95.6, BP 127/76, HR 89, RR 23, 100% on 100% FiO2
GEN: Somnolent, making some spontaneous movements but not
rousable, not following commands or opening eyes to voice
HEENT: Pupils reactive
NECK: Supple
PULM: Referred upper airway noises from ventillator; no
wheeze/rales
CARD: RRR, no M/R/G
ABD: Soft, non-distended, no apparent tenderness on exam
EXT: 2+ DP pulses. Fine linear excoriations on R wrist, small
laceration on L wrist, sutured
SKIN: No urticaria noted
NEURO: Not able to follow commands at this time
PSYCH: Somnolent
DISCHARGE:
Gen: alert, oriented, no acute distress
HEENT: sclera anicteric, moist mucous membranes
CV: S1/S2, RRR, no m/r/g
Pulm: CTAB, no wheezes, rhonchi or rales
Abd: soft, non-tender, non-distended
Ext: warm, no edema
Neuro: face symmetric, moves all extremities
Psych: denies suicidal ideation, mood and affect appropriate
Pertinent Results:
Labs on admission:
URINE:
[**2186-2-9**] 12:50AM URINE HOURS-NO URINE I
[**2186-2-9**] 12:50AM URINE HOURS-RANDOM
[**2186-2-9**] 12:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
[**2186-2-9**] 12:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2186-2-9**] 12:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-TR
[**2186-2-9**] 12:50AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-0-2 RENAL EPI-0-2
[**2186-2-9**] 12:50AM URINE HYALINE-48*
[**2186-2-9**] 12:50AM URINE MUCOUS-OCC
BLOOD:
[**2186-2-9**] 12:30AM PH-7.33* COMMENTS-GREEN TOP
[**2186-2-9**] 12:30AM GLUCOSE-109* LACTATE-1.4 NA+-141 K+-4.2
CL--102 TCO2-25
[**2186-2-9**] 12:30AM freeCa-1.18
[**2186-2-9**] 12:29AM UREA N-21* CREAT-0.9
[**2186-2-9**] 12:29AM ALT(SGPT)-17 AST(SGOT)-20 ALK PHOS-78 TOT
BILI-0.2
[**2186-2-9**] 12:29AM LIPASE-45
[**2186-2-9**] 12:29AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2186-2-9**] 12:29AM WBC-13.0* RBC-4.61 HGB-13.9 HCT-40.6 MCV-88
MCH-30.1 MCHC-34.2 RDW-13.5
[**2186-2-9**] 12:29AM PT-10.7 PTT-18.4* INR(PT)-0.9
[**2186-2-9**] 12:29AM PLT COUNT-423
[**2186-2-9**] 12:29AM FIBRINOGE-315
ECG [**2186-2-9**]: Sinus rhythm. J point elevation with early
repolarization in precordial leads is probably a normal variant.
No previous tracing available for comparison.
CXR [**2186-2-9**]: FRONTAL CHEST RADIOGRAPH: A transesophageal
catheter extends to at least the level of the stomach, possibly
post-pyloric. An ET tube terminates 2.1 cm above the carina. The
lungs are underinflated. The heart size is normal. The hilar and
mediastinal contours are within normal limits. The central
pulmonary vessels appear prominent, with no evidence of overt
edema. There is no pneumothorax or pleural effusion. IMPRESSION:
1. ET tube terminating 2.1 cm above the carina. Recommend
pull-back 1-2 cm. 2. Transesophageal catheter extending to at
least the level of the stomach, possibly post-pyloric.
CXR [**2186-2-9**]: FINDINGS: As compared to the previous radiograph,
there is no relevant change. The tip of the endotracheal tube is
still abutting the carina and should be pulled back by
approximately 2 cm. The course of the nasogastric tube is
unchanged and in correct status. Low lung volumes with
developing left retrocardiac atelectasis. No larger pleural
effusions. No focal parenchymal opacity suggesting pneumonia or
aspiration.
Brief Hospital Course:
HOSPITAL SUMMARY:
52 W with a history of depression/anxiety who took a "handful"
of Xanax after argument with her partner and attempted to slit
wrists with a kitchen knife. Intubated on arrival to ED for
airway protection but successfully extubated the next day. Seen
by Psychiatry for evaluation of worsening depression, who
recommended transfer to an inpatient Psychiatric facility once
medically stable. Patient is now medically stable for transfer.
.
ACTIVE ISSUES:
.
# BENZODIAZEPINE OVERDOSE: Urine toxicology screen was positive
for benzodiazepines and amphetamines. Serum toxicology screen
was negative. She received Naloxone in the ED in addition to
activated charcoal. Her case was evaluated by the Toxicology
team, who recommended holding off on Flumazenil given the risk
of precipitating withdrawal. Remainder of electrolytes and LFTs
were normal. Repeat acetaminophen level after 8 hours was
negative as well. This is likely an isolated benzodiazepine
overdose (given her characteristic presentation of CNS
depression with normal vital signs), though ultimately exact
ingestion remains unclear. She was extubated on the afternoon
following admission and recovered uneventfully.
.
# AIRWAY PROTECTION: Patient was intubated on arrival to ED for
airway protection. She was successfully extubated the afternoon
following admission without complication. She was maintained on
propofol for sedation while intubated. Following extubation she
was able to maintain O2 sats 97-100% on room air with no
subjective shortness of breath.
.
# DEPRESSION, ANXIETY: Patient acknowledges two prior
psychiatric admissions for Depression. She was evaluated by the
Psychiatry consulting team who recommended Wellbutrin 200 mg
daily and Lamictal 125 mg nightly. She was also seen by SW/RN
specializing in issues of substance abuse. She had a 1:1 sitter
during this admission for safety. Once medically cleared she was
transferred to an inpatient Psychiatric facility for continued
management.
.
# LEUKOCYTOSIS: Possibly secondary to ingestion or aspiration.
However, an elevated white count has been present in the online
medical record since [**2180**]. CXR showed no pneumonia, urinalysis
was negative for infection. Differential revealed a neutrophil
predominance, but no bands. She remained afebrile and had no
localizing symptoms concerning for infection. This should be
further evaluated in the outpatient setting by her Primary Care
Physician.
.
INACTIVE ISSUES:
.
# ALLERGIES: Stable. Continued on Fluticasone nasal spray and
Cetirizine as needed for urticaria. Has a follow up appointment
scheduled with her Allergist.
.
# ASTHMA: Stable. Continued on Albuterol inhaler.
.
# Code Status: FULL CODE
.
# CONTACT: [**First Name4 (NamePattern1) 1116**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 65508**] (partner)
.
# TO DO:
-Primary Care Physician should pursue additional work up of
leukocytosis should it persist after discharge
Medications on Admission:
- Xanax 1 mg PO TID
- Wellbutrin 200 mg PO daily
- Lamictal 125 mg QHS
- Cetirizine 10 mg PO 1-2 times daily
- Ranitidine 150 mg PO BID
- Trazodone
- "Painkillers"
- Dulcolax PRN
- Omeprazole 20 mg PO daily
- Calcium
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for indigestion.
3. cetirizine 10 mg Capsule Sig: One (1) Capsule PO once a day
as needed for allergy symptoms.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
5. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO at bedtime:
please take with 25 mg tab to make a total of 125 mg nightly.
7. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO at bedtime:
please take with 100 mg tab for a total of 125 mg nightly.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
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 BID (2 times a day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever/pain.
14. Cepacol Sore Throat + Coating 15-5 mg Lozenge Sig: One (1)
Mucous membrane every four (4) hours as needed for sore throat.
15. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
16. Wellbutrin SR 200 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
benzodiazepine overdose
depression
anxiety
asthma
allergic rhinitis
leukocytosis of unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were initially admitted to the Intensive Care Unit after you
overdosed on medication, and were intubated for respiratory
support. Once you were stabilized you were transferred to a
Medicine floor. You did well and now you are medically stable
and ready to be transferred to a different inpatient hospital
for continued Psychiatric help.
.
We are making a few changes to your outpatient medication
regimen. These medications may change again at your next
facility:
-Please STOP Xanax
Followup Instructions:
Please schedule a follow up appointment with your Primary Care
Physician (Dr. [**Last Name (STitle) 3576**] at [**Telephone/Fax (1) 3581**]) when you are discharged.
.
The following appointments were scheduled prior to your
admission:
.
Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2186-2-21**] at 4:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], RNC [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: RADIOLOGY
When: THURSDAY [**2186-10-5**] at 9:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"288.60",
"881.02",
"969.4",
"V45.86",
"493.90",
"E950.3",
"300.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
12564, 12579
|
7677, 8132
|
327, 406
|
12724, 12724
|
5127, 5132
|
13420, 14248
|
4198, 4215
|
10885, 12541
|
12600, 12703
|
10644, 10862
|
12875, 13397
|
4230, 5108
|
2859, 3348
|
264, 289
|
8147, 10122
|
434, 2840
|
10139, 10618
|
5147, 7654
|
12739, 12851
|
3370, 3944
|
3960, 4182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
426
| 191,682
|
2954
|
Discharge summary
|
report
|
Admission Date: [**2201-4-8**] Discharge Date: [**2201-4-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: [**Age over 90 **] yoM w/ h/o CAD s/p CABG, AF on coumadin, HTN presents to
ED s/p fall. This a.m., pt reports he "slipped" while going to
the bathroom, falling between his bed and the dresser. His wife
called EMS, who found the pt coughing up pink sputum, lying on
his left side, initially "mottled" improving w/ O2
administration. In ED, he was hypotensive w/ sbp 80s-90s, O2 sat
86% RA, improving to 95% on 5L NC. CXR showed RLL infiltrate w/
?RML mass and pt received levofloxacin 500 mg IV X 1, Flagyl 500
mg IV X 1 and 1L NS. The pt reports mild shortness of breath and
cough productive of yellow sputum (denies hemoptysis) X 3 days.
He denies chest pain, LH, palpitations, F/C, myalgias. He
reports he vomited several times yesterday (no hemetemesis);
denies abd pain, diarrhea. No recent sick contacts or recent
travel.
Past Medical History:
1) Atrial flutter: s/p ablation [**2192**]
2) CAD: s/p NSTEMI [**12-18**]
- [**12-18**] cardiac cath: LM 80% prox and 60% distal, LAD 60%, RCA
50% prox and 90% mid, LCx 70% prox and 100% distal, EF 30% w/
severe anterolateral, apical and inferior hypokinesis w/ 2+ MR
- [**8-20**] PMIBI: No angina or ischemic EKG changes. No myocardial
perfusion defects EF 68%
- [**3-19**] TTE: LA and RA mod dilated, asymmetrical LVH, LVEF
50-55%, aortic root moderately dilated, trace AR, 1+ MR
3) GERD
4) Spinal stenosis
5) s/p prostatectomy
6) squamous bladder metablasia
7) HTN
8) Hyperlipidemia
9) CRI: baseline Cr 1.4-1.7
Social History:
lives with wife, ambulates with walker. Former tob 100 pk-yrs,
quit 20 yrs ago. No EtOH or other drug use
Family History:
NC
Physical Exam:
PE: Tc 97.1, pc 70, bpc 90/49, resp 25, 95% 5L
Gen: elderly male, alert, OX3, although slightly confused,
tachypnic, (+) accessory muscle use
HEENT: PERRL, EOMI, anicteric, pale conjunctiva, OMM dry, OP
clear, neck supple, (+) right anterior cervical LAD, mildly
tender, JVP 15 cm
Cardiac: RRR, II/VI SM at apex
Pulm: Crackles at bases bilaterally up 1/3. No wheezes
Abd: NABS, soft, NT/ND, no masses
Ext: No C/C/E, 2+ DP bilaterally
Neuro: CN II-XII grossly intact and symmetric bilaterally, [**4-21**]
strength throughout, symmetric bilaterally, 2+ DTR [**Name (NI) **] and [**Name2 (NI) **]
bilaterally, sensation intact to light touch proximally and
distally in upper and lower extremities bilaterally.
Brief Hospital Course:
[**Age over 90 **] yoM w/ CAD s/p CABG, AF and HTN who presented s/p mechanical
fall and was found to have hypotension which resolved with 1 L
of NS and PNA.
Pneumonia: CRX concerning for RML mass on top of PNA which may
be multilobar with also LLL involvement. Responding to
levofloxacin with rapid clinical imporvement and now nl room air
oxygen.
- Continued on levofloxacin renally dosed
- A CT was performed which did not reveal a mass, but showed a
large AAA.
Sepsis: resolved. Lactate improved from 8.3 -> 1.8 and his BP
normalized with only 1 L NS and early antibiotic Tx suggesting
that volume depletion may have been the main culprit.
Blood Cx negative to date.
s/p Fall: pt had witnessed mechanical fall w/o LOC or head
trauma. Head CT and C-spine CT were also negative for new acute
pathology including bleed or fx. Most likely etiology was
weakness from underlying infection.
-Fall precautions were instituted. He was evaluated by PT who
assessed him able to go [**Last Name (un) 6529**] home from the hospital without
any further rehab.
CAD: minimal lateral ST depressions on EKG with positive CK MB
and trop leak, asymptomatic. Possibly demand ischemia caused by
transient hypotension and infection.
- Continued on ASA, lipitor, and BB
HTN: normotensive now. Pt usually on aldactone and BB. He
ignores the doses.
-He was restarted on a low dose of aldactone and lopressor.
CRI: Cr was initially elevated at 1.8 from a baseline of Cr
1.4-1.7. This resolved over 24 hours with hydration and it was
attributed to prerenal etiology
AF: anticoagulation was held for possible procedure upon arrival
to micu. INR therapeutic at 2.7
-restart on coumadin at 5mg po qd in am. At d/c his INR was 3.2
Medications on Admission:
metoprolol, aspirin, aldactone, coumadin
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO once a
day: Do not take on day of discharge.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Fall
Multilobar Pneumonia
Afib
COnstipation
Discharge Condition:
Good- at baseline
Followup Instructions:
Please see your primary care doctor (Dr. [**Last Name (STitle) 2472**] in 1 week
|
[
"401.9",
"V45.81",
"530.81",
"272.4",
"414.00",
"790.92",
"441.4",
"244.9",
"486",
"E888.9",
"458.9",
"038.9",
"253.6",
"593.9",
"995.92",
"564.00",
"412",
"427.31",
"790.99"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4929, 5015
|
2664, 4378
|
270, 276
|
5103, 5122
|
5145, 5229
|
1914, 1918
|
4469, 4906
|
5036, 5082
|
4404, 4446
|
1933, 2641
|
221, 232
|
304, 1138
|
1160, 1775
|
1791, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,678
| 102,286
|
44048
|
Discharge summary
|
report
|
Admission Date: [**2143-12-16**] Discharge Date: [**2143-12-21**]
Date of Birth: [**2082-5-16**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin / Keflex
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hemoptysis/post-obstructive pneumonia
Major Surgical or Invasive Procedure:
IR embolization of bleeding pulmonary site
History of Present Illness:
Mr. [**Known lastname 51305**] is a 61 year old male smoker with 50 pack year
history, COPD, hemachromatosis, and multiple invasive squamous
cell
carcinoma/basal cell carcinoma who is being transferred to the
ICU for post-procedural monitoring following rigid bronchoscopy
for hemoptysis and likely post obstructive pneumonia.
.
He initially presented who had an episode of hemoptysis and
shortness of breath in the early AM prior to presenting to the
OSH. Patient reports that he had 2 episodes of hemoptysis of
approximately [**5-22**] oz. There, he underwent a CT scan that showed
a mass obstructing the
left main stem bronchus with a post obstructive pneumonia on the
left. The patient was started on CAP coverage with
CTX/azithromycin, to which flagyl was added. Patient denies
and fevers, chills, sweats. Patient reports a diminished
appetite, and 25 weight loss of the past 6-8 weeks. Patient
reports that he has difficulty walking greater than 50 feet
before he becomes short of breath and develops calf pain.
.
Of note, he has a major history of numerous squamous cell
carcinomas of the bilateral frontal and parietal scalp, probably
due to excessive sun exposure. He receives dermatologic care
here at [**Hospital1 18**] from Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] is to see Dr. [**Last Name (STitle) 1837**] for a
Mohs procedure of a recurrent left temporal lesion. He believes
that he has melanoma of the left temporal region though this was
not demonstrated by recent pathology. He also believes he has
melanoma of the lip.
.
He was initially admitted to the general medicine floor in
stable condition. His oxygen saturations intermittently fell to
88-89% and he coughed up a few teaspoons of frank hemoptysis.
With a CXR demonstrating major left lower lobe collapse and
likely obstruction of the LMSB, decision was made to go directly
to OR for rigid bronchoscopy with subsequent MICU admission for
observation.
.
His bronchoscopy revealed a large blood clot in the left main
stem bronchus with a malignancy of 10% stenosis behind it.
There were multiple tumors in the airways of both LUL and LLL,
each of which were cauterized with good effect. Distal slow
oozing was seen in smaller airways NOT amenable to bronchoscopic
intervention. IP recommended IR for angiography/embolization in
the AM.
.
Upon return from the MICU, his initial vitals were:BP:150/65
P:76 R:18 O2:100% 2Lventuri mask. He was comfortable without
complaints, though was still drowsy from anesthesia and a ROS
could not be ellicited
Past Medical History:
-Hemochromatosis
-COPD
-PVD
-HTN
-lymphedema of LUE, RLE
-IBS
-anxiety
-invasive squamous cell carcinoma of left temple.
-multiple squamous cell carcinomas of frontal and temporal scalp
Social History:
lives at home. He has a 50+PY smoking history with continued
use. Major previous sun exposures. ETOH intake ranges [**1-18**]
beers per day.
Family History:
Mother: CAD, DM
Father
Siblings [**Name (NI) **]: DM, CAD
Physical Exam:
Admission exam
Vitals: T: BP:150/65 P:76 R:18 O2:100% 2Lventuri mask
General: patient is fatigued-appearing and weak.
HEENT: Sclera anicteric, MM dry, dried blood on lip with lower
lip lesion. Multiple scaling lesions over the frontal and
parietal scalp bilaterlly, with an ulcerated lesion over the
left temple.
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds on the left with rhonchi, no
wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, asymmetric 2+ pitting edema with L arm >> R, and R
leg >> left.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam: deceased
Pertinent Results:
Admission labs
[**2143-12-17**] 01:32AM BLOOD WBC-23.4*# RBC-3.22* Hgb-9.9* Hct-30.0*
MCV-93 MCH-30.7 MCHC-32.9 RDW-14.4 Plt Ct-439
[**2143-12-17**] 01:32AM BLOOD Neuts-97.5* Lymphs-1.6* Monos-0.8*
Eos-0.1 Baso-0
[**2143-12-16**] 05:20PM BLOOD Glucose-103* UreaN-20 Creat-0.6 Na-139
K-4.1 Cl-108 HCO3-20* AnGap-15
[**2143-12-18**] 04:20AM BLOOD ALT-12 AST-11 LD(LDH)-139 AlkPhos-65
TotBili-0.1
[**2143-12-16**] 05:20PM BLOOD Calcium-7.7* Phos-3.8 Mg-1.7
.
Discharge labs:
Labs stopped being drawn, as patient made [**Year/Month/Day 3225**].
.
Studies
.
PATHOLOGY REPORT OF LUNG MASS
SPECIMEN SUBMITTED: right lower lobe endobronchial bx.
Procedure date Tissue received Report Date Diagnosed
by
[**2143-12-16**] [**2143-12-17**] [**2143-12-19**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf
DIAGNOSIS:
Lung, right lower lobe, endobronchial biopsy:
Squamous cell carcinoma, moderately differentiated.
Note: The patient's history of cutaneous squamous cell
carcinoma is noted. Although the endobronchial tumor may
represent metastasis from a cutaneous primary, a primary lung
squamous cell carcinoma cannot be excluded.
.
CT Head [**2143-12-16**]
There is no evidence of hemorrhage, infarction, shift of midline
structures, or mass effect. The ventricles and sulci are normal
in size and
configuration. The visible paranasal sinuses show small amount
of fluid
within the right maxillary sinus. Several tiny calcifications in
the left
frontal lobe (2:18, 2:11)and right frontal lobe (2:14) may be
sequelae of old infection. IMPRESSION: No acute intracranial
process, including large metastasis. If metastasis continue to
be a clinical concern, then an MR is recommended for further
evaluation.
.
LENIs [**2143-12-16**]
No DVT in the right lower extremity. Mild subcutaneous edema and
calcifications within the arterial vessels.
.
CXR [**2143-12-16**]
Single frontal view of the chest demonstrates marked
opacification
of the left middle and lower lung with significant volume loss
as evidenced by marked leftward cardiomediastinal shift. As
correlated to the preceding
reference CT from [**Hospital 882**] Hospital of the same day, there is
significant
endobronchial material obstructing the left main bronchus. There
is likely a combination of consolidation, bronchial wall
thickening, and pleural effusion in the left lung as well as
volume loss, producing the overall opacification. The right lung
remains relatively well aerated. There is evidence of underlying
emphysema, without radiographic evidence of pneumothorax.
Findings consistent with left main bronchial obstruction with
left middle and lower lobe collapse, in addition to
consolidation, bronchial wall thickening, and large left pleural
effusion. Overall constellations are highly concerning for
malignancy, although supervening infection and/or aspiration may
be present.
.
Embolization procedure [**2143-12-17**]
1. Single bronchial artery visualized supplying the left lung
with visualized tumor blush, embolized utilizing 500-700 micron
Embospheres.
2. Post-embolization arteriogram did not demonstrate any
bronchial arteries
either originating from the aorta or the internal mammary artery
supplying the left lung. Despite the suggestion that there is an
additional left bronchial arterial branch on the CT, this could
not be found despite using a number of different catheter
shapes. IMPRESSION: Successful uncomplicated embolization of
left bronchial artery utilizing 500-700 micron Embospheres.
.
CXR [**2142-12-18**]
In comparison with the study of [**12-17**], there has been some
re-aeration of the left lung following bronchoscopy. However,
extensive opacification persists and there is still shift of the
mediastinum to the left with hyperexpansion of the right lung.
Hazy opacification at the right base raises the possibility of
some atelectasis and effusion.
Brief Hospital Course:
Mr. [**Known lastname 51305**] is a 61yoM with multiple squamous cell skin cancers
who presents with hemoptysis and a LLL post obstructive
pneumonia.
.
# HEMOPTYSIS: CXR and CT suggested tumor burden in the left
mainstem bronchus, and this likely explained his hemoptysis. He
was brought for rigid bronchoscopy, which showed a large tumor
burden with distal oozing not amenable to bronchoscopic
engagement. Pathology report from this procedure showed this
tumor to be squamous cell, although could not differentiate
between metastasis from skin squamous cell cancer vs primary
lung squamous cell cancer. He underwent an IR angio/embolectomy,
which was successful in reducing his total amount of hemoptysis.
However, he did continue to have intermittent hemoptysis, and
overall felt very poorly and mildly SOB. Meeting with patient
and family was held, and it was decided that he would not want
any further intervention, and just wanted to be made
comfortable. He was made [**Known lastname 3225**] and transferred to the general
medicine floor.
.
On the general medicine floor, pall care continued to follow the
patient. His pain control was morphine drip initially, and then
he was later transitioned to a fentanyl patch and PO pain
control. The patient was made as comfortable as possible. He
was going to be transferred to outpatient hospice, but the
patient ultimately passed overnight.
.
# COMMUNITY ACQUIRED PNEUMONIA (?POST-OBSTRUCTIVE): His imaging
showed complete collapse of the LLL with a mass compromising the
left mainstem bronchus as well as likely consolidation of the
inferior LUL. OSH labs show concerning bandemia to 25%. His
sputum cultures grew out moraxella + s. pneumo. He initially was
covered broadly, but now that culture data are back he will be
treated with a 7 day total course of antibiotics, now on just
levofloxacin. Although he is [**Name (NI) 3225**], pt and family would like to
treat PNA. His bandemia improved and he remained afebrile. The
patient was on a Levofloxacin course when he passed.
.
# SQUAMOUS CELL CARCINOMA: He has an invasive left temporal SCC
and possible airway metastases. He is now [**Name (NI) 3225**], and ultimately
ended up passing while in the hospital, prior to discharge to
outpatient hospice.
.
# PERIPHERAL ARTERY DISEASE: Plavix was stopped; the only
medications that were continued were those that ensured the
patient's comfort.
.
# COPD: From ongoing smoking, now [**Name (NI) 3225**] and passed during this
hospitalization.
.
# HYPERTENSION: anti-HTN meds held, pt now [**Name (NI) 3225**] and ultimately
passed during hospitalization.
.
# CHRONIC LYMPHEDEMA: asymmetric upper and lower extremity from
unclear source.
Medications on Admission:
-Percocet
-plavix
-trazodone
-diovan
-spiriva
-ventolin
Discharge Medications:
pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis:
obstructing mass in airway
basal cell/squamous cell carcinoma
Secondary Diagnosis:
COPD
Discharge Condition:
Expired
Discharge Instructions:
Patient was made [**Name (NI) 3225**] and expired on [**2142-12-21**] at 7:45am. Brother
[**Name (NI) **] and [**Name2 (NI) 802**] [**Name (NI) 698**] were present. Autopsy was declined by
all siblings.
Followup Instructions:
N/A
Completed by:[**2143-12-23**]
|
[
"173.31",
"E926.2",
"173.42",
"V66.7",
"162.5",
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"V49.86",
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"496",
"440.20",
"783.21",
"783.0",
"303.91",
"401.9",
"275.03",
"481",
"300.00",
"173.32",
"786.30",
"519.19",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.79",
"88.44",
"38.97",
"33.24",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
10994, 11003
|
8150, 10849
|
320, 364
|
11154, 11163
|
4260, 4716
|
11414, 11449
|
3323, 3382
|
10955, 10971
|
11024, 11024
|
10875, 10932
|
11187, 11391
|
4732, 8127
|
3397, 4214
|
4230, 4241
|
243, 282
|
392, 2938
|
11127, 11133
|
11043, 11106
|
2960, 3147
|
3163, 3307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,326
| 136,909
|
17951
|
Discharge summary
|
report
|
Admission Date: [**2123-4-3**] Discharge Date: [**2123-4-7**]
Date of Birth: [**2074-6-14**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 48-year-old
man with cardiac risk factors of tobacco use who presents to
[**Hospital1 18**] from transfer from an outside hospital with an
IMI/right ventricular infarct. On the evening of
presentation, the patient had been swimming without symptoms.
Approximately one hour later, he felt substernal chest pain
radiating to the left arm plus shortness of breath plus
diaphoresis times 15-20 minutes. He called EMS and was
transferred to the [**Hospital6 33**] and received
nitroglycerin times two and IV fluids, aspirin, morphine
sulfate. He was bolused with these medicines and had a
decrease in his chest pain slightly. His ECG in the field
showed [**Street Address(2) 2051**] elevations in II, III, aVF with ST depressions
in aVL, III greater than II. Vital signs at the outside
hospital showed a blood pressure of 129/89, pulse 88,
respiratory rate 18. At presentation at the outside
hospital, he had a right-sided ECG that showed V4 R with
greater than [**Street Address(2) 4793**] elevations. At the outside hospital he
was given 10 of IV Lopressor, 300 of Plavix, Integrelin,
heparin drips as well as a nitroglycerin drip. He was
transferred to the Catheterization Laboratory and directly at
[**Hospital1 18**] for interventions within three hours of the time his
symptoms began.
PAST MEDICAL HISTORY: He has no known CAD. Cardiac risk
factors were tobacco. He has no diabetes, hyperlipidemia, or
hypertension. Positive family history of MI at 60 years old
in the family but not less than 55. He denied cocaine use.
REVIEW OF SYSTEMS: Denied PND, orthopnea. He smokes one
pack per day. He had exertional angina times five to six
weeks. In the Catheterization Laboratory, his numbers were
wedge 26, PA 44/25, cardiac index 3.62, cardiac output 7.38.
IV fluid was 1,200 cc. Also, in the Catheterization
Laboratory, he was found to have RCA status post two stents.
He had a total proximal lesion which was acute, consistent
with thrombotic occlusion. He also had a long proximal mid
RCA with TIMI-III flow, 0% restenosis, small mitral side
branch was jailed. His RV infarct hemodynamics was RV 44/15,
left main was okay, calcified. He had an 85% mid LAD
involving the diagonal. His left circumflex had minor
irregularities. The procedure was complicated by
hypotension, bradycardia which required temporary pacing and
temporary dopamine. He complained of nausea, vomiting with
groin pressure. ECGs at the outside hospital: ECG number
one showed ST elevations in II, III, and aVF with III greater
than II, approximately 4 mm, sinus, 92, normal axis. Number
two: Right-sided leads V4 greater than 1 mm. Post
catheterization, the ECG at II, III, and aVF showed that the
ST elevations had decreased to 2 mm.
LABORATORY DATA AT THE OUTSIDE HOSPITAL: PT 15, INR 1.2.
Hemoglobin 14.1, hematocrit 41.1, platelets 29.8. Here at
the [**Hospital1 18**], the white count was 18.7, hematocrit 38.8,
platelets 257,000, PMNs 81%. Sodium 141, potassium 3.9,
chloride 101, bicarbonate 27, BUN 14, creatinine 0.8, CK 147,
MB 3, AST 31, ALT 48, INR 1.3, calcium 9.4, phosphorus 4,
albumin 4.1. The patient's peak CK was 3,238 on [**2123-4-3**].
It had decreased to 1,793 and then 147 on [**2123-4-3**]. The MB
index was 19.8 on the second.
PHYSICAL EXAMINATION ON ADMISSION: On examination the day
following catheterization revealed a blood pressure of
140/76, pulse 91. General: In no acute distress, lying
flat, leg in the leg immobilizer. HEENT: EOMI. PERRLA. OP
clear. JV to the angle of the mandible. Lungs: Clear to
auscultation anteriorly. Heart: Regular rate and rhythm.
S1, S2, no murmurs, rubs, or gallops appreciated. He is
obese. Abdomen: Nontender, no rebound tenderness, soft.
Extremities: No clubbing, cyanosis or edema, [**1-24**] dorsalis
pedis and posterior pulses. Neurologic: A&O times three.
Cranial nerves II through XII. The right groin had a
hematoma which was soft. There was no bruit. Right groin
Swan was in place.
HOSPITAL COURSE: He had no drips at the time of arriving at
the floor. The patient is a 48-year-old male with a history
of tobacco use, IMI, right ventricular infarct who presents
to [**Hospital1 18**] from an outside hospital for catheterization status
post RCA stenting complicated by hypertension, bradycardia
requiring transient pressors, transient temporary pacing.
1. CORONARY ARTERY DISEASE: The patient received a beta
blocker at the outside hospital and restarted beta blocker
after the dopamine was weaned. Plavix, aspirin, and
Integrelin 18 hours postprocedure. Lipids were checked and
current smoke cessation. The patient has beta blocker dose
titrated up, had an ACE inhibitor added, started on a statin.
On [**2123-4-6**], the patient was taken to the
Catheterization Laboratory for intervention on the left
system. He had left angiography of the left system. The
left main was normal, proximal LAD had mild disease, middle
LAD had 70% stenosis involving the D2 origin which had a 60%
stenosis at the circumflex without significant disease.
Successful PTCA of the D2 ostium was performed. There was 30%
residual stenosis, normal flow, no apparent dissection.
Successful stent. Direct stenting of the LAD was performed.
There was distal straightening/stenosis that required
placement of an additional stent. There was no original
stenosis, normal flow, and no apparent dissection.
2. CONGESTIVE HEART FAILURE: Despite the patient's JVD, he
had no symptoms consistent with CHF. The lungs were clear to
auscultation. He had no PND, no orthopnea. He had an
echocardiogram on [**2123-4-5**] which showed a TR gradient
of approximately 15 mmHg, left atrium was mildly dilated,
right atrium mildly dilated, left ventricular wall thickness
was normal, left ventricular size was normal. Overall left
ventricular systolic function was normal wall motion. The
following regional left ventricular wall abnormalities were
seen: Basal inferior AK, midinferoseptal AK, basal inferior
AK, midinferior AK, basal inferolateral AK, mid inferior
lateral AK, septal apex AK, inferior apex AK. The remaining
septums of the left ventricular wall were hypokinetic. Right
ventricular wall thickness was normal. Right ventricular
chamber size was normal. Right ventricular systolic function
appeared depressed, mildly dilated aortic trivial MR, no
pericardial effusion. EF was estimated to be 20-25%,
severely depressed.
3. RENAL: The patient had normal creatinine function
despite the two dye loads. His renal function was monitored
without a bump.
4. HEME: He had a right groin hematoma. It was monitored
and was stable. The patient had an ultrasound of the groin
on [**2123-4-7**] which showed a right inguinal hematoma
after cardiac catheterization. There was duplex carotid
Doppler of the right inguinal area. Small AV fistula
involving the right common femoral, iliac artery, and right
common femoral vein. No evidence of pseudoaneurysm and the
recommendation was only to perform a follow-up if the patient
became symptomatic.
The Team saw the patient, feeling again that there was no
indication for surgical intervention and that the patient
would have a follow-up ultrasound as an outpatient, should
just follow the progress of the right groin. It was felt by
the Primary Cardiology Team that there was no reason to
anticoagulate given the right-sided lesion and that the
patient would likely regain his EF with time and the risk was
not as great with a right-sided lesion as compared to a
left-sided lesion despite the wall motion abnormality.
5. RHYTHM: The patient had some bouts of NSVT times three
in the first 24 hours, status post MI. He was asymptomatic
during all of them. In fact, he was sleeping during all of
them. His lytes were monitored and adjusted appropriately
and the patient had no further SVT during his stay. The
patient had signal-averaged EKG prior to discharge and was to
follow with Dr. [**Last Name (STitle) 284**] and Electrophysiology one month
status post discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Inferior myocardial infarction with right ventricular
involvement.
2. Hyperlipidemia.
3. Coronary artery disease.
4. Hypertension.
5. Congestive heart failure.
6. AV fistula, right groin.
DISCHARGE INSTRUCTIONS: The patient was instructed not to
drive for one week. Instructed not to overtire for six
weeks. Instructed not to lift greater than 20 pounds. The
patient was instructed to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8467**] of
Cardiology in two weeks status post discharge and instructed
to call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] of Electrophysiology and
follow-up within one month. Instructed to follow-up with Dr.
[**Last Name (STitle) 1391**] of Vascular within two weeks to have follow-up with
the right AV fistula and instructed to call Radiology to make
a follow-up appointment.
MAJOR SURGICAL PROCEDURE: He had cardiac catheterization
times two. Status post RCA stent times two. Status post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] times one. Status post PTCA to the diagonal.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Lipitor 10 mg q.d.
4. Toprol XL 200 mg q.d.
5. Zestril 5 mg q.d.
6. Nitroglycerin sublingual p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2123-6-14**] 04:12
T: [**2123-6-22**] 09:34
JOB#: [**Job Number 49712**]
|
[
"458.2",
"427.1",
"V17.3",
"272.4",
"410.31",
"305.1",
"998.12",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.20",
"36.01",
"39.64",
"36.06",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
9389, 9831
|
8255, 8453
|
4178, 8202
|
8478, 9366
|
1732, 3457
|
3472, 4160
|
1493, 1712
|
8227, 8234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,136
| 155,374
|
40721
|
Discharge summary
|
report
|
Admission Date: [**2187-6-19**] Discharge Date: [**2187-6-24**]
Date of Birth: [**2146-9-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Left Flank Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 40 year old man with hypertension, OSA, and
morbid obesity. He reports yesterday morning waking up and
noticing a dull ache in his left flank. He reports the pain
gradually worsened over the course of the day. The pain was
worse with laying flat or sitting. It was improved with standing
up straight. It was described as a dull type of pain. He reports
occasionally having pain in the left upper quadrant/lower
lateral chest. This pain was more of a sharp pain. He describes
this as an extension of the pain from his flank. At midnight the
pain was a [**10-8**]. Because of this he walked to the emergency
department at [**Hospital1 6136**].
At [**Hospital 6136**] Hospital his initial vital signs were 287/162. He
was given dilaudid (3 mg), hydralazine, and ondansetron. A CT of
the abdomen showed a left sided 6.5x6.2x10 cm perirenal
hematoma. He was transferred to [**Hospital1 18**] for further care.
In the ED at [**Hospital1 18**], initial vs were: 96.8 108 210/143 16 96% 4L.
Patient was started on a labetalol gtt after 20 mg IV labetalol.
He was noted to fall asleep while talking with him. This was
reported to be slightly worse than his baseline. He maintained
his O2 sat when awake, but would drop to the 70's when sleeping.
He was briefly placed on a non-rebreather, then placed on CPAP.
Vitals on transfer: afebrile 77 147/79 15 95% on CPAP.
On arrival to the ICU, he was off the labetalol gtt and on room
air. He reported feeling slightly more sleepy than normal, but
stated that he usually falls asleep in mid-sentence. He reports
his pain is a [**2-8**]. He described it as a dull ache. He denied
any hematuria or dysuria.
Mr. [**Known lastname **] reports that he has not seen a PCP in several years.
He states that he had been on a medication for hypertension, but
he is not sure which one. He went to the hospital several months
ago for a cut on his leg and was given samples of irbesartan. He
took them, but ran out of them several months ago. He does not
take his blood pressure and does not know what it normally runs.
He denies headaches or recent vision changes. He has a home
CPAP, but has not used it in over a year.
Past Medical History:
Hypertension
Obstructive Sleep Apnea
Morbid Obesity
Social History:
He shares an apartment with his friend [**Name (NI) **]. [**Name2 (NI) **] is currently
on disability. He states he was fired from his job several years
ago because he was falling asleep constantly. He spends most of
his time playing games on the computer. Reports he generally has
no difficulty walking around in his apartment. Denies any
tobacco or illicits. Rare alcohol
Family History:
Reports several family members with hypertension and heart
disease. Reports maternal grandmother with an MI. No history of
cancer, renal problems, or aneurysms.
Physical Exam:
Vitals: T: 98.8 BP: 161/100 P: 115 R: 19 O2: 92% on RA
General: obese man, oriented, appears comfortable, would
intermittently fall asleep if not stimulated, in no acute
distress
HEENT: Sclera anicteric, dry mucous membranes
Lungs: Clear to auscultation bilaterally
CV: Regular rate, distant heart sounds
Abdomen: obese, soft, bowel sounds present, no rebound
tenderness or guarding
Ext: warm, well perfused, 2+ edema
Pertinent Results:
ADMISSION LABS [**2187-6-19**]
WBC-12.5* RBC-5.17 Hgb-14.4 Hct-43.7 MCV-85 MCH-27.9 MCHC-33.0
RDW-14.6 Plt Ct-242 Neuts-83.3* Lymphs-12.8* Monos-3.2 Eos-0.3
Baso-0.4
PT-12.8 PTT-22.1 INR(PT)-1.1
Glucose-127* UreaN-14 Creat-1.0 Na-140 K-6.6* Cl-100 HCO3-27
AnGap-20
ALT-37 AST-73* AlkPhos-28* TotBili-0.4
CK-MB-3 cTropnT-0.04*
Calcium-8.8 Phos-4.6* Mg-1.9
%HbA1c-5.8 eAG-120
.
CT [**Last Name (un) **]/pelvis:
IMPRESSION: 6.7 x 4.8 cm hyperdense, non-enhancing left adrenal
hematoma with minimal extension of hemorrhage elsewhere in the
retroperitoneum. An
underlying mass cannot be excluded but is not evident. The
overall appearance is unchanged since the [**2187-6-19**]
reference CT examination.
.
[**2187-6-23**] 12:40PM BLOOD WBC-10.1 RBC-4.43* Hgb-13.0* Hct-37.8*
MCV-85 MCH-29.4 MCHC-34.4 RDW-13.8 Plt Ct-264
[**2187-6-24**] 06:45AM BLOOD Glucose-92 UreaN-21* Creat-1.3* Na-140
K-3.8 Cl-99 HCO3-30 AnGap-15
Brief Hospital Course:
1. Adrenal Hematoma: This was felt most likely due to severe
uncontrolled hypertension. Imaging does not show any compression
of renal structures. Urology consulted and recommended no
interventions. Hematocrit dropped from 43 -> 35, but remained
stable thereafter. Given persistent labile blood pressures and
concern for possible underlying adrenal mass, nephrology was
consulted and will continue to follow after discharge.
Metanephrines were sent and were pending.
2. Hypertensive emergency with hemorrhage: On admission, sBP >
200 and pt was admitted to the ICU with use of a labetalol drip.
Pt was transitioned to amlodipine but continued to have
significantly labile BP overnight ranging in the 240/140s and
Labetalol was added, titrated up to 400 mg three times daily.
Pt was given lasix for evidence of volume overload. Pt was also
on nifedipine daily. He will be followed with renal team. The
importance of follow-up was emphasized in detail as well as
risks of unmanaged hypertension. He expressed understanding.
3. Acute renal failure: This was thought likely due to
hypertensive emergency with some degree of prerenal etiology on
admission. Creatinine improved with better BP control but he
remains proteinuric and would benefit from addition of [**First Name8 (NamePattern2) **] [**Last Name (un) **]
once approved by his insurance. Pt reported intolerance to ACE
in the past.
4. Severe untreated OSA with daytime somnolence: Appears to be a
chronic issue with serum bicarb of 33. Pt has CPAP/BiPAP at
home, but has not used it in over a year. Pt was noted to have
severe hypoxia at night (60-70% in ICU). His excessive
sleepiness was likely made worse by narcotics. Discussed CPAP
with patient, who has tried all type of different machines and
has not been able to tolerate any of them. Pt encouraged to
consider further follow-up with sleep medicine
5. Coag negative staph: Noted on one blood culture, and all
surveillance cultures were negative for growth. Repeat imaging
of the perirenal hematoma did not reveal any enhancement and pt
was monitored off antibiotics without any fevers/leukocytosis.
This was most likely a contaminant.
.
TRANSITIONAL ISSUES:
1. Serum Metanephrines pending- result should be followed up
when seen in renal clinic
Medications on Admission:
None
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypertension, malignant
2. Pararenal hematoma
3. Acute renal failure
4. Acute blood loss anemia
5. Bacteremia/septicemia, GPC
6. Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with severely elevated blood pressures and a
hematoma (bleeding) around your kidney, further imaging suggests
that the bleeding is coming from the adrenal glands. You were
seen by nephrology for the adrenal bleeding and labile blood
pressures which seem most likely related to your untreated sleep
apnea but you will need follow up for pending labs
(metanephrines). You will also need to keep the follow up
appointment as shown below with urology.
.
We have been increasing medications to get your blood pressure
under better control and would strongly recommend that you
continue taking these every day to prevent further complications
of your high blood pressure.
.
It is CRUCIAL that you follow-up with a doctor THIS WEEK for
management of your blood pressure. You will need your blood
work checked as well at this time.
.
Please note the following changes to your medications:
1. Start Nifedipine 90 mg daily
2. Start Labetalol 400 mg three times daily
3. Start Lasix 40mg daily
Followup Instructions:
We could not make a follow-up appointment with the kidney
specialists as it is a weekend. However, the number to call is
[**Telephone/Fax (1) 721**]. You need follow-up within 2-3 weeks
.
You told us that you wanted to change primary care physicians.
You need to see A primary care doctor this week -- either your
former one or a new one. Please either see your old doctor or
establish care with a new doctor urgently.
.
Department: UROLOGY
When: THURSDAY [**2187-7-12**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"403.00",
"285.1",
"327.23",
"255.9",
"584.9",
"585.9",
"278.01",
"593.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6904, 6910
|
4574, 6740
|
321, 327
|
7110, 7110
|
3634, 4551
|
8291, 9003
|
3018, 3181
|
6931, 7089
|
6875, 6881
|
7261, 8135
|
3196, 3615
|
6761, 6849
|
8164, 8268
|
265, 283
|
355, 2535
|
7125, 7237
|
2557, 2611
|
2627, 3002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,937
| 134,390
|
45960
|
Discharge summary
|
report
|
Admission Date: [**2186-4-10**] Discharge Date: [**2186-4-14**]
Service: CME
ADMITTED TO THE CMI SERVICE AND TRANSFERRED TO CARDIAC
INTENSIVE CARE UNIT WITHIN THE DAY OF ADMISSION.
HISTORY OF PRESENT ILLNESS: This is an 88-year-old male, who
was referred by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for outpatient cardiac
catheterization due to a positive stress echo. Mr. [**Known lastname 27772**]
has been followed by his cardiologist, Dr. [**Last Name (STitle) **], who felt he
had a history of silent ischemia. His daughter reports that
he has never had a cardiac catheterization before. Over the
month to 2 months prior to admission, the patient had 3-4
episodes of weakness, lightheadedness with exertion. It
occurs after walking more than [**1-26**] blocks. He denies any
syncope. He also denies chest pain. He does have a history
of dyspnea that occurs occasionally at rest.
On [**2186-4-5**], the patient had a stress echo, during which the
patient exercised for 5 minutes and had dyspnea and fatigue.
His EKG revealed 0.5 to 1 mm ST segment depressions in leads
II, III and AVF. There was a brief episode of NSVT in
recovery. Echo also revealed apical, septal and mid apex
ischemia, and probable inferior bilateral ischemia, as well
as moderate MR, trace TR, and moderate LAE, and mild
concentric LVH.
The patient denies history of claudication, edema, orthopnea,
or PND. He has a history of hypertension, high cholesterol.
No tobacco history. However, he does report a history of
diabetes mellitus. The patient does deny a family history of
premature coronary artery disease before the age of 55.
PAST MEDICAL HISTORY:
1. Lower GI bleed, [**8-26**].
2. Bladder cancer, status post 3 week course of chemotherapy
directly infused into the bladder.
3. Diabetes mellitus type 2.
4. Silent ischemia, prior silent MI.
5. Diverticulosis.
6. Retinopathy.
7. Hard of hearing.
8. TURP.
9. Cholecystectomy.
10.Multiple stuff to be tested for melanoma removed from
forehead.
11.Hernia repair.
ALLERGIES:
1. Benzo's.
2. Ativan--confusion.
3. Vasotec--tickling in the throat.
4. Nifedipine--lightheadedness.
MEDICATIONS ON ADMISSION:
1. Metoprolol 175 mg [**Hospital1 **].
2. Micro-K 30 mEq [**Hospital1 **].
3. Folic acid 1 mg [**Hospital1 **].
4. Lasix 80 mg po qd.
5. Lipitor 5 mg po qd.
6. Isosorbide 30 mg po tid.
7. Diovan 160 mg po bid.
8. Glucotrol 10 mg po bid.
9. Glucophage 500 mg po bid.
10.Multivitamin qd.
11.Ecotrin 325 mg po qd.
12.Plavix 75 mg po qd.
13.Protonix 40 mg po qd.
SOCIAL HISTORY: The patient is a widower. He lives with his
sister and [**Name2 (NI) 802**] who are very involved in his care.
BRIEF HOSPITAL COURSE: The patient underwent elective
cardiac catheterization on [**2186-4-10**] to follow-up on his
positive stress echo. During the catheterization, the
patient was noted to have a normal left main coronary artery,
95 percent stenosis of the proximal LAD, a 70 percent
stenosis of the diagonal which was stented, a 40 percent mid
left circumflex lesion, and a 40 percent OM1 lesion, as well
as a 30 percent mid RC lesion. The stent to the LAD was
successful without residual stenosis. There was no
compromise noted to the diagonal artery. Post cardiac
catheterization, the patient was continued on half dose
Integrilin times 18 hours. He was also initiated on aspirin,
Plavix for 9 month's duration.
The patient was noted to have significant groin hematoma
postprocedure that was noted on removal of the venous sheath.
There was significant bleeding, and the hematoma was noted to
rapidly enlarge. There was concern that the patient was
developing pseudoaneurysm. The vascular surgical service was
consulted for assistance with the management of his large
groin hematoma. The vascular service recommended
discontinuing heparin and Integrilin. In addition, they
recommended holding
pressure. A groin ultrasound was requested which
demonstrated no obvious pseudoaneurysm, or AV fistula.
However, given the rapid expansion of the hematoma in the
groin, the patient was taken by vascular surgery to OR for
repair. During right groin exploration, the patient
underwent closure of arteriotomies times 2, as well as
evacuation of the hematoma. The patient had several JP
drains placed that continued to drain the area.
Post groin exploration, the patient was noted to be severely
agitated requiring 80 mg of IV Haldol. His QTC was about 400
on telemetry at this time. Overnight, the patient's mental
improved significantly. In addition, he had been extubated
postprocedure, and did well in terms of his pulmonary status.
1. CARDIAC: Status post PCI with stent placement of the LAD,
complicated by groin hematoma, status post evacuation.
The patient was restarted on beta blockers, aspirin and
Plavix after his hypotension postprocedure resolved. His
cardiac medications were titrated up as tolerated during
the remainder of his hospital course.
CARDIAC PUMP FUNCTION: The patient's LV gram during his
cardiac catheterization documented a preserved ejection
fraction of 67 percent. He did not appear to be volume
overloaded by exam.
1. HEMATOCRIT DROP: Post cardiac catheterization, the
patient's hematocrit was noted to fall significantly,
requiring 1 unit of packed red blood cells. During this
transfusion, there was a question of an allergic reaction,
given that the patient developed an erythematous diffuse
rash. On review of the possible transfusion reaction, the
blood bank felt that this was likely an urticarial
transfusion reaction. This type of reaction does not
preclude future transfusions, but rather the patient may
require Benadryl in the future.
1. STATUS POST GROIN PSEUDOANEURYSM: The patient's JP drains
continued to have sanguineous output. The vascular
service team continued to follow the patient. His distal
pulses were preserved, and the groin hematoma appeared to
be resolving prior to discharge. The patient was
discharged with the JP drains in place per vascular
service. The patient was continued on cefazolin postop
per the vascular surgery recommendations. Due to the
desire to continue antibiotics until the JP drains were
removed, the patient was continued on Keflex 500 mg po qid
times 7 days on discharge.
1. DIABETES MELLITUS: The patient has a history of type 2
diabetes mellitus. He had significant hyperglycemia post
groin exploration. He required an insulin drip for
approximately 24 hours and then was transitioned to subcu
insulin. Prior to discharge, he was restarted on his
glipizide, as well as his Glucophage. The patient was
discharged home in stable condition.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post cardiac
catheterization with stent to left anterior descending.
2. Right groin hemorrhage, hematoma requiring
arteriotomy/closure and hematoma evacuation.
DISCHARGE FOLLOW-UP:
1. The patient should follow-up with his cardiologist, Dr.
[**Last Name (STitle) **], within the next 7-10 days.
2. He is also advised to call Dr. [**Last Name (STitle) **] to follow-up with
him on Wednesday, [**4-19**], for further management of his JP
drains.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed to continue only quiet
activities until his clinic appointment with Dr. [**Last Name (STitle) **].
2. He is advised to take the Keflex as directed until the
drains come out.
3. He is also advised to call his doctor, ER, if he has any
chest pain, shortness of breath, or enlarging mass in his
groin.
4. The patient will be followed by [**Hospital6 407**]
until his drains are removed.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po qd. He is advised not to discontinue this
medication without consulting his cardiologist.
2. Aspirin 325 mg po qd.
3. Lasix 40 mg po bid.
4. Calcium carbonate 500 [**Hospital1 **].
5. Pantoprazole 40 qd.
6. Valsartan 160 mg po qd.
7. Lipitor 40 mg po qd.
8. Glipizide 10 mg po bid.
9. Potassium and sodium phosphate packet 2 packets po tid
times 1 day.
10.Metformin 500 mg po bid.
11.Metoprolol 75 mg po tid.
12.Keflex 500 mg po qid times 7 days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Last Name (NamePattern1) 10641**]
MEDQUIST36
D: [**2186-4-16**] 16:27:49
T: [**2186-4-17**] 12:35:50
Job#: [**Job Number 97854**]
|
[
"442.3",
"998.12",
"458.29",
"E879.0",
"999.8",
"790.01",
"997.2",
"782.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.22",
"36.01",
"39.31",
"36.07",
"88.53",
"38.08",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2710, 6782
|
6803, 7300
|
7778, 8522
|
2196, 2556
|
7324, 7755
|
223, 1667
|
1689, 2170
|
2573, 2686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,467
| 141,229
|
19522
|
Discharge summary
|
report
|
Admission Date: [**2164-1-17**] Discharge Date: [**2164-1-27**]
Date of Birth: [**2087-4-27**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 76-year-old white
male with a recent onset of chest pain approximately 2-3 days
prior to admission associated with shortness of breath and
retrosternal chest pressure, which was relieved with
sublingual nitroglycerin. Patient was transferred to [**Hospital1 18**]
from outside hospital for emergent cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Coronary artery disease.
3. Hypertension.
4. Benign prostatic hypertrophy.
5. Bell's palsy.
6. Peripheral vascular disease.
7. Blindness in the right eye due to cataracts.
8. Meniere's disease.
PAST SURGICAL HISTORY: Prostatectomy in [**1-24**].
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q.d.
2. Toprol XL 25 mg q.d.
3. Aspirin 325 mg p.o. q.d.
4. Norvasc 5 mg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. Nitro patch 0.2 TP prn.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM: On physical exam, patient was afebrile.
Vital signs are stable in no apparent distress. Alert and
oriented times three. Patient has paralysis to the left side
of the face, which is known from previous medical history.
Otherwise, atraumatic, normocephalic, no scleral icterus
noted. Heart was regular rate and rhythm with a 2/6 systolic
ejection murmur auscultated. Chest had diminished breath
sounds throughout, but no wheezes or rales. Abdomen was
soft, nontender, slightly distended, and positive bowel
sounds. Extremities was significant for [**11-25**]+ pitting edema
without varicosities. Pulse exam was palpable femorals
bilaterally. Palpable popliteals bilaterally. Dopplerable
DP and PT on the right and palpable on the left.
LABORATORIES ON ADMISSION: White count 9.2, hematocrit 36.4,
platelets 276. Sodium 137, potassium 3.6, chloride 104,
bicarb 23, BUN 30, creatinine 1.5, glucose 165. PT 13.6, INR
1.2, PTT 29.5. ALT 29, AST 21, alkaline phosphatase 69,
total bilirubin 0.8.
SUMMARY OF HOSPITAL COURSE: Patient is a 76-year-old man
with coronary artery disease, who presents to [**Hospital1 18**] for
further evaluation and workup of chest pain episodes.
On [**2164-1-17**], date of admission, the patient went emergently
to cardiac catheterization, where patient was noted to have
50-60% occlusion of the left main, 60% occlusion of the
proximal LAD, and 40-50% occlusion in the distal LAD, 90%
occlusion of the ostial diagonal and 90% occlusion of the
left circumflex to proximal RCA.
After reviewing these results, Cardiac Surgery was consulted
for evaluation and treatment via coronary artery bypass graft
surgery. Patient was seen by Dr. [**Last Name (STitle) 70**] and thought to be
a good candidate for surgery, and patient was taken to the OR
on [**2164-1-18**] for CABG x2, LIMA to LAD and SVG to diagonal.
For more detailed account of the procedure, please see
operative report. Postoperatively, the patient was cared for
in the CSRU.
On postoperative day #1, patient was adequately diuresed.
Patient had a nitro drip requirement to keep his blood
pressure in the 120s. Patient came off the nitroglycerin on
the morning of postoperative day #2 with a blood pressure in
the 160s.
On postoperative day #2, the patient was extubated and placed
on 50% face mask. On postoperative day #2, chest tube was
pulled in the p.m. uneventfully.
On postoperative day #3, patient had some compromised mental
status with combative attitude and striking out at nurses.
Patient was alert and oriented times two at this time.
Sitter was placed at the bedside to encourage the patient's
safety.
On postoperative day #4, the patient continued to be slightly
confused not knowing where he was. Patient was given Haldol
prn for agitation.
On postoperative day #5, patient was again slightly agitated.
Had an episode of transient respiratory distress, which
resolved with Lasix and Morphine. Chest x-ray was normal.
On postoperative day #6, patient went into AFib to the 130s
controlled with IV Lopressor x2. Was never hemodynamically
unstable. Patient was placed on amiodarone drip, and
eventually later in the day changed over to p.o. amiodarone.
Later on in the day, the patient was transferred to the
floor.
On postoperative day #7, the patient was noted to have an
infiltrated intravenous line, which resulted in slight
phlebitis with tenderness to touch and erythema, which was
treated with elevation, warm compresses, and IV antibiotics.
On the floor, the patient remained in normal sinus rhythm
throughout. Cardiovascular medications included aspirin 325,
Lasix, hydralazine, and metoprolol.
The remainder of [**Hospital 228**] hospital course was unremarkable,
and on postoperative day #9, patient slipped and fell on his
backside with no loss of consciousness and no head trauma.
Patient was placed on Norvasc for blood pressure control and
hydralazine was D/C'd. Patient at this time was on Kefzol
intravenously for resolving phlebitis. Patient was deemed
well enough to be discharged to rehab. Patient was PT level
[**1-26**] alert and oriented times three. Patient's white count
decreased from 16.4 on postoperative day #8 to 13 on
postoperative day #9.
DISCHARGE STATUS: To rehab.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Mental status changes.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Metoprolol 75 mg p.o. b.i.d.
3. Lasix 20 mg p.o. q.d. x1 week.
4. Potassium chloride 20 mEq p.o. q.d. x1 week.
5. Kefzol 1 gram IV q.8h. x7 days.
6. Norvasc 10 mg p.o. q.d.
7. Protonix 40 mg p.o. q.d.
8. Lipitor 10 mg p.o. q.d.
FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr.
[**Last Name (STitle) **], patient's primary care physician [**Last Name (NamePattern4) **] [**1-26**] weeks
and Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2164-1-27**] 09:01
T: [**2164-1-27**] 09:01
JOB#: [**Job Number 52971**]
(cclist)
|
[
"272.0",
"E878.2",
"411.1",
"427.31",
"414.01",
"997.1",
"786.09",
"401.9",
"999.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.15",
"39.61",
"88.53",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5331, 5338
|
5359, 5456
|
5479, 5739
|
841, 1056
|
785, 815
|
1072, 1829
|
2105, 5309
|
177, 516
|
1844, 2076
|
5764, 6256
|
538, 761
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,916
| 163,228
|
24003
|
Discharge summary
|
report
|
Admission Date: [**2134-4-9**] Discharge Date: [**2134-5-12**]
Date of Birth: [**2095-9-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
Transjugular intrahepatic portosystemic shunt
Endoscopic gastroduodenoscopy
History of Present Illness:
38 year old male with a longstanding history of cirrhosis due to
alcohol abuse and hemachromatosis was transferred from [**Hospital 1562**]
hospital to [**Hospital1 18**] for vomiting of bright red blood. Patient was
lavaged in the [**Hospital1 1562**] ED which returned over two liters of red
blood. He was then taken for emergent EGD and found to be
bleeding from the gastric cardia that was not responsive to
hemoclipping or sclerotherapy. The site was believed to be a
bleeding varix. Patient was then air lifted to [**Hospital1 18**] having
received 11 units of PRBCs and 2 units of FFP prior to arrival.
He was given octreotide, versed and fentanyl prior to arrival.
Past Medical History:
Alcoholic cirrhosis
Ascites
Social History:
Longstanding alcohol abuse, 1ppd Tob, works as a chef, lives
with family
Physical Exam:
On discharge, patient's physical exam is as follows:
Vitals: T=97.1, P=82, BP=113/76, R=16, SpO2=99% on RA
Gen: NAD, AAOx2
CVS: RRR
Pulm: CTA bilaterally
Abd: soft, NT/ND, +BS
Ext: no CCE
Pertinent Results:
TIPS [**2134-4-9**] 8:48 PM
1. Successful transjugular intrahepatic portosystemic shunt
using 10 mm by 94 mm bare metal wall stent extending from the
main right portal vein to the distal right hepatic vein, with no
residual portosystemic gradient seen at the end of the
procedure.
2. Embolization of large coronary vein varix with alcohol with
good venographic result.
3. Placement of a 9 French triple lumen venous access catheter
in the right internal jugular vein with tip in the superior vena
cava, ready for use.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2134-4-10**] 11:26 AM
1) Patent TIPS with wall-to-wall color flow in the appropriate
direction. There is appropriate reversal of flow within the left
portal vein, consistent with a patent TIPS.
2) Sludge within the gallbladder and within the common duct. The
common duct is slightly dilated at its mid portion.
RENAL U.S. [**2134-4-12**] 9:34 AM
There is no evidence of hydronephrosis.
[**2134-5-12**] 04:59AM BLOOD ALT-42* AST-56* AlkPhos-137* TotBili-6.2*
Brief Hospital Course:
Mr. [**Known lastname 61109**] was admitted to [**Hospital1 18**] on [**2134-4-9**] as a direct
transfer from [**Hospital 1562**] Hospital for an acute upper GI bleed and
hemodynamic lability. Upon arrival, he underwent an EGD which
showed active bleeding from a gastric varix in the fundus and
portal gastropathy but no esophageal varices. Later that
evening, he underwent a transjugular intrahepatic portosystemic
shunt (TIPS) procedure with good results and having tolerated
the procedure well. His recovery process was challenging due to
his overall ill health. He remained in the SICU for several days
and was gradually improving. He was transferred to the floor
after his neurologic and hemodynamic status improved. On the
floor he was continued on total parenteral nutrition through his
subclavian line, and a Hepatamine mixture was used for protein
to facilitate liver recovery. As his status improved, he was
able to tolerate food by mouth. As his oral intake improved, his
TPN was reduced and eventually stopped. Although initially quite
disoriented, Mr [**Known lastname 61109**] improved greatly and was alert and
oriented x3 at all times. His ability to handle his activities
of daily living was of great concern, and he was seen often by
physical and occupational therapy, who eventually got him back
to an acceptable baseline function.
Of note, near the end of his hospital course his bilirubin was
noted to be rising, as noted in pertinent results. Drs [**Last Name (STitle) 497**] and
[**Name5 (PTitle) **] of the hepatology service are following this patient
closely, and wish to see him in follow up to ensure a good
recovery of his profoundly damaged liver.
Medications on Admission:
None noted at time of admission.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Pyridoxine HCl 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
Disp:*900 ML(s)* Refills:*2*
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 3244**] TSS
Discharge Diagnosis:
Variceal bleed
Oliguria
Blood loss anemia
Hypovolemia
Dental caries
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
You have no restrictions to your activity.
You may resume your regular diet as tolerated.
You may shower.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2134-5-14**] 10:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 3628**] SURGICAL ASSOC [**Name11 (NameIs) 3628**]-3A (NHB) Where: LM
[**Hospital Unit Name 3665**] ASSOCIATES Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2134-5-21**] 2:15
It is strongly recommended that you seek dental follow up for
extraction and stabilization, and likely placement of dentures.
|
[
"456.8",
"578.0",
"784.7",
"276.3",
"428.0",
"425.4",
"521.00",
"276.5",
"518.81",
"427.31",
"584.9",
"788.5",
"571.2",
"286.9",
"275.0",
"786.8",
"285.1",
"572.2",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.04",
"89.64",
"44.44",
"96.72",
"96.04",
"39.1",
"44.43",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5127, 5182
|
2524, 4206
|
328, 406
|
5293, 5299
|
1477, 2501
|
5586, 6168
|
4289, 5104
|
5203, 5272
|
4232, 4266
|
5323, 5563
|
1268, 1458
|
274, 290
|
434, 1112
|
1134, 1163
|
1179, 1253
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,331
| 127,206
|
52044
|
Discharge summary
|
report
|
Admission Date: [**2158-12-26**] Discharge Date: [**2159-1-12**]
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 107446**] is an 85-year-old
female with a past medical history significant for
hypertension, chronic obstructive pulmonary disease, as well
as diverticular disease who presented to the Emergency
Department with syncope and supraventricular tachycardia, as
well as progressive abdominal tenderness. Of note, is that
the patient was recently discharged from [**Hospital6 1760**] after being admitted for a
subarachnoid hemorrhage after a fall. She was also
readmitted earlier in [**Month (only) 404**] for a fall at the
rehabilitation center and then sent back. Prior to
admission, the patient was apparently having diarrhea and
emesis. She had a KUB performed at the rehabilitation
facility. She has also been having decreased oral intake and
decreased appetite.
On the night prior to admission, the patient was found
nonverbal, on the floor. She was found to be tachycardic to
120/130s with systolic blood pressure of approximately 100
per report. Consequently, the patient was transferred to
[**Hospital6 256**] where she was found to
be in supraventricular tachycardia and a heart rate in the
160s. The heart rate was broken with some beta-blocker and
fluid repletion. In addition, in the Emergency Room, the
patient was noted to be significantly hypertensive to low
200s systolic blood pressure. She was also noted to be
having progressive abdominal tenderness with peritoneal
signs. A CT of the abdomen and chest performed on [**2158-12-26**] showed extensive wall thickening and probable
pneumatosis coli of the distal jejunum, highly suspicious for
ischemic bowel. There was no evidence of free air in the
abdomen to suggest perforation. In addition, a large
periaortic enhancing mass was noted with central
calcification. The patient was consequently admitted to
General Surgery for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Arthritis.
3. History of breast carcinoma.
4. Chronic obstructive pulmonary disease.
5. History of subarachnoid hemorrhage.
6. Diverticular disease.
7. Macular degeneration.
ALLERGIES: No known drug allergies.
PAST SURGICAL HISTORY:
1. History of bilateral mastectomy approximately 20 years
ago.
2. History of subarachnoid aneurysm coiling.
3. Transabdominal hysterectomy.
MEDICATIONS ON ADMISSION:
1. Lopressor 50 mg po q.d.
2. Lisinopril 10 mg po q.d.
3. Hydrochlorothiazide 12.5 mg po q.d.
4. Norvasc 2.5 mg po q.d.
5. Vioxx 25.1 mg po q.d.
6. Celexa 20 mg po q.d.
7. Levaquin for a presumed urinary tract infection.
8. Tylenol.
9. Trazodone.
10. Imodium.
11. Milk of Magnesia.
SOCIAL HISTORY: History of tobacco use. Lives alone.
PHYSICAL EXAMINATION: Temperature 98.1. Heart rate 89.
Blood pressure 175/102. Respiratory rate 15. 98% on room
air. General exam: Alert and oriented elderly female with
abdominal pain. Head, eyes, ears, nose and throat exam:
Pupils reactive to light, anicteric, mucous membranes moist.
Neck exam: Supple, no lymphadenopathy. Chest exam: Clear
to auscultation bilaterally. Cardiac exam: Tachycardic with
regular rhythm at the time. Abdomen: Flat, with
periumbilical lower abdominal tenderness, peritoneal signs.
Rectal exam: Guaiac positive. Extremities: No edema, warm,
well-perfused.
LABORATORY STUDIES ON ADMISSION: White blood cell count
24.9, hematocrit 45.2, platelet count 332,000. Sodium 139,
potassium 3.1, BUN 30, creatinine 1.0, glucose 169. Troponin
less than 0.3. Creatinine kinase 41. Urinalysis showed no
signs of urinary tract infection. Electrocardiogram showed
supraventricular tachycardia, no ST changes.
SUMMARY OF HOSPITAL COURSE: The patient had a CAT scan of
the abdomen and chest which showed a large periaortic
enhancing mass with central calcification. In addition,
extensive wall thickening and probable pneumatosis coli of
the distal jejunum was noted which was highly suspicious for
ischemic bowel. In light of the CT findings, as well as
supraventricular tachycardia and physical examination, the
decision was made to proceed to the Operating Room for a
surgical intervention. The decision was discussed with the
family and consent was obtained.
On [**2158-12-26**], the patient was taken to the Operating
Room and underwent exploratory laparotomy, reduction of the
internal hernia, segmental enterectomy. end-to-end
anastomosis, as well as sharp wedge biopsy of the
retroperitoneal mass seen on the CAT scan. Blood loss was
less than 100 cc. The patient received approximately 5000 cc
of fluid. There were no complications. Please see the full
operative report for details. The small bowel and the
retroperitoneal biopsy were sent to the Pathology Department.
The patient remained intubated and was transferred to the
Intensive Care Unit in fair condition. She was resuscitated
with intravenous fluids. She remained tachycardic. Her
heart rate was controlled with a diltiazem drip. Pulmonary
toilet was initiated. She still demonstrated metabolic
acidosis by blood gas. She was placed on Flagyl. The
pulmonary artery catheter was placed at the time.
The patient continued to be very lethargic. She was afebrile
postoperatively. Her blood gas showed some improvement
postoperatively. Her hematocrit remained stable and her
white blood cell count remained elevated. Ciprofloxacin was
added to her regimen. In addition, she was placed on a
beta-blocker. An echocardiogram was obtained on [**2158-12-28**] which showed an ejection fraction of 60%. The
nasogastric tube appeared to be functioning properly. On
[**2158-12-28**], after discussion with the family, the
patient was made "Do Not Resuscitate" and "Do Not Intubate."
The patient continued to have persistent significant
requirement for fluid and a fixed metabolic acidosis, which
was concerning for continued bowel ischemia.
The patient was consequently taken back to the Operating Room
on [**2158-12-29**]. She again underwent segmental
enterectomy including the anastomosis, as well as resection
partial enterostomy with secondary necessary to resect the
Ileo right colon with a jejunal colic. The blood loss was
less than 100 cc. The perioperative course was significant
for hypotension and decreased urine output. The patient
remained intubated and was transferred back to the Intensive
Care Unit. Please see the full operative note for details.
Her postoperative course was significant for decreased urine
output, as well as increasing requirement for ventilator
support. Her urine output picked up slightly. The patient
was started on trans-parental nutrition. She was given fresh
frozen plasma for an INR of 2.0. She remained to have large
base excess on the blood gas. Blood cultures obtained on
[**2159-1-5**] grew coagulase positive Staph aureus. Her
white blood cell count remained elevated. She was eventually
switched to CPAP. She continued to have low cardiac index
and cardiac output. An echocardiogram was repeated on
[**2159-1-3**] which again showed an ejection fraction of
at least 60%.
On postoperative day eight and five, the patient was
transferred with one unit of packed red blood cells. The
patient was also noted to have melena and assumed to have
gastrointestinal bleed, likely lower gastrointestinal bleed.
She continued to be intubated. She was treated with
Captopril for after load reduction. The patient was also
started on tube feedings. The ventilator was changed to
SIMV. The patient was maintained on ampicillin for positive
blood cultures. She remained afebrile with stable blood
pressure.
The patient continued to show no significant improvement.
Her creatinine was noted to be rising as well. A Dop-off
tube was placed for tube feedings. Another discussion with
the family took place. The decision was made to extubate the
patient and transfer the patient to the regular floor. The
patient was consequently made comfort measures only. The
patient continued to receive respiratory care on the floor.
She was given some intravenous albumin. After being made
comfort measures only, the patient's TPN was discontinued and
the tube feedings were stopped. The patient expired on
[**2159-1-12**] at 2:25 p.m. The patient was examined by
House Staff. She was found to be unresponsive to any
stimulus. She had no heart sounds. She had no respiratory
sounds. Peripheral pulses were absent. There was no tracing
on the monitor. Corneal reflexes were absent. The patient
was officially pronounced dead at the time.
A discussion was carried out with the patient's family and
they agreed to performing an autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2159-1-19**] 09:02
T: [**2159-1-19**] 21:32
JOB#: [**Job Number 107741**]
|
[
"518.5",
"995.92",
"428.0",
"038.9",
"560.81",
"584.5",
"785.59",
"196.2",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"45.93",
"40.11",
"54.59",
"45.73",
"96.6",
"54.23",
"99.15",
"45.71",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2417, 2709
|
2247, 2391
|
3743, 8962
|
2788, 3388
|
114, 1962
|
3403, 3714
|
1984, 2224
|
2726, 2765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,105
| 121,138
|
33449
|
Discharge summary
|
report
|
Admission Date: [**2142-5-31**] Discharge Date: [**2142-6-2**]
Date of Birth: [**2107-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Acute ethanol intoxication and withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 30 year old male with PMH of alcoholism, polysubstance
abuse, and hepatitis C who is presenting acutely intoxicated
after being found down in the bushes with an ecchymoses over his
right orbit. As he was sobering up in the ED, he reported
suicidal ideation and desire for detox.
.
In the ED, initial VS 97.6 97 125/73 17 99% RA. Exam notable for
altered mental status due to alcohol intoxication with labs
notable for an EtOH level of 528, platelets of 80, and a lipase
of 130. An EKG and CXR were unremarkable. He received 3L of NS
and 20mg of IV Valium. He was noted to have sinus tachycardia to
the 140s which resolved after fluid administration and benzos.
Psychiatry was consulted and recommended having a sitter on the
medical floor and for psych re-evaluation when he was sober.
.
ROS: unable to obtain due to intoxication/inattention
Past Medical History:
--ETOH abuse
--IV drug abuse
--HCV
Social History:
Patient is homeless. He is estranged from his 3 children and
their mother. [**Name (NI) **] has a twin brother who is now living with
the mother of his children. As a child the patient was in [**Doctor Last Name **]
care but then he was eventually adopted (but now estranged from
adopted parents as per OMR notes). He has had multiple
encarcerations. Patient has had two prior suicide attempts, both
while intoxicated. In [**2139**] he jumped in front of a bus, and in
[**2137**] he jumped off a bridge resulting in a broken leg. Mr.
[**Known lastname 77499**] drinks [**12-17**] gallon of ETOH per day. His first drink was
at the age of 14 when he drank a bottle of Southern Comfort and
blacked out. He will pass out, wake up with DTs, and then treat
himself with ETOH (though he says sometimes this is difficult as
he's dry-heaving from the DTs). He has had at least 1 withdrawal
seizure. Mr. [**Name14 (STitle) 77500**] uses IV drugs (that's how he thinks he
contracted HCV) and has shared needles. He is homeless and has
no desire to live in a shelter.
Family History:
Brother with alcoholism and poly-substance abuse. Other family
history unknown.
Physical Exam:
On admission:
VS: T=99.5, HR=90, BP=144/90, RR=20, POx=99% 2L NC
GENERAL: acutely intoxicated male, tremulous.
HEENT: NC/AT, PERRLA, EOMI, dry MM, OP clear, ecchymosis over
right orbit.
NECK: Supple, no JVD.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement.
ABDOMEN: Soft/ND, no rebound/guarding, moderate tenderness in
bilateral upper quadrants.
EXTREMITIES: WWP, no c/c/e.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-19**] throughout, absence of sensation in his feet bilaterally,
but otherwise sensatioin is intact.
Pertinent Results:
ADMISSION LABS
--------------
[**2142-5-31**] 01:27PM BLOOD WBC-4.7 RBC-4.60 Hgb-14.7 Hct-43.1 MCV-94
MCH-32.1* MCHC-34.2 RDW-15.5 Plt Ct-80*
[**2142-5-31**] 01:27PM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2142-6-1**] 06:35AM BLOOD Glucose-88 UreaN-7 Creat-0.5 Na-141
K-3.2* Cl-103 HCO3-26 AnGap-15
[**2142-6-1**] 06:35AM BLOOD ALT-228* AST-421* LD(LDH)-443*
AlkPhos-118 TotBili-1.2
[**2142-6-1**] 06:35AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.1 Mg-1.6
[**2142-6-1**] 06:35AM BLOOD VitB12-1547* Folate-GREATER TH
[**2142-5-31**] 01:27PM BLOOD ASA-NEG Ethanol-528* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-5-31**] 01:33PM BLOOD Glucose-115* Lactate-2.2* Na-151* K-3.5
Cl-105 calHCO3-24
.
DISCHARGE LABS
--------------
[**2142-6-2**] 03:22AM BLOOD WBC-3.3* RBC-4.22* Hgb-13.3* Hct-38.3*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.8 Plt Ct-49*
[**2142-6-2**] 03:22AM BLOOD Glucose-81 UreaN-8 Creat-0.6 Na-133 K-3.8
Cl-95* HCO3-27 AnGap-15
[**2142-6-2**] 03:22AM BLOOD ALT-210* AST-379* AlkPhos-127
[**2142-6-2**] 03:22AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2
.
MICROBIOLOGY
------------
[**2142-6-1**] 4:35 pm URINE Source: Catheter.
**FINAL REPORT [**2142-6-2**]**
URINE CULTURE (Final [**2142-6-2**]): NO GROWTH.
.
[**2142-6-1**] 7:10 pm SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Pending):
.
Time Taken Not Noted Log-In Date/Time: [**2142-6-2**] 4:10 pm
IMMUNOLOGY
TAKEN FROM HEM# 0136K,ADDED HIQ TEST @ 4:10PM ON [**2142-6-2**]..
HIV-1 Viral Load/Ultrasensitive (Pending)
.
IMAGING
-------
Chest X-ray on admission:
IMPRESSION: No acute cardiopulmonary process.
.
CT C-spine on admission:
IMPRESSION: No acute fracture or subluxation.
.
CT head on admission:
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
This is a 30 year old male with PMH of alcoholism, polysubstance
abuse, and hepatitis C who is presenting acutely intoxicated
after being found down in the bushes with an ecchymosis over his
right orbit with imaging negative for acute injury requiring
inpatient stay for alcohol detoxification/withdrawal.
.
#. Alcohol withdrawal/intoxifiication (Left AMA). The patient
has a long history of many admissions for alcohol detox and
withdrawal and has a history of delirium tremens. He requests
alcohol rehabilitation when he is intoxicated and is regularly
section 12'd but quickly leaves AMA once he is sober and
released from his section by psychiatry. Patient was given oral
multivitamins, folate and thiamine upon presentation. He
required diazepam orally for control of withdrawal symptoms. A
proton pump inhibitor was given every 12 hours to prevent
gastritis. Supportive care was administered via antiemetics.
After his diazepam requirements decreased and he was out of the
seizure window he was called out to the floor. During his
transfer to the floor the patient left the hospital AMA.
.
# Bilateral foot numbness: may be due to alcoholic neuropathy.
CT head suggested no acute intracranial process such as stroke
or intracranial hemorrhage. Brainstem stroke was unlikely given
lack of other findings. Spinal cord process such as epidural
abscess and mass compressing the cord causing cauda equina
syndrome was possible, given episode of urinary retention, but
rectal tone was intact. Differential also included
[**Last Name (un) 4584**]-[**Location (un) **] and tick paralysis, though less likely and
reflexes were intact. Folate and vitamin B12 levels were not
low.
.
#. Pancreatitis. Lipase was elevated to 130 and patient had
abdominal pain on presentation. Supportive care was given with
IV fluids. Pain management was administered via IV dilaudid.
.
#. Hepatitis C. Chronic, never treated. The patient's
transaminases were elevated, but generally around his baseline.
HIV test was obtained and was pending at the time of discharge.
Hepatocellular carcinoma screening should be pursued in the
future with alpha fetoprotein and right upper quadrant
ultrasound.
.
# Follow-up: patient has HIV tests and RPR pending at the time
of discharge, which will need to be followed up.
.
#. CODE: Full
.
Pt left the hospital AMA
Medications on Admission:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY
4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain
Discharge Medications:
Pt left the hospital AMA after transfer to the floor
Discharge Disposition:
Home
Facility:
Pt left AMA
Discharge Diagnosis:
Primary: EtoH Intoxication
Discharge Condition:
Left AMA
Discharge Instructions:
Left AMA
Followup Instructions:
Left AMA
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"357.5",
"292.0",
"070.54",
"276.51",
"291.81",
"287.5",
"303.01",
"577.1",
"304.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7593, 7622
|
4869, 7211
|
345, 351
|
7692, 7702
|
3077, 4645
|
7759, 7896
|
2387, 2469
|
7516, 7570
|
7643, 7671
|
7237, 7493
|
7726, 7736
|
2484, 2484
|
264, 307
|
379, 1232
|
4802, 4846
|
1254, 1291
|
1307, 2371
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,320
| 100,589
|
17015
|
Discharge summary
|
report
|
Admission Date: [**2109-7-5**] Discharge Date: [**2109-7-10**]
Date of Birth: [**2045-9-23**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old
female with a history of rheumatic heart disease with mitral
stenosis with a valve area of 0.75 to 0.9 cm squared and
resulting pulmonary hypertension with PA pressures of 90 to
100 mmHg who was admitted to [**Hospital1 188**] for mitral valvuloplasty. Per the patient's daughter
the patient has been short of breath and ultimately
bedridden. For the past few months the patient has had
severe dyspnea with even short trips out of her bed.
PAST MEDICAL HISTORY:
1. Rheumatic heart disease and mitral stenosis.
2. Pulmonary hypertension.
3. Questionable asthma/chronic obstructive pulmonary
disease.
4. Hypothyroidism.
5. Gastroesophageal reflux disease.
6. Depression/anxiety.
PAST SURGICAL HISTORY: Status post cholecystectomy, status
post knee surgery.
MEDICATIONS:
1. Effexor.
2. Remeron.
3. Klonopin.
4. Levoxyl.
5. Nexium.
6. Vioxx.
7. Morphine.
8. Hydrochlorothiazide questionable dose.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No history of heart disease.
HOSPITAL COURSE: 1. Cardiac: The patient has undergone a
left heart catheterization, which showed clean coronaries.
The patient had a TEE, which showed mean mitral valve
gradient of 12 mmHg with moderate mitral stenosis, mild
mitral leaflet thickening, good MC mobility, normal left
ventricular function and severe pulmonary hypertension of
more then 100 mmHg. The patient was taken to valvuloplasty,
which improved mitral valve area of 2.6 cm squared by
catheterization and 2.0 cm squared by TEE. The procedure was
complicated by development of new pericardial
effusion with increasing RA pressures to 22 mmHg.
Pericardiocentesis yielded 350 cc of blood with improved RA
pressures to 8. Hemopericardium was felt to be secondary to
left atrial perforation, therefore the patient was
transferred to the cardiac care unit for observation. The
patient has done very well in the cardiac care unit. The
patient's pericardial drain was discontinued the day
following its placement. The patient's repeat echocardiogram
has shown mild left atrial dilation, no effusion and normal
left ventricular systolic function. The patient has had a
repeated echocardiogram on [**2109-7-10**], which was unremarkable and
unchanged. The patient was subsequently transferred to the
regular medicine floor. The patient's home medications were
restarted including Zebeta 5 mg, which was increased to 5 mg
subsequently, Hydrochlorothiazide 12.5 mg as well as all of
the patient's outpatient medications. The patient has done
extremely well and was seen by physical therapy, but was
shown to have decreased endurance, balance and gait due to
prolonged bed rest prior to the hospitalization. As far as
the status post mitral valvuloplasty the thought is the patient's
pulmonary hypertension that she had on admission is likely to
improve. The patient has had good systolic function. On
telemetry the patient has had a few episodes of ventricular
ectopy, which is thought to be due to pericardial irritation. The
patient is to continue Zebeta at her current dose.
2. Pulmonary is stable.
3. Renal is stable. Stable creatinine, normal electrolytes,
which were followed throughout the admission.
4. Infectious disease: One of the patient's blood cultures
were positive for gram positive cocci in clusters. All
subsequent blood cultures were negative for 42 hours. It was
initially concerning since the patient has been persistently
tachycardic with a rate in the 130s, but this was felt to be
rebound tachycardia fro being off of beta blockers the
patient has been use to taking at home and resolved once the
patient's Zebeta was started at the outpatient dose. The
patient has remained afebrile throughout the hospital stay
and we opted not to administer antibiotic treatment.
5. Endocrine: Hypothyroidism, Levothyroxine was started at
25 mg po q day. The patient is to be followed by TSH and
free T4 in four to six weeks by her primary care physician.
[**Name10 (NameIs) **] patient has had borderline elevated fasting blood sugars
during the hospitalization. The patient is to have
hemoglobin A1C checked by her primary care physician.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home with VNA for nursing and physical
therapy.
DISCHARGE MEDICATIONS:
1. Zebeta 10 mg po q.d.
2. Hydrochlorothiazide 12.5 mg po q.d.
3. Clonazepam.
4. Remeron.
5. Venlafaxine.
6. Levothyroxine 25 mg po q.d.
7. Nitroglycerin sublingual prn.
FOLLOW UP PLANS: The patient is to follow up with Dr.
[**Last Name (STitle) **] in two weeks following discharge. The patient is
also to follow up with her primary care physician in one week
following discharge. The patient is to schedule this
appointment. The patient is to return home with VNA for
nursing and physical therapy.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Doctor Last Name 47849**]
MEDQUIST36
D: [**2109-7-21**] 11:52
T: [**2109-7-26**] 12:15
JOB#: [**Job Number 47850**]
|
[
"493.20",
"E878.8",
"997.1",
"401.9",
"998.2",
"244.9",
"394.0",
"530.81",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.23",
"88.56",
"35.96",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
1158, 1188
|
4453, 5239
|
1206, 4330
|
900, 1141
|
160, 632
|
654, 876
|
4355, 4430
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,260
| 124,559
|
52238
|
Discharge summary
|
report
|
Admission Date: [**2166-4-4**] Discharge Date: [**2166-5-10**]
Date of Birth: [**2100-10-22**] Sex: M
Service: MEDICINE
Allergies:
Darvocet-N 50
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Hemmorhagic Gastritis
Congestive Heart Failure
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
Colonoscopy
History of Present Illness:
66 Year Old Male with PMHx of CAD s/p ICD placement in [**2158**],
metallic Aortic Valve Replacement, s/p MI, CVAx4 who presents
with acute hematocrit drop due to hemmorhagic gastritis. The
patient has had recurrent bleeding over the last 8 months, and
was just discharged from the MICU on [**2166-3-31**] after episodes of
melena and hypotension. The patient has had a total of 29 blood
transfusion since [**2164-10-30**] due to this.
He has been on warfarin since [**2158**] and had only been having
problems since middle of last year. He said that he has had an
[**Year (4 digits) **] recently and it did not show any source of bleeding.
He has not had a recent colonoscopy or capsule study. He has
been having increasing dyspnea and cough over the past week and
was started on a Z-pack empirically. He also has noticed some
increased weakness and black stool over the past week.
In the ED his vitals were HR: 91, BP: 95/52, RR: 29, 98% RA,
guaiac positive stool. lasix 20mg IV x1 and tranfused 2 units of
pRBC. He was then transferred to the floor for further
management.
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)
- Benign Hypertension
- CAD - single vessel distal LAD
- MI - in [**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**]
- Type 2 Diabetes
- 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:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia, + melena
PULM: + Chronic Dyspnea, - Cough, - Hemoptysis
HEME: + Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99.1, 106/58, 95, 20, 95%RA
GEN: NAD
Pain: 0/10
HEENT: EOMI, MMM, - OP Lesions
PUL: Bibasilar rales, EE Wheezes
COR: RRR, S1/S2, III/VI SEM
ABD: NT/ND, +BS, - CVAT, - rebound/guarding
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
[**2166-4-5**] 01:13PM BLOOD WBC-5.1 RBC-2.82* Hgb-8.9* Hct-26.3*
MCV-93 MCH-31.4 MCHC-33.7 RDW-18.4* Plt Ct-147*
[**2166-4-5**] 03:47AM BLOOD WBC-5.3 RBC-2.44* Hgb-7.8* Hct-23.0*
MCV-94 MCH-32.1* MCHC-34.0 RDW-18.2* Plt Ct-154
[**2166-4-4**] 04:30PM BLOOD WBC-4.3 RBC-2.09* Hgb-6.6* Hct-20.1*
MCV-96 MCH-31.7 MCHC-33.0 RDW-18.2* Plt Ct-152
[**2166-4-4**] 04:30PM BLOOD Neuts-50.2 Lymphs-26.8 Monos-10.1
Eos-12.0* Baso-0.8
[**2166-4-5**] 03:47AM BLOOD PT-28.7* PTT-43.0* INR(PT)-2.8*
[**2166-4-4**] 04:30PM BLOOD PT-28.8* PTT-42.5* INR(PT)-2.8*
[**2166-4-5**] 03:47AM BLOOD Glucose-75 UreaN-18 Creat-0.8 Na-140
K-3.4 Cl-110* HCO3-24 AnGap-9
[**2166-4-4**] 04:30PM BLOOD Glucose-166* UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-111* HCO3-22 AnGap-10
[**2166-4-4**] 04:30PM BLOOD cTropnT-<0.01
[**2166-4-4**] 04:30PM BLOOD proBNP-696*
[**2166-4-5**] 03:47AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.8
[**2166-4-5**] 03:47AM BLOOD Cortsol-4.3
[**2166-4-4**] 4:30 pm BLOOD CULTURE #1 R AC.
Blood Culture, Routine (Pending):
CHEST (PORTABLE AP) Study Date of [**2166-4-4**] 4:52 PM
IMPRESSION:
Mild congestive heart failure with small bilateral pleural
effusions and
bibasilar airspace opacities, likely atelectasis. Infection,
however, is not completely excluded.
EKG: NSR@90, QTc 456, Q II, AVF, V4-V6, Flattened ST V5-6
Portable TTE (Complete) Done [**2166-4-22**]
Conclusions
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The distal septum may be hypokinetic. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. A bileaflet aortic valve prosthesis is present and
appears well-seated. 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. Tricuspid regurgitation is seen (views suboptimal for
quantification). There is moderate pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2166-2-13**], findings are similar.
EGD [**2166-4-15**]
Findings:
Esophagus: Normal esophagus.
Stomach:
Mucosa: Abnormal vascularity of the mucosa was noted in the
antrum and stomach body. These findings are compatible with
AVM's. No active bleeding. Other Gastritis resolved
Duodenum: Normal duodenum.
Impression: Gastric AVM's
No blood/active bleeding in upper GI tract. Otherwise normal EGD
to third part of the duodenum.
Recommendations: Follow up with in-patient GI team
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology. Patient's home medication list was
reconciled.
Colonoscopy [**2166-4-15**]
Findings: Excavated Lesions Multiple diverticula were seen in
the sigmoid colon, descending colon, transverse colon, ascending
colon and cecum. Diverticulosis was severe but no active
bleeding from diverticulum.
Other No active bleeding/blood in the colon
Impression: Colonic Diverticulosis. No active bleeding/blood in
the colon. Otherwise normal colonoscopy to cecum
Recommendations: Follow up with inpatient GI team
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology Patient's home medication list was
reconciled
Brief Hospital Course:
65yoM with h/o chronic diastolic CHF (EF > 55%), NYHA Class III,
CAD w/ RCA stent and distal LAD occlusion w/ apical akinesis,
s/p AVR on warfarin, DM, HTN, CVA, and with gastritis and
gastric AVMs who was initially admitted on [**2166-4-4**] for GIB c/b
CHF exacerbation, transferred to the CCU for hypotension in
setting of diuresis, called out to [**Hospital1 **] [**2166-5-4**].
.
1. Chronic Blood Loss Anemia due to Gastrointestinal Bleeding:
Patient presented with a hct drop of 10. He has been admitted
multiple times for recurrent hemorrhagic gastritis. His INR on
admission was 2.8. His coumadin was stopped and he was
monitored while waiting for his INR to trend down for possible
EGD. Surgery was also consulted for possible gastrectomy given
these recurrent episodes and recommended biopsies to rule out
malignancy. A heparin drip was started once his INR was below
2.5 given his risk of stroke with his aortic valve replacement.
He received a total of 6units of pRBC during his time on the
general medicine floor. His H/H stabilized and he underwent EGD
and colonoscopy which revealed multiple gastric angiectasias,
but no clear signs of bleeding. He subsequently underwent a
capsule study that revealed one angiectasia in the distal
jejunum, but no other sources of active bleeding. His warfarin
was restarted (with heparin and then lovenox bridge) and
titrated to goal INR 2.5-3.5. On the cardiology service, his
Hcts ranged from 20-23 and he was transfused 1 unit with goal
Hct >21. He was started on iron, vitamin B12, and vitamin C. He
was transferred to the CCU on [**4-28**] for chest pain, hypotension,
and Hct that did not respond appropriately to blood
transfusions. On [**4-28**], he was transfused 3U PRBCs for a Hct of
19.6. On the evening of [**4-28**], he had an episode of hematemesis
w/ 125 cc's of bright red blood. GI and IR were notified. He was
managed conservatively with IV protonix and close monitoring of
his Hct. Hct remained fairly stable for the subsequent 2 days,
though he did require 1U PRBC on [**4-28**]. GI deferred further
intervention. Coumadin was held briefly and he was started on a
heparin gtt in case of further GI bleeding. He continued to have
hematocrit drop on [**5-2**] which stabilized again. Heparin gtt
was discontinued. GI was reconsulted who determined he would
only be a candidate if he has significant acute hematocrit drop
or large volume hematemesis. He required an additional 1U PRBC
on [**5-2**] and was called out of the ICU on [**5-3**]. Coumadin was
restarted on [**5-3**] as the patient had relative stability in his
Hct and no further hematemesis. His Hct continued to fluctuate,
however, ranging from 24 to 27 and he received additional
transfusions prn Hct <25. He will need to have serial Hcts as
an outpatient with goal Hct of 25. He will f/u with GI as an
outpatient with plan for repeat scope and consideration of APC
in the future. He is set up with pheresis unit at [**Hospital1 **] to receive
weekly blood transfusions as needed. He will have hct checked
prior to his weekly appointments at the pheresis unit and his
PCP will place an order for blood transfusion if needed. He
will follow-up closely with his cardiologist/NP to monitor fluid
status in the setting of transfusions. At this time, we
recommend goal Hct 25 (ie. 1 unit if hct <25, 2 units if <23,
send to ED if <21) and would suggest considering an extra dose
of torsemide 20 mg with each transfusion. He will be seen in
[**Hospital 1944**] clinic on [**5-12**] where he can have a Hct check and
will f/u with his cardiology-NP on [**5-14**] where a decision
regarding extra diuretic dose can be made as his first pheresis
unit appointment is [**5-14**] afternoon. Thereafter he will have
weekly pheresis appointments (scheduled) and should have
additional f/u appointments with PCP and Cardiology. He will be
discharged with a picc line in place for access which should be
removed (tentatively in 4 weeks) to avoid risk of infection.
Would recommend type and screen with Hct checks so that he
always has an active type and screen. This plan has been
reviewed with his PCP, [**Name10 (NameIs) 2085**], gastroenterologist,
pheresis unit nurse coordinator and [**Hospital1 1516**] case manager. **Hct on
discharge is 27.4**
2. Dyspnea: Initially thought to be an acute COPD exacerbation
in the outpatient setting for which the patient was placed on a
z-pack that was completed in-house. He was given nebulizers
around the clock as well as guaifenesin and tesslon pearls for
his cough. His breathing remained labored and his cough
persisted despite treatment. His lasix, lisinopril and
metoprolol had been held in the setting of GI bleed and he
became volume overloaded. Metoprolol was restarted and he was
treated with IV lasix. Initially he was diuresing well with
lasix boluses 40mg IV but developed hypotension to SBP 80s. He
was transferred to the cardiology service for treatment of acute
on chronic CHF exacerbation. On the cardiology floor, he was
placed on a lasix drip at 7mg/hr and uptitrated to 10mg/hr. His
BP was stable in the 80s-90s systolic, without symptoms. He was
started on metolazone. He diuresed 500mL-1L per day. His
weight trended down to dry weight and he clinically improved
with resolution of dyspnea and improvement in lower extremity
edema. On [**4-28**], he was transferred to the CCU. In the CCU,
diuresis was continued in hopes of relieving high venous
pressure to help slow the upper GI oozing. He started on a lasix
gtt and was diuresed 4L over the course of 3 days. Lasix gtt was
changed to torsemide 20 mg daily with good response. He will
have close follow-up with Dr. [**First Name (STitle) 437**]. He should have outpatient
blood pressure monitoring and we recommend close follow-up with
his PCP. **Weight on discharge is 78 kg**
3. CAD: s/p AVR, ICD and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] and has been medically
managed. No acs sx. His metoprolol, lisinopril and lasix were
initially held, but were slowly restarted as described in the
plans above. Aspirin was held in the setting of GI bleed. He
will be discharged on metoprolol and torsemide. Recommend
restarting aspirin in the future, when Hcts have been
stabilized.
.
4. DM2: Last A1c was 6.4, FSG were well controlled throughout
the course of his stay.
5. Aortic valve replacement: Patient had AVR in [**2158**]. He is on
coumadin with goal INR 2.5-3.5. In prior notes, it was
mentioned that he had recurrent CVAs on coumadin, though from
MRI in [**2159**], it appears that the CVAs were microvascular in
origin and not embolic from valve or apical hypokinesis. Due to
his persistent GI bleeding, he may benefit from INR goal of
2.0-3.0.
.
6. Chronic low back pain: currently stable, was not an issue
during this hospitalization.
7. CVA: Patient had many strokes in the past. His coumadin was
managed as described above.
8. Hypergammaglobulinemia: Is being monitored in the outpatient
setting. Recommend close PCP f/u.
Medications on Admission:
bactroban nasal 2% ointment intranasally [**Hospital1 **]
lipitor 80mg PO Daily
citracel 250mg-200unit tab 3 tabs am/ 2 tabs pm
Pantoprazole 40mg PO Delayed Release PO Q12H
combivent 18mcg-103mcg 1 puff INH [**Hospital1 **]
NS nasal Spray 2 sprays INH [**Hospital1 **]
Furosemide 20mg PO Daily
lisinopril 5mg PO Daily
glyburide 5mg 2 tabs Daily
nitro 0.3 SL PRN for chest pain
colace 100mg PO BID
oxycodone 10mg PO Q6-8H:PRN Pain
azithromycin 250mg PO Q24H x3 days
albuterol 90mcg INH 2 puffs Q4H:PRN
sucralfate 1gm QID
Folic Acid 1mg PO Daily
Flovent 110mcg INH [**Hospital1 **]
Metoprolol 25mg 0.5tab Daily
polyethylene glycol 1 packet Daily:PRN
warfarin 2.5mg PO Daily
Discharge Medications:
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*
23. Outpatient Lab Work
Please check INR and Hct weekly. Goal INR is 2.0-3.0. Goal
Hct is 25. Notify MD if patient is less than goal.
Send results to:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**], DIVISION OF GENERAL MEDICINE
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]
Email: [**University/College 108047**]
AND
Name: [**Last Name (LF) 437**], [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 18**] DIVISION OF CARDIOLOGY
Address: [**Location (un) **], E/RW-453, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 4005**]
Email: [**University/College 108048**]
24. Outpatient Lab Work
Please Check Hct and INR on [**Last Name (LF) 766**], [**5-12**].
Send results to:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**], DIVISION OF GENERAL MEDICINE
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]
Email: [**University/College 108047**]
AND
[**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
25. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous once
a day: For INR < 1.8.
26. PICC
PICC line care per protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Upper GI bleed
Acute on chronic diastolic heart failure
Secondary:
Diabetes type II
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 107923**],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] for a bleed in your gastrointestinal tract. You required
blood transfusion because your blood count had dropped. Your
blood counts stablized and the GI doctors performed [**Name5 (PTitle) **]
[**Name5 (PTitle) **], small bowel capsule study, and colonoscopy which was
negative for active bleeding. It showed irritation in your
stomach that was likely the site of your bleeding, however it
was not bleeding at the time of the procedure.
During your hospitalization you had cough and shortness of
breath, as well as fluid accumulation in your legs and lungs
because of your heart failure. Your blood pressures were low,
and caused you to be dizzy when you had intravenous doses of
Lasix (a diuretic). You were transferred to the cardiology
service to give you a continuous intravenous infusion of lasix
to help remove the excess fluid. Your blood pressures remained
stable and we were able to remove the excess fluid that had
accumulated. Your shortness of breath was improved.
You began having bleeding again, however, with dropping blood
counts. You were transferred to the Cardiac Care Unit where you
were closely monitored and diuresed. You again received several
transfusions. When your blood levels were stabilized, you were
transferred to the regular cardiac floor.
On the cardiac floor, you continued to intermittently require
blood transfusions. When you receive blood however, you retain
fluid and need to have the fluid removed. Currently, your blood
levels are at a normal level and your volume status is normal.
We believe that you may require blood transfusions and extra
diuretics to remove fluid over the next several weeks. For this
reason, we have arrange for you to have weekly appointments at
the Pheresis Unit at [**Hospital1 69**] - [**Hospital Ward Name 5074**] where you can receive blood transfusions if you need it.
You will need to have blood work to check your blood count prior
to these appointments.
You will also need to have your INR checked weekly to adjust
your warfarin dose.
goes up more than 3 lbs. Limit your fluid intake to 1-2 liters
per day. You may need an extra dose of torsemide (a diuretic)
with blood transfusions to prevent fluid accumulation.
We made the following changes to your medications:
CONTINUE:
- Bactroban nasal 2% ointment intranasally twice a day
- Atorvastatin 80 mg Daily
- Citracel 250mg-200unit tab 3 tabs in the morning and 2 tabs at
night
- Pantoprazole 40mg twice a day
- Combivent 18mcg-103mcg 1 puff inhaled twice a day
- NS nasal Spray 2 sprays twice a day
- Glyburide 10 mg Daily
- Nitroglycerin 0.3 mg sublingual as needed for chest pain
- Colace 100 mg twice a day
- Oxycodone 10 mg every six to eight hours as needed for pain
- Albuterol 90 mcg 2 puffs as needed every 4 hours for shortness
of breath
- Sucralfate 1 g four times a day
- Folic acid 1 mg Daily
- Flovent 110 mcg inhaled twice a day
- Metoprolol succinate 12.5 mg Daily
- Polyethylene glycol 1 packet Daily as needed for constipation
STOP:
- Warfarin 2.5 mg DAILY
- Furosemide 20 mg Daily
- Lisinopril 5 mg Daily
START:
-Warfarin 2 mg daily
-iron 325 mg daily
-vitamin B12 1000 units daily
-vitamin C 500 mg daily take with iron to increase absorption
-torsemide 20 mg daily
Followup Instructions:
The following appointments have been made for you. IT IS
CRTICIAL THAT YOU ATTEND THESE APPOINTMENTS.
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2166-5-12**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD/[**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
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.**
****HAVE YOUR HCT and INR CHECKED AT THIS VISIT****
Department: CARDIAC SERVICES
When: WEDNESDAY [**2166-5-14**] at 10:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
****HAVE YOUR TORSEMIDE DOSE ADJUSTED AT THIS VISIT****
Department: PHERESIS UNIT
When: WEDNESDAY [**2166-5-14**] at 1:00 PM
With: PHERESIS UNIT FOR BLOOD [**Hospital 108049**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
****THIS APPOINTMENT IS FOR YOUR BLOOD TRANSFUSION****
After these appointments, you will need to have weekly
appointments to see cardiology, have your hct checked, and
receive blood transfusions. It is CRITICAL that you attend all
appointments and have your blood levels monitored closely.
|
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30,722
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20955
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Discharge summary
|
report
|
Admission Date: [**2182-9-2**] Discharge Date: [**2182-9-24**]
Date of Birth: [**2126-2-14**] Sex: F
Service: NEUROLOGY
Allergies:
Percocet / Heparin Agents
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Headache on presentation to OSH.
Major Surgical or Invasive Procedure:
1. Right craniectomy
2. IVC filter placement.
3. Tracheostomy
4. Percutaneous Gastrostomy tube placement.
5. Attempted mechanical thrombectomy via cerebral
angiogram/angio jet.
History of Present Illness:
Pt. is a 56 year old with a history of Breast CA, treated 3
years ago with surgery and chemoradiation, no active disease at
present per husband, recent traumatic L1 fracture, d/ced [**8-25**]
from ortho, still wearing TLSO, and migraine headaches, who
presents with a headache much worse than her baseline migraines
and an episode of unresponsiveness today that sounds consistent
with seizure, found to have a R sided SAH and dural sinus
thrombosis on Head CT at OSH and transferred here.
Husband reports that pt. has been complaining of a headache for
the past 3 days. Initially they thought it was one of her
migraines, and treated it with the same Codeine and Tylenol that
she was taken for her back pain after the fracture. Today,
however, she felt that the headache was much worse, and in the
morning she called her surgeon to see if she could take some
Excedrin, which is usually more helpful for her migraines. Her
husband feels that she seemed uncomfortable this morning from
the
headache, but was otherwise in her usual state of health. The
headache was bothering her much more than the back pain, which
was surprising.
Then around 1:30 he was downstairs and her heard a thump above
him. He called up to her and she didn't answer. He ran
upstairs
and found her face down in the bedroom. He tried to arouse her
and talk to her but she didn't respond. He tried to turn her
over but felt that she was "stiff" and couldn't move her. He
did
not notice any shaking or jerking of her arms or legs. He
called
EMS, and while he was waiting for them she vomited. When they
arrived they describe her as face down on the floor surrounded
in
vomit and unresponsive with a bottle of Excedrin spilled next to
her. While on the ambulance she woke up and was very combative.
At the OSH she complained of [**10-23**] headache and nausea. She
vomited in the ED there and received 8 mg Zofran. They describe
her as alert and oriented x 3, PERRL, with some difficulty with
short term memory and remembering words. Head CT was performed,
and prelim read was significant for R sided hemorrhage (SDH vs
SAH) and R transverse and sigmoid dural sinus thrombosis and ?
superior sagittal sinus thrombosis. She was transferred
emergently to [**Hospital1 18**], and received 1 g Dilantin load en route
here.
She currently complains of continued [**10-23**] headache which is
bifrontal and pounding. She is still quite nauseated. This
headache is much worse than her normal migraines. She denies
any
focal weakness or numbness, lightheadedness or dizziness,
vertigo, diplopia, blurry vision, vision loss, or bowel or
bladder incontinence.
Past Medical History:
Breast CA- Stage I ( T1c, M0) 1.4 cm, grade 2, LVI negative,
ER/PR negative, HER-2/neu negative breast cancer of the right
breast, diagnosed 05/[**2179**]. Treated with wide excision with
sentinel lymph node procedure. Adriamycin, Cytoxan every three
weeks, [**6-/2179**] until 09/[**2179**]. Radiation completed in 11/[**2179**].
Migraines
L1 fracture after a fall off a horse- admitted [**Date range (1) 55710**], fitted
with TLSO
GERD
Osteoporosis
R parotid resection
Hyperlipidemia
Social History:
lives with husband, [**Name (NI) **] [**Name (NI) 3827**] ([**Telephone/Fax (1) 55711**])
Family History:
no FH of aneurysms
Physical Exam:
T- 98.8 BP- 129/81 HR- 94 RR- 14 O2Sat- 99% on RA
Gen: Lying in bed, appears uncomfortable, lying in bed with eyes
closed
HEENT: NC/AT, moist oral mucosa, + tongue lac on R
Neck: No tenderness to palpation, decreased ROM, no carotid or
vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam. Oriented
to person, place, and date. Mildly inattentive but says [**Doctor Last Name 1841**]
backwards, though slowly. Speech is fluent with normal
comprehension and repetition; naming intact. No dysarthria.
[**Location (un) **] and writing intact. Registers [**3-16**], recalls 0/3 in 5
minutes, [**2-16**] with prompting. No right left confusion. No
evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact V1-
V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. + asterixis bilaterally.
No pronator drift. Incomplete effort with strength testing due
to neck pain, but no obvious assymmetry to strength exam.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 4+ 4+ 5- 5 5- 5- 5 5- 5 5 5 5 5 5
L 4+ 4+ 5- 5 5- 5- 5 5- 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
Brisk throughout. Toes upgoing bilaterally. 4 beats of clonus at
ankles bilaterally.
Coordination: finger-nose-finger normal
Gait: Not assessed
Pertinent Results:
[**2182-9-2**] 08:10PM BLOOD WBC-14.1* RBC-3.79* Hgb-11.4* Hct-31.7*
MCV-84 MCH-30.1 MCHC-35.9* RDW-13.6 Plt Ct-109*#
[**2182-9-11**] 03:17AM BLOOD WBC-20.0* RBC-2.69* Hgb-8.1* Hct-23.5*
MCV-87 MCH-30.1 MCHC-34.4 RDW-15.2 Plt Ct-191
[**2182-9-19**] 03:31AM BLOOD WBC-14.1* RBC-3.00* Hgb-9.1* Hct-26.4*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.4 Plt Ct-536*
[**2182-9-19**] 08:30AM BLOOD PT-17.4* PTT-53.1* INR(PT)-1.6*
Lupus anticoagulant negative, antithrombin three normal.
prtotein C and S were normal. Anti-cardiolipin levels were
normal. No factor V leiden gene mutation. Homocysteine level
was low.
[**2182-9-19**] 03:31AM BLOOD Glucose-142* UreaN-14 Creat-0.3* Na-131*
K-4.3 Cl-96 HCO3-28 AnGap-11
[**2182-9-2**] 08:10PM BLOOD Glucose-149* UreaN-6 Creat-0.5 Na-136
K-3.5 Cl-101 HCO3-23 AnGap-16
[**2182-9-11**] 04:40PM BLOOD ALT-522* AST-319* LD(LDH)-623*
AlkPhos-134* Amylase-202* TotBili-0.5
[**2182-9-19**] 03:31AM BLOOD ALT-216* AST-49* LD(LDH)-464*
AlkPhos-128* Amylase-214* TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2182-9-3**] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2182-9-19**] 03:31AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.6 Mg-2.2
MICRO:
[**2182-9-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{ENTEROBACTER AEROGENES} INPATIENT
[**2182-9-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL
[**2182-9-10**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
[**2182-9-3**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
Imaging: Please note that not all imaging studies are included
- only those critical for defining the patient's course.
[**2182-9-3**] Head CT - noncontrast -
IMPRESSION:
1. New large intraparenchymal hematomas of the right temporal,
parietal, and occipital lobes with surrounding vasogenic edema
which are causing approximately 5 mm of right to left midline
shift.
2. Diffuse cerebral edema which is new.
3. Bilateral subarachnoid hemorrhages, worse on the right and
worsening intraventricular hemorrhage.
4. Hyperdensity of the right sigmoid and transverse sinus
consistent with venous thrombosis.
Brief Hospital Course:
This is a 56 year old woman who presents as a transfer from an
OSH with dural venous sinus thrombosis and subarachnoid
hemorrhage.
Neuro: The patient underwent hemicraniectomy to alleviate the
pressure and midline shift casued by the vascular congestion,
hemorrhage and edema on [**2182-9-4**]. The cranial fragement is
embedded in her anterior right abdominal wall and she should
follow up with Dr. [**Last Name (STitle) 548**] for reversal in 3 months. Osmotic
attempts to alleviate swelling with manitol and steroids were
made. An attempt was made at clot retrieval via angio jet, but
this failed to achieve mechanical thrombectomy. The patient was
initially placed on heparin, given the clot burdern in the
superior saggital sinus, right lateral sinus, and right internal
jugular vein. Unfortunately her platelets dropped from 109 on
admission to 41. Heparin induced thrombocytopenia serologies
were positive. This brings up one proposed mechanism of the
patient's dural venous sinus thrombosis. It is known that the
patient recieved heparin during her hospitalization for her L1
burst fx. It is hypothesized that she may have developped the
HIT-thrombosis after that hospitalization. When her
HIT-serologies returned positive heparin was stopped and
argatroban was started. Unfortunately this likely contributed
to hepatotoxicity (phenytoin was the other possible culprit) and
whe was changed from argatroban to lepirudin per the hematology
consult service (goal PTT 60). The patient was also started on
coumadin for long-term anticoagulation (goal INR [**2-16**]). Of note
the coumadin was erroneously held for two days between 93 and
[**9-18**] based on an INR of 3.6. The hematology service followed the
patient. The patient was hypothesized to have had some seizure
activity before presentation and this was treated initially with
phenytoin. As stated above it was thought that the phenytoin
might have contributed to liver toxicity (especially in the
setting of coumadin) and it was stopped in favor of keppra. The
patient had a relatively normal EEG on [**2182-9-3**]. Blood pressure
goals were mean arterial pressure <130. The patien's physical
exam findings have improved dramatically over the course of her
hospitalization. She is now alert and oriented, able to follow
cross body commands, antigravity in the right with full strength
on the left. Left lower extrem 4+/5 in IP, Quad, Hamstrings.
She will follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] of the vascular
neurology service at [**Hospital1 18**]. She will follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 548**] of the neurosurgery department in 3 months for
cranioplasty.
Respiratory: The patient was ventilated for over two weeks and
thus underwent tracheostomy placement. On [**2182-9-18**] mechanical
ventilation was no longer required and the patient was able to
tollerate a trach-mask. She was transitioned to a passy muir
valve 5 days prior to discharge.
ID: The patient developped a fever on hospital day 5. She was
started on vancomycin for vanc sensitive enterococcus in her
urine. She spiked again later in her hospitalization and at
that time grew enterobacter in her sputum. Chest x-ray on
[**2182-9-7**] was read as possibly showing a consolidation. She was
started on zosyn for this. The infectious disease service
followed her. She was taken off of antibiotics on [**2182-9-17**] and
her temperature has remained below 101 since then. She has had
temperatures as high as 100.7, but a decision was made not to
treat unless her temperature rose above 101.
HEME: The patient was noted to have a large right femoral DVT,
which seemed to have developed while on anticoagulation. An IVC
filter was placed. The liver was checked for portal vein
thrombosis by ultrasound. This was negative. Her LFT's were
trending down to near normal at time of discharge. Goal INR on
coumadin is 2-2.5. INR should be checked regularly at rehab.
GI: The patient was maintained on TF starting [**2182-9-4**]. Peptic
ulcer prophylaxis was with lansoperazole. In the ICU the
patient was maintained on electrolyte sliding scales. She was
given a PEG tube for feedings, then later cleared by speech and
swallow for regular diet. Her tube feedings may be stopped once
adequate daily caloric intake is achieved PO.
GU: The patient had a foley catheter, which was switched in the
setting of her fevers and urinary tract infections. This was
discontinued prior to disharge.
Physical therapy:
pt has craniotomy skull fragment in her abdomen. She is to wear
her helmet at all times to prevent hemorrhage or trauma to
exposed brain tissue.
Medications on Admission:
Omeprazole 40 mg QD
Simvastatin 20 mg QD
Fosamax 70 mg Qweek
Codeine 30 mg Q4-6 H PRN
Discharge Medications:
1. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: One
(1) Packet PO TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution [**Telephone/Fax (3) **]: Dose per
sliding scale. Injection ASDIR (AS DIRECTED).
3. Levetiracetam 250 mg Tablet [**Telephone/Fax (3) **]: Three (3) Tablet PO BID (2
times a day).
4. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (3) **]: Two (2) Tablet PO TID
(3 times a day).
5. Warfarin 2 mg Tablet [**Telephone/Fax (3) **]: Three (3) Tablet PO DAILY (Daily):
check INR 3 times per week. goal 2-2.5.
6. Acetaminophen 325 mg Tablet [**Telephone/Fax (3) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Nystatin 100,000 unit/mL Suspension [**Telephone/Fax (3) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush: continue until thrush
clears.
8. Docusate Sodium 100 mg Capsule [**Telephone/Fax (3) **]: One (1) Capsule PO BID (2
times a day): hold for loose stools.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
Dural Venous Sinus Thrombosis
Heparin Induced Thrombocytopenia
Deep Venous Thrombosis
Discharge Condition:
Resolving left Hemiplegia. Following commands. Moving right side
spontaneously.
Discharge Instructions:
You were admitted for a dural sinus thrombosis. You had multiple
complications as a result including intracranial hemorrhage,
deep venous thrombosis, heparin induced thrombocytopenia,
argatroban induced liver toxicity.
Please continue to take all medications as prescribed.
Call your doctor or 911 if you experience worsening weakness,
numbness, change in mental status or any other concerning
symptoms.
Followup Instructions:
You have an appointment to see Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] for follow up
in the vascular neurology clinic at [**Hospital1 18**]. [**10-25**] at
10:30am. Office phone [**Telephone/Fax (1) 2574**]
Patient will need to follow up with Dr. [**Last Name (STitle) 548**] in the department
of neurosurgery for cranioplasty (re-attachment of your skull)
around [**2182-12-5**]. Please call ([**Telephone/Fax (1) 88**] for appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"430",
"780.39",
"325",
"287.4",
"041.04",
"453.41",
"E934.2",
"V10.3",
"599.0",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"01.21",
"88.41",
"00.40",
"88.61",
"31.1",
"38.7",
"43.11",
"39.74",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13849, 13936
|
7859, 12402
|
319, 497
|
14066, 14148
|
5742, 7836
|
14602, 15178
|
3805, 3825
|
12704, 13826
|
13957, 14045
|
12593, 12681
|
14172, 14579
|
3840, 4219
|
12420, 12567
|
247, 281
|
525, 3167
|
4704, 5723
|
4258, 4688
|
4243, 4243
|
3189, 3681
|
3697, 3789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,354
| 135,864
|
44537
|
Discharge summary
|
report
|
Admission Date: [**2155-5-6**] Discharge Date: [**2155-5-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fever, respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 87 year old male with a past medical history of
stroke with persistent R near-hemiplegia and averbal s/p PEG
placement, DM2, CKD (baseline Cr 1.6-2) who presented from his
nursing home today for evaluation of fevers and acute on chronic
renal failure. He is at [**Hospital 100**] Rehab since [**Month (only) 404**], in the MACU,
stable on a trach mask, with his course punctuated by c diff
colitis and a return for fevers. This past weekend, he initially
started spiking fevers with increasing diarrhea. He was started
empirically on PO vanco (given his + c diff in the past). His
respiratory status then acutely decompensated requiring return
to mechanical ventilation.
Sputum collected returned positive for ESBL Klebsiella for which
he initially received Imipenem which was then switched to Zosyn
based on culture data. He also was noted to have anasarca with
worsening urine output and his creatinine was above his
baseline. He was given D5W with bicarb to which he did not
respond. Today he spiked through Zosyn, so he was sent to the ED
for further work up.
.
In the ED, his vital signs were stable with HR in the 80's and
BP in the 120's. He was febrile to 101.7, and was satting 93% on
A/C 500x 14 FiO2 0.4 and peep 5. He was found to be anasarcic on
exam and his CXR was notable for a persistent LLL effusion and
pulmonary edema.
He received vanco and cefepime and about 1L of IVF. He also
underwent a bedside echocardiogram which was negative for
pericardial effusion or ascites. A UA was grossly positive. Also
of note, he was in and out of afib on tele in the 80's.
.
He is admitted to the MICU for further work up and evaluation
Past Medical History:
- Diabetes mellitus
- Chronic kidney disease, Cr 1.6-2
- Hypertension
- dyslipidemia
- Aortic insufficiency
- Thoracic aortic aneurysm
- Osteoarthritis.
- First degree A-V delay
- GERD
- BPH
- Nephrolithiasis
- Cataracts
- Ventral hernia
- History of malaria
- Baseline chronic anemia
- s/p PEG tube placement [**10/2154**]
Social History:
No smoking, occasional alcohol, no drug use.
Family History:
non-contributory
Physical Exam:
VS: 98.8 75 143/49 23 100%ra A/C 500 x 14 FiO2 0.5 peep 8
pulsus = 9
GEN: NAD, responds to voice, can shake head yes/no to simple
questions
HEENT: AT, NC, EOMI, glaucomatous changes in left eye, no
conjuctival injection, anicteric, OP clear, MM dry. Neck supple,
no LAD, no carotid bruits. JVP @ 6cm @ 30 degrees.
CV: RRR, nl s1, s2, soft [**12-8**] SM at base, distant heart sounds
PULM: trached. scattered rhonchi with decreased breath sounds at
the bases
ABD: mild-moderate distention, grimacing with palpation
diffusely. No shifting dullness. +BS. G tube c/d/i.
EXT: warm, dry, +1 distal pulses BL, 1+ pitting edema diffusely
NEURO: residual right hemiplegia, averbal but will shake head
yes/no appropriately
SKIN: warm/dry. Diffuse trace to 1+ edema, including face. No
rash.
Pertinent Results:
[**2155-5-6**] 07:55PM WBC-9.9# RBC-2.95* HGB-9.1* HCT-26.7* MCV-90
MCH-30.7 MCHC-33.9 RDW-14.2
[**2155-5-6**] 07:55PM PLT COUNT-290
[**2155-5-6**] 07:55PM NEUTS-69.8 LYMPHS-22.1 MONOS-4.5 EOS-3.2
BASOS-0.4
[**2155-5-6**] 07:55PM GLUCOSE-384* UREA N-104* CREAT-2.7*#
SODIUM-129* POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-19* ANION GAP-19
[**2155-5-6**] 07:55PM CK-MB-NotDone proBNP-3469*
[**2155-5-6**] 07:55PM ALBUMIN-2.9*
[**2155-5-6**] 07:55PM CORTISOL-25.9*
pre-hosp:
Sputum Culture: ESBL Klebsiella pneumonia
Hosp:
Afib with LAFB @ 71bpm. Scattered P waves noted on the EKG
however. Second ekg with NSR @ 98
CXR ([**2155-5-6**]) -
1. Persistent left lower lobe collapse/consolidation.
2. Mild CHF.
CT torso ([**2155-5-6**]) -
1. High position of the endotracheal tube just at the thoracic
inlet. The tube should be advanced for more optimal placement.
2. Moderate-sized bilateral low-attenuation pleural effusions
with associated bibasilar atelectasis.
3. Moderate low attenuation pericardial effusion and coronary
artery calcifications.
4. Diffuse anasarca within the regional soft tissues with
scattered ascites consistent with volume overload.
5. Multiple bilateral renal hypodensities, the largest
compatible with cysts and others too small to characterize.
TTE ([**2155-5-7**])-
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is probably
normal. Overall left ventricular systolic function is probably
normal (LVEF 50-60%). There is no ventricular septal defect.
Right ventricular chamber size is normal. with mild global free
wall hypokinesis. There is abnormal septal motion/position. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild to moderate ([**12-4**]+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is at least mild pulmonary artery systolic hypertension. There
is a small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade.
Brief Hospital Course:
In brief, the patient is an 87 yo male with history of CVA s/p
trach/peg in LTAC unit admitted with increasing respiratory
distress, fevers, diarrhea and acute on chronic renal failure.
.
1) Respiratory Distress: patient was trached after difficult
attempts to wean post CVA. He has been treated in the last
several months for HAP, most recently finishing a course of
antibiotics on [**2155-4-11**] for pansensitive pseudomonas and proteus
from sputum on last admission. He has a persistent left sided
effusion and evidence of pulmonary edema on plain chest imaging
on presentation. His pre-hospital sputum cultures revealed and
ESBL Klebsiella species consistent with a ventilator associated
pneumonia and he was continued on appropriate antibiotics.
While being volume resusitated from his sepsis his respiratory
status was challenged by the fluid load. Investigations for
other infectious causes such as UTI or c. diff associated
colitis were negative. As his sepsis improved, he was able to
tolerate gradual diuresis which allowed him to return to
pressure support ventilation.
.
2) Acute on Chronic Renal Failure: The patient presented in
acute on chronic renal failure which seemed to be in a low flow
state, although acute worsenining of renal function could be
medication induced, secondary to ATN or prerenal azotemia. The
most likely cause was thought to be pre-renal due to the septic
physiology then worsened by volume overload. He was gradually
diuresed as above and discharged on his hospital dose of 120 mg
IV Lasix daily. This can be gradually tapered down as his
respiratory status and peripheral edema improves. His creatinine
and electrolytes should be monitored as his diuresis continues.
.
3) Hyponatremia/metabolic acidosis: The patient presented as
hypovolemic hyponatremic and mild metabolic acidosis associated
with renal failure. He was volume repleted as above and his
metabolic derangements improved.
.
4) Hypertension: The patient has a history of hypertension. His
blood pressure medications were held during his stay and resumed
prior to discharge.
.
5) Atrial fibrillation: The patient presented in paroxysmal
atrial fibrillation. This was a new finding for the patient
according to our records. His rate was well controlled during
the hospital stay. The decision to anti-coagulate the patient
with coumadin was deferred to the patient's primary care
providers and LTAC physicians.
.
6) Diabetes mellitus type 2: Elevated blood glucose on arrival
likely indicative of intravascular volume depletion. insulin
sliding scale for now with insulin gtt if uncontrolled. Monitor
fingersticks.
.
# Hyperlipidemia: Statin was continued.
.
# S/p CVA: Plavix was continued.
.
# Chronic Anemia: at baseline.
Medications on Admission:
Folic Acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
Atorvastatin 80 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: One (1)
Tablet PO once a day.
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID PRN
HIGH RESIDUALS ().
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q4H (every 4 hours).
Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q4H (every 4 hours).
Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection three times a day.
Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H
(every 12 hours).
Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
Modafinil 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Forty Six (46) units
Subcutaneous at bedtime.
Sevelamer HCl 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Insulin Sliding Scale
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
2. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q4H (every 4 hours).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Sevelamer HCl 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
13. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day).
14. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
15. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days: Last day is [**2155-5-20**].
.
16. Furosemide 10 mg/mL Solution [**Month/Day/Year **]: One [**Age over 90 **]y (120)
mg Injection once a day: Can titrate down as peripheral
edema/respiratory status improves. .
17. Insulin
Continue Insulin regimen per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Ventilator associated pneumonia
Pre-renal azotemia
Secondary:
Stroke
Hypertension
Diabetes mellitus type 2 with complication of nephropathy
Discharge Condition:
stable vital signs. tolerating pressure support ventilation.
tolerating tube feeds at goal.
Discharge Instructions:
You were admitted with pneumonia and kidney dysfunction. You
received antibiotics for your pneumonia, which you will continue
for a total of 14 days. Your kidney function recovered gradually
as your infection improved and your blood pressure normalized.
You are now being discharged to [**Hospital3 **] Center
where your medical care will be continued.
Take the medications as prescribed.
If there are new or concerning symptoms such as shortness of
breath, fever, chest or abdominal pain; please seek medical
attention.
Followup Instructions:
per rehab facility
|
[
"482.1",
"403.90",
"285.9",
"584.9",
"250.40",
"438.20",
"518.81",
"276.2",
"276.1",
"585.9",
"V44.0",
"427.31",
"999.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12294, 12360
|
5671, 8406
|
289, 296
|
12554, 12648
|
3241, 5648
|
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|
2405, 2423
|
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12381, 12533
|
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12672, 13196
|
2438, 3222
|
222, 251
|
324, 1979
|
2001, 2326
|
2342, 2389
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,327
| 176,858
|
33459
|
Discharge summary
|
report
|
Admission Date: [**2148-6-26**] Discharge Date: [**2148-7-6**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Adhesive Bandage / Dicloxacillin
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
PICC placement
Therapeutic Paracentesis
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 19420**] is a 42 year old male with a history of end stage
liver disease on the [**Known lastname **] list, pulmonary hypertension who
presents from home with fevers and hypotension. Per his mother
he was in his usual state of health until the afternoon of
presentation. He walked around the house this afternoon and
watched tv. She noticed that his forehead was hot at around noon
and took his temperature and it was elevated at 103. He did not
have any specific complaints. Since his most recent
hospitalization for hepatorenal syndrome his only medication
change has been restarting lasix. He had a therapeutic
paracentesis on [**2148-6-18**] with removal of 8.5 liters of fluid. He
has been taking his lactulose as schedule although he had fewer
than normal bowel movements yesterday and so his dose was
increased with good effect today. He has continued on his tube
feeds for supplemental nutrition. He has not had any other
fevers. He has not been complaining of cough, shortness of
breath, nausea, vomiting, abdominal pain, dysuria, hematuria or
leg pain. His lower extremity edema is at baseline. All other
review fo systems negative in detail.
.
In the ED, initial vs were: T: 103.0 P: 140 BP: not detectable
R: 26 O2 sat 93% on RA. He received 4 liters of normal saline
for resuscitation. Lacatate was elevated at 6.7 with normal pH.
His creatinine was 1.8 from baseline of 1.4. WBC count was 12.0
with 14% bands. Total bilirubin was slightly elevated from
baseline at 12.2. He had a CXR which showed very small lung
volumes but no definite acute process. He had a diagnostic
paracentesis without evidence of SBP. He received vancomycin and
ceftriaxone. He received 60 meq of potassium. He had blood and
urine cultures sent. He was transferred to the MICU for further
management.
.
On arrival to the MICU he is confused but has no complaints. He
is alert and talkative.
Past Medical History:
- End Stage Liver Disease [**1-22**] alcohol and hepatitis C. Currently
on the [**Month/Day (2) **] list. Course complicated by recurrent ascites,
SBP, pulmonary hypertension. Currently on the [**Month/Day (2) **] list
(s/p aborted liver [**Month/Day (2) **] given elevated pulmonary pressures
in OR [**2148-2-28**])
- Spontaneous bacterial peritonitis early [**7-27**] on Cipro
prophylaxis
- Grade II esophageal varices
- Recurrent hepatic encephalopathy on vegetarian diet
- Pulmonary hypertension
- Hypothyroidism
- Anxiety disorder
- History of alcohol and IVDU
- Osteoporosis of hip and spine per pt
- Anemia with history of guaiac positive stool
Social History:
He lives with his mother. Remote history of smoking [**12-23**] ppd.
Quit drinking 11 years ago. Prior history of IVDU as a teenager.
Family History:
Mother with diabetes and hypertension. Father with rheumatic
heart disease.
Physical Exam:
In MICU:
Vitals: T: 98.3 BP: 88/41 P: 118 R: 18 O2: 98% on RA
General: Alert, oriented to [**Hospital1 18**], not time
HEENT: Sclera icteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, + fluid wave, no rebound
tenderness or guarding
GU: foley draining dark urine
Ext: warm, well perfused, unable to appreciate pulses, 3+ lower
extremity edema, + clubbing, no cyanosis
Neurologic: + asterixis
Skin: + jaundice
Rectal: Guaiac negative in emergency room
On the floor:
Physical Exam:
Vitals: T: 97.3 BP:105/70 P:78 R:18 O2: 93% RA
General: Alert and Oriented x 3, Conversant with some mild
slowing of speech. Ill appearing. NAD
HEENT: Sclera Icteric, MMM, oropharynx clear, Dobhoff placed
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: Distended with tense ascites, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, impressive
umbilical hernia.
Ext: warm, well perfused, 3+ pitting edema to the knees
bilateral lower extremity.
Skin: Stasis dermatitis bilateral lower extremity. Jaundiced.
Neuro: CN II-XII intact, +Asterixis
Pertinent Results:
[**2148-6-26**] 07:00PM BLOOD WBC-12.0*# RBC-2.80* Hgb-8.6* Hct-25.9*
MCV-93 MCH-30.6 MCHC-33.0 RDW-22.5* Plt Ct-64*
[**2148-6-26**] 07:00PM BLOOD Neuts-72* Bands-14* Lymphs-2* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2148-6-27**] 02:38AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-1+
Macrocy-2+ Microcy-3+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+
Burr-2+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 24904**]
[**2148-6-26**] 08:22PM BLOOD PT-27.5* PTT-48.6* INR(PT)-2.7*
[**2148-6-26**] 07:00PM BLOOD Glucose-100 UreaN-28* Creat-1.8* Na-137
K-2.9* Cl-95* HCO3-25 AnGap-20
[**2148-6-27**] 02:38AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.8
[**2148-6-26**] 07:00PM BLOOD ALT-17 AST-78* CK(CPK)-675* AlkPhos-131*
TotBili-12.2* Albumin-3.3* Lipase-80* Ammonia-48*
[**2148-6-27**] 03:26AM BLOOD Temp-38.2 pO2-28* pCO2-46* pH-7.37
calTCO2-26
[**2148-6-26**] 07:13PM BLOOD Lactate-6.7*
.
Microbiology:
[**2148-6-26**]: PERITONEAL CULTURE: No Growth.
[**2148-6-26**] 7:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = Sensitive , MIC OF <=0.12 MCG/ML.
ENTEROCOCCUS SP..
ISOLATE SENT TO [**Hospital1 4534**] LABORATORIES FOR FURTHER
IDENTIFICATION
[**2148-7-1**].
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. .
SENSITIVE TO Daptomycin (MIC: 0.5MCG/ML).
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 16 R
CLINDAMYCIN----------- S
DAPTOMYCIN------------ S
ERYTHROMYCIN----------<=0.25 S
LINEZOLID------------- 2 S
PENICILLIN G----------<=0.06 S 8 R
VANCOMYCIN------------ <=1 S I
Anaerobic Bottle Gram Stain (Final [**2148-6-27**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19840**] #[**Numeric Identifier 77608**] AT 0740, [**2148-6-27**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final [**2148-6-27**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
URINE CULTURE (Final [**2148-6-28**]): NO GROWTH.
.
Imaging:
[**2148-6-26**] CXR: Low lung volumes without definite acute process.
.
[**2148-6-27**] CXR: An AP portable supine chest radiograph is compared
to [**2148-6-26**]. Nasogastric tube terminates within the stomach,
as before. The lung volumes are overall improved, but remain
low. The cardiomediastinal contours are stable. There are no
focal areas of consolidation
.
[**2148-6-27**] Lower Extremity Doppler: 1) No DVT. 2) Left-sided
medial popliteal fossa ([**Hospital Ward Name 4675**]) cyst.
.
[**2148-6-27**] Abd Ultrasound: 1. Hepatopetal and patent main portal
vein.
2. Cirrhotic liver with gallbladder wall edema and distention.
This might be related to third spacing, chronic liver disease,
and enteric status--please correlate clinically as to whether
there is abdominal pain which may be attributable to the
gallbladder.
.
[**2148-6-27**] TTE: No valvular vegetations seen. Mild symmetric left
ventricular hypertrophy with preserved global and regional
systolic function. Borderline right ventricular systolic
function. Mild to moderate mitral regurgitation. Mild pulmonary
hypertension.
.
[**2148-7-3**] TEE: The left atrium is normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology.
.
[**2148-7-3**] CT abd/pelvis:
1. Large volume abdominal ascites, similar in appearance to
study from [**1-2**], 09.
2. Mildly distended gallbladder containing innumerable stones,
but no
gallbladder wall thickening to suggest acute cholecystitis. If
this is a
concern nuclear medicine hepatobiliary scan would likely be the
best test.
3. Air in the nondependent portion of the bladder, would
recommend
correlation with recent Foley instrumentation.
4. No bowel obstruction or small bowel abnormality. Mild colonic
ileus with
fluid, which could reflect diarrhea.
.
Brief Hospital Course:
42 year old male with a history of end stage liver disease on
the [**Month (only) **] list, pulmonary hypertension who presents from
home with fevers and hypotension.
Sepsis with Group B strep and Enterococcus Avium: Unclear
etiology. Patient presents with fevers, tachycardia, hypotension
in the setting of end stage liver disease. WBC count of 12.0
with 14% bands. Urinalysis negative. No evidence of SBP on
paracentesis. Urine culture negative. Blood cultures with 4/4
bottles GPC initially. He initially received 5 liters of normal
saline for reuscitation and this was switched to albumin and
blood in the MICU. He was started on vancomycin and ceftriaxone
in the emergency room and this was switched to vancomycin and
cefipime. He never required pressors or central line placement.
His blood pressures improved to 100s systolic which is his
baseline. He continued to have poor urine output 20-30 cc/hr
and was treated with albumin. Lactate was initially elevated at
6.7 and this trended down to normal. When cultures grew Group B
Streptococcus, cefipime was discontinued and he was receiving
only vancomycin via PICC line. On [**2148-7-2**], blood cultures were
also preliminarily growing Enterococcus avium, a rare organism
found predominantly in the GI tract. TEE was negative for
vegitations. CT abdomen/pelvis was negative. Colonoscopy was
negative and no source of GI etiology of bacteremia was found.
Because the enterococcus organism had only intermediate
sensitivity to vancomycin, Mr. [**Known lastname 19420**] was switched to linezolid
600mg [**Hospital1 **] for a one month course (until [**2148-8-2**]). One month
course was recommended by ID since no etiology of bacteremia had
been found. He will follow up with ID on [**2148-7-22**]. Platelet
counts must be followed as linezolid can cause thrombocytopenia
after 2 weeks. He will have weekly CBC's checked. He will
follow up in hepatology [**Date Range **] clinic on [**2148-7-10**].
EKG Changes: No complaints of chest pain or shortness of breath.
Likely related to demand in the setting of profound tachycardia
and hypotension. His CKs were elevated on presentation with
flat MBs and troponins. Repeat EKG was improved. CKs trended
down. During colonoscopy, Mr. [**Known lastname 19420**] had runs of SVT with no
electrolyte changes. He was monitored overnight after
colonoscopy and had no further telemetry events.
Hepatorenal Syndrome: Recent admission for acceleration of
hepatorenal syndrome requiring octreotide and midodrine with Cr
of 3.8. He had mild worsening creatine likely secondary to
hyperperfusion in the setting of infection. No evidence of GI
bleeding or peritonitis. He was given daily albumin 1 gram/kg
for 72 hours and continued on octreotide and midodrine. His
diuretics were held throughout hospitalization. Post
paracentesis 50grams of albumin was given. On discharge,
creatinine was 1.2. Mr. [**Known lastname 19420**] had not been discharged on
diuretics, but was later called on the day of discharge and told
to restart diuretics.
Pulmonary Hypertension: Pulmonary artery pressures on recent TTE
were 35 mmHg but recent right heart catherization with mean PA
pressures of 33 with PCWP 16. Of concern was the finding of mild
RV dilitation. His case was considered carefully by the
[**Known lastname **] committee and he is currently listed for [**Known lastname **].
He was continued on iloprost.
Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse
and hepatitis C. Currently on [**Known lastname **] list. No evidence of
SBP on paracentesis from emergency room. He was encephalopathic
on arrival but this has improved with IV hydration. He was
continued on lactulose, rifaximin, midodrine and octreotide.
His diuretics were held during hospitalization. Ciprofloxacin
was restarted after cefepime was stopped.
Anemia: Baseline hematocrit in mid 20s. On admission his
hematocrit was stable at 25.9 but this decreased to 18 on
hospital day two after 5 L IVF without signs of active bleeding.
He received two units of packed red blood cells with stable
hct. His stools were guaiac negative. He was continued on his
home PPI.
Hypothroidism: He was continued on synthroid.
Code Status: Full.
Communication: [**Name (NI) **] [**Name (NI) 19420**] (mother, health care proxy)
[**Telephone/Fax (1) 77606**], [**Telephone/Fax (1) 77607**]
Disposition: pending clinical improvement
Medications on Admission:
Clotrimazole 10 mg Troche 5X/DAY (5 Times a Day).
Ursodiol 600 mg daily
Miconazole Nitrate powder TID
Levothyroxine 88 mcg daily
Rifaximin 400 mg TID
Simethicone 80 mg QID
Zinc Sulfate 220 mg daily
Cholecalciferol 800 mg daily
Calcium Carbonate 1250 mg daily
Omeprazole 20 mg daily
Iloprost 10 mcg/mL nebulization Q4H
Ciprofloxacin 500 mg daily
Midodrine 10mg TID
Lactulose 30-60mL QID (> 6 BMs per day)
Octreotide 100 mcg Q8H
Codeine Sulfate 15-30 mg PO Q12H:PRN
Lasix 40 mg daily
Magnesium Oxide 400 mg [**Hospital1 **]
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
five times a day.
2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Iloprost 10 mcg/mL Solution for Nebulization Sig: One (1)
inh Inhalation every four (4) hours.
12. Midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q12H PRN as
needed for pain.
14. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day): titrate to 6+ BM's per day.
15. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
injection Injection Q8H (every 8 hours).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
17. Linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 28 days: Please continue until [**2148-8-2**].
Disp:*56 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
Please check CBC, Chem 10, ALT, AST, [**Name (NI) 3539**], INR, PT, PTT on
Monday, [**2148-7-8**]
PATIENT WAS INSTRUCTED TO RESTART LASIX 40MG DAILY VIA
TELEPHONE, POST-DISCHARGE ON [**2148-7-6**].
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Sepsis
2. Hepatorenal Syndrome
3. Hepatic encephalopaty
SECONDARY DIAGNOSES:
1. Pulmonary Hypertension
2. End Stage Liver Disease secondary to ETOH abuse and Hepatitis
C
Discharge Condition:
Mental Status back to baseline per mother. Afebrile. Systolic
Blood pressures 90's to 100's. Other vital signs stable.
Discharge Instructions:
You were admitted to [**Hospital1 **] hospital on [**2148-6-26**]
with fevers and low blood pressure. You were in the medical
intensive care unit, where you received albumin and blood
products. You had bacteria growing in your blood so you were
started on antibiotics. You are on linezolid, and you will need
to continue this antibiotic until [**2148-8-2**].
Ultrasound pictures of your calves and abdomen were taken. There
was no evidence of a clot. We also did an echocardiogram of
your heart, which showed not clots on your heart valves.
We took cultures of your urine and the fluid in your abdomen,
but there was no bacteria growing in either of these yet. On
the chest X-ray, there was no sign of pneumonia. There was no
source in your GI tract when we did a CT scan, so we did a
colonoscopy to take a closer look. It is unclear what the source
of the bacteria in your blood is at this point.
While you were in the hospital, there were some changes on your
EKG (heart tracing). We tested your heart enzymes, which showed
that you were not having a heart attack, and your EKG changes
resolved when repeated. You had some abnormal rhythm on the
heart monitor while you had your colonoscopy, but it resolved.
Your kidney function was somewhat decreased while you were in
the hospital. It is now resolved. Your kidney failure is due
to your liver failure.
You are currently on the liver [**Month/Day/Year **] list.
The following changes have been made in your medications:
-START taking ciprofloxacin 500mg every 24 hours.
-START taking linezolid 600mg twice a day until [**2148-8-2**].
You will have outpatient lab work done every week.
You should continue tube feedings via bridled nasal tube. VNA
services will assist you with tube feedings. Continue a low
protein, vegetarian diet. Continue to take in less than 2 grams
of sodium per day.
You must take daily weights. If you gain >3 lbs weight over a
few days, you must call your doctor.
Please return to the ER or call your doctor if you experience a
change in mental status, confusion, dizziness, shortness of
breath, weight gain, chest pain, fevers/chills, abdominal pain,
or any other symptoms that are concerning to you.
Followup Instructions:
You have the following appointments:
1. Provider: [**Name10 (NameIs) **] [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-7-10**] 11:40am
2. PCP [**Name Initial (PRE) 2169**]: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (an associate of Dr. [**First Name (STitle) 6330**]
[**Telephone/Fax (1) 46571**]. You have an appointment scheduled [**2148-7-9**]
at 11:10am.
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24,562
| 191,137
|
2097
|
Discharge summary
|
report
|
Admission Date: [**2205-9-23**] Discharge Date: [**2205-9-27**]
Date of Birth: [**2164-10-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11348**]
Chief Complaint:
respiratory distress, tachycardia, pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained through ED notes and with discussion nursing
home nurse as patient is uncommunicative at baseline. She is a
40yo with PMH significant for cerebral palsy and chronic
aspiration PNA with previous intubation and trach, who presents
with 1-2d of fever to 101 and desats to 88%, + mucus production,
minimal cough. Pt. is a resident at [**Hospital **] Health Center,
with difficulty protecting airway/swallowing and has PEG tube at
baseline. She was treated for 24h on levo/flagyl at NH but
continued to have tachypnea nd fever so was sent to ED here.
.
In ED, temp to 102.3, tachy to 130, with nl pressures, satting
94% on 4L. She wasa started on vanc/zosyn and given 1L IVFs.
CXR negative, U/A with evidence of UTI (chronic foley). Able to
suction some mucus from OP, and came up to floor satting 100% on
3L.
Past Medical History:
1. Cerebral palsy- Pt was diagnosed at the age of 2. She has
spastic cerebral palsy and is confined to a wheelchair.
2. S/P right femur fracture in [**2200**]
3. H/O multiple aspiration PNAs
4. H/O tonic clonic seizures since the age of six.
5. Blindness secondary to bilateral cataracts, s/p surgeries
6. Dysphagia s/p PEG tube placement. Pt currently does not take
anything by mouth.
7. S/P tracheostomy- This is now closed
Social History:
Lives at nursing home. No tobacco, ETOH, or drugs.
non-communicative at baseline
Family History:
Unknown
Physical Exam:
On admission:
VS: T 98.7 (Tmax 102.3 in ED) BP 117/76 HR 103 O2 100%/3L
Gen: NAD, pt interactive with roving eye movements (also noted
as such in previous notes), following some commands but not
clearly answering quesitons
HEENT: eyes moving side to side, surgical pupils, non reactive.
MM dry, OP otherwise clear
Neck: no LAD, no JVD, trach scar well healed
Heart: tachy, regular rhythm, nls1s2, no murmur
Lungs: CTAB
Abdom: soft, NDNT, g-tube in place non tender
Extrem: no c/c/e, flexed at all joints. R fem line C/D, no
erythema
Skin: no rashes
Neuro: eyes moving in all directions, able to move tongue and
lips, motor [**3-23**] bilateral grips, food biceps strength, not
moving LEs to painful stimuli, babinski downgoing bilaterally
Pertinent Results:
[**2205-9-23**] 10:20AM BLOOD WBC-17.2*# RBC-4.39 Hgb-14.4 Hct-41.3
MCV-94 MCH-32.7* MCHC-34.7 RDW-12.9 Plt Ct-215
[**2205-9-26**] 05:35AM BLOOD WBC-6.4 RBC-3.53* Hgb-11.7* Hct-33.9*
MCV-96 MCH-33.2* MCHC-34.7 RDW-12.2 Plt Ct-220
[**2205-9-23**] 10:20AM BLOOD Neuts-88.6* Bands-0 Lymphs-6.9* Monos-4.0
Eos-0.3 Baso-0.1
[**2205-9-26**] 05:35AM BLOOD Glucose-101 UreaN-8 Creat-0.3* Na-141
K-4.1 Cl-106 HCO3-25 AnGap-14
[**2205-9-23**] 10:20AM BLOOD ALT-19 AST-16 CK(CPK)-28 AlkPhos-84
Amylase-31 TotBili-0.6
[**2205-9-23**] 10:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2205-9-26**] 05:35AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1
[**2205-9-23**] 01:31PM BLOOD Lactate-1.3
CXR: Right lower lobe consolidation consistent with developing
pneumonia. Possible involvement of the anterior segment of right
upper lobe.
Left retrocardiac opacity most likely representing atelectasis
or scarring.
PICC Placement: Placed under IR with confirmed placement in
distal SVC.
Brief Hospital Course:
# PNA: The patient has history of multiple aspiration
pneumonias. Her initial respiratory distress appeared to be
caused by mucous plugging, alleviated by suctioning. She was
briefly in the MICU for close monitoring but was not intubated
and remained hemodynamically stable. Her CXR showed a RLL
infiltrate and an induced sputum culture only grew sparse
oropharyngeal flora, all of which are consistent with an
aspiration PNA. She was initially treated with vanomycin and
Zosyn but her regimen was eventually changed to meropenem with
continued improvement of her respiratory status. There was no
evidence of MRSA infection. She became afebrile and was weened
to room air. She was suctioned as needed and received aggressive
chest PT to assist with clearance of her secretions, as well as
her scopalamine patch. She was kept on aspiration precautions
with an increased HOB. She was eventually changed to a regimen
of cefepime and flagyll to better cover both resistant gram
negative organisms and anaerobes in what was likely an
aspiration pneumonia
.
# UTI: Initial U/A showed 20-50 WBC, positive LE, positive
nitrites and eventually grew out E.coli resistant to cipro and
vanco sensitive enterococcus. It was found that both of these
organisms were sensitive to meropenem and will be treated
concurrently with her pneumonia. She will require a repeat U/A
at the completion of her therapy to ensure clearance.
.
# Possible vaginitis - There was a white clumpy vaginal
discharge noted by nursing staff, which was treated with one
dose of diflucan with good effect.
# Seizure: stable, no e/o sz. activity. continue zonegran,
lamotrigine, keppra
# FEN: Probalance TF at goal with no residuals.
# ppx: hep SC, lansoprazole, home bowel regimen
# Access: Right PICC line placed in IR on [**9-25**] under flouroscopy
with confirmed good placement.
# contact info: mom [**Name (NI) **] [**Name (NI) 11333**] ([**Telephone/Fax (1) 11349**], ([**Telephone/Fax (1) 11350**]
FULL CODE
Medications on Admission:
- Jevity 1.2 300ml qid with 200cc H20 flush
-Keppra 1500 mg [**Hospital1 **]
-Lamictal 75 mg [**Hospital1 **]
-Zonegran 200 mg qAM
-scop patch 1.5 mg TD q72h
-Enulose (lactulose) 30 mg qhs
-Senna 2 tabs qhs
-timolol 0.5% eye drops to R-eye [**Hospital1 **]
-Ca++ carb [**Hospital1 **], vit D daily
-[**Hospital1 11346**] 15ml [**Hospital1 **]
-vit C 500 mg daily
-zegerol 20mg-2 packs daily
-MVI
-Tylenol prn
-albuterol prn, ipratrop prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Zonisamide 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY
(Daily).
3. Lamotrigine 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2
times a day).
4. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: 1500 (1500) mg PO BID
(2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
6. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day).
9. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO QHS
(once a day (at bedtime)).
10. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO QHS (once a day (at bedtime)).
11. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed for wheezing.
13. Timolol Maleate 0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
14. Scopolamine Base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours).
16. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
19. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day) for 14 days.
20. Cefepime 1 gram Recon Soln [**Hospital1 **]: One (1) Intravenous Q24H
(every 24 hours) for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
Aspiration Pneumonia
Urinary Tract Infection
Discharge Condition:
All vitals signs stable. Afebrile. O2 sat >96% on RA.
Discharge Instructions:
You were admitted with a pneumonia, likely from aspiration, and
a urinary tract infection. You also had some mucous plugging in
your lungs. You were treated with broad-spectrum antibiotics and
suctioning with great improvement in your condition. A culture
of your urine showed a resistant organism but it was killed by
the antibiotics your are on. Please continue to take your
medications as directed. You will have an long-term IV called a
PICC line for continued IV antibiotics which may be removed
after the completion of your antibiotics.
Please call your doctor or return to the emergency room if you
experience fevers/chills, shortness of breath, or any other
symptom that concerns you.
Followup Instructions:
Please call Dr.[**Name (NI) 11351**] office at [**Telephone/Fax (1) 608**] to schedule a
follow up appointment in the next few weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 11352**]
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]
] |
8122, 8175
|
3558, 5540
|
361, 367
|
8264, 8320
|
2579, 3535
|
9063, 9310
|
1787, 1797
|
6028, 8099
|
8196, 8243
|
5566, 6005
|
8344, 9040
|
1812, 1812
|
277, 323
|
395, 1224
|
1826, 2560
|
1246, 1673
|
1689, 1771
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,134
| 193,629
|
10969
|
Discharge summary
|
report
|
Admission Date: [**2201-3-5**] Discharge Date: [**2201-3-8**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 9415**]
Chief Complaint:
Abatacept reaction
Major Surgical or Invasive Procedure:
ICU Monitoring
History of Present Illness:
Mr. [**Known lastname 17385**] is a 37 yo man with psoriatic arthritis, inflammatory
bowel disease, HTN, DM2 and peripheral neuropathy who presents
for scheduled administration of abatacept due to anaphylactoid
reaction following previous administration.
He reports that on the evening of receiving abatacept, he
developed shortness of breath, wheezing and chest tightness. He
said he felt as though he was having an asthma attack (he had
asthma as a child). he spent the night at an OSH and was d/c'ed
the next day.
He saw allergy as an outpt, and they recommended a treatment
strategy.
He currently has no complaints.
Past Medical History:
Psoriatic arthritis
Inflammatory bowel disease
HTN
DM2
Peripheral neuropathy
Social History:
The patient is married, has 4 children one of whom is autistic.
The patient himself works as a teacher in an autistic school, a
school for autistic children. He is a nonsmoker, does not drink
alcohol and has caffeine beverages very seldomly.
Family History:
Mother who has hypertension, elevated cholesterol and ulcerative
colitis. His father has hypertension and asthma. He has a male
sibling with ulcerative colitis and psoriasis and a female
sibling who is alive and well.
Physical Exam:
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM, oropharynx clear
Neck - Supple, JVP not elevated, no LAD
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - RRR, normal S1/S2; no murmurs, rubs, or gallops
Abdomen - Normoactive bowel sounds; soft, non-tender,
non-distended
Ext - Warm, well perfused, radial and DP pulses 2+; no clubbing,
cyanosis or edema
Pertinent Results:
[**2201-3-7**] 06:44AM BLOOD WBC-14.2*# RBC-4.86 Hgb-14.2 Hct-42.4
MCV-87 MCH-29.2 MCHC-33.5 RDW-13.7 Plt Ct-307
[**2201-3-7**] 06:44AM BLOOD Glucose-158* UreaN-17 Creat-0.7 Na-139
K-4.1 Cl-102 HCO3-24 AnGap-17
[**2201-3-7**] 06:44AM BLOOD ALT-38 AST-19 LD(LDH)-229 AlkPhos-36*
TotBili-0.5
[**2201-3-7**] 06:44AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.4
Brief Hospital Course:
#. Abatacept reaction: Had anaphylactoid reaction in the past.
Already started premedicating with higher-dose prednisone prior
to admission. Plan was as follows:
1. Abatacept 1000 mg Infuse over 90 minuts
2. The day before and the day after the infusion, 80 mg of
prednisone per day
3. 100 mg methylprednisolone prior to the abatacept infusion
4. Diphenhydramine 50 mg q 4 hours and famotidine 20 mg q 12
hours. First dose of both one hour before the infusion, and
continue for 24 hour
5. Maintain in the hospital for observation for 24 hours.
6. Dr. [**Last Name (STitle) 2603**] ([**Numeric Identifier 35585**]) should be called if necessary.
Patient had hand and arm swelling/erythema about 2 hours after
infusion was started. This responded to benedryl infusion. He
then developed chest tightness which responded to atrovent neb.
He remained stable after that overnight and was discharged home
after 24hours of monitoring.
#. Psoriatic arthritis: Received steroids and abatacept as
above.
#. IBD: Currently inactive, on flagyl ppx
#. DM2: Held PO hypoglycemics and started ISS. Was discharged on
PO hypoglycemics.
#. HTN: held antihypertensives in case of anaphylaxis. Was
discharged on home regimen.
#. Code status: FULL
Medications on Admission:
ALENDRONATE 35 mg weekly
DICYCLOMINE 20 mg qid
GLYBURIDE 10 mg daily
HYDROCHLOROTHIAZIDE 25 mg daily
LISINOPRIL 40 mg daily
METOPROLOL SUCCINATE 100 mg daily
PIMECROLIMUS Cream [**Hospital1 **]
PRAVASTATIN 20 mg daily
PREDNISONE 80 mg daily (stared yesterday, usually takes 40 mg)
MONTELUKAST 10 mg daily
CALCIUM CARBONATE-VITAMIN D3
Flagyl 500 tid
Discharge Medications:
1. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Pimecrolimus 1 % Cream Sig: One (1) application Topical
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Psoriatic Arthritis
allergy to medications
Secondary:
IBD
DM2
HTN
Discharge Condition:
Patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital to receive your medication for
arthritis. You had steroids and benedryl to keep you from having
an allergic reaction to this medication. You did not develop any
serious allergic reaction.
No changes were made to your medications
Please call your doctor or come to the emergency room if you
have fainting or near-fainting, throat swelling, face swelling,
palpitations, difficulty breathing, itchiness, rash, or any
other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2201-4-7**] 2:40
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2201-4-13**]
8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2201-5-18**] 8:00
|
[
"357.2",
"786.59",
"729.81",
"V07.1",
"401.9",
"250.60",
"564.1",
"278.00",
"696.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4996, 5002
|
2358, 3596
|
284, 301
|
5113, 5183
|
1987, 2335
|
5708, 6190
|
1331, 1550
|
3995, 4973
|
5023, 5092
|
3622, 3972
|
5207, 5685
|
1565, 1968
|
226, 246
|
329, 954
|
976, 1055
|
1071, 1315
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,561
| 127,831
|
6561
|
Discharge summary
|
report
|
Admission Date: [**2197-7-10**] Discharge Date: [**2197-7-18**]
Date of Birth: [**2131-4-2**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Briefly, this is a 66 year-old
female who presented with hemoptysis. Chest x-ray showed a
mass. The patient was taken to the Operating Room for a
presumption of lung cancer. She had diagnosed T4N0 stage 3B
lung cancer in the right upper lobe involving the main stem
bronchus. She had coughing with shortness of breath,
nonspecific chest pain, one episode of hemoptysis.
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post coronary artery bypass graft in [**2187**],
chronic obstructive pulmonary disease, emphysema and non
Hodgkin's lymphoma in [**2186**].
PAST SURGICAL HISTORY: Gastrectomy, coronary artery bypass
graft, Port-A-Cath insertion, which has been removed, tubal
ligation.
MEDICATIONS ON ADMISSION: Aspirin 81 mg q.d., Tagamet,
Lopresor, Synthroid, Ambien, Norvasc, Lipitor and Neurontin.
ALLERGIES: Taxol.
PHYSICAL EXAMINATION: The patient is afebrile and vital
signs are stable. 96% on room air. Her lungs were clear to
auscultation bilaterally. Heart was regular rate and rhythm
with no murmurs, rubs or gallops. Abdomen soft, nontender,
nondistended with normal bowel sounds. Well healed scars
both midline and lower abdomen. Extremities were warm and
well perfuse with no clubbing, cyanosis or edema.
HOSPITAL COURSE: The patient was taken to the Operating Room
where a right upper lobe and middle lobe resection was
performed. The patient was transferred to the Intensive Care
Unit postoperatively and she did well. The patient was
extubated and continued to do well. She was transferred to
the floor where she continued to improve. Her diet was
advanced. Her Foley was removed. The patient was seen by
physical therapy, which continued to work with her. She had
difficulty clearing secretions and was often unable to do
deep breathing, which required a lot of motivation, however,
the patient continued to improve and slowly started to begin
ambulating. The patient was seen also by medicine for
hypertension and was started on Amiodarone. The patient
continued to improve and on [**2197-7-18**] is discharged home in
stable condition with plans to have home physical therapy to
continue aggressive pulmonary toilet and to improve
ambulation.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Vicodin for pain. Lopressor 25
b.i.d., Combivent, Albuterol, Amiodarone 400 mg q.d.,
Synthroid, Flovent, Zantac.
The patient is instructed to follow up with her primary care
physician in one to two weeks.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2197-7-18**] 10:58
T: [**2197-7-24**] 06:44
JOB#: [**Job Number 25123**]
|
[
"427.31",
"V45.81",
"492.8",
"285.9",
"E878.8",
"511.0",
"997.1",
"162.3",
"512.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.4",
"33.22",
"32.4",
"40.29",
"32.1",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
2394, 2403
|
2427, 2907
|
899, 1010
|
1435, 2372
|
765, 872
|
1033, 1417
|
155, 530
|
553, 741
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,027
| 166,622
|
40037+58345
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-11-4**] Discharge Date: [**2193-11-11**]
Date of Birth: [**2109-1-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
shortness of breath with extertion
Major Surgical or Invasive Procedure:
[**2193-11-7**] Coronary artery bypass graft x3: Left internal
mammary artery to the left anterior descending; reverse
saphenous vein graft to the first obtuse marginal; and
reverse saphenous vein graft in the distal right coronary
artery.
History of Present Illness:
84 year old male reports that he has
experienced exertional dyspnea which started approximately one
month ago and seems to be worsening gradually. He presently
notes
shortness of breath after walking [**1-31**] of a mile and when
climbing
stairs which is also accompanied by occasional lightheadedness.
Otherwise, he denies chest pain or pressure, palpitations,
syncope, lightheadedness, claudication, edema, orthopnea, PND.
Stress test was abnormal and cath revealed multivessel CAD. He
is referred for CABG.
Past Medical History:
Coronary Artery Disease, s/p CABG
PMH:
Diabetes
Hypertension
Hyperlipidemia
BPH
Arthritis
Social History:
Lives with:alone, children around for support
Occupation:retired
Tobacco:denies
ETOH:denies
Family History:
Father had CAD and Rheumatism died in his 60's
Physical Exam:
Pulse:73 Resp:18 O2 sat: 99/RA
B/P Right:175/81 Left:182/74
Height:5'7" Weight:205 lbs
General:NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [], well-perfused [] Edema Varicosities: None
[]venous stasis changes, +3 pitting edema
Neuro: Grossly intact
Pulses:
Femoral Right:+1 Left:+1
DP Right: not palpable Left:not palpable
PT [**Name (NI) 167**]:not palpable Left:not palpable
Radial Right: +2 Left:+2
Carotid Bruit Right: Left:
Pertinent Results:
[**2193-11-11**] 04:37AM BLOOD Hct-35.9*
[**2193-11-10**] 05:13AM BLOOD WBC-11.2* RBC-3.55* Hgb-12.4* Hct-35.4*
MCV-100* MCH-34.9* MCHC-35.0 RDW-13.4 Plt Ct-188
[**2193-11-11**] 04:37AM BLOOD UreaN-31* Creat-1.2 Na-136 K-4.3 Cl-102
[**2193-11-10**] 05:13AM BLOOD Glucose-120* UreaN-27* Creat-1.2 Na-134
K-4.2 Cl-100 HCO3-29 AnGap-9
[**2193-11-7**]
PRE BYPASS The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. A patent foramen ovale is present.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST BYPASS The patient is AV paced. There is normal
biventricular systolic function. Valvular function is unchanged.
The thoracic aorta appears intact after decannulation.
Brief Hospital Course:
The patient was brought to the operating room on [**2193-11-7**] where
the patient underwent CABG x 3 with Dr. [**Last Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4, the patient was deconditioned but
ambulating, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to [**Hospital1 **] House
Rehab in good condition with appropriate follow up instructions.
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet -
1
Tablet(s) by mouth once daily
CLOTRIMAZOLE - (Prescribed by Other Provider) - 10 mg Troche -
take 1 troche four times per day
FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once daily
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once daily
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - 150 mg
Tablet - 1 Tablet(s) by mouth once daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth once daily
OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 15 mg
Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once daily
SITAGLIPTIN-METFORMIN [JANUMET] - (Prescribed by Other
Provider)
- 50 mg-500 mg Tablet - 1 Tablet(s) by mouth once daily
SOLIFENACIN [VESICARE] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth once daily
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Tablet, Chewable - 1 Tablet(s) by mouth once daily
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. 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*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. sitagliptin-metformin 50-500 mg Tablet Sig: One (1) Tablet
PO once a day.
12. solifenacin 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
20mg daily ongoing after 1 week of 40mg daily is complete.
16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] House Rehabilitation & Nursing Center - [**Location (un) 5087**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
PMH:
Diabetes
Hypertension
Hyperlipidemia
BPH
Arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2193-12-4**]
1:00
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 4475**] [**2193-12-2**], 1pm
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 1730**] O. [**Telephone/Fax (1) 4475**] in [**3-4**] 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:[**2193-11-11**] Name: [**Known lastname 13954**],[**Known firstname 33**] F Unit No: [**Numeric Identifier 13955**]
Admission Date: [**2193-11-4**] Discharge Date: [**2193-11-11**]
Date of Birth: [**2109-1-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 135**]
Addendum:
Statin was added to d/c meds
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. 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*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. sitagliptin-metformin 50-500 mg Tablet Sig: One (1) Tablet
PO once a day.
12. solifenacin 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
20mg daily ongoing after 1 week of 40mg daily is complete.
16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
17. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4368**] House Rehabilitation & Nursing Center - [**Location (un) 5670**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2193-11-11**]
|
[
"250.00",
"414.01",
"600.00",
"530.81",
"401.9",
"V45.73",
"274.9",
"426.11",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"88.56",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11461, 11731
|
3525, 4627
|
315, 558
|
7827, 7983
|
2133, 3502
|
8771, 9830
|
1338, 1386
|
9853, 11438
|
7714, 7806
|
4653, 6050
|
8007, 8748
|
1401, 2114
|
240, 277
|
586, 1098
|
1120, 1212
|
1228, 1322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,576
| 128,632
|
38148
|
Discharge summary
|
report
|
Admission Date: [**2162-4-29**] Discharge Date: [**2162-5-26**]
Date of Birth: [**2135-1-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transferred from OHS for management of acute necrotizing
pancreatitis and respiratory failure
Major Surgical or Invasive Procedure:
Percutaneous gallbladder drain placement
Drain reinsertion
Broncheal lavage
Thoracocentesis
History of Present Illness:
27 yo male with pmh significant for ETOH abuse and peptic ulcer
who was admitted to the [**Hospital 1562**] Hospital on [**2162-4-22**] for
abdominal pain, nausea and vomiting. He was found to have
pancreatitis with lipase at 2946 at presentation. He was
initially treated on medicine floor with IV fluids and pain
meds. He then became hypotensive and tachycardic. They thought
this was related to ETOH withdraw there was a question of
aspiration and SIRs. There was concern for airway protection and
he was intubated. Initially thought to have evolving ARDS. He
was given fluids and pressors. He self extubated on [**4-28**] and
was placed on bipap intermittently. He had ABD CT studies that
showed extensive swelling of the pancreas with extensive fluid
in the peripancreatic tissue.
He was initially febrile and was started on vanco, flagyl,
imepenem. As per notes he has not been febrile in the last few
days. He had increase abdominal distention consistant with
ascitis and had a paracentesis on [**4-28**] which showed
greenish/brownish fluid with amylase 68, glucose of 132, LDH
1585, which were concerning for necrotizing pancreatitis. There
is no diff of the peritoneal fluid. Both blood and peritoneal
cultures are still pnd. As per discharge summary pt was
hemodynamically stable with BP 130/90, RR 24 and 100% on non
rebreather prior to discharge. Today's his amylase is 47, lipase
80, GGT 289, t.bili 1.6 Na 137, K 4.5, Creatine of 0.6. His WBC
23,000, Hct 30, plts 307K. He also developed [**Doctor First Name 48**] with creatine
3.4 which has improved.
On arrival, he was A+O x3 very anxious with increase WOB, RR
40s, o2 sat 100% on non-rebreather. HR 120 Sinus tachy, BP
142/88, temp 99.7.
He was then intubated due increase work of breathing. During
intubation he desated for a few seconds to 50s% and quickly
recovered to 100% while intubated. He was awake and required
increased amounts of sedation.
Past Medical History:
Gastric ulcer disease requiring EGD in [**2159**] with clipping
ETOH abuse
Social History:
Pt lives alone. Both mother and father are very involved on his
care. He drinks on average 4-5 drinks of whiskey per day 4-5x
wk. He does not smoke, and has used marijuana in College, but
denies using any other illicit drugs
Family History:
CAD father at age of 62
Physical Exam:
Vitals: Temp 99.7, HR 120s-160s sinus tachy, BP 142/88, RR 40s
100% on non-rebreather
General: increase wob and anxiety
HEENT: Sclera mildly icteric, dry MM, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: shallow breathing with diminished BS at bases, upper and
central rhonchi, no wheezes crackles
CV: +S1 + S2, no murmurs, rubs, gallops, +tachycardia
Abdomen: tense, non-tender, distended with ascitis, +bowel
sounds, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses,no edema in bilateral LE
Neuro: A+ o x3
Pertinent Results:
[**2162-4-22**] at admisson: lipase 2946, amylase 249, TG 2715. , GGT
4182, Tbili 2.7, ALT 148, AST 285, ALK phos 321
Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2162-5-25**] 04:56 13.1* 2.65* 7.9* 24.7* 93 29.9 32.0 16.5*
937*
ADMISSION LABS:
[**2162-4-29**] 10:45PM BLOOD WBC-21.3* RBC-3.35* Hgb-10.3* Hct-31.4*
MCV-94 MCH-30.8 MCHC-32.9 RDW-16.0* Plt Ct-419
[**2162-4-29**] 10:45PM BLOOD Neuts-89* Bands-4 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2162-4-29**] 10:45PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+
[**2162-4-29**] 10:45PM BLOOD PT-14.5* PTT-28.7 INR(PT)-1.3*
[**2162-5-5**] 04:03AM BLOOD Plt Ct-1065*
[**2162-5-9**] 04:13AM BLOOD Plt Smr-VERY HIGH Plt Ct-1263*
[**2162-4-29**] 10:45PM BLOOD Glucose-141* UreaN-12 Creat-0.6 Na-140
K-4.4 Cl-103 HCO3-25 AnGap-16
[**2162-4-29**] 10:45PM BLOOD ALT-21 AST-33 LD(LDH)-658* AlkPhos-80
Amylase-36 TotBili-1.2
[**2162-5-17**] 04:31AM BLOOD ALT-12 AST-43* LD(LDH)-319* AlkPhos-243*
TotBili-2.9* DirBili-2.3* IndBili-0.6
[**2162-5-18**] 05:31AM BLOOD ALT-18 AST-47* AlkPhos-385* TotBili-4.0*
[**2162-5-18**] 11:45PM BLOOD AlkPhos-492* TotBili-4.1*
[**2162-5-19**] 05:06AM BLOOD ALT-20 AST-44* LD(LDH)-221 AlkPhos-500*
TotBili-3.8*
[**2162-5-20**] 04:31AM BLOOD ALT-15 AST-37 AlkPhos-653* TotBili-2.1*
[**2162-5-8**] 04:09AM BLOOD calTIBC-105* VitB12-1156* Folate-11.0
Ferritn-GREATER TH TRF-81*
[**2162-4-29**] 10:45PM BLOOD Triglyc-293*
[**2162-5-9**] 04:13AM BLOOD TSH-3.0
[**2162-4-29**] 09:07PM BLOOD Type-ART pO2-122* pCO2-35 pH-7.48*
calTCO2-27 Base XS-3
MICROBIOLOGY:
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 1.2 H <0.5
RESULT INTERPRETATION:
Sera with an Index <0.5 are considered to be negative.
Sera with an Index >=0.5 are considered to be positive
.
B-GLUCAN
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
<31 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.1 <0.5
RESULT INTERPRETATION:
Sera with an Index <0.5 are considered to be negative.
Sera with an Index >=0.5 are considered to be positive.
[**2162-4-29**], [**4-30**], [**5-2**], [**5-3**], [**5-4**], [**5-7**], [**5-10**] BLOOD CULTURE:
NO GROWTH.
[**2162-4-29**] 10:46 pm URINE Source: Catheter. NO GROWTH
[**2162-4-30**] 10:17 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2162-5-2**]**
GRAM STAIN (Final [**2162-4-30**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2162-5-2**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2162-4-30**] 11:20 pm CATHETER TIP-IV Source: R CVC.
**FINAL REPORT [**2162-5-3**]**
WOUND CULTURE (Final [**2162-5-3**]): No significant growth.
[**2162-5-3**] 10:48 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2162-5-5**]**
GRAM STAIN (Final [**2162-5-3**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2162-5-5**]):
SPARSE GROWTH Commensal Respiratory Flora.
**FINAL REPORT [**2162-5-1**]**
URINE CULTURE (Final [**2162-5-1**]): NO GROWTH.
[**2162-5-4**] 11:43 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2162-5-7**]**
FECAL CULTURE (Final [**2162-5-7**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2162-5-7**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2162-5-5**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2162-5-7**] 11:45 am CATHETER TIP-IV Source: aline.
**FINAL REPORT [**2162-5-9**]**
WOUND CULTURE (Final [**2162-5-9**]): No significant growth.
[**2162-5-10**] 12:01 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2162-5-12**]**
GRAM STAIN (Final [**2162-5-10**]):
[**9-20**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2162-5-12**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2162-5-11**] 1:01 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-CVL.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2162-5-12**] 3:40 am BLOOD CULTURE Source: Line-CVL- TPN LINE.
**FINAL REPORT [**2162-5-15**]**
Blood Culture, Routine (Final [**2162-5-15**]):
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. .
Daptomycin = SENSITIVE ( 1.5 MCG/ML ).
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2162-5-12**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1030PM [**2162-5-12**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final [**2162-5-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2162-5-12**] 12:11 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2162-5-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2162-5-14**]): NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2162-5-12**] 7:29 pm BILE
**FINAL REPORT [**2162-5-19**]**
GRAM STAIN (Final [**2162-5-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2162-5-16**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2162-5-19**]): NO GROWTH.
[**2162-5-13**] 1:01 am CATHETER TIP-IV Source: right IJ triple
lumen.
**FINAL REPORT [**2162-5-15**]**
WOUND CULTURE (Final [**2162-5-15**]): No significant growth.
[**2162-5-13**] 10:28 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2162-5-19**]**
Blood Culture, Routine (Final [**2162-5-19**]): NO GROWTH.
[**2162-5-15**] 6:07 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
[**2162-5-16**] 4:16 pm BILE
GRAM STAIN (Final [**2162-5-16**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2162-5-19**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2162-5-18**] 3:00 pm PERITONEAL FLUID
GRAM STAIN (Final [**2162-5-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2162-5-19**] 3:09 pm PLEURAL FLUID
**FINAL REPORT [**2162-5-25**]**
GRAM STAIN (Final [**2162-5-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2162-5-22**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2162-5-25**]): NO GROWTH.
PLEURAL
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro Other
[**2162-5-19**] 15:09 370* 2325* 16* 28* 33* 4* 1* 17*1 1*2
SEVERAL SIGNET FORMS NOTED
REACTIVE MESOTHELIAL CELLS
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 85107**] [**2162-5-20**]
PLEURAL CHEMISTRY TotProt Glucose Creat LD(LDH) Amylase Albumin
[**2162-5-19**] 15:09 3.5 113 0.4 186 15 1.8
ASCITES
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Eos Mesothe Macroph
[**2162-5-10**] 14:17 315* 410* 12* 17* 0 1* 2* 68*
SOURCE IS PERITONEAL FLUID
ASCITES CHEMISTRY Amylase TotBili Misc
[**2162-5-18**] 15:11 24 1.9 LIPASE = 21
CT Abdomen and Pelvis [**2162-5-17**]:
1. A large amount of ascites in the abdomen and pelvis, as
before. There is increased enhancement of the margins of fluid
in both flanks with areas of loculation.
2. New area of enhancing perihepatic fluid adjacent to the
lateral margin of the right hepatic lobe, which may represent a
biloma following prior
cholecystostomy.
3. The cholecystostomy tube now lies in the right anterior
abdominal wall,
with a small portion in the subcapsular portion of the right
hepatic lobe. The gallbladder is not distended, and contains
intraluminal debris.
4. No PE is seen. Large bilateral pleural effusions have
slightly increased in size.
Echo [**2162-5-25**]:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2162-5-13**], the left ventricular systolic function is less
vigorous, but still normal.
Brief Hospital Course:
27 yo male who was admitted from outside hospital ICU initially
admitted on [**4-22**] and transferred to our [**Hospital Ward Name 332**] MICU on [**2162-4-29**]
with alcoholic necrotizing pancreatitis and ARDS. He was
extubated twice once in outside hospital and once in the our ICU
he became tachypenic and was unable to protect his airway, so he
was reintubated. He was intubated on the vent in our hospital
for > 10 days and transitioned to trach.
#Pancreatitis: He developed necrotizing pancreatitis complicated
with ARDS. He was weaned off vent, ultimately to trach collar on
room air. He received meropenem for 10 days, stopped on [**2162-5-9**].
He had diffuse abdominal inflammation and ascites thought to be
due to his pancreatitis. He had gallbladder, pleural, and
peri-hepatic fluids therapeutically and diagnostically drained.
He had bowel rest with TPN and ultimately transitioned to
[**Last Name (un) 1372**]-jejunal tube feeds. Surgery closely followed pt throughout
hospital course. Will follow-up with surgery, Dr. [**Last Name (STitle) 468**], to
asses his progress and repeat CT - details on Page 1.
# Pulmomary Embolus: Pt was diagnosed with PE on CT scan which
showed probable PE versus motion artifact: LENIs were negative.
Started on heparin drip then switched to lovenox. Repeat chest
CTA done on [**5-17**] did not show a PE, however this was difficult
to interpret since he was already treated for 7 days with
lovenox and clot might have been absorbed. He continued on
lovenox and started coumadin during admission. He will need to
continue lovenox until he is therapeutic in INR (goal [**12-30**]) for
at least 48 hours. At that time, he can be maintained on
coumadin.
# Bacteremia: Pt had Vanco Resistent Eneteroccocus from [**5-12**]
culture, antibiotic switched from Vanco to linezolid started on
[**5-13**] with a 14 day course (to be completed by [**5-27**].). He had
fevers much of his stay which eventually trended down with
antibiotics. On discharge, he was asymptommatic, afebrile and
hemodynamically stable. PICC line was removed prior to
discharge, tip was NOT sent for culture.
#C. Diff: pt had positive C. diff toxin from outside hospital.
He was started on flagyl (took 15 day course) then switched to
PO vancomycin (will continue until 2 weeks after broad spectrum
antibiotics are stropped).
# Hypoxemic respiratory failure: Pt likely developed ARDS in the
setting of pancreatitis. Pt was treated with 14 day course of
[**Last Name (un) 2830**] and Vanco and 8 day course of levo for aspiration/HAP pna.
After extubation, he aspirated and was covered broadly with
vanc/zosyn for 7 + days which was d/ced on [**5-15**]. Pt was
briefly treated with micafungin for 6 days for + B-galactamanan,
but repeat test was negative so it was stopped. Pt continued
with linazolid with stop date on [**2162-5-27**].
# Vent: Pt weaned off vent after around 30 days and ultimately
transitioned to trach collar. On day of discharge, he was
comfortable on trach collar room air, able to talk with
Passe-Muir valve.
#Delerium and sedation: Pt experienced delerium thought to be
secondary to his high doses of narcotics and benzos for sedation
while intubated for 30 days. He was given haldol and tapered
methadone which improved his mental status. His delerium
gradually improved dramatically over the course of his
hospitalization and he was lucid, conversant, ambulatory by the
day of discharge.
#Nutrition: Was on TPN and transitioned to Tube feeds [**First Name8 (NamePattern2) **]
[**Last Name (un) **]-jejunal tube. A few days prior to discharge, he was
tolerating a soft food diet.
#Tachycardia: Pt was tachycardic in the 120-130s most of his
admission. It was initially thought that his tachcyardia was
secondary to withdrawel from sedation and optiod administration
for the entire month that he was ventilated. However, fluid
boluses, methadone and benzos did not help. We ultimately put
him on beta blockers Carvedilol 6.25 [**Hospital1 **] to rate control him and
prevent tachycardia induced cardiomyopathy. Carvedilol should be
titrated to HR in 100-120's as BP will tolerate.
Medications on Admission:
Medications at transfer:
Imipenem 500mg IV Q 8 hrs
Flagyl 500mg Q8hrs
Vancomycin 1000mg Q8hrs
Lactobacillus
MVI
Promethazine prn
Zofran
Nebulizers: Duoneb
Dexmedetomidine infusion at 0.5mcg/kg per hour
Protonix 40mg Qday
Discharge Medications:
1. Vancomycin 250 mg Capsule [**Hospital1 **]: 500mg Capsules PO Q6H (every 6
hours): Last Day [**6-10**] - Continue for 14 days after last dose
of Linezolid. .
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month (only) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day): Continue as long as pt is
on trach.
3. Enoxaparin 80 mg/0.8 mL Syringe [**Hospital1 **]: 80mg Subcutaneous Q12H
(every 12 hours): Can switch to oral coumadin. .
4. Acetaminophen 325 mg Tablet [**Hospital1 **]: 650mg Tablets PO Q6H (every
6 hours) as needed for pain/fever.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: 30mg
Tablet,Rapid Dissolve, DRs [**Last Name (STitle) **] [**Name5 (PTitle) **] (Daily).
6. Nystatin 100,000 unit/mL Suspension [**Name5 (PTitle) **]: 5mL MLs PO QID (4
times a day) as needed for thrush: for oral thrush. swish and
swallow 4 times a day.
7. Trazodone 50 mg Tablet [**Name5 (PTitle) **]: 25mg Tablets PO HS (at bedtime)
as needed for sedation: for sleep if needed.
8. Camphor-Menthol 0.5-0.5 % Lotion [**Name5 (PTitle) **]: One (1) Appl Topical
QID (4 times a day) as needed for Rash: For rash on leg.
9. Linezolid 600 mg Tablet [**Name5 (PTitle) **]: 600mg Tablets PO Q12H (every 12
hours): Take through [**2162-5-27**].
10. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
11. Thiamine HCl 100 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a
day.
12. Carvedilol 6.25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2
times a day).
13. Warfarin 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily):
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] [**Location (un) 701**]
Discharge Diagnosis:
Necrotizing pancreatitis
ARDS - Acute Respiritary Failure
Pneumonia
Vancomycin resistent enterococcus bacteremia
Pulmonary embolism
Clostridium Difficile diarrhea
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
You will go to a rehab center to continue your care for
alcoholic pancreatitis and respiratory failure. You were
admitted to the hospital for over a month for treatment of
alcoholic pancreatitis and respiratory failure. You were very
sick and required a machine to help you breath for about one
month. Eventually, we transitioned you to a tracheostomy (hole
in your neck for breathing) to continue to protect your lungs as
you improved. We gave you antibiotics for infections of your
blood and abdomen which must be continued after discharge as
listed below. Your pancreas was very inflamed causing fluid
build up in your abdomen and lungs, requiring drainage. You also
had a blood clot in one of your veins and were started on a
blood thinner, lovenox (shot) and warfarin (pill). It is
important that you have your warfarin level checked as
instructed by your physician once you leave rehab. You
clinically improved throughout the hospital course and are ready
for your next step in treatment at a rehabilitation center.
CHANGES IN MEDICATION:
Please start all medications as listed on your discharge
paperwork. You were not admitted to the hospital on any
medications.
Followup Instructions:
Dr. [**Last Name (STitle) 468**] appt and CT on [**2162-7-12**]:
CT scan at 9am.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2162-7-12**]
11:15am.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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icd9pcs
|
[
[
[]
]
] |
20328, 20398
|
14278, 18418
|
409, 503
|
20617, 20617
|
3410, 3674
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20419, 20596
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11251, 11455
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276, 371
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531, 2455
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11745, 14255
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20632, 20654
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2477, 2553
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2569, 2795
|
11694, 11709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,476
| 101,259
|
53233
|
Discharge summary
|
report
|
Admission Date: [**2137-10-14**] Discharge Date: [**2137-10-22**]
Date of Birth: [**2057-5-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim / Nsaids
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
shortness of breath, productive cough
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
The patient is an 80-year-old female with a past medical history
significant for chronic bronchiectesis, MV-repair/tricuspid
valve replacement, CHF, and atrial fibrillation who presented to
to her primary care physician's office at [**Company 191**] just prior to this
hospital admission complaining of worsening dyspnea and cough.
At baseline, the patient has moderate amount of yellow sputum
and is on 2.5 L oxygen via home NC with typical oxygen
saturations ranging from 95-96%. Prior to presentation she
describes having 3-4 days of extreme fatigue, nausea, weakness
and worsening sputum production that was darker yellow-greenish
in color along with a more frequent cough. She was sent from the
[**Hospital 191**] clinic visit over to the ED for further workup. In clinic
she had a temperature of 100.3 F, RR 33 and she had notable
accessory muscle use and obvious labored breathing.
.
In the [**Hospital1 18**] ED her vitals were: Temperature of 101.6F, HR 80,
SBP 130s, and oxygen saturations were in the low 90's on 4L NC
and remained in low 90s with higher rates on non-rebreather
mask. Despite her presentation, she had no significant WBC
elevations. On exam, she had rales throughout both lung fields.
On EKG she was V-paced as she has a pacemaker. She also had
evidence of atrial fibrillation on EKG. CXR in ED showed both
RUL and LLL opacities. She was given nebulizer treatments with
little effect. IV Vancomycin and Levofloxacin were also
initiated in the emergency room soon after her arrival. She was
felt to be too unstable for the general medical floor and was
admitted to the MICU service.
.
Following admission to MICU the patient continued to have
increased work of breathing and productive cough with low oxygen
saturations and was felt to be in hypoxic respiratory distress
with some hypercarbia as well as ABG showed a pO2 of 63mmHg and
pCO2 of 49. Fortunately, she did not require intubation but she
was started on non-invasive ventilation. She was mostly
normotensive with a few drops of SBP into the high 80s but she
did not require any pressors. IVFs were used sparingly given her
CHF history. She has a history of resistant pseudomonas so there
was some concern for re-infection, especially since gram
negative rods were found on sputum culture. Urine legionella
testing was sent off as well and she was continued on her
Levofloxacin coverage at time of her transfer to the general
medical floor until urine legionella results returned.
Vancomycin was discontinued at time of transfer out of MICU.
While in the MICU she also underwent daily chest PT and received
ongoing nebulizer treatments.
Upon arrival to the general medical floor she had been
successfully weaned down to 4-5L on nasal cannula with oxygen
saturation levels of 93%-95%. In general, she stated she was
feeling "much better" with more energy and less shortness of
breath at time of her transfer. Despite her CHF history she did
not seem to have any signs of fluid overload as her JVD was
5-6cm and she had no crackles on lung exam and no pedal edema.
She was continued on her usual Coumadin therapy for her atrial
fibrillation and tricuspid valve replacement but she had to hold
her Coumadin for a few evenings due to a high INR. Because of
her bronchiectasis her INR goal is uniquely 2.0 so the team made
note of this fact during her stay.
.
Past Medical History:
1. CAD - Cath ([**3-/2134**]) - LMCA and LCx, no disease; LAD: proximal
and mid vessel 30% stenoses; RCA - mild luminal irregularities
- Pacemaker/ICD ([**Company 1543**] Sigma SDR303 B pacemaker), in [**1-/2132**]
2. Atrial fibrillation, status post AVJ ablation and DDD pacer
3. Congestive heart failure (EF 30% in [**2135**])
4. MV repair and TVR ([**4-/2132**])
5. Bronchiectasis with presumed pseudomonal colonization
([**2135-12-19**] and treated with ceftazidime and azithromycin):
Previously suffered exacerbations in [**Month (only) **] and [**2135-8-19**]
that were treated with meropenem/ciprofloxacin and ceftazidime
as outpatient
6. Depression
7. Hyperparathyroidism
Social History:
Lives in [**Location (un) 55**]. She worked as a lecturer on Egyptology
at the MFA in [**Location (un) 86**]. Husband is deceased. She lives with her
son and has an aid most days of the week. Has three sons, [**Name (NI) **],
[**Doctor First Name **] and [**Doctor Last Name **]. Quit smoking 30 years ago, had a 5 pack year
history. Previously, she drank one drink/day but no ETOH now
for many years.
Family History:
Her father and mother are both deceased. Her father had HTN. Her
mother had [**Name (NI) 19917**] disease and died as an elderly woman. There
is a negative family history of colon cancer, breast cancer,
diabetes, and premature coronary artery disease. She has three
natural children who are alive and well and one brother who is
alive and well.
Physical Exam:
PHYSICAL EXAM:
VS: 97.6, HR 81, BP 128/50, RR20s, 93% (92-97%) on 4L NC
GENERAL: no distress at rest, mild nasal flaring with
respirations but no accessory muscle use noted, alert and
oriented to person, place and time, pleasant demeanor
HEENT: moist mucosal membranes, EOMI, OP clear of exudates, mild
erythema at posterior pharynx
Neck: JVD at 5-6cm, supple, no thyromegaly, no lymphadenopathy
CVS: Loud S2 noted, regular S1, pulse is irregular,no
murmurs/rubs/gallops
Pulm: Diffuse coarse rhonchi throughout lung fields bilaterally
and decreased lung sounds at LLL. No dullness to percussion.
Abd: Normoactive BS throughout, NT/ND, no hepatosplenomegaly
Extrem: no edema, 2+ DP and PT pulses distally at lower
extremities
Skin: No rashes, warm, pink complexion
Neuro: CNs [**1-29**] in tact, no focal motor or sensory deficits
noted, appropriate affect
.
Pertinent Results:
ADMISSION LABS:
.
[**2137-10-14**] BLOOD WBC-9.2 RBC-4.86 Hgb-14.0 Hct-42.2 MCV-87
MCH-28.7 MCHC-33.1 RDW-14.3 Plt Ct-237, differential:
Neuts-73.6* Lymphs-19.5 Monos-5.8 Eos-0.5 Baso-0.7
[**2137-10-14**] BLOOD PT-17.4* PTT-23.9 INR(PT)-1.6*
[**2137-10-14**] BLOOD Glucose-127* UreaN-18 Creat-0.8 Na-134 K-4.4
Cl-97 HCO3-28 AnGap-13, Calcium-10.7* Phos-2.8 Mg-2.3,
Glucose-122, Lactate-1.3 K-4.5
.
INITIAL URINE :
[**2137-10-14**] URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2137-10-14**] URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG
KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2137-10-14**] URINE RBC-[**5-28**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0
.
OTHER TESTS/IMAGING:
.
[**2137-10-14**] EKG : Rate 80 and ventricular paced with slow atrial
fibrillation noted, no ST changes. Compared with EKG [**2137-6-9**]
.
[**2137-10-14**] CXR: Chronic interstitial lung disease with increased
right upper lobe and LLL opacities which may represent atypical
pneumonia or atelectasis.
.
[**2137-10-16**] CXR: The lungs are again well expanded. Evidence of
bronchiectasis is better seen on CT. Wedge-shaped opacity behind
the left heart appears slightly more consolidative; while this
could represent atelectasis related to impacted airways, if the
patient had fever, this could also represent consolidation.
Ill-defined opacity in the right upper lung is worse. Opacity
seen on CT in the left lung apex is not evident
radiographically. No new area of consolidation is noted.
No evidence of pneumothorax or pleural effusion is seen.
Cardiomediastinal
contours are unchanged. A left-sided transvenous pacemaker with
right atrial and right ventricular leads remain in place.
Sternotomy wires remain in place, tricuspid valve prosthesis and
possible mitral annular prosthesis remain in place.
.
MICROBIOLOGY:
.
[**2137-10-17**] Blood cultures x2 -No growth
[**2137-10-14**] Blood cultures x2 -No growth
[**2137-10-14**] Urine culture -No growth
[**2137-10-15**] Urine Legionella Antigen -negative
[**2137-10-15**] MRSA nasal swab -negative
[**2137-10-15**] Sputum Culture:
GRAM STAIN (Final [**2137-10-15**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2137-10-22**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.MODERATE GROWTH.
UNABLE TO PERFORM SENSITIVITIES DUE TO LACK OF INTERPRETATION..
.
DISCHARGE LABS:
.
[**2137-10-22**] 05:58AM BLOOD WBC-10.6 RBC-4.08* Hgb-11.7* Hct-35.2*
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.4 Plt Ct-324, Plt Ct-324
[**2137-10-22**] 05:58AM BLOOD Glucose-80 UreaN-14 Creat-0.5 Na-137
K-4.2 Cl-98 HCO3-35* AnGap-8, Calcium-9.4 Phos-3.0 Mg-2.1
Brief Hospital Course:
In summary, the patient is an 80-year-old female with chronic
bronchiectasis and home oxygen dependence, MV-repair/tricuspid
valve replacement, and atrial fibrillation who presented with
fevers, worsening cough, and shortness of breath which
progressed to hypoxic respiratory failure in the setting of
suspected new acute PNA which was corroborated by CXR.
.
# Hypoxic respiratory failure: At time of transfer to the
regular medicine [**Hospital1 **] from the MICU the patient's oxygen
requirements had improved and her hypoxia appeared to be
resolving well. She had an ABG with pO2 63 and pCO2 of 49 in
MICU shortly after admission consistent with hypoxic failure
mixed with hypercarbia. Patient has chronic bronchiectasis which
was initially noted in the late [**2108**] per patient and on further
discussion with the patient's pulmonologist it was noted that
the root of her bronchiectasis dates back to a severe pertussis
infection many years ago. She has had repeated PNAs and URIs
since that time with progressive decompensation and shortness of
breath leading to home oxygen dependency. At time of her
transfer out of the MICU she had been waened to 4-5L on nasal
cannula with oxygen saturations in the mid-90s. At home her
baseline oxygen saturations range between 94-97 % on 2.5L nasal
cannula per patient and her family. She progressed steadily and
her shortness of breath improved throughout her hospital course
with ongoing antibiotics and resolution of her PNA and
additional albuterol nebulizers and chest PT. Her ipatropium
regimen was changed to tiotropium and advair was continued. By
time of discharge she was back at her baseline of 2.5 L nasal
cannula with oxygen saturations in the high 90s.
.
# Pneumonia: Despite no leukocytosis, she presented with
worsened cough from her baseline, respiratory distress (RR >30),
fevers to 101 range, and CXR with consolidations noted at LLL
and RUL which were all suggestive of a new PNA. The patient was
also known to be colonizated with Pseudomonas in the past and
she had been treated in the past several times with various
antibiotics. Per records, her last recorded sputum had grown out
GNR (non-pseudomonas) sensitive to Ceftazidime, Levofloxacin,
Meropenem, and Zosyn. Given these sensitivity patterns and her
significant underlying lung pathology with bronchiectasis she
was continued on Levofloxacin initally for coverage for
atypicals/Legionalla PNA but once urine legionella returned
negative the levofloxacin was discontinued. She was continued on
broad coverage with Doripenem and switched to Meropenem just
prior to discharge. A PICC line was placed and home services
were arranged to help Mrs. [**Known lastname **] administer her antibiotics as an
outpatient until [**2137-10-28**] when she will complete a full 14 days
of antibiotics. Blood cultures all returned negative. She
continued her chest PT and spirometry at the bedside and she was
given daily mucinex, nebulizers alongside her antibiotics and
her cough and phlegm production gradually improved. Her fevers
gradually tapered as well and by time of discharge she had been
afebrile for several days.
.
# Bronchiectasis: As mentioned, her initial bronchiectasis and
pulmonary scarring was secondary to an older Pertussis infection
> 15 years ago. On this admission she had no hemoptysis noted
but cough and baseline sputum were much worse than usual at
admission per patient. She was continued on her Albuterol Nebs,
Advair, and Mucinex twice daily. The patient was encouraged to
continue her home inhalers, and ongoing chest PT as an
outpatient as she is predisposed to PNAs from her baseline
bronchiectasis.
.
# Systolic CHF: Last EF was 30% in [**2135**]. She had JVD=3-4cm on
exam, no crackles on lung exam, and no evidence of pedal edema
to indicate volume overload. She was in no apparent CHF distress
despite her acute PNA. During her hospital course she was
continued on Furosemide at 20mg dose with eventual taper to her
home dose of 10mg daily. She was also continued on Lisinopril
2.5mg PO daily and Spironolactone daily.
.
# Atrial fibrillation: She was placed on continuous telemetry
monitoring and several EKGs were assessed as well. She remained
V-paced with HR in 80s and occasional PVCs with no other notable
ectopy. Anticoagulation was continued with Coumadin with her INR
goal kept at 2.0 because of her extensive bronchiectasis. She
has a CHADS score 2. Coumadin dose was held for a few days due
to a brief period of time while her INR was supratherapeutic but
it was restarted prior to discharge with instructions for her
home services nurses to draw her blood on Wednesday [**10-23**]
and have her INR/PT levels sent to the [**Hospital 197**] Clinic at [**Company 191**]
in order to make sure her Coumadin level was within a proper
range. Mrs.[**Known lastname 109589**] INR was 1.9 at time of discharge.
.
# Hyperlipidemia: She was continued on her usual daily dose of
20mg Simvastatin for her hypercholesterolemia management. She
had no chest pain or angina during her hospital stay.
.
# Anxiety: The patient had well controlled anxiety levels
throughout her hospital course despite the undoubted stress of
being admitted to an intensive care unit in repiratory distress.
She was maintained on her usual home Citalopram 20 mg daily and
Lorazepam 1.0 mg QHS as needed.
.
# Fluids, electrolytes and nutrition: Mrs. [**Known lastname **] was given a
regular cardiac healthy diet and her electrolytes were checked
daily and replete on an as-needed basis. PO intake was
encouraged and IVFs were used sparingly due to her CHF history.
.
# Prophylaxis Issues: She was continued on Coumadin for
anticoagulation which also provided DVT prevention as well,
protonix was given for GI protection and Senna and Colace to
promote stool regularity.
.
The patient was maintained as a full code status for the
entirety of her hospitalization as communication occured
directly with the patient on a daily basis and with her three
sons as requested per patient. The patient's primary
pulmonologist,Dr. [**Last Name (STitle) **], was also updated on Mrs.[**Known lastname 109589**]
status during her hospital stay.
Medications on Admission:
1. Albuterol prn
2. Alendronate 70 mg qweek
3. Citalopram 20 mg daily
4. Advair [**Hospital1 **]
5. Furosemide 10 mg daily
6. Lisinopril 2.5 mg daily
7. Lorazepam 0.5-1.0 mg QHS PRN
8. Omeprazole 20 mg daily
9. Simvastatin 20 mg daily
10. Spironolactone 12.5 mg daily
11. Spiriva daily
12. Warfarin 1 mg daily
13. Calcium + Vit D
14. Guaifenisen 1200 mg [**Hospital1 **] PRN
15. MVI
Discharge Medications:
1. Outpatient Lab Work
Please check INR on Wednesday [**10-23**] and call results to
[**Hospital 191**] [**Hospital 197**] Clinic at [**Telephone/Fax (1) 2173**], report will be forwarded to
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
2. PICC line care
Routine PICC line care. Please flush PICC line with normal
saline [**4-27**] mL flushes PRN and heparin 10 units/mL [**2-20**] mL PRN
for line maintenance. Discontinue PICC upon completion of
antibiotics.
3. Meropenem 1 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 6 days.
Disp:*18 * Refills:*0*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: .5 Tablet PO DAILY (Daily).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. Albuterol Inhalation
12. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. Guaifenesin 600 mg Tablet Sustained Release Sig: [**12-19**] Tablet
Sustained Releases PO BID (2 times a day).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation AS DIR.
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please continue to have regular [**Company 191**] coumadin level checks as
directed by PCP .
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
18. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Pneumonia
Dyspnea / Hypoxic respiratory failure
Bronchiectasis
.
Secondary:
Coronary Artery Disease
Systolic congestive heart failure
Primary hyperparathyroidism
Osteoporosis
Atrial fibrillation s/p ablation and pacemaker
Depression
Discharge Condition:
At time of discharge the patient was clinically doing well with
stable vital signs and her oxygen requirements had returned to
her usual baseline on 2.5L oxygen via nasal cannula which was
her pre-admission home oxygen requirement. The patient's cough
had lessened in severity and she was in no distress.
Discharge Instructions:
It was a pleasure taking care of you during your hospital stay
here at [**Hospital1 69**].
You were admitted with worsening shortness of breath and a
productive cough and found to have a pneumonia. This diagnosis
was supported on additional imaging and lab studies. Your
shortness of breath was so severe that you needed to be admitted
to the medical intensive care unit for a few days prior to
transferring to a general medical floor once you were more
stable. Your were given high flow, non-invasive oxygen therapy
to help resolve your respiratory distress. You were also given
frequent nebulizer treatments to help your shortness of breath.
Antibiotics were given to treat your pneumonia. Your additional
medical issues which include atrial fibrillation, coronary
artery disease, depression, hyperparathyroidism and a history of
congestive heart failure were all monitored and managed during
your hospitalization.
Please continue with your usual outpatient physical therapy and
home health services. A script with instructions for your blood
to be drawn at home on Wednesday [**10-23**] has been included
in your discharge paperwork. Your INR level will be checked sent
to the [**Hospital 197**] Clinic at [**Company 191**] in order to make sure your
Coumadin level is correct.
Medication Instructions:
During your hospital stay a PICC line was placed for ongoing
antibiotic therapy which must be given intravenously. You will
continue to get your daily Meropenem antibiotic through your
PICC line (1g Meropenem every 8 hours)for a total of 2 weeks of
antibiotic therapy which are scheduled to end [**2137-10-27**]. The PICC
will be removed once antibiotic therapy is completed.
Because of your history congestive heart failure it is important
to weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs as
this may indicate fluid overload in your body. Adhere to 2 gm
sodium diet daily.
Please call your primary care physician or return to the
Emergency Department immediately if you experience fever,
chills, sweats, dizziness, lightheadedness, chest pain,
palpitations, shortness of breath, worsening of your baseline
cough, abdominal pain, vomiting, diarrhea, bloody or dark
stools, leg swelling or pain, numbness, weakness, or tingling.
Followup Instructions:
Please follow-up with your primary pulmonologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], on [**12-4**] at 11:30a.m. Phone # [**Telephone/Fax (1) 612**]. Dr. [**Name (NI) 76864**] office has been contact[**Name (NI) **] to try to get an earlier
appointment and you will be contact[**Name (NI) **] to arrange a [**Name (NI) **]
appointment.
Please follow-up with your primary care physician at [**Name9 (PRE) 191**], Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-13**] at 1:40pm. Phone # [**Telephone/Fax (1) 250**]
Completed by:[**2137-10-26**]
|
[
"733.00",
"V45.01",
"300.4",
"482.1",
"428.22",
"427.31",
"707.21",
"707.07",
"252.00",
"518.81",
"428.0",
"V43.3",
"494.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17347, 17405
|
8864, 15023
|
326, 348
|
17692, 17999
|
6104, 6104
|
20314, 20926
|
4863, 5211
|
15457, 17324
|
17426, 17671
|
15049, 15434
|
18023, 19307
|
8584, 8841
|
5241, 6085
|
249, 288
|
376, 3720
|
6120, 8568
|
19333, 20291
|
3742, 4426
|
4442, 4847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,889
| 159,307
|
5480
|
Discharge summary
|
report
|
Admission Date: [**2141-7-24**] Discharge Date: [**2141-7-27**]
Date of Birth: [**2077-6-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64yo man with history of pulmonary fibrosis on 2L home O2, on
lung transplant list, presents with worsening cough, fever,
chills and increasing O2 requirement. He has felt generally
unwell for about 2 weeks, noting that he had decreased exercise
tolerance and decreased energy. Then starting Thursday, he had
fevers up to 101.7 accompanied by sweats. Notes worsening of his
baseline, dry cough. He stopped taking pirfenidone then. Started
on azithromycin Saturday morning without improvement. Went to
see his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] in clinic for a physical, where he had
rales at his bilateral bases and appeared unwell.
In the ED, initial vs were: T 98.0 P 104 BP 134/73 R 24 O2 sat
96% 4L. Patient was given levofloxacin and 1L NS. Afebrile. UA
negative, WBC count 15 with left shift. Initially to go to floor
but had repeated desats to the 80s requiring additional oxygen.
.
On the floor, the patient has a frequent, paroxysmal,
non-productive cough. He has mild chest pain when coughing. He
has had loose BM's for the last couple of days. Has occasional
mild burning with urination, not worse currently. Denies N/V,
abdominal pain, headache, rash or arthralgias. He has never been
hospitalized. All other ROS negative.
Past Medical History:
- idiopathic pulmonary fibrosis, diagnosed in [**2134**], has been
progressive. Currently on transplant list at [**Hospital1 2025**], where his
work-up included a right-heart cath one year ago with mild
pulmonary HTN. Most recent PFTs have moderate restrictive
pattern and severe diffusion limitation. Wears between 2 and 6
liters O2 at home depending on level of exertion.
- systolic murmur
Social History:
Lives with wife and daughter. [**Name (NI) 1403**] for a mutual fund company.
- Tobacco: denies
- Alcohol: social
- Illicits: denies
Family History:
Father died of TB. Mother died of esophageal cancer. Has two
sisters who are healthy. No history of interstitial lung
disease.
Physical Exam:
On admission:
Vitals: T: 99.1 BP: 133/56 P: 102 R: 25 O2: 88-90% on 4L NC when
talking, 94% at rest
General: Alert, oriented, moderate respiratory distress when
coughing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Fine crackles throughout, fair air movement.
CV: Regular rate and rhythm, faint systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses. Finger tips with clubbing
and mild cyanosis. No edema.
On Discharge:
97.5 110/68 74 18 98% 1L
Well appearing, breathing comfortably with oxygen in place.
Bilateral crackles persist on discharge but improved from
admission.
Pertinent Results:
ADMISSION LABS
--------------
[**2141-7-24**] 02:00PM BLOOD WBC-15.0*# RBC-4.91 Hgb-15.4 Hct-44.7
MCV-91 MCH-31.3 MCHC-34.4 RDW-14.6 Plt Ct-223
[**2141-7-24**] 02:00PM BLOOD Neuts-90.0* Lymphs-6.3* Monos-3.1 Eos-0.5
Baso-0.2
[**2141-7-24**] 02:00PM BLOOD Glucose-105* UreaN-22* Creat-1.0 Na-138
K-3.9 Cl-101 HCO3-22 AnGap-19
[**2141-7-24**] 02:09PM BLOOD Lactate-1.6
.
DISCHARGE LABS
--------------
[**2141-7-27**] 06:45AM BLOOD WBC-8.9 RBC-4.50* Hgb-13.8* Hct-41.1
MCV-91 MCH-30.7 MCHC-33.6 RDW-14.3 Plt Ct-243
[**2141-7-27**] 06:45AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-139
K-4.7 Cl-102 HCO3-27 AnGap-15
.
MICROBIOLOGY
------------
Blood culture [**7-24**] x 2: pending
Legionella urine antigen: negative
.
[**2141-7-25**] 11:13 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final [**2141-7-25**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
.
IMAGING
-------
Chest X-ray on admission:
IMPRESSION: Mild increase in interstitial markings which could
reflect
worsening fibrosis or superimposed pulmonary interstitial edema.
Please
correlate clinically.
Brief Hospital Course:
64 year old male w/ h/o of advanced idiopathic pulmonary
fibrosis presenting with fever, cough and increased O2
requirement.
ACTIVE ISSUES
-------------
# Dyspnea: Patient had worsening of chronic dyspnea, which was
most likely secondary to infection, either viral or bacterial
superinfection after viral infection. Viral studies are so far
negative, and are thus far pending. Worsening of patient's
idiopathic pulmonary fibrosis is also a possibility, and repeat
CT scan may be useful as an outpatient. Given patient's tenuous
baseline respiratory status and ICU admission, coverage for
hospital acquired pneumonia was deemed reasonable,, and he is
often in pulmonary rehabilitation and at support groups with
chronically ill individuals, giving him significant exposure to
resistant organisms and patient was initiated on vancomycin,
levofloxacin and cefepime. Patient was narrowed to
levofloxacin, after patient improved and culture data remained
negative
At this point, since we are 48 hours out without culture
positivity, antibiotic regimen can be narrowed to seven day
course of levofloxacin. Blood cultures and viral swab are
currently pending. Patient's pirfenidone, a study drug, was
held on admission, and patient will follow up with his
pulmonologist, Dr. [**Last Name (STitle) **], after discharge to determine if he
should continue this medication. He will also follow up with
his primary care provider.
TRANSITION OF CARE:
# Follow-up: patient will follow up with his primary care
provider and pulmonologist upon discharge. He has pending blood
cultures and nasopharyngeal viral swab data which will need to
be followed up.
# Code: full code, confirmed
Medications on Admission:
- iodoquinol 1% cream apply [**Hospital1 **]
- mupirocin 2% ointment daily
- pirfenidone 3 tabs TID (study drug - anti fibrotic [**Doctor Last Name 360**] that
blocks various growth factors) -> stopped Thursday
- sildenafil 20mg TID -> stopped 1 month ago w/o change
- Vitamin D
- multivitamin
Discharge Medications:
1. iodoquinol-HC [**2-4**] % Cream Sig: One (1) application Topical
twice a day.
2. mupirocin 2 % Ointment Sig: One (1) application Topical once
a day.
3. sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Vitamin D Oral
5. multivitamin Oral
6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
7. Outpatient medication
Please do not resume taking pirfenidone until instructed by your
pulmonologist, Dr. [**Last Name (STitle) **]
8. Outpatient oxygen therapy
Please resume oxygen therapy per home regimen
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Healthcare-associated pneumonia
Secondary diagnosis:
Idiopathic pulmonary fibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You came for further evaluation of shortness of
breath and fever. Testing showed that you may have bacterial
pneumonia. It is important that you follow up with your
pulmonologist and primary care provider as listed below and
continue to take your medications as indicated.
The following changes have been made to your medications:
We ADDED levofloxacin, to treat pneumonia, which you should take
until it is totally finished, one more day after discharge
Followup Instructions:
Name: White, [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Address: [**Doctor First Name **],STE 9A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 10492**]
Appt: [**Last Name (LF) 2974**], [**7-28**] at 9:30am
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2141-8-3**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"515",
"486",
"V49.83",
"V46.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7131, 7137
|
4499, 6180
|
319, 325
|
7285, 7285
|
3118, 4295
|
8013, 8742
|
2206, 2335
|
6524, 7108
|
7158, 7158
|
6206, 6501
|
7435, 7990
|
2350, 2350
|
2944, 3099
|
266, 281
|
353, 1623
|
7233, 7264
|
7178, 7211
|
4309, 4476
|
7300, 7411
|
1645, 2039
|
2055, 2190
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,579
| 130,091
|
55002
|
Discharge summary
|
report
|
Admission Date: [**2184-7-7**] Discharge Date: [**2184-7-11**]
Date of Birth: [**2114-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Exertional chest pain and dyspnea
Major Surgical or Invasive Procedure:
[**2184-7-7**]: Coronary bypass grafting x2 with left internal mammary
to left anterior descending and reverse saphenous vein graft to
circumflex
History of Present Illness:
70 year old male who noted intermittant, exertional left arm
pain to primary care physician during his annual physical exam.
He underwent a stress test which was positive for ischemia. He
subsequently underwent a cardiac catheterization which revealed
two vessel coronary artery disease. Given the severity of his
disease, nature of his lesions and the fact that he is diabetic
he was been referred for surgical revascularization.
Past Medical History:
PMH:
- Coronary artery disease
- History of delerium/encephalopathy following anesthesia. ? if
it was due to withdrawal from ETOH. He was drinking 3 beers per
night at the time. Work-up negative for all other causes.
- Aortic stenosis - mild
- Mild CRI (baseline Creat 1.1)
- Cataract
- Diabetes Mellitus
- Peripheral neuropathy -Bilateral legs
- Hypercholesterolemia
- Hypertension
- Transient ischemic attack
- Lumbar disc disease
PSH:
Lumbar laminectomy [**1-/2181**]
Tonsillectomy
Teeth extractions
Social History:
Race: Caucasian
Last Dental Exam: Edentulous
Lives with: Wife
Occupation: Retired
Cigarettes: Smoked no [] yes [X] last cigarette 26 yrs ago Hx:
(few cigarettes per day for 4-5 years)
Other Tobacco use: no
ETOH: < 1 drink/week [X] Has not consumed ETOH since [**1-/2181**]
Family History:
Premature coronary artery disease:
Father with [**Name2 (NI) **] at age 85,
Mother died at 65 during angioplasty,
brother with CABG/AVR in mid 60's
Physical Exam:
Pre-op exam
Vital Signs sheet entries for [**2184-6-29**]:
BP: 106/73. Heart Rate: 68. Resp. Rate: 16. O2 Saturation%: 98.
Height: 68" Weight: 21lb
General: WDWN in NAD
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X] Sclera anicteric, OP benign,
Edentulous.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, II/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Trace-1+ LE Edema _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit: Question faint right vs. transmitted murmur.
Pertinent Results:
Admission labs
[**2184-7-7**] 09:40AM HGB-12.4* calcHCT-37
[**2184-7-7**] 09:40AM GLUCOSE-124* LACTATE-1.4 NA+-137 K+-3.8
CL--106
[**2184-7-7**] 01:00PM FIBRINOGE-190
[**2184-7-7**] 01:00PM PT-13.6* PTT-31.0 INR(PT)-1.3*
[**2184-7-7**] 01:00PM PLT COUNT-182
[**2184-7-7**] 01:00PM WBC-15.8*# RBC-3.33*# HGB-10.3*# HCT-29.4*#
MCV-88 MCH-31.0 MCHC-35.2* RDW-12.9
[**2184-7-7**] 02:33PM UREA N-13 CREAT-0.9 SODIUM-145 POTASSIUM-4.2
CHLORIDE-112* TOTAL CO2-25 ANION GAP-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.9 cm
Left Ventricle - Fractional Shortening: *-0.63 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Stroke Volume: 179 ml/beat
Left Ventricle - Cardiac Output: 10.01 L/min
Left Ventricle - Cardiac Index: 4.79 >= 2.0 L/min/M2
Right Ventricle - Diastolic Diameter: *4.7 cm <= 2.1 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Aortic Valve - LVOT VTI: 47
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *1.3 cm2 >= 3.0 cm2
Discharge Labs:
[**2184-7-11**] 08:25AM BLOOD WBC-11.1* RBC-3.37* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.6 MCHC-34.6 RDW-13.4 Plt Ct-170
[**2184-7-11**] 08:25AM BLOOD Plt Ct-170
[**2184-7-11**] 08:25AM BLOOD PT-16.9* INR(PT)-1.6*
[**2184-7-11**] 08:25AM BLOOD UreaN-27* Creat-1.2 Na-133 K-3.2* Cl-90*
Echo:
Findings
LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. The MR
vena contracta is <0.3cm. Mild (1+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. No TEE related complications. The patient appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the patient.
Conclusions
Prebypass
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.3 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2184-7-7**]
at 1030 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation and moderate tricuspid regurgitation persts. Aorta
is intact post decannulation. Rest of the examination is
unchanged post bypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician
Radiology Report CHEST (PA & LAT) Study Date of [**2184-7-11**] 11:27
AM
Final Report:
Patient is status post CABG. The heart and mediastinum remain
somewhat
enlarged. A left lower pleural effusion and some left basilar
atelectasis are present. No evidence of failure or pneumonia is
present.
IMPRESSION: Unremarkable post-CABG film.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2184-7-7**] where the patient underwent Coronary
artery bypass grafting x2 using
cardiopulmonary bypass: Left internal mammary artery to the
left anterior descending artery. Bypass from ascending aorta to
the obtuse marginal-2 branch of the circumflex artery using
reverse autologous saphenous vein graft.
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 on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD #4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home with visiting nurses in good condition with appropriate
follow up instructions.
Medications on Admission:
1. Multivitamins 1 TAB PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Niacin SR 1000 mg PO DAILY
5. Zolpidem Tartrate 5 mg PO HS:PRN sleep
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Rosuvastatin Calcium 5 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN angina
10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
11. Clopidogrel 75 mg PO DAILY
12. Aspirin EC 81 mg PO DAILY
13. GlipiZIDE XL 2.5 mg PO DAILY
14. coenzyme Q10 *NF* 10 mg Oral daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. Niacin SR 1000 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
7. coenzyme Q10 *NF* 10 mg Oral daily
8. Multivitamins 1 TAB PO DAILY
9. Zolpidem Tartrate 5 mg PO HS:PRN sleep
10. GlipiZIDE 2.5 mg PO BID
11. Rosuvastatin Calcium 5 mg PO DAILY
12. Acetaminophen 650 mg PO Q4H:PRN pain/temp
13. Losartan Potassium 25 mg PO DAILY
this is [**11-24**] your home dose
14. Amiodarone 400 mg PO BID
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
15. Diltiazem 30 mg PO QID
16. Ranitidine 150 mg PO BID Duration: 2 Weeks
17. Docusate Sodium 100 mg PO BID
18. MetFORMIN (Glucophage) 1000 mg PO BID
19. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**11-24**] tablet(s) by mouth every four (4)
hours Disp #*72 Tablet Refills:*0
20. Furosemide 40 mg PO BID Duration: 7 Days
RX *furosemide 20 mg 2 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
21. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
RX *potassium chloride 20 mEq 20 mEq by mouth twice a day Disp
#*14 Tablet Refills:*0
22. Warfarin MD to order daily dose PO DAILY16 afib
RX *Coumadin 2 mg as directed tablet(s) by mouth once a day Disp
#*90 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
coronary artery disease s/p CABG x2
PMH:
- History of delerium/encephalopathy following anesthesia. The
thought was that it was due to withdrawal from ETOH. He was
drinking 3 beers per night at the time. Work-up negtaive for all
other causes.
- Aortic stenosis - mild
- Mild CRI (Creat 1.1 on recent labs)
- Cataract
- Diabetes Mellitus
- Peripheral neuropathy - Bilateral legs
- Hypercholesterolemia
- Hypertension
- Transient ischemic attack
- Lumbar disc disease
PSH:
Lumbar laminectomy [**1-/2181**]
Tonsillectomy
Teeth extraction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Edema: trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-3.0
First draw [**2184-7-12**]
Results to phone cardiac surgery office [**Telephone/Fax (1) 170**] on [**2184-7-12**]
for contact person
Followup Instructions:
The cardiac surgery office will call you and schedule the
following appointments
Surgeon: Dr. [**First Name (STitle) **]
Wound check with cardiac surgery
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**]
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-3.0
First draw [**2184-7-12**]
Results to phone cardiac surgery office [**Telephone/Fax (1) 170**] on [**2184-7-12**]
for contact person
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 112309**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 17663**] in [**2-26**] 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:[**2184-7-14**]
|
[
"V13.01",
"997.1",
"357.2",
"413.9",
"366.9",
"V15.82",
"272.0",
"E878.2",
"403.90",
"424.1",
"V12.54",
"722.93",
"250.60",
"427.31",
"585.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11055, 11106
|
7838, 9172
|
335, 483
|
11685, 11936
|
2738, 4208
|
12940, 13838
|
1778, 1928
|
9718, 11032
|
11127, 11664
|
9198, 9695
|
11960, 12917
|
4224, 7815
|
1943, 2719
|
262, 297
|
511, 944
|
966, 1471
|
1487, 1762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,737
| 144,861
|
54581
|
Discharge summary
|
report
|
Admission Date: [**2166-11-24**] Discharge Date: [**2166-12-3**]
Date of Birth: [**2117-7-14**] Sex: M
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: Electrocardiogram changes at primary care
physician's office.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old man
with a past medical history of hypertension,
hypercholesterolemia who is admitted by his primary care
physician after inferolateral electrocardiogram changes. The
patient presented to his primary care physician's office for
routine physical and follow up for his hemorrhoids. He did
tell his primary care physician about episodes of some left
arm tightness over the past six weeks when walking from his
office to his car. He denies any symptoms when walking
around the reservoir with his wife. [**Name (NI) **] also noted symptoms
while at rest. He denies chest pain except for one episode
of left arm tightness walking to car. No orthopnea. No
paroxysmal nocturnal dyspnea. He does report occasional
ankle swelling noticed by wife on vacation. There is no
dyspnea on exertion. He denies any fevers or chills, upper
respiratory symptoms, cough, abdominal pain, nausea,
vomiting, black stools and he did have some bright red blood
per rectum about three weeks ago secondary to his
hemorrhoids. He is due for a banding procedure for his
hemorrhoids next week. He denies any dysuria.
PAST MEDICAL HISTORY:
1. Hemorrhoids.
2. Hypertension.
3. Hypercholesterolemia.
4. Hyperplastic colonic polyps.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg once a day.
2. Aspirin 325 mg once a day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: His father died of coronary artery disease
in his 70s.
SOCIAL HISTORY: He quit smoking about 20 years ago. He
never used cocaine. He uses occasional ethanol. He does
work long hours as an attorney. His wife is a social worker
at the [**Hospital1 69**] outpatient HIV
unit.
PHYSICAL EXAMINATION: He is afebrile. Heart rate 57 to 64.
Blood pressure 104/57 to 176/100. Respiratory rate 16.
Oxygen saturation 99% on room air. General, he is
comfortably alert, oriented times three and in no acute
distress. Head and neck mucous membranes are moist. No
lymphadenopathy. No JVD. No carotid bruits. Cardiovascular
regular rate and rhythm. S1 and S2. No murmurs, rubs or
gallops. His lungs are clear to auscultation bilaterally.
No rales, wheezes or rhonchi. His abdomen is soft, bowel
sounds positive, nontender, nondistended. No
hepatosplenomegaly. Extremities have no edema and he has 2+
equal pulses.
LABORATORY VALUES: Within normal limits. Chest x-ray shows
no pleural effusions, but increased pulmonary vasculature in
the upper lung zones. Electrocardiogram showed ST depression
in lead 2 and AVF. Urinalysis was negative. His troponin
was less then .01 and his CK was 74.
HOSPITAL COURSE: The patient was admitted for a workup of
atypical chest pain and for a cardiac evaluation. He was
admitted to the telemetry service initially. On hospital day
two [**11-25**] he underwent an exercise stress test, which
was discontinued secondary to inferolateral electrocardiogram
changes. He had ST depressions in V3 to V6 and 2, 3 and AVF
while he was exercising. He was given one sublingual
nitroglycerin, which resolved the pain. On [**11-26**], he
underwent cardiac catheterization, which showed a good left
ventricular function, but a three vessel coronary artery
disease. At this point cardiothoracic surgery was consulted
for a possibility of a coronary artery bypass graft
procedure. On [**11-28**] after Mr. [**Known lastname 111647**] was preopped and
consented for the coronary artery bypass graft procedure he
was taken to the Operating Room. Please refer to the
previously dictated operative note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
[**2166-11-28**]. Of note in this procedure first off the patient
was a difficult intubation. Secondly the left internal
mammary coronary artery was grafted onto the distal left
anterior descending coronary artery in the usual fashion and
a saphenous vein graft was used to form three other
anastomoses. The patient tolerated the procedure well and he
was transferred to the CSRU without complications. Later in
the evening of his first procedure the patient had a GCS of
15 and was doing well so he was extubated without
complications in the Operating Room. On postoperative day
one the rest of his drainage tubes were pulled and he did
very well to the point that he was transferred to the floor
on postoperative day two where he had a relatively
unremarkable course. His major floor issues were physical
therapy. He underwent physical therapy and by the time of
discharge he was walking at least 500 feet about the floor.
His diet was advanced as tolerated and by the time of
discharge he was tolerating a regular diet without nausea,
vomiting or abdominal pain. He was diuresed with Lasix to a
weight of 93.9 kilograms, which was approximately 4 kilograms
from his preoperative weight. Mr. [**Known lastname 111647**] was discharged to
home on [**12-3**] in good condition with services.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft.
2. Status post cardiac catheterization.
3. Status post positive exercise stress test.
4. Unstable angina.
5. Hypertension.
6. Hypercholesterolemia.
7. Hemorrhoids.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q.d.
2. Percocet one to two tablets every four hours as needed
for pain.
3. Plavix 75 mg po q.d. for one month.
4. Lipitor 10 mg once a day.
5. Ativan 0.5 mg q.h.s. as needed for sleep.
6. Metoprolol 100 mg po twice a day.
7. Colace 100 mg po twice a day.
He has orders for potassium chloride and for Lasix for one
week, however, these will not be continued as an outpatient.
He is recommended to have a low fat, low cholesterol, no
added salt diet. He is recommended to have follow up with
Dr. [**Last Name (STitle) 1728**] his primary care physician in one to two weeks and
Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2166-12-3**] 03:11
T: [**2166-12-4**] 07:44
JOB#: [**Job Number 111648**]
|
[
"401.9",
"272.0",
"300.00",
"414.01",
"411.1",
"455.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.22",
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1649, 1705
|
5188, 5405
|
5428, 6361
|
1532, 1632
|
2868, 5167
|
1952, 2850
|
170, 233
|
262, 1389
|
1411, 1506
|
1722, 1929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,604
| 167,584
|
37741
|
Discharge summary
|
report
|
Admission Date: [**2123-2-19**] Discharge Date: [**2123-2-22**]
Date of Birth: [**2057-1-31**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Amoxicillin
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
non-responsiveness, right hemiparesis
Major Surgical or Invasive Procedure:
[**2123-2-19**] - Intubation with mechanical ventilation
[**2123-2-21**] - Extubation
History of Present Illness:
66 yo M with pancreatic cancer s/p Whipple [**2119**], currently on
FOLFIRI (5-FU, irinotecan, leukovorin), CAD s/p PCI, CHF EF
35-40%, prior CVA, diabetes, HTN initially presenting for ERCP
in the setting of biliary obstruction. ERCP was done with
placement of a metal stent (no spincterotomy). The patient was
A+Ox3 prior to the procedure and remained hemodynamically stable
throughout the case. After the procedure, he was sleepy,
although he was moving all extremities until around noon. He
reportedly shook his head "no" when asked about pain (before
nooon), but was unresponsive after noon.
.
He was noted to be diaphoretic, and at around 1:10 p.m., his
wife noted that he was not moving the right side of his body.
Fingerstick blood glucose was 228. The [**Hospital Unit Name 153**] was called, and a
new right facial droop, leftward gaze deviation, and right
hemiplegia were noted. A code stroke was called. CT head was
negative for acute hemorrhage. Based on a time last "normal" of
around noon (when the patient was noted to be moving all
extremities), tPA was given, but subsequently the perfusion
images showed hyperperfusion of an area in the left cortex, more
suggestive of seizure. At that point tPA was stopped, and the
patient was given ativan 1 mg IV x 2 and keppra 1000 mg IV x 1
without improvement in his mental status.
.
An EKG was done prior to transfer to the ICU, and this was
unchanged from prior. However, EKG was done at 3:30 p.m.,
showing new lateral ST depressions. Cardiology was called to
evaluate the patient.
.
The patient's code status was initially DNR/DNI, but after
discussion with the neurology team, the patient's wife decided
to make him DNR, okay to intubate, if this would permit more
aggressive treatment of the seizures.
.
Review of systems is unobtainable due to the patient's
unresponsiveness.
.
The patient was recently hospitalized for hypotension, treated
with IV fluids. During that hospitalization, he was diagnosed
with C. diff, treated with flagyl.
Past Medical History:
PMHx:Hypertension, Hyperlipedemia, IHD h/o MI in [**2114**] with
stents placed, Systolic dysfunction, CVA [**2117**], Type 2 DM,
Anxiety/Depression.
PSHx: Right thumb surgery, EGD/EUS [**2120-9-10**], ERCP with biliary
stent placed, staging laparoscopy [**2120-9-18**].
Social History:
Married. Former corrections officer, now retired. 60 pack-year
smoking history, now discontinued. Previously alcohol use
discontinued 1.5 years ago. Denies illicits.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
.
General: Non-responsive.
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: neck deviated to left, JVP not elevated
Lungs: Diffusely rhonchorous.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no cyanosis
Neuro: Non-responsive to sternal rub. Pupils equal 4 mm and
sluggish bilaterally. Right facial droops. Does not close right
eye. Withdraws slightly to pain on left side. No responsive on
left side. Has spontaneous movements of left upper and lower
extremities.
.
DISCHARGE EXAM:
.
Lungs: Diffusely rhonchorous.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no cyanosis
Neuro: Non-responsive to sternal rub. Pupils equal 4-mm and
sluggish bilaterally with nystagmoid lateral eye gaze. Withdraws
slightly to pain. Has spontaneous movements of left upper and
lower extremities. Babinski's upgoing bilaterally.
Pertinent Results:
ADMISSION LABS:
.
[**2123-2-19**] 09:05AM BLOOD WBC-6.2 RBC-3.36* Hgb-11.5* Hct-33.8*
MCV-101* MCH-34.2* MCHC-33.9 RDW-18.5* Plt Ct-126*
[**2123-2-19**] 01:31PM BLOOD Neuts-89* Bands-10* Lymphs-1* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2123-2-19**] 01:31PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-3+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Target-2+ Schisto-1+
[**2123-2-19**] 09:05AM BLOOD PT-15.6* INR(PT)-1.5*
[**2123-2-19**] 09:05AM BLOOD Plt Ct-126*
[**2123-2-19**] 09:05AM BLOOD UreaN-13 Creat-1.1 Na-135 K-4.4 Cl-97
HCO3-31 AnGap-11
[**2123-2-19**] 09:05AM BLOOD ALT-65* AST-113* AlkPhos-2261* Amylase-11
TotBili-9.2*
[**2123-2-19**] 01:31PM BLOOD CK-MB-3 cTropnT-0.02*
[**2123-2-19**] 03:04PM BLOOD CK-MB-4 cTropnT-0.01
[**2123-2-19**] 09:16PM BLOOD CK-MB-9 cTropnT-0.08*
[**2123-2-20**] 01:34AM BLOOD CK-MB-7 cTropnT-0.10*
[**2123-2-20**] 07:46AM BLOOD CK-MB-5 cTropnT-0.08*
[**2123-2-19**] 09:05AM BLOOD Albumin-3.2*
[**2123-2-19**] 01:31PM BLOOD Calcium-8.5 Phos-2.8 Mg-1.3*
[**2123-2-19**] 08:04PM BLOOD Lactate-1.8 Na-130* K-3.8 Cl-97
[**2123-2-19**] 08:04PM BLOOD Hgb-12.3* calcHCT-37
[**2123-2-19**] 08:04PM BLOOD freeCa-1.07*
[**2123-2-19**] 08:04PM BLOOD Type-ART pO2-265* pCO2-25* pH-7.59*
calTCO2-25 Base XS-4
.
DISCHARGE EXAMS:
.
[**2123-2-21**] 05:40AM BLOOD WBC-11.6* RBC-3.22* Hgb-11.2* Hct-32.3*
MCV-100* MCH-34.7* MCHC-34.7 RDW-19.3* Plt Ct-142*
[**2123-2-21**] 05:40AM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2123-2-21**] 05:40AM BLOOD PT-17.9* INR(PT)-1.7*
[**2123-2-21**] 05:40AM BLOOD Glucose-219* UreaN-21* Creat-1.1 Na-132*
K-3.8 Cl-99 HCO3-24 AnGap-13
[**2123-2-21**] 05:40AM BLOOD ALT-65* AST-142* LD(LDH)-313*
AlkPhos-2355* TotBili-10.7*
[**2123-2-21**] 05:40AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.2
[**2123-2-20**] 08:41AM BLOOD Type-[**Last Name (un) **] pO2-84* pCO2-52* pH-7.32*
calTCO2-28 Base XS-0
[**2123-2-20**] 08:41AM BLOOD Lactate-1.2
[**2123-2-19**] 08:04PM BLOOD freeCa-1.07*
.
IMAGING STUDIES:
.
[**2123-2-20**] EEG - pending
.
[**2123-2-20**] CXR - There has been interval increase in size in left
lower lobe atelectasis and new or newly appearing left pleural
effusion. Mild vascular congestion is stable. Right lower lobe
atelectasis is unchanged. Cardiac size is top normal. ET tube is
in the standard position. Right subclavian catheter tip is in
the lower SVC. There is pneumoperitoneum.
.
[**2123-2-20**] CT HEAD W/O CONTRAST - Increased edema and sulcal
effacement, predominantly within the left frontal lobe and
superior left parietal lobe. This could be secondary to
persistent status epilepticus, though an infarction would be
difficult to exclude. No acute hemorrhage.
.
[**2123-2-21**] EEG - pending
.
MICROBIOLOGIC DATA:
.
[**2123-2-19**] MRSA screen - pending
[**2123-2-19**] Blood culture - pending
[**2123-2-21**] Blood culture - pending
Brief Hospital Course:
66M with metastatic pancreatic cancer (status-post Whipple
procedure in [**2119**]), CAD (s/p PCI), CHF (LVEF 35-40%), h/o CVA
(without residual deficits), DM, HTN, who initially presented
for ERCP in the setting of biliary obstruction attributed to
tumor burden, with subsequent development of right hemiparesis
and non-responsiveness thought to be related to non-convulsive
status epilepticus, who is status-post intubation for hypoxemia
and airway protection with subsequent extubation, with hospital
course complicated by hypotension (now off pressor support) and
pneumoperitoneum who has shown minimal neurologic improvement.
Given his pancreatic cancer, pneumoperitoneum and poor
neurologic status, the family opted for comfort care measures.
The decision was made to focus on comfort measures only on
[**2123-2-21**] and the patient was transitioned home with hospice on
[**2123-2-22**].
Medications on Admission:
CARVEDILOL - (Prescribed by Other Provider) - 12.5 mg Tablet -
[**12-14**]) Tablet(s) by mouth twice a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - [**12-14**] Tablet(s)
by
mouth q4-6h as needed for pain
INSULIN GLARGINE [LANTUS] - (Prescribed by Other [**Provider Number 84545**]
units [**Hospital1 **]) - 100 unit/mL Solution - 15 units twice a day
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) -
Dosage uncertain
LIPASE-PROTEASE-AMYLASE [CREON] - (Prescribed by Other
[**Provider Number 84546**] tabs in am; 3 tabs with lunch, 4 tabs with dinner) - Dosage
uncertain
LORAZEPAM - 0.5 mg Tablet - [**12-14**] Tablet(s) by mouth every six (6)
hours as needed for nausea or anxiety
LOSARTAN - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
1
(One) Tablet(s) by mouth twice a day
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every eight
(8) hours as needed for nausea
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth DAILY
PAROXETINE HCL [PAXIL] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
PROCHLORPERAZINE MALEATE - 5 mg Tablet - 1 Tablet(s) by mouth
every six (6) hours as needed for nausea
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daily
LOPERAMIDE [IMODIUM A-D] - (OTC) - 2 mg Tablet - 1 Tablet(s) by
mouth three times a day
Discharge Medications:
1. Roxanol 20mg/mL Solution Sig: 2-20 mg/1 mL PO Q1 hour as
needed for pain.
Disp:*40 mL* Refills:*0*
2. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.25-2 mg/1 mL PO
every four (4) hours as needed for pain: Not to exceed 8 mg (4
mL) per 24-hours.
Disp:*10 mL* Refills:*0*
3. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**12-14**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
1. Metastatic pancreatic adenocarcinoma
2. Pneumoperitoneum
3. Non-convulsive status epilepticus
4. Acute hypoxic respiratory failure requiring intubation and
mechanical ventilation
.
Secondary Diagnoses:
1. Coronary artery disease
2. Hypertension
3. Diabetes mellitus, type 2
4. Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Critical Care Medicine service at [**Hospital1 1535**] on the [**Location (un) **] of the [**Hospital Ward Name 332**]
building of the Intesive Care Unit regarding management of your
seizures and your on-going pancreatic cancer. You required
intubation briefly but your breathing tube was removed and you
were stable for home hospice on discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Roxinol 5-325 mg/5 mL solution (2-20 mg/1 mL) by mouth
every hour as needed for pain.
START: Lorazepam Intensol 2 mg/mL (0.25-2 mg/1 mL) PO every
4-hours as needed for pain or anxiety (not to exceed 8 mg or 4
mL in 24-hours)
START: Polyvinyl alcohol-povidone (1.4-0.6 %) dropperette ([**12-14**]
drops) ophthalmic as needed for dry eyes.
.
* ALL of your other home medications were DISCONTINUED this
admission given our focus on comfort measures only.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2123-3-1**] at 12:00 PM
With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/BMT
When: MONDAY [**2123-3-1**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 3237**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V10.09",
"345.3",
"518.81",
"789.59",
"518.1",
"V49.86",
"250.00",
"576.2",
"197.8",
"272.4",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"99.10",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10097, 10148
|
6986, 7882
|
322, 410
|
10506, 10506
|
4082, 4082
|
12564, 13110
|
2938, 2957
|
9642, 10074
|
10169, 10372
|
7908, 9619
|
10718, 12541
|
2972, 3636
|
10393, 10485
|
3652, 4063
|
244, 284
|
438, 2443
|
4098, 6084
|
10521, 10662
|
2465, 2738
|
2754, 2922
|
6101, 6963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,710
| 158,908
|
24733
|
Discharge summary
|
report
|
Admission Date: [**2167-7-13**] Discharge Date: [**2167-7-28**]
Date of Birth: [**2094-2-10**] Sex: F
Service: SURGERY
Allergies:
Benadryl / Lorazepam
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain and purulent drainage from urostomy
Major Surgical or Invasive Procedure:
[**2167-7-14**]
CT guided drainage of intraabdominal abcess
[**2167-7-18**]
Ultrasound drainage of intraabdominal abcess
[**2167-7-26**]
Abdominal catheter exchanged for larger size
History of Present Illness:
73F s/p surgery on [**2167-6-6**] for a strangulated
ventral/periurostomal hernia with resection of necrotic bowel
and
extensive LOA. Patient is s/p cystectomy approx 10 years ago
with urostomy. She states that since her surgery she has had
continued intermittent abdominal pain located near her urostomy
and N/V. She also states that she has been constipated
requiring
enemas/laxatives for relief. +Flatus. Today her urostomy
started to produce purulent material and she was sent from the
ED
from her rehab facility for further treatment. She denies
fevers/chills or other complaints.
.
Past Medical History:
PMH: rheumatoid arthritis, hypothyroidism, goiter, HTN, hiatal
hernia, restless leg syndrome, multiple myloma, GERD, h/o
atypical mycobacterium, OSA, cervical spondylosis
PSH: Rt humerus repair, Urostomy by Dr. [**Last Name (STitle) 365**] for unclear reasons
at [**Name (NI) 882**] (patients daughter states that originally done
because her "bladder was stripped" and caused constant burning
but not malignancy) - complicated by postoperative complications
requiring multiple bowel surgeries 10 years ago, shoulder repair
Social History:
No ETOH, remote tobacco
Prior to her illness she lived at home with her husband who has
some form of dementia. Daughter [**Name (NI) 2048**] lives locally and is
trying to manage both parents needs.
Family History:
NA
Physical Exam:
Exam: 97.2 86 124/76 18 95RA
NAD
CTAB
RRR, -MRG
large periurostomal hernia w some surrounding redness, ostomy
bag
with thick white liquid, midline incision s/p recent removal of
retention sutures, soft, NT, ND, +BS
Pertinent Results:
[**2167-7-13**] 01:20PM WBC-11.8* RBC-3.73* HGB-10.1* HCT-31.2*
MCV-84 MCH-26.9* MCHC-32.2 RDW-14.9
[**2167-7-13**] 01:20PM NEUTS-76.6* LYMPHS-14.4* MONOS-7.3 EOS-1.1
BASOS-0.5
[**2167-7-13**] 01:20PM PLT COUNT-662*
[**2167-7-13**] 01:20PM ALT(SGPT)-6 AST(SGOT)-13 ALK PHOS-93 TOT
BILI-0.2
[**2167-7-13**] 01:20PM GLUCOSE-108* UREA N-10 CREAT-0.6 SODIUM-132*
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15
[**2167-7-13**] Abd Ct : 1. Dilated loops of small bowel with transition
point in a large right abdominal wall hernia is consistent with
small bowel obstruction.
2. Patient is status post ileal conduit urinary diversion and
urostomy,
adjacent to which is a moderate-to-large right-sided abdominal
wall hernia.
3. Locules of gas are seen within the right abdominal wall
hernia, which are concerning for bowel perforation. High-density
fluid within the right
abdominal wall hernia is concerning for leakage of oral
contrast. There is no IV contrast administered to exclude bowel
ischemia. No clear wall is seen around the fluid in the hernia,
although no IV contrast was administered. Consider repeat with
IV contrast for further delineation.
4. Bilateral hydronephrosis appears increased compared to CT
scan of [**2167-6-3**] but likely not significantly changed from
[**2167-6-13**].
5. Atelectasis and minimal right lower lobe ground-glass opacity
likely
represents volume overload or positioning edema; however, mild
infectious
process cannot be completely excluded.
[**2167-7-18**] Abd CT : 1. Interval development of multifocal
ground-glass peribronchial opacities involving left upper lobe
and the lower lobes, likely represent infection and/or
aspiration. Left predominant abnormality is consistent likely
preferential left lateral decubitus position due to right sided
abscess, and layering fluid within the upper esophagus,
suggesting aspiration.
2. Persistent large rim-enhancing and gas-containing right lower
quadrant
subcutaneous peristomal abscess with significant adjacent
inflammatory
stranding. No evidence for fistula formation. No new abscess.
3. Persistent but decreased bilateral reflux hydronephrosis,
longstanding and likely related to ileal conduit urinary
diversion. Unremarkable right lower quadrant urostomy.
4. Bilateral renal cysts are unchanged.
[**2167-7-21**] CXR : Lung volumes are lower, the small bilateral
pleural effusions are new, but the most important change is
widespread multifocal peribronchial opacification--most likely
widespread infection, perhaps embolic--almost nodular in the
left upper lobe, a new large region of consolidation at both
lung bases, the right anterior and the left posterior.
Mild-to-moderate cardiomegaly is stable. No pneumothorax.
[**2167-7-26**] Abd CT : 1. Persistence of large rim-enhancing
collection in the right lower quadrant, although the collection
has decreased in size. The collection measures 11.6 cm x 4.6 cm
on the current exam. Given the persistence of the collection in
spite of an indwelling pigtail drainage catheter, the patient
will be transferred to the radiology department for upsizing of
the catheter.
2. Interval improvement in bibasilar airspace opacities, with a
new small
left pleural effusion.
3. Persistent mild left hydronephrosis, likely related to ileal
conduit
urinary diversion.
4. No evidence of bowel obstruction.
[**2167-7-15**] 1:20 am ABSCESS Source: abdominal.
**FINAL REPORT [**2167-7-22**]**
GRAM STAIN (Final [**2167-7-15**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2167-7-22**]):
LACTOBACILLUS SPECIES. HEAVY GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2167-7-22**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
[**2167-7-18**] 5:00 pm ABSCESS Source: RLQ.
**FINAL REPORT [**2167-7-22**]**
GRAM STAIN (Final [**2167-7-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2167-7-21**]):
LACTOBACILLUS SPECIES. MODERATE GROWTH.
Susceptibility testing requested by DR. [**First Name8 (NamePattern2) 62369**] [**Last Name (NamePattern1) **]
([**Numeric Identifier 62370**]).
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
LACTOBACILLUS SPECIES
|
AMPICILLIN------------ 1 S
GENTAMICIN------------ <=2 S
PENICILLIN G---------- 1 S
ANAEROBIC CULTURE (Final [**2167-7-22**]): NO ANAEROBES ISOLATED.
[**2167-7-20**] 10:25 am URINE Source: Suprapubic.
**FINAL REPORT [**2167-7-23**]**
URINE CULTURE (Final [**2167-7-23**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
Mrs.[**Last Name (STitle) 62371**] was evaluated by the Acute Care service in the
Emergency Room, admitted to the hospital and made NPO, hydrated
with IV fluids and placed on IV antibiotics. Plans were made for
drainage of her abdominal abscess in Interventional radiology.
She underwent CT guided drainage on [**2167-7-14**] and after draining
close to 1 liter the drain accidently fell out. She underwent
serial exams thereafter and she gradually became distended. She
also had multiple episodes of emesis requiring nasogastric tube
placement for decompression. On [**2167-7-17**] she had some
hypotension and abdominal pain and was transferred to the
Surgical ICU for further management. Her initial wound culture
grew gram negative and gram positive rods and eventual
Lactobacillus.
She was then treated with IV Zosyn, Vancomycin and Flagyl. A CT
showed re accumulation of her abdominal fluid collection and she
had a drain replaced under ultrasound guidance.
Following transfer to the Surgical floor she remained NPO and
was hydrated with IV fluids. Her gastric fluid drainage
diminished and she was passing flatus so her nasogastric tube
was removed. She gradually tolerated a regular diet without
difficulty. During this time she developed diarrhea and
specimens for C difficile were sent on 3 different occasions.
In the interim she remained on Flagyl and eventually oral
Vancomycin was added. Over 3 days the diarrhea gradually
resolved and a C Difficile PCR toxin was sent which was
negative. Her Flagyl was discontinued but her oral Vancomycin
remains as the plan for antibiotic treatment of her
polymicrobial organisms including lactobacillus will continue
indefinitely until her abscess is totally drained. The oral
vancomycin will also remain for 2 weeks after the Zosyn has been
discontinued. She has been off of IV Vancomycin since [**2167-7-24**].
She remains afebrile with a normal WBC.
From a pulmonary standpoint she developed a congested cough on
[**2167-7-20**] without fevers but her WBC was 19K. A chest Xray was
done which showed bilateral lower lobe consolidations and she
was already being treated with Vancomycin and Zosyn. She
underwent chest PT, incentive spirometry and nebulizer
treatments and within 24 hours had symptomatically improved with
a decreased cough and Room Air saturations of 94-95%. Of note
she had a urine culture done on [**2167-7-20**] which grew .100K VRE.
The Infectious Disease service has been following her on a daily
basis and felt that she was simply colonized with VRE. They will
continue to follow her in their out patient clinic. See
appointments for details.
Over the last few days she continues to improve with no fevers,
a good appetite and [**11-29**] bowel movements a day. She is up and
walking with assistance and after a long hospitalization she was
discharged to rehab on [**2167-7-28**] with the hope of returning home
after she regains some of her stamina.
Medications on Admission:
Requip 2mg TID, Alendronate 35mg qwk, Omeprazole 20mg daily
Methotrexate 15mg qwk, Iron 325mg TI week, metoprolol 25mg
daily,
synthroid 125mg daily, salsalate 1500mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Injection TID (3 times a day).
2. Methotrexate Sodium 2.5 mg Tablet Sig: Six (6) Tablet PO
1X/WEEK (WE).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
5. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours). to continue for 2 additional weeks AFTER Zosyn is
discontinued.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to lower back.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. 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.
11. Piperacillin-Tazobactam 4.5 g IV Q6H Continue until
abdominal drain is removed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. intra abdominal abcess
2. pneumonia
3. small bowel obstruction
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 abdominal pain from an
intra abdominal abcess. The drain should remain in place and
the drainage will be measured daily. You will have a CT scan in
a few weeks to check the area and see if the fluid is all
drained. The catheter will be removed when we are assured that
the area is totally drained. You will continue on antibiotics
until that time.
* You need to stay hydrated and eat well so that you can heal
well.
* Continue to check your temperature twice daily and call the
[**Hospital 2536**] Clinic if it is greater than 101.
* If you develop any more nausea and/or vomiting please let us
know.
Followup Instructions:
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in 2 weeks with an abdominal CT with PO and IV contrast.
Infectious Disease follow up:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2167-8-24**]
9:30
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2167-9-14**] 9:30
Completed by:[**2167-7-28**]
|
[
"682.2",
"507.0",
"041.84",
"008.45",
"244.9",
"721.0",
"996.65",
"552.29",
"714.0",
"E878.3",
"998.59",
"401.9",
"276.1",
"327.23",
"333.94",
"530.81",
"787.91",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.19",
"86.01",
"97.29"
] |
icd9pcs
|
[
[
[]
]
] |
12218, 12284
|
7867, 10810
|
330, 513
|
12394, 12394
|
2173, 7844
|
13216, 13388
|
1918, 1922
|
11033, 12195
|
12305, 12373
|
10836, 11010
|
12545, 13193
|
1937, 2154
|
13399, 13699
|
240, 292
|
541, 1137
|
12409, 12521
|
1159, 1685
|
1701, 1902
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,850
| 134,643
|
54028
|
Discharge summary
|
report
|
Admission Date: [**2194-5-6**] Discharge Date: [**2194-5-16**]
Date of Birth: [**2152-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
Femoral CVL
PICC placed
Blood transfusion
History of Present Illness:
42 year old woman with history of alcohol abuse, anemia of
chronic disease, depression/anxiety, gastric bypass who presents
with encephalopathy. The patient was found by her family in her
bathtub, covered in urine and stool with an empty bottle of
vodka nearby. The patient was also jaundiced and lethargic and
brought in by her EMS for further evaluation.
.
In the ED, initial vs were: T96.8 HR 51 BP 136/96 RR16 95% on
RA. CXR was negative for pneumonia, ultrasound without ascites,
CT head negative for intracranial processes. Labs were notable
for WBC 13.3 with left shift and 3% bands, ammonia was elevated
at 68, INR 2.1 transaminitis (ALT 57, AST 272, TBili 19.7,
Albumin 3.3 and AlkPhos 196). Urine and serum tox were negative,
including for tylenol and alcohol levels. Lactate was 9.1, 4.6
after aggressive volume resuscitation with ~7L normal saline.
The patient received vancomycin and ceftriaxone and a femoral
line was placed. Given question of a seizure episode (per
family) with mild shaking in the ED, patient received valium
10mg IV X1. The patient reports a history of withdrawal
seizures. The patient also received sedation with antoher 10mg
IV Valium for the femoral line placement (inability to get
access anywhere else). Hepatology was called who felt this could
be consistent with alcoholic hepatitis. The patient was able to
tolerate lactulose PO and thiamine 100mg IV in the ED but was in
four point restraints for some time.
.
On the arrival to the MICU, the patient was agitated but
verbally responsive. Denies any pain, shortness of breath, chest
pain, diarrhea, recent trauma. States her last alcohol
consumption was two days ago, unclear the quantity.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, cough, shortness of breath. Denies
chest pain, nausea, vomiting, diarrhea, dysuria, rashes or skin
changes. Denies any bleeding.
Past Medical History:
* Anemia of chronic disease
* Depression - two suicide attempts in past (one an overdose),
followed by counselor (unsure location)
* Anxiety
* Recent memory loss/black out spells
* Roux-en-Y gastric bypass
* Small bowel obstruction, lysis of adhesions
* Urinary incontinence
* Open cholecystectomy
* Tubovarian abscess [**2193-6-3**]
* Left hip plate s/p fall as child
Social History:
Separated from her husband, lives alone. Does not work.
Brother and boyfriend help her out. Patient denies tobacco and
illicits. Heavy alcohol use, last drink "two days ago" per
patient. Adopting a dog.
Family History:
Mother and father with diabetes mellitus.
Physical Exam:
Upon admission:
Vitals: T: 99.9 BP: 113/69 P: 115 R: 18 O2: 99% on RA
General: Alert, oriented, no acute distress, jaundiced
HEENT: PERRL, EOMI, sclera icteric, dry mucus membranes,
oropharynx clear
Neck: Soft, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachy, regular rhythm, normal S1/S2, no murmurs/gallops/rubs
Abdomen: Soft, non-tender, non-distended, +bowel sounds, obese,
surgical incision site well healed
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses
At discharge:
VS: 99.6 99.6 102/59 107 18 99% on RA 109.7kg
FS: 83-105-119-109
I/O: [**Telephone/Fax (1) 110751**] no BM
General: alert, oriented, no acute distress, appropriate
HEENT: PERRL, EOMI, scleral icterus
Neck: Soft, supple, no JVD
Lungs: CTAB, no w/r/c
CV: RRR, normal S1/S2, no murmurs/gallops/rubs
Abdomen: Obese, +BS, distended, TTP at RUQ, no peritoneal signs,
surgical incision site well healed.
Ext: Warm, well perfused, 2+ pulses, 2+ tender edema, L>R, left
calf tender, moving all four extremities
Neuro: Oriented to place and time, DOWb intact. No asterixis.
Sensation intact.
Pertinent Results:
LABS UPON ADMISSION:
[**2194-5-6**] 11:08PM LACTATE-3.8*
[**2194-5-6**] 08:54PM LACTATE-4.6*
[**2194-5-6**] 11:04PM WBC-11.7* RBC-2.24* HGB-7.6* HCT-22.6*
MCV-101* MCH-33.9* MCHC-33.6 RDW-17.2*
[**2194-5-6**] 09:40PM GLUCOSE-82 UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-2.5* CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2194-5-6**] 09:40PM CALCIUM-5.8* PHOSPHATE-1.6* MAGNESIUM-0.7*
[**2194-5-6**] 09:40PM DIR BILI-14.1*
[**2194-5-6**] 01:43PM ALT(SGPT)-57* AST(SGOT)-273* ALK PHOS-196*
TOT BILI-19.7*
[**2194-5-6**] 01:43PM LIPASE-23
[**2194-5-6**] 01:43PM ALBUMIN-3.3*
[**2194-5-6**] 01:43PM PLT SMR-LOW PLT COUNT-91*#
[**2194-5-6**] 01:43PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
LABS PRIOR TO DISCHARGE:
CBC: 15.8/8.3/25.5/163 MCV 103
Chem 7: 138/3.9/99/31/9/0.5< 62
Chem 10: Ca: 8.0 Mg: 1.5 P: 2.1
ALT: 50 AST: 137 AP: 111 Tbili: 15.1
PT: 18.6 PTT: 30.2 INR: 1.7
Micro:
[**2194-5-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2194-5-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2194-5-8**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-7**] URINE URINE CULTURE-FINAL
[**2194-5-6**] MRSA SCREEN MRSA SCREEN-FINAL
[**2194-5-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2194-5-6**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
EKG: Sinus tachycardia, HR109, normal axis, QTC 451, poor
baseline (?asterixis) but no St elevations, TW inversions
IMAGING:
[**2194-5-15**] CXR: No pneumothorax or pleural effusion is seen. The
cardiac size is moderately enlarged, unchanged. The mediastinal
and hilar contours are normal. IMPRESSION: Stable cardiomegaly
with no acute cardiopulmonary abnormality.
[**2194-5-14**] LENI: Color and grayscale son[**Name (NI) 1417**] of bilateral common
femoral, left-sided superficial femoral, popliteal and calf
veins were performed. Flow was seen within the calf veins.
Remaining vessels demonstrated normal flow, augmentation, and
compressibility. There is edema within the superficial tissues
of the calf. IMPRESSION: No evidence of DVT. Calf edema.
[**2194-5-6**] RUQ: The liver is diffusely echogenic, consistent with
fatty
infiltration or cirrhosis. The main portal vein is patent with
hepatopetal flow. This study is severely limited due to body
habitus and liver echogenicity. The patient is status post
cholecystectomy. The common duct is not identified. There is no
ascites. IMPRESSION: Limited study with echogenic liver,
consistent with fatty infiltration or cirrhosis; advanced liver
disease including significant hepatic fibrosis/cirrhosis cannot
be excluded on this study. Portal vein is grossly patent.
[**2194-5-6**] CXR: The previously noted right upper extremity approach
PICC line has been removed in the interval. Lung volumes are
markedly diminished. There is resultant bronchovascular crowding
at the lung bases and linear opacity at the right lung base in
particular. No focal consolidation or superimposed edema is
noted. The mediastinum is grossly unremarkable. The cardiac
silhouette, though accentuated by low lung volumes is stable in
size. No effusion or pneumothorax is noted. The visualized
osseous structures are unremarkable. Low lung volumes, with
bronchovascular crowding. No definite acute pulmonary process
identified.
[**2194-5-6**] CT head: No acute intracranial process. Again note is
made of
nonspecific low density bilaterally within internal capsules. As
previously, we would recommend a nonurgent MRI to follow up this
finding.
Brief Hospital Course:
42 year old female with history of EtOH abuse, depression,
anxiety, and prior Reux-en-Y gastric bypass surgery admitted
with encephalopathy and jaundice found to have alcoholic
hepatitis, whose course has been c/b UTI, encephalopathy, and
EtOH withdrawal.
# Alcoholic hepatitis: The patient presented with jaundice,
AST>>ALT, and markedly elevated Tbili. Discriminant function was
~54. Steroids were initially held due to concern about possible
infection. Then, prednisone was started on [**2194-5-8**]. Viral
hepatitis serologies were negative. Bilirubin trended down to
nadir of 13.9, but then stabilized around 14-15. All
hepatically cleared medications were held during this time. She
was given pantoprazole, vitamin D, and calcium given high dose
steroids. Her sugars were monitorred on high dose steroids but
she did not require any insulin administration, likely a result
of impaired gluconeogenesis. Prednisone was stopped on [**2194-5-15**]
given new leukocytosis and fevers. Pantoprazole and calcium
were subsequently stopped. Vitamin D therapy was continued
given documented history of vitamin D deficiency. She was given
oxycodone for her pain. She will follow up with liver as an
outpatient. She was told to abstain from alcohol or risk
permanent liver damage from alcohol.
# Urinary tract infection: Initially a source of infection was
unclear, so the patient was started on empiric vancomycin and
ceftriaxone, broadened to vanc/cefepime upon admission to the
ICU. Urine culture grew E. coli. Antibiotics were narrowed to
ceftriaxone when urine culture data/sensitivies became
available. She was continued ceftriaxone for a total 7 day
course.
# Encephalopathy: Likely secondary to hepatic encephalopathy in
the setting of alcoholic hepatitis and UTI. No ascites on
ultrasound for SBP. No portal/splenic vein thrombosis. Head CT
was negative. The patient was treated with antibiotics as above.
She was also given lactulose 30mL QID, titrated to to [**3-19**] bowel
movements daily. At the time of discharge, her mental status was
back to her baseline with attention intact.
# Elevated lactate: Patient with initial lactate 9 --> 2.8 with
aggressive volume resuscitation. She also initially had an anion
gap lactic acidosis. This was most likely secondary to
alcoholic hepatitis and UTI.
# Alcohol withdrawal: Patient and family states she has had
seizures in the past. Reportedly last drink two days ago and
patient's alcohol level was negative on tox screen. She was
maintained Ativan 1-2mg IV q2 hours with CIWA >10. She was
given a banana bag overnight, then continued on IV thiamine and
given PO folate/MVI. Social work was involved and set her up
with [**Hospital 12091**] community health center where there is individual
counseling and a structured relapse prevention program. The
patient began to withdraw on [**5-8**] and was treated with IV
lorazepam intially every one hour per CIWA >10. This was
gradually broadened back to every 2-4 hours. Her CIWA scale was
discontinued four days prior to discharge. She was continued on
oral thiamine, MVI, and folate. She was given Ensure
supplementation.
# Fever and leukocytosis: The patient developed fever and
leukocytosis after alcoholic hepatitis was improving. She was
hemodynamically stable with the exception of persistent
tachycardia. She had no localizing signs or symptoms of
infection. LENI of the left leg was negative for DVT, with CXR
without infiltrate. UA was within normal limits. Blood
cultures are pending at the time of discharge.
Fever has resolved and leukocytosis is trending down now that
steroids have been stopped.
# Megaloblastic Anemia: Possibly multifactorial with chronic
liver disease, with poor marrow response and poor nutrition
contributing. The patient was guaiac positive, with INR 2.1 in
the setting of decompensated liver disease and alcohol abuse.
The patient was also hemodiluted with ~7L normal saline given in
the emergency room. The patient's hematocrit has intermittently
been this low in the past. She received 2 unit of PRBCs and
bumped hct appropriately. This also was used as colloid
resuscitation which improved her BP. Iron studies were done but
are unrelieable after blood transfusion. B12 and folate were
within normal limits. Her hematocrit was stable around 25 for
the week prior to discharge. She will need iron studies
performed as an outpatient.
# Thrombocytopenia: Likely in the setting of splenic
sequestration from portal hypertension, liver disease.
Pneumoboots were used for DVT prophylaxis.
# Depression/Anxiety: Stable, med rec was performed with
pharmacy and the patient is not on antidepressants at home. All
sedating medications were held given hepatotoxicity or hepatic
clearance including trazodone, zolpidem, and gabapentin.
Gabapentin was re-started on [**5-10**].
# Urinary incontinence: Stable during admission. The patient is
followed by urology as outpatient. Solifenacin was held during
admission.
# Depression: Emotionally labile, currently not on
antidepressants. Improved mood and affect towards the end of
admission. Psychiatry followed along inpatient and recommended
Celexa once LFT's improved.
# Left Leg Weakness: This is most likely secondary to alcohol,
prolonged immobility, and deconditioning. There was also an
element of functional weakness as the patient was able to hold
her leg up upon exam. TSH slightly elevated but free T4 within
normal limits. A PT consult was obtained who recommended
rehabilitation.
Medications on Admission:
* Gabapentin 300mg three times daily
* Hydroxyzine ?25mg three times daily
* Lidocaine 5% patch
* Solifenacin 5mg daily (antispasmodic, antimuscarinic)
* Trazodone 100mg qHS
* Zolpidem 10mg twice daily
* Docusate 100mg twice daily
* Ferrous sulfate 325mg daily
* Multivitamin daily
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin/perineal irritation .
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain: Only during rehab stay for alcoholic
hepatitis. Not to be discharged home on this medication.
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Hospital at [**Hospital 1263**] Hospital
Discharge Diagnosis:
Primary Diagnosis: Alcoholic Hepatitis, Depression, Urinary
Tract Infection
Secondary Diagnosis: Alcohol Abuse
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 110746**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with
inflammation of your liver secondary to heavy alcohol use. This
is known as alcoholic hepatitis. This is extremely detrimental
to your health. You should not drink alcohol or risk permanent
damage to your liver. Please work with the services at [**Hospital1 **]
so that they may help you avoid alcohol in the future.
You had a urinary tract infection. This was treated with IV
antibiotics for seven days.
The following changes have been made to your medication record:
START lasix 40mg daily
START spironolactone 50mg daily
START folic acid
START thiamine
START miconazole
START oxycodone 10mg every 6 hours as need for pain related to
alcoholic hepatitis, not to be continued after rehab stay
HOLD Vesicare
STOP Trazodone
STOP Ambien
STOP Hydroxyzine
Followup Instructions:
The following appointments were made for you:
Department: LIVER CENTER
When: MONDAY [**2194-6-30**] at 11:30 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
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"572.2",
"V45.86",
"300.4",
"303.90",
"291.81",
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"788.30",
"571.1",
"268.9",
"276.2",
"V49.87",
"263.9",
"286.7",
"780.39",
"599.0",
"572.3",
"281.9",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
15060, 15159
|
8233, 13745
|
326, 370
|
15313, 15313
|
4111, 4118
|
16417, 16742
|
2903, 2946
|
14078, 15037
|
15180, 15180
|
13771, 14055
|
15495, 16394
|
2961, 2963
|
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|
2101, 2270
|
264, 288
|
398, 2082
|
8017, 8210
|
15277, 15292
|
15199, 15256
|
4132, 8008
|
15328, 15471
|
2292, 2662
|
2678, 2887
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,648
| 182,485
|
305
|
Discharge summary
|
report
|
Admission Date: [**2148-1-2**] Discharge Date: [**2148-1-6**]
Date of Birth: [**2085-9-6**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Bupropion / Rosiglitazone Derivatives
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known firstname 2894**] [**Known lastname 2895**] is a very nice 62 year-old woman with
significant past medical history of diabtes mellitus type 2,
hypertension, hyperlipidemia, CAD s/p CABG who comes with three
weeks of shortness of breath and dyspnea on excertion. Patient
states that she is not very active at home given baseline
shortness of breath, which is thought to be secondarely to her
heart disease and COPD/Asthma, but she is able to do 1 flight of
stairs with difficulty. However, during the last 3 weeks she has
noted progressive SOB with less activity such as 10 steps. She
denies any nausea, vomit, cough, chest pain, palpitations,
wheezing associated with the SOB. She still uses either 1 or no
pillows at night and can lie flat without difficulty. She
weights herself daily and has been with diet to try to lose
wieght. There have been no sick contacts and she denies any
fever, chills, rigors, cough, rhinorrhea, arthralgias, muscle
pains, diarrhea, dysuria, urinary frequency. She went to see her
endocrinologist that follows her for her diabetes mellitus and
was asked to come to our emergency room. Her VS at that time
were: BP 167/71 mmHg, P 72 BPM, SpO2 O2 93% oN RA.
.
Per patient's report she had a stress test done in [**Month (only) **] last
year, but could not walk for more than a couple of minutes.
There was no imaging done. She had not had a cardiac cath since
her CABG.
.
In the ER her initial VS were BP 163/61 mmHg, P63 BPM, RR 17,
94% on RA, T 98.4 F. She had an ECG that showed occasional PVCs
with LVH by Sokolow-[**Doctor Last Name **] cirteria with TWI in I, II avL and
V5-V6 as well as <1mm ST depression in I, II and V5-V6 without
any dynamic changes. Patient was admitted for ROMI.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: ~10 years ago. Anatomy unknown.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
CAD
PAST MEDICAL HISTORY:
* Hypertension
* Hyperlipidemia
* Diabetes Mellitus Type 2 on insulin
* H/o Left thyroid macro-follicular nodule s/p lobectomy in [**2133**]
by Dr. [**Last Name (STitle) 2896**]
Asthma/COPD
GERD
Colonic Adenoma
CURRENT [**Last Name (un) **]
Social History:
She lives in [**Location 2268**] with her husband. History of smoking and
quit in [**2136**] with 12.5 pack-years aproximately. Denies any
current or past history of alcohol intake or illegal substance
use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Mother died of
chronic kidney disease secondarely to DM; father died of "old
age". No family history of cancer.
Physical Exam:
VITAL SIGNS - Temp 96.1 F, BP 154/74 mmHg, HR 58 BPM, RR 16 X',
O2-sat 98% RA. Glucose 106
GENERAL - well-appearing african-american woman in NAD, Oriented
x3, comfortable, Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, JVD 7 cm, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-17**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
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:
[**2148-1-2**] 07:38PM GLUCOSE-133* UREA N-27* CREAT-1.3* SODIUM-143
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
[**2148-1-2**] 07:38PM CK(CPK)-232*
[**2148-1-2**] 07:38PM cTropnT-<0.01
[**2148-1-2**] 07:38PM CK-MB-4 proBNP-456*
[**2148-1-2**] 07:38PM WBC-10.2 RBC-4.29 HGB-11.1* HCT-34.0* MCV-79*
MCH-25.8* MCHC-32.6 RDW-15.5
[**2148-1-2**] 07:38PM NEUTS-68.7 LYMPHS-24.6 MONOS-4.3 EOS-1.5
BASOS-0.8
[**2148-1-2**] 07:38PM PLT COUNT-246
[**2148-1-5**] 03:39AM BLOOD WBC-11.0 RBC-4.52 Hgb-11.6* Hct-35.4*
MCV-78* MCH-25.6* MCHC-32.6 RDW-15.4 Plt Ct-250
[**2148-1-5**] 03:39AM BLOOD Plt Ct-250
[**2148-1-5**] 03:39AM BLOOD Glucose-246* UreaN-20 Creat-1.6* Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
[**2148-1-5**] 03:39AM BLOOD CK(CPK)-191
[**2148-1-5**] 03:39AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-1-5**] 03:39AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
[**2148-1-6**] 08:24AM BLOOD WBC-11.7* RBC-4.43 Hgb-11.4* Hct-35.4*
MCV-80* MCH-25.7* MCHC-32.2 RDW-15.1 Plt Ct-238
[**2148-1-6**] 08:24AM BLOOD Glucose-193* UreaN-28* Creat-1.5* Na-137
K-4.8 Cl-102 HCO3-25 AnGap-15
[**2148-1-6**] 08:24AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.3
[**2148-1-3**] 06:40AM BLOOD %HbA1c-9.3*
.
Echo: [**2148-1-4**]
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
and mid-inferior walls, as well as basal inferoseptal and
inferolateral segments (dominant RCA or LCx territory). The
remaining segments contract normally (LVEF = 45%). 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 valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. No clinically-significant valvular disease seen.
.
[**2148-1-3**]- cardiac perfusion
IMPRESSION:
1. Fixed, medium sized, moderate reduction in photon counts
involving the PDA territory.
2. Normal left ventricular cavity size. Hypokinesis of the mid
and basal
inferior wall and the basal inferoseptum with preserved systolic
function.
.
[**2148-1-3**] - stress
This is a 62 year old IDDM woman s/p CABG, htn, COPD
who was referred for exercise stress with nuclear imaging
following
serial negative cardiac enzymes to evaluate symptoms of dyspnea
on
exertion. The patient completed 6.75 minutes of a modified [**Doctor First Name **]
protocol and reached a peak MET capacity of 4.8 which represents
a fair
functional capacity for her age. The test was terminated due to
fatigue. There were no complaints of chest, neck, back, or arm
pain.
Compared to baseline ECG with prominent voltage consistent with
LVH and
associated repolarization changes, there were no significant ST
segment
changes appreciated. The rhythm was sinus throughout the study
with
multifocal PVCs and two ventricular couplets. Blood pressure
response to
exercise was appropriate. The heart rate response was blunted in
the
setting of beta blockade therapy.
IMPRESSION: No anginal symptoms or significant ST segment
changes over
baseline abnormalities at a fair functional capacity for age.
Nuclear
report sent separately.
.
[**2148-1-2**]
PA AND LATERAL VIEWS OF THE CHEST: The patient is status post
median
sternotomy and CABG. The cardiac silhouette is mildly enlarged.
The
pulmonary vascularity is prominent, but there is no evidence of
overt
pulmonary edema. Linear opacities within both lung bases are
compatible with subsegmental atelectasis. No pleural effusion,
focal consolidation, or
pneumothorax is seen. The osseous structures demonstrate no
acute skeletal
abnormalities.
IMPRESSION: Bibasilar subsegmental atelectasis.
Brief Hospital Course:
Mrs. [**Known firstname 2894**] [**Known lastname 2895**] is a 62 year-old woman with significant
past medical history of diabtes mellitus type 2, hypertension,
hyperlipidemia, CAD s/p CABG who comes with three weeks of
shortness of breath and dyspnea on exertion.
.
CAD: s/p CABG ([**2137**]). Patient presented with dyspnea over three
weeks. She did not have EKG changes and she did not have
elevation in her cardiac enzymes. Given her risk factors and her
equivocal presentation, she underwent a nuclear stress test
which showed a fixed defect in the PDA territory and
hypokinesis of the mid and basal inferior wall and the basal
inferoseptum with preserved systolic function. She underwent
cardiac catheterization which showed a patent LIMA to LAD graft,
patent SVG to OM1 and an occluded SVG to RCA. She had stenosis
of the native RCA. An attempt was made to angioplasty the native
RCA; however, this was complicated by dissection. The patient
remained hemodynamically stable and completely asymptomatic
during and after the attempted intervention, and a
post-procedure ECG demonstrated no changes from baseline. The
patient and her husband were apprised of the complication in
detail, and appeared to understand that the vessel was not
amenable to further intervention at this time, and that medical
management was appropriate. She was admitted to the CCU
overnight for monitoring and remained stable. She returned to
the regular floor for medical optimization. She was discharged
on aspirin, a betablocker, [**Last Name (un) **], and a statin. She was scheduled
for repeat nuclear stress test as an outpatient with an eye
toward enrollment in cardiac rehabilitation to be coordinated by
her cardiologist.
.
#. SOB - Her dyspnea was likely an anginal equivalent for this
patient or a manifestation of heart failure due to occlusion of
her SVG-RCA graft. She also had a history of diastolic heart
failure, although no current evidence of pulmonary edema. Her EF
on this hospitalization was 45% due to regional dysfunction. She
also endorsed weight gain over the last year and has a history
of COPD, all of which could have contributed to her symptoms.
She was encouraged to take her Spiriva consistently and weight
loss is encouraged. Her presentation and hospital course was
discussed with her PCP with whom she will have close outpatient
follow up. She was without dyspnea on exertion at the time of
discharge, and was able to ambulate maintaining her oxygen
saturation in the high 90s on room air. She reported feeling
markedly improved in regards to her shortness of breath as
compared to her baseline presentation.
.
#HTN: Prior to admission she had presented to her
endocrinologist's office with systolic blood pressures in the
180s. Her atenolol was discontinued at that time and she was
started on Coreg 25mg twice a day. She was bradycardic in the
50s on admission, and her Coreg as reduced to 12.5mg twice a
day. She was discharged on this dose. Her blood pressure should
continue to be monitored as an outpatient and she was encouraged
to check home BP readings periodically to ensure optimal
control.
.
#. Increased creatinine - Her Cr was 1.3 on admission. She
received prehydration and treatment with mucomyst prior to
catheterization. Her Cr increased to 1.6 post cath. Her lasix
and avapro were temporarily held, and restarted as her
creatinine improved.
.
# Diabetes: She had a history of diabetes mellitus managed with
insulin. Her HBA1C on this admission was 9.3%. Tighter glycemic
control was encouraged, with insulin dosing to be titrated as an
outpatient, in conjunction with dietary discretion and exercise.
She was counseled on the adverse cardiovascular and general
health consequences of suboptimal glycemic control.
Medications on Admission:
Avapro 300 mg PO Daily
Vytorin 10/40 mg PO Daily
Lantus 30 am 50 PM
Novolog 30 u with meals
Almodipine 10 mg PO Daily
Vitamin D (cholecalciferol) 1,000 mg PO Daily
Furosemide 40 mg PO Daily
Carvedilol 25 mg PO BID
Omeprazole 20 mg PO BID
Spiriva with HandiHaler 18 mcg IH Daily
Aspirin 325 mg PO Daily
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Lantus 100 unit/mL Cartridge Sig: Thirty (30) units
Subcutaneous in the mornings.
8. Lantus 100 unit/mL Cartridge Sig: Fifty (50) units
Subcutaneous at bedtime.
9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Dyspnea on exertion.
.
Secondary
Obesity.
Coronary Artery Disease status post CABG
Hypertension
Hyperlipidemia
Discharge Condition:
stable, baseline ambulatory status (fully ambulatory)
alert and oriented to person, place and time
Discharge Instructions:
You were admitted to the hospital because you were having
worsening shortness of breath. You had a cardiac catheterization
which showed that you had had a heart attack. During the
procedure, one of the heart blood vessels was dissected. You
went to the intensive care unit. You did well and returned to
the regular floor. Some of your symptoms are also likely due to
your COPD from past smoking. Please take your spiriva
consistently.
.
The following changes were made to your medications.
.
We DECREASED carvedilol to:
carvedilol 12.5 mg twice a day.
.
We STARTED:
Atorvastatin 80mg daily
.
We STOPPED Ezetimibe/Vytorin:
No other changes were made to your medications
.
Continue the following medications:
-Avapro 300mg po daily
-Home dose lantus and insulin
-amlodipine 10mg daily
-Vitamin D 1000mg daily
-Lasix 40mg po daily
-omeprazole 20mg daily
-Spiriva 18mcg inhaled daily
-Aspirin 325mg daily
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: [**Last Name (LF) 766**], [**1-8**] at 11:20am
Location: [**Location (un) 2274**]-[**Location (un) 2898**], [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone number: [**Telephone/Fax (1) 2115**]
.
Appointment #2
Please call [**Telephone/Fax (1) 62**] and make an appointment to follow up
with Dr. [**Last Name (STitle) **] in 4 weeks.
.
We will schedule you to have a stress imaging test as an
outpatient to aide in cardiac rehab. Please have our stress test
and then discuss the results and cardiac rehab with Dr. [**Last Name (STitle) **]
at your follow up appointment.
|
[
"585.9",
"414.02",
"403.90",
"414.01",
"278.00",
"272.4",
"250.00",
"496",
"414.2",
"530.81",
"414.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"88.56",
"37.23",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
13934, 13940
|
8971, 12723
|
316, 323
|
14103, 14204
|
4860, 8948
|
15153, 15907
|
3331, 3558
|
13075, 13911
|
13961, 14082
|
12749, 13052
|
14228, 15130
|
3573, 4841
|
2721, 2827
|
269, 278
|
351, 2615
|
2849, 3091
|
3107, 3315
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,290
| 117,881
|
52533
|
Discharge summary
|
report
|
Admission Date: [**2113-1-17**] Discharge Date: [**2113-1-21**]
Date of Birth: [**2057-4-23**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55 healthy male
who presented to the hospital on [**2113-1-17**] with sudden onset of
epigastric pain after eating pie. The pain persisted through
[**1-16**] and increased in severity, which sought him to treat
medical attention. He noted a fever of 101.7 and was
referred to the Emergency Department for workup of gallstone
pancreatitis. The patient had increased bilirubin, which was
also concerning for cholangitis with recent fever. On
physical examination at presentation the patient was middle
aged and in mild distress, pupils are equal, round, and
reactive to light and accommodation. Oropharynx is clear.
Scleral icterus was appreciated. Lungs were clear to
auscultation bilaterally. Heart was regular rate and rhythm.
There was some epigastric tenderness. No rebound. No
guarding. Palpable dorsalis pedis pulses were noted. No
peripheral edema. Rectal was guaiac negative and no masses.
The patient does not smoke, does not take alcohol. Has a
family history of cholelithiasis.
ALLERGIES: No known drug allergies.
MEDICATIONS: Protonix occasionally.
PAST MEDICAL HISTORY: Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Noncontributory.
ADMISSION STUDIES: On admission he had right upper quadrant
ultrasound that showed numerous stones and 9 mm common bile
duct. No gallbladder wall thickening.
ADMISSION LABORATORY: White count 13.9, 38 hematocrit, 179
platelets, 136/3.8, 100/26, 19/1.1, glucose of 114. Arterial
blood gas was 7.39, 33 for CO2, 86 for oxygen, 21 for bicarb
and -3 for base deficit with a lactate of .3. ALT was 174,
AST 130, amylase was 1027, alkaline phosphatase was 183, T
bili 6.4, lipase was 31.07.
ASSESSMENT: The patient is a 55 year-old male with gallstone
pancreatitis and cholangitis. The patient was admitted to
the Intensive Care Unit per Dr. [**Last Name (STitle) 468**]. Endoscopic
retrograde cholangiopancreatography was ordered. Aggressive
intravenous fluids were ordered. The patient was NPO.
Nasogastric tube was placed if the patient vomited and the
patient was on intravenous Unasyn. The patient was admitted
to the Intensive Care Unit and quieted down with pain
control. His base deficit was reversed with aggressive
intravenous fluid therapy. The patient was stabilized and on
hospital day number two he was further stabilized. He
underwent an endoscopic retrograde cholangiopancreatography.
He had an increased O2 requirement on postoperative day
number two. His white blood cell count dropped to 7 from
admission of 13. The patient was placed on maintenance
fluid. On hospital day number three the patient was
transferred out to the floor and had no events overnight.
His temperature max that day was 99.1. His Foley was
discontinued. Discharge planning was begun. However, on
[**1-20**] it was decided that it would be appropriate for the
patient to undergo a laparoscopic cholecystectomy with
intraoperative cholangiogram as he was status post endoscopic
retrograde cholangiopancreatography with biliary tree
drainage. Please see operative dictation for laparoscopic
cholecystectomy. The patient had a normal postoperative
course. On postoperatively day number one his abdomen was
soft, nontender, benign. On postoperative day number two the
patient was improved and it was decided that the patient met
criteria for discharge and was discharged in stable
condition.
Of note, I have had no clinical contacts with this patient
and have dictated this summary from the chart that was found
in the medical records.
DISCHARGE DIAGNOSES:
1. Gallstone pancreatitis.
2. Choledocholithiasis.
3. Status post cholangitis.
4. Status post endoscopic retrograde
cholangiopancreatography.
5. Status post laparoscopic cholecystectomy with
intraoperative cholangiogram.
DISCHARGE CONDITION: Stable.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 740**]
MEDQUIST36
D: [**2113-3-13**] 03:09
T: [**2113-3-15**] 07:45
JOB#: [**Job Number 108501**]
|
[
"576.1",
"577.0",
"530.81",
"574.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.53",
"51.23",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
3966, 4238
|
3717, 3944
|
1333, 3696
|
156, 1252
|
1275, 1309
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,400
| 180,928
|
29959
|
Discharge summary
|
report
|
Admission Date: [**2152-4-17**] Discharge Date: [**2152-4-22**]
Date of Birth: [**2090-6-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Caffeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Palpitations, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2152-4-17**] Mitral Valve Replacement (33mm [**Company 1543**] Mosaic tissue
valve)
History of Present Illness:
61 year old female with known mitral regurgitation followed by
serial echo which has shown progression of left ventricular
dilation and appearance of pulmonary hypertension.
Past Medical History:
Mitral Regurgitation
Mitral Valve Prolapse
Tricuspid Regurgitation
Lyme disease
s/p rotator cuff repair Rt
S/P T&A
s/p D&C
S/P hysterectomy
s/p bladder suspension
s/p bunionectomy
Social History:
Lives with spouse
Retired
[**Name2 (NI) 1139**] 1 ppd x 20 years quit [**2137**]
ETOH 1 glass wine/day
Family History:
uncle deceased MI age 55
Physical Exam:
Admission
General NAD 153/75, 18 RR, 65 SR, 145 lbs
Heart RRR 4/6 SEM
Abd soft, nt, nd + bs
Ext warm well perfused no edema pulses +2
Neuro grossly intact
Neck supple, Full ROM
Pertinent Results:
[**2152-4-20**] 06:45AM BLOOD WBC-5.7 RBC-2.61* Hgb-8.5* Hct-24.4*
MCV-93 MCH-32.4* MCHC-34.7 RDW-14.2 Plt Ct-124*
[**2152-4-20**] 06:45AM BLOOD Plt Ct-124*
[**2152-4-20**] 06:45AM BLOOD Glucose-101 UreaN-10 Creat-0.7 Na-137
K-4.4 Cl-105 HCO3-26 AnGap-10
Brief Hospital Course:
Ms. [**Known lastname **] was was same day admission and was brought to the
operating room where she underwent mitral valve replacement.
Please see operative report for surgical details. She tolerated
the procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day she was weaned
from sedation, awoke neurologically intact and was extubated. On
post-op day one she remained on neosynephrine and fluid boluses
for hypotension. She continued to progress and was weaned off
pressors, she was started on beta blockers and lasix, chest
tubes were removed and she was transferred to [**Hospital Ward Name **] 2 post
operative day 2. She has remained hemodynamically stable, has
progressed well with her mobility, and is ready to be discharged
home.
Medications on Admission:
Lisinopril 10mg daily
HCTZ 25mg daily
Calcium plus D 500mg TID
MVI
Flax seed oil
Iron 45mg TID
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:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. Naprosyn 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: then [**Hospital1 **] prn.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Central and [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
Mitral Regurgitation s/p MVR
Mitral Valve Prolapse
Pulmonary Hypertension
Discharge Condition:
Good
Discharge Instructions:
Please shower daily, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) **] in 1 week - please call for appointment
Dr [**Last Name (STitle) 20948**] in [**1-1**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2152-4-21**]
|
[
"E849.7",
"E878.1",
"424.0",
"458.29",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"39.61"
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icd9pcs
|
[
[
[]
]
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3678, 3766
|
1458, 2252
|
309, 398
|
3884, 3891
|
1179, 1435
|
4375, 4765
|
941, 967
|
2398, 3655
|
3787, 3863
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2278, 2375
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3915, 4352
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982, 1160
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236, 271
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426, 601
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623, 804
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820, 925
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,101
| 129,287
|
46127+46128+46129
|
Discharge summary
|
report+report+report
|
Admission Date: [**2123-9-20**] Discharge Date: [**2123-10-14**]
Date of Birth: [**2069-5-9**] Sex: M
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 54 year old gentleman
with multiple medical problems including coronary artery
disease, congestive heart failure, prosthetic mitral valve
placement. The patient was admitted with shortness of breath
and pulmonary edema. The patient was status post mitral
valve replacement and tricuspid valve replacement,
pericardial stripping on [**2123-8-10**]. He had a prolonged
postoperative course complicated by failure to wean from
ventilator with tracheostomy and percutaneous endoscopic
gastrostomy tube placement and Methicillin resistant
The patient was transferred to the rehabilitation center on
[**2123-9-6**]. At that time, his weight was 184 pounds and he was
on 40% trach mask. The patient has had problems with mild to
moderate pulmonary edema since transfer. The patient had his
right chest tube discontinued today on the day of admission.
He had worsening shortness of breath afterwards. He was
noted to be in pulmonary edema on examination and was
transferred to the [**Hospital1 69**] for
evaluation and treatment of his pulmonary edema and possible
transfusion for low hematocrit.
In the Emergency Department, the patient was found to be with
a oxygen saturation in the low 90s on 50% trach mask. He was
vigorously suctioned. Afterwards, he was 99% on 40% FIO2.
He also was given Lasix 60 mg times one with good urine
output 500 cc in the first two hours and 750 cc total.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post inferior myocardial
infarction in [**2115**], complicated by left ventricular thrombus,
status post left circumflex stent in [**4-1**].
2. Congestive heart failure.
3. Status post mitral valve replacement and tricuspid valve
replacement [**2123-8-10**].
4. AICD [**4-1**].
5. History of cerebrovascular accident secondary to coronary
artery disease, residual left finger numbness.
6. History of Hodgkin's lymphoma at the age of 27, status
post mantel radiation and splenectomy.
7. Hypercholesterolemia.
8. History of cervical discectomy.
9. History of nasal treatment.
10. Tracheostomy [**2123-8-25**].
11. Gastrostomy tube placement [**2123-8-25**].
12. Methicillin resistant Staphylococcus aureus pneumonia
diagnosed [**2123-9-2**].
13. Constrictive pericarditis.
14. Iron deficiency anemia.
MEDICATIONS ON ADMISSION:
1. Amiodarone 400 mg q.d.
2. Captopril 6.25 mg q.d.
3. Thyroxine 125 mcg q.d.
4. Potassium Chloride 10 meq q.d.
5. Ranitidine 150 mg q.d.
6. Oxazepam q.h.s.
7. Coumadin.
8. Lasix 60 mg q.d.
9. Lovenox 60 mg subcutaneous b.i.d.
FAMILY HISTORY: Father died from colon cancer. No history
of coronary artery disease.
SOCIAL HISTORY: The patient is married. He does not smoke
or drink alcohol. He currently lives in [**Hospital1 **]
Rehabilitation Center.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: In general, the patient is resting
comfortably in bed in no acute distress. Vital signs
revealed temperature 97.2, blood pressure 104/48, pulse 83,
oxygen saturation 97% on 50% trach mask. Head, eyes, ears,
nose and throat - The pupils are equal, round, and reactive
to light and accommodation. Extraocular movements are
intact. Anicteric sclerae. Hearing aids in place. Moist
mucous membranes. The neck is supple without
lymphadenopathy. Lungs - coarse sounds throughout, no
wheezes, crackles about half way up bilaterally.
Cardiovascular - jugular venous distention about 10
centimeters, carotids normal with brisk upstrokes, regular
rate and rhythm, normal S1 and S2, with metallic opening
snap. Abdomen - soft, nontender, nondistended, normoactive
bowel sounds. Extremities - Positive pitting edema of the
lower extremities to thigh Positive pitting edema in arm.
Well healed scar on left arm, PICC in the right arm,
dressings to both heels for decubitus ulcers. Chest - well
healed medicine scar, dressings to both chest tube sites with
serosanguinous drainage. Rectal - guaiac negative.
LABORATORY DATA: Hematocrit 23.9, platelets 598,000, white
blood cell count 9.2. Sodium 141, potassium 5.1, chloride
104, bicarbonate 20, blood urea nitrogen 81, creatinine 1.1,
glucose 90. Calcium 7.6, magnesium 3.8, phosphorus 4.8,
albumin [**2123-9-8**], 1.7. Prothrombin time 14.2, partial
thromboplastin time 35.4, INR 1.3. CK #1 was 50. Total
bilirubin 0.85, LDH 229, transferrin low 2.02, folate 43.7,
haptoglobin 81, TIBC 45, iron 4.0, reticulocyte count 3.0% on
[**2123-9-17**]. Urinalysis - specific gravity 1.009, positive
blood, [**4-5**] white blood cells, negative bacteria, negative
nitrites. TSH on [**2123-9-2**], was 26. Free T4 was 0.7. T3 was
less than 30.
Chest x-ray - right loculated effusion, increased left
effusion.
Electrocardiogram - ventricular paced electrocardiogram,
Transthoracic echocardiogram from [**2123-8-18**], revealed an
ejection fraction of 20 to 25%, severe left ventricular
hypokinesis, decreased right ventricular systolic function,
2+ aortic insufficiency, prosthetic mitral valve and
tricuspid valve, positive ascites, positive left pleural
effusions.
Catheterization [**2123-4-6**], revealed ejection fraction of 35%,
global left ventricular hypokinesis, 2 to 3+ mitral
regurgitation, right coronary artery normal, obtuse marginal
normal, left anterior descending normal, circumflex 90%
stenosis proximally, patch pericardiac calcifications, right
atrium 22/24/19, right ventricle 38/19, left ventricle
108/19, pulmonary capillary wedge pressure 20/20/18, cardiac
output 3.1, cardiac index 1.7.
IMPRESSION: This is a 54 year old man with multiple medical
problems including coronary artery disease, congestive heart
failure, prosthetic mitral valve and tricuspid valve, who has
been on a trach mask since discharge on [**2123-9-6**]. He has
chronic problems with pulmonary edema. He presents on
[**2123-9-20**], with increased shortness of breath and pulmonary
edema in the context of having a chest tube pulled that day.
HOSPITAL COURSE:
1. Cardiovascular - Myocardium - The patient's ejection
fraction postoperative was 20 to 25% with severe left
ventricular hypokinesis. His outpatient regimen is Captopril
6.25 mg t.i.d., Lasix 60 mg q.d., Amiodarone 400 mg q.d.,
with p.r.n. Lasix. On admission, he had pulmonary edema and
it was decided to continue to diurese him with a goal of
negative two liters by the next day.
During the first four days of admission, the patient's
Captopril was increased from 6.25 mg to 25 mg t.i.d. Digoxin
as well as Aldactone was added to his regimen. It was
attempted to diurese him but he seemed intravascularly dry
with blood urea nitrogen/creatinine ratio of 80. It was felt
that his fluid was all third spaced.
The patient was placed on Digoxin 0.125 mg q.d., Aldactone 25
mg and Lasix 70 mg p.o. q.d. It was thought to increase his
Lasix dose and to change his Captopril to Mavik 2 mg. He was
continued on this regimen of medications until [**2123-9-28**], with
systolic blood pressure of 60 to 80s. His Mavik was
discontinued secondary to this low blood pressure. His
Digoxin was also discontinued secondary to increased Digoxin
level.
His blood pressure was thought to be low because he was
intravascularly dry secondary to continual third spacing of
all fluids. His blood pressure was difficult to maintain
because there was a 20 point systolic blood pressure
difference between his right and left arm, his right being 20
points greater than the left arm, but unable to use right
upper extremity for blood pressure measurements because his
PICC line was in place.
In the setting of his decreased blood pressure, right femoral
arterial line was placed. He was started on Dopamine.
Central venous pressure line was placed and was unable to go
across the tricuspid valve replacement with a central venous
pressure of 12, cardiac output of 7.1 and SVR of 700.
The etiology of his shock was felt to be vasodilatory, sepsis
versus myxedema versus adrenal suppression and the patient
was started on Neo-Synephrine. His Neo-Synephrine was
maintained for five days and weaned to off on [**2123-10-3**], with
systolic blood pressure in the 120s.
He was started on Captopril and titrated to 25 mg p.o. t.i.d.
His mean arterial pressures were 60 to 70. The patient on
[**2123-10-5**], was on Captopril 25 mg t.i.d., Digoxin 0.0625 mg
q.d. with systolic blood pressure in the 120/50 range.
Repeat echocardiogram on [**2123-9-28**], showed an ejection
fraction of less than 25% with severe global left ventricular
hypokinesis. His blood cultures did not grow anything. His
Neo-Synephrine was weaned off. The patient was placed on
Zosyn for his sepsis. The patient was eventually placed on a
Lasix drip with a fluid goal of negative one liter. His
Captopril was increased to 37.5 mg t.i.d. on [**2123-10-6**]. His
fluid balance goal continued to be negative 500 to negative
one liter. He seemed slightly fluid overloaded. Digoxin was
restarted. Lasix drip was titrated for adequate urine
output.
On [**2123-10-8**], the patient was thought to be euvolemic. On
[**2123-10-9**], the patient was thought to be negative fluid
balance which was the goal at that time. Because of low
blood pressure in the morning following his Captopril dose,
his Captopril dose was decreased to 25 mg t.i.d. on [**2123-10-9**].
On [**2123-10-10**], his Lasix drip was stopped secondary to a bump
in his blood urea nitrogen and creatinine up to 115 and 1.7.
On that same day, his Captopril was changed to Zestril 10 mg
q.d. for better blood pressure control without the episodes
of hypotension.
On [**2123-10-11**], it was felt that the patient was dry and his
goal fluid status was changed to euvolemic to positive over
24 hours. On [**2123-10-11**], his right femoral arterial line was
taken out and his blood pressure was being able to be
monitored on his right arm despite his PICC line. On
[**2123-10-12**], the patient was felt to be dry especially since he
was not receiving any tube feeds because of possible
procedure that day. His urine output was also low so he was
bolused 250 cc of normal saline three times. This increased
his urine output.
Coronary arteries - The patient's last catheterization was
[**2123-4-16**], showing one vessel coronary artery disease which
was stented. He was continued on Aspirin throughout his
hospitalization stay. Stenosis was in his left circumflex at
90% stenosis. The patient should be considered to begin beta
blocker as an outpatient once he is discharged.
Conduction - The patient has a history of nonsustained
ventricular tachycardia with inducible ventricular
tachycardia on electrophysiology study. He has an ICD in
place and Amiodarone started in [**2123-4-1**]. On admission, he
was in ventricular paced rhythm and remained this way
throughout his hospitalization stay.
Dual chamber pacer - His Amiodarone was continued at the dose
of 400 mg q.d., paced to 80 beats per minute. The patient
will need pulmonary function tests at some point as an
outpatient because of the possible side effect of pulmonary
fibrosis with Amiodarone. He will need to be less
deconditioned for this. His electrolytes remained fairly
stable throughout his hospital stay and were repleted as
needed.
Valves - The patient has prosthetic mitral valve and
tricuspid valve. His goal INR is 2.5. The patient was
subtherapeutic on admission, was given Lovenox on the day of
admission, but was started on Heparin drip while he was in
the hospital until his therapeutic INR was reached. The
patient's Heparin drip was stopped for several days in the
beginning of [**Month (only) **] because of a large left groin and
thigh hematoma which developed. It was restarted but then
stopped again briefly because of bright red blood from his
trachea, however, this stabilized and by discharge, he was
back on the Heparin drip for several days. Please see
hematology section for more details.
2. Pulmonary - The patient has a history of congestive heart
failure. He has been on tracheal mask at 40% FIO2. He
presented with pulmonary edema and left pleural effusion. It
was decided to diurese him. Additionally, right chest tube
was removed on [**2123-9-20**], no pneumothorax seen on chest x-ray.
He continued to require frequent suctioning and sputum was
sent for culture. In addition, the patient's chest x-ray
showed bilateral pulmonary edema and possibly pneumonia. His
white blood cell count began to increase in the first few
days of hospitalization. Because of his history of
Methicillin resistant Staphylococcus aureus pneumonia, he was
began on Levaquin, Flagyl and Vancomycin.
On [**2123-9-24**], the patient's right pleural effusion was tapped
and it was found to be a transudate. Left pleural effusion
was still present. At that point, his sputum culture was
positive for Methicillin resistant staphylococcus aureus and
it was decided to treat that for ten days. On [**2123-9-24**], he
was saturating well on 40% FIO2.
In the first few days of hospitalization, bronchoscopy was
done showing dried blood, no active bleeding which was
consistent with suction trauma. It was decided to
bronchoscope him because of bloody mucus that he developed.
Once he was identified with Methicillin resistant
Staphylococcus aureus, his Levaquin and Flagyl were
discontinued. It was decided to continue his Vancomycin for
a total of 28 day course.
On [**2123-9-28**], in the setting of decreased blood pressure, the
patient requiring increased oxygen requirement and
desaturation into the 80% range on FIO2 100% trach mask, the
patient was ventilated with good oxygenation on FIO2 60% and
PEEP of 10. He stayed intubated for five days and
transitioned to a trach mask on [**2123-10-2**].
He then maintained good oxygenation with 95% oxygen
saturation on 15 liters of FIO2, 50% trach mask. Chest
x-ray on [**2123-9-30**], was consistent with bilateral pleural
effusions and right lower lobe pneumonia. Methicillin
resistant Staphylococcus aureus with question of adult
respiratory distress syndrome.
On [**2123-10-3**], the patient was noted to have a hernia/bulge on
the left chest wall at the chest tube site approximately five
centimeters in size. CT showed pleural herniation, no lung
tissue.
On [**2123-10-6**], his Zosyn course of seven days for possible
sepsis was finished and it was discontinued. CT surgery
indicated that the left sided bulge was stable and that there
was nothing to be done for it. The patient's Vancomycin was
held on [**2123-10-4**], for a high level of 42.3. His Vancomycin
trough continued to be high and so it was continued to be
held. His repeat chest x-ray on [**2123-10-6**], showed decreased
bilateral pleural effusions and no change in his right middle
lobe infiltrate. CT surgery indicated that the left bulge is
a chest wall defect intercostal with no lung present on CT
scan. There is moderate left sided effusion and they
recommend a thoracentesis but no treatment for the bulge. It
was decided by the CCU team to hold off on tapping his
pleural effusion.
The patient failed a trial with trach valve on
[**2123-10-9**], and it was decided to replace his tracheostomy to a
#6 from a #8. On [**2123-10-11**], the patient's Vancomycin trough
level was 15.9 and it was decided to give him one gram
intravenously times one. The patient did experience two days
of bright red blood from his tracheostomy tube and
interventional pulmonology was following him. They did do a
scope and found some superficial bleeding vessels and were
planning to cauterize it but then the bleeding stopped on its
own and it was decided to hold off on cauterization and
scoping. The patient failed the trach valve again on
[**2123-10-11**], and the plan was for interventional pulmonology to
scope to look for an obstruction causing this failure with
the valve, however, on [**2123-10-12**], a new tracheostomy was
placed, this time size #4, and on [**2123-10-13**], the trach
valve was retried with success, having the patient talk
without it popping off. Therefore, the scope of his trachea
was held off.
On [**2123-10-13**], it was noted that the left chest wall bulge was
increased in size and was firmer. CT surgery was called to
take a look at it and they decided that there was nothing to
be concerned about, that there was pleural fluid in that
bulge and could be treated conservatively and left alone.
3. Renal - The patient's blood urea nitrogen and creatinine
on admission appeared to be at his baseline, however, he was
also felt to be intravascularly dry with a high ratio of
blood urea nitrogen/creatinine on [**2123-9-24**], with third
spacing of his fluids so there was an increase in his blood
urea nitrogen and creatinine over the next three to four days
with decreased urine output not responding to Lasix. On
[**2123-9-28**], his blood urea nitrogen/creatinine peaked at
137/2.2.
He was started on Dopamine which was changed to
Neo-Synephrine with increased urine output of greater than
150 cc/hour for two days. Urine output started to decrease
so he was transitioned to Lasix boluses which was then
changed to Lasix drip with continued good urine output.
Renal consultation was requested on [**2123-9-28**]. They thought
him to be severely prerenal. His blood urea
nitrogen/creatinine decreased over three to four days to
71/1.3. On [**2123-10-5**], he had a slight decrease in urine
output and it was decided to transfuse the patient with two
units of packed red blood cells to help mobilize his fluids.
His creatinine clearance on [**2123-10-2**], was 24 via a 24 hour
collection.
At the beginning of [**Month (only) **], his bicarbonate was noted to
be elevated up to 40 on [**2123-10-6**]. It was decided if it rose
any further, Acetazolamide would be started for better
diuresis, however, it did not go over 40 and actually
decreased to approximately low 30s and Acetazolamide was
never started.
On [**2123-10-7**], the patient's goal net fluid balance was
negative 500 to negative one liter. His increased
bicarbonate was thought to be secondary to diuretic
treatment/transfusion/contract alkalosis. His potassium was
kept above 4.0. On [**2123-10-10**], since the patient was felt to
be dry, his goal fluid balance was changed to
positive/neutral and the Lasix drip was discontinued.
His Lasix drip was also discontinued because of an increase
in his blood urea nitrogen and creatinine. On [**2123-10-10**], his
blood urea nitrogen and creatinine were 115 and 1.7. Even
after the Lasix drip was discontinued, the patient's blood
urea nitrogen and creatinine continued to be elevated with
blood urea nitrogen of 100 and creatinine 1.6 on discharge.
On [**2123-10-12**], the patient was given fluid boluses of 250 cc
times three, total of 750 cc for low urine output and a dry
state.
4. Hematology - The patient was anemic on admission thought
to be iron deficiency anemia, which seemed to be chronic. He
had continuous serosanguinous drainage from his chest tube
sites. He was continued on iron and on admission was
transfused two units of packed red blood cells with Lasix.
Anticoagulation wise, he was placed on a Heparin drip. The
patient's baseline hematocrit at home or in the
rehabilitation center was 27.0 to 29.0. After receiving the
two units of packed red blood cells, he stayed at 30.0. He
did have guaiac positive stools, but his lavage was negative.
Esophagogastroduodenoscopy showed gastritis and Barrett's
esophagus but no active bleeding. On [**2123-9-24**], he was no
longer guaiac positive.
The patient did have a low haptoglobin and hemolysis workup
was done. Initially his hemolysis laboratories were negative
as was his bronchoscopy negative for active bleeding. The
patient's hematocrit fluctuated between 26.0 and 30.0 and he
received two units of packed red blood cells on [**2123-9-29**]. On
[**2123-9-28**], in the setting of decreased systolic blood pressure
and increased hypoxia, central arterial access and central
venous access was attempted and after multiple sticks
bilaterally, right femoral artery and right femoral CVL were
obtained, however, the patient received a right femoral
hematoma, small and well circumscribed, and a left large
hematoma, but remained clinically stable.
Since [**2123-9-28**], and [**2123-10-6**], the patient received a total of
six units of packed red blood cells for hematocrit between
24.0 and 30.0. On [**2123-10-3**], he received two units of packed
red blood cells with increased hematocrit to 27.0 which
decreased to 24.0 two days later. He was given then two more
units of packed red blood cells. CT of the abdomen and
pelvis were obtained on [**2123-10-5**], showing left groin hematoma
and right psoas hematoma, 4.0 by 4.0 centimeters. Throughout
the decreased hematocrit values, the patient was maintained
on Heparin drip for his St. [**Male First Name (un) 923**] artificial valve. He was on
Coumadin but was switched to Heparin for better control.
Goal partial thromboplastin time was low 50s.
The patient was guaiac negative on [**2123-10-6**]. It was planned
to check his percutaneous endoscopic gastrostomy lavage.
Ultrasound of his groin was negative for pseudoaneurysm and
it was decided on [**2123-10-6**], to recheck his hematocrit at noon
because of decreased from 32.0 to 28.0. Vascular surgery was
consulted about his right psoas and left groin hematomas.
His noon hematocrit on [**2123-10-6**], was 30.7 so it was decided
not to lavage his percutaneous endoscopic gastrostomy fluid
and he was not transfused. On [**2123-10-6**], it was decided to
stop his Heparin drip for the decreased hematocrit but then
on [**2123-10-7**], it was decided to restart it at 1000 units per
sliding scale with goal partial thromboplastin time of 50 to
60. Since his noon hematocrit was 30.7 on [**2123-10-6**], it was
decided to transfuse for less than 27.0 or 28.0. Direct
Coombs test and haptoglobin, LDH and indirect bilirubin were
checked.
On [**2123-10-8**], the patient was noted to have bright red blood
coming out of his tracheostomy. His Heparin drip was turned
off. Pulmonary team was called to assess this. On [**2123-10-8**],
it was noted that his left groin thigh hematoma was less
indurated. Vascular surgery team believed that no surgical
or interventional radiology intervention was appropriate at
this time. The patient's direct Coombs was negative.
Haptoglobin was low and direct bilirubin was normal. LDH was
high. He was thought to have hemolytic anemia, most likely
due to his artificial valves.
On [**2123-10-8**], his Heparin drip was restarted at 7:00 p.m. with
the approval of the interventional pulmonology team. On
[**2123-10-10**], the patient was transfused one unit of blood for
hematocrit of 26.9. His hematocrit did not bump very much
with this and he went up to 27.6. The patient's right groin
A line was pulled on [**2123-10-10**], and he developed a small right
groin hematoma which remained stable. It was decided to
recheck his hematocrit at noon on [**2123-10-11**], and transfuse if
less than 27.0, however, this was not needed. His
tracheostomy stopped bleeding after a couple days. The
patient's hematocrit did bump to 31.2. His Heparin drip was
restarted on [**2123-10-8**].
On [**2123-10-13**], the patient's hematocrit was 27.7 and it was
decided to transfuse him one unit of blood, not so much for
the thought of him actively bleeding anywhere, but more for
intravascular volume. The patient was guaiac negative on
discharge. It was decided to give him a dose of Lovenox 60
mg on the day of discharge and to stop the Heparin drip three
hours later. Coumadin was given the afternoon of discharge
as well 5 mg with a goal INR of 2.5 to 3.5 for valvular
protection.
5. Infectious disease - The patient was afebrile on
admission with copious secretions. Per nursing reports, this
was a problem for some time, three to five days prior to
admission. Culture was sent. The patient completed
Vancomycin for Methicillin resistant Staphylococcus aureus
pneumonia on [**2123-9-2**]. He was thought to have pneumonia on
admission. Sputum culture was positive for Methicillin
resistant Staphylococcus aureus. The patient was started on
Vancomycin for a total of 28 days. For Methicillin resistant
Staphylococcus aureus pneumonia, Vancomycin was being dosed
p.r.n. and levels were followed. He was redosed for
Vancomycin level of less than or equal to 15.0. On [**2123-9-29**],
he was noted to have rigors and increased temperature from
his baseline hypothermic of 98 to 99. In the setting of an
increased cardiac output and decreased SVR to the 200 to
600s, he was felt to have sepsis and he was covered with
Zosyn for seven days to cover pseudomonas. Repeat urine and
sputum cultures were negative. Blood cultures continued to
be negative.
On [**2123-10-5**], the patient was afebrile with a white blood cell
count of 14.0. White blood cell count continued to decrease
and he continued to remain afebrile until discharge. On
[**2123-10-11**], the patient was given one gram intravenously times
one of Vancomycin after it had been held for several days for
high trough level. On [**2123-10-11**], it was 15.9. On [**2123-10-13**],
his Vancomycin trough level was 22.1.
6. Endocrine - The patient has diagnosis of hypothyroidism.
His TSH was high at 87 and free T4 low at 0.8. It was
decided to increase his Synthroid to .175 mcg. By suggestion
of the endocrine team which was consulted, it was thought to
be secondary to Amiodarone although he was not thought to be
in myxedema coma. His thyroid function tests were rechecked
on [**2123-10-7**]. In addition, endocrine consultation was
obtained for adrenal crisis on [**2123-9-28**], in the setting of
hypotension, decreased urine output and respiratory failure.
He was given a stress dose of steroids and drew random
cortisol level which was 23. It was felt an adequate
response per endocrine and no more steroids were given.
On [**2123-10-7**], repeat thyroid function tests were done.
Because of continued increased level of TSH and decreased
level of free T4, the endocrine team recommended increasing
his Synthroid dose to 0.2 mg q.d. and asked for his thyroid
function tests to be rechecked on [**2123-10-16**].
7. Gastrointestinal - The patient had a percutaneous
endoscopic gastrostomy tube in on admission. He was
continued on tube feeds and Zantac for prophylaxis. The
patient was guaiac positive on admission and was evaluated
for gastrointestinal bleed. Esophagogastroduodenoscopy was
negative. The patient was on Prevacid through his tube
feeds. His stools then became guaiac negative. Video
swallowing study from previous hospital admission showed
positive aspiration.
8. FEN - The patient was in fluid overload on admission.
Goal was negative two liters. Electrolytes were within
normal limits on admission. Nutrition was poor with low
albumin of 1.7 and he was started on tube feeds. He was also
thought to be intravascularly dry with third spacing.
Nutrition was consulted and he was placed on Impact with
fiber tube feeds. The patient was not placed on intravenous
fluids given his total body fluid overload and third spacing.
In the setting of diuresis, the patient was repleted his
magnesium and potassium.
On [**2123-9-30**], he was noted to have undigested tube feeds in
the setting of Fentanyl drip for sedation. This resolved
stopping the Fentanyl. His albumin continued to be low at
2.0 to 2.5. His fluid balance goal then changed negative 500
to negative one liter. On [**2123-10-11**], his goal fluid balance
was then changed to positive/euvolemic. He was thought to be
dry with low urine output. On [**2123-10-13**], the patient was
transfused one unit of packed red blood cells for
intravascular volume repletion.
9. Neuropsychiatry - During his hypotensive episodes, the
patient was placed on Fentanyl drip for sedation but was
weaned off the next day. The patient does have a history of
stroke in the past prior to admission with left finger
numbness as a residual effect. This question was raised on
rounds about the patient's mood, anhedonia signs. Discussed
with the patient's wife. She felt he was not depressed but
more frustrated with not being able to eat and his having to
have a tracheostomy in. In discussion with his wife, it was
decided to hold his antidepressants at this time.
On [**2123-10-13**], when his ************* valve was successful and
the patient was finally able to speak, he did seem to have a
more elevated mood due to his feeling happy about being able
to speak.
10. Prophylaxis - The patient was turned regularly. He was
on the Heparin drip on and off. He was on Prevacid for
gastrointestinal prophylaxis and multipedis splints.
11. Lines - The patient had a right PICC placed, right
femoral artery, tracheostomy, Foley and rectal stool bag
during this admission. Because of multiple attempts to place
an arterial line, he had a large left groin hematoma. On CT
scan of the abdomen and pelvis, he was clinically stable.
Ultrasound showed no pseudoaneurysm and he was followed and
the induration due to the hematoma did seem to decrease in
size as did the tenderness. He remained neurologically
intact with intact pulses in his feet. The rectal bag was
discontinued.
Physical therapy who evaluated the patient during his
hospitalization stay could not mobilize him very much because
of his right groin femoral arterial line, however, this was
maintained for longer than would have been ideal because of
his intermittent decreases in blood pressure. On [**2123-10-10**],
his right groin A line was removed and he was able to sit up
with the help of physical therapy and do more exercises with
them. He did develop a small hematoma in the area but his
remained stable.
His right PICC line remained in and will remain in because of
his continued Vancomycin treatment but the nurses were able
to measure blood pressure on his right arm.
12. Code Status - Full.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Back to [**Hospital1 49166**].
DISCHARGE MEDICATIONS:
1. Albuterol/Atrovent nebulizers q4hours p.r.n.
2. Amiodarone 400 mg q.d.
3. Miconazole cream 2% apply to folds b.i.d.
4. Aspirin 325 mg p.o. q.d.
5. Aldactone 25 mg p.o. q.d., hold for systolic blood
pressure less than 85.
6. Digoxin 0.0625 mg p.o. q.d., hold for pulse less than 50.
7. Prevacid 30 cc via percutaneous endoscopic gastrostomy
tube q.d.
8. PICC flush 200 units Heparin and 60 cc normal saline
b.i.d.
9. Impact with fiber at 40 cc/hour and increase as tolerated
to goal of 80 cc/hour. Check residual q4hours and hold for
greater than 100 cc
10. Iron Sulfate 325 mg p.o. percutaneous endoscopic
gastrostomy tube t.i.d.
11. Synthroid 0.2 mg p.o. percutaneous endoscopic gastrostomy
tube q.d.
12. Zestril 10 mg p.o. percutaneous endoscopic gastrostomy
tube Q.d.
13. Tylenol 650 mg p.o. percutaneous endoscopic gastrostomy
tube q4-6hours p.r.n.
14. Serax 15 to 30 mg p.o. q.h.s. p.r.n.
15. Ativan 0.5 to 1 mg intravenously q4-6hours p.r.n.
16. Lovenox 60 mg subcutaneous b.i.d.
17. Coumadin 5 mg p.o. q.h.s.
DISCHARGE INSTRUCTIONS:
1. The patient to receive physical therapy two to three
times a week.
2. The patient to be NPO and have a video swallow study on
the day after arriving at the rehabilitation center, possibly
[**2123-10-14**], or [**2123-10-15**], to compare with the previous one and
to evaluate him for aspiration before restarting p.o. intake.
3. Please check every day prothrombin time and INR and stop
the Lovenox when the INR is therapeutic between 2.5 and 3.5
for two days.
4. Please check every day Vancomycin trough level. If less
than or equal to 15.0, may give one gram intravenous times
one, but stop checking or giving Vancomycin on [**2123-10-20**].
That will be the end of his course.
5. The patient has a left chest wall bulge. It has been
evaluated by CT surgery team and is not concerning and should
be left alone.
6. Please check TSH, free T4 and T3 on [**2123-10-16**], and inform
the patient's doctor with possible change in his Synthroid.
7. Please check blood urea nitrogen and creatinine every 48
hours.
8. Please check electrolytes, Chem7, calcium, magnesium, and
phosphorus every week.
9. Please check Digoxin level in one week.
10. The patient does receive percutaneous endoscopic
gastrostomy tube feedings.
11. Please have occupational therapy and speech therapy
evaluate the patient.
12. Please have the patient's primary care physician see the
patient within five days after discharge.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Right middle lobe Methicillin resistant Staphylococcus
aureus pneumonia.
3 Left groin thigh resolving hematoma.
4. Tracheostomy in place with a ************* valve.
5. Coronary artery disease, status post inferior myocardial
infarction in [**2115**], complicated by left ventricular thrombus,
status post left circumflex stent [**4-1**].
6. Status post mitral valve replacement and tricuspid valve
replacement, St. [**Male First Name (un) 923**], [**2123-4-10**].
7. AICD [**4-1**].
8. History of cerebrovascular accident secondary to coronary
artery disease with residual left finger numbness.
9. History of Hodgkin's lymphoma at the age of 27, status
post mantel radiation and splenectomy.
10. Hypercholesterolemia.
11. History of cervical discectomy.
12. History of nasal treatment.
13. Percutaneous endoscopic gastrostomy tube placement
[**2123-8-25**].
14. History of constrictive pericarditis.
15. Combination of iron deficiency and hemolytic anemia.
DR.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12-270
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2123-10-13**] 16:40
T: [**2123-10-13**] 17:54
JOB#: [**Job Number 98134**]
cc:[**Hospital1 98135**]
[**Location (un) **]
, [**Numeric Identifier 98136**]
Fax [**Telephone/Fax (1) 98137**]
Admission Date: [**2123-9-20**] Discharge Date: [**2123-10-14**]
Date of Birth: [**2069-5-9**] Sex: M
Service:
ADDENDUM: Mr. [**Known lastname **] continued to improve from a
cardiovascular and respiratory standpoint. His dopamine was
initially discontinued with a Lasix drip and dobutamine drip
continued. He diuresed well at 800 cc to 1000 cc per day.
The Lasix drip was switched to a bolus regimen of 100 mg
intravenously q.8h. and eventually to 80 mg intravenously
q.8h. with a consistent diuresis of 200 cc to 500 cc per day.
The dobutamine drip was discontinued on [**11-29**] with
systolic pressures in the low 100 range. His renal function
continued to do well. He underwent extension of his
gastrostomy tube to a post pyloric jejunostomy tube without
incident. On [**11-29**], his trachea was extended in a
percutaneous fashion to a bypass granuloma tissue on the
anterior aspect of the trachea diagnosis on bronchoscopy on
[**11-29**]. He now is able to ventilate considerably better.
His ventilator was ultimately weaned to a pressure support of
between 10 and 12 with a PEEP of 10, and an FIO2 of 0.4,
pulling in volumes of 300 cc to 400 cc per breath. His
mental status continued to clear to his baseline; however, he
appeared more depressed than usual, and per Psychiatric
consultation was started on Celexa at 10 mg p.o. q.d. to be
advanced 20 mg p.o. q.d. His renal function continued to
remain stable with a creatinine of 0.9 to 1. His edema
resolved impressively with minimal pitting edema below the
knee, 1+ above the knee, and 2+ in the presacral region. He
was maintained on Lovenox for anticoagulation with regard to
his valves.
MEDICATIONS ON DISCHARGE: Will be dictated in a second
addendum.
DISCHARGE STATUS: Will be dictated in a second addendum.
CONDITION AT DISCHARGE: Will be dictated in a second
addendum.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern4) 98138**]
MEDQUIST36
D: [**2123-11-30**] 17:44
T: [**2123-11-30**] 15:51
JOB#: [**Job Number **]
(cclist)
Admission Date: [**2123-9-20**] Discharge Date: [**2123-10-14**]
Date of Birth: [**2069-5-9**] Sex: M
Service:
ADDENDUM: Mr. [**Known lastname **] continued to improve from a
cardiovascular and respiratory standpoint. His dopamine was
initially discontinued with a Lasix drip and dobutamine drip
continued. He diuresed well at 800 cc to 1000 cc per day.
The Lasix drip was switched to a bolus regimen of 100 mg
intravenously q.8h. and eventually to 80 mg intravenously
q.8h. with a consistent diuresis of 200 cc to 500 cc per day.
The dobutamine drip was discontinued on [**11-29**] with
systolic pressures in the low 100 range. His renal function
continued to do well. He underwent extension of his
gastrostomy tube to a post pyloric jejunostomy tube without
incident. On [**11-29**], his trachea was extended in a
percutaneous fashion to a bypass granuloma tissue on the
anterior aspect of the trachea diagnosis on bronchoscopy on
[**11-29**]. He now is able to ventilate considerably better.
His ventilator was ultimately weaned to a pressure support of
between 10 and 12 with a PEEP of 10, and an FIO2 of 0.4,
pulling in volumes of 300 cc to 400 cc per breath. His
mental status continued to clear to his baseline; however, he
appeared more depressed than usual, and per Psychiatric
consultation was started on Celexa at 10 mg p.o. q.d. to be
advanced 20 mg p.o. q.d. His renal function continued to
remain stable with a creatinine of 0.9 to 1. His edema
resolved impressively with minimal pitting edema below the
knee, 1+ above the knee, and 2+ in the presacral region. He
was maintained on Lovenox for anticoagulation with regard to
his valves.
MEDICATIONS ON DISCHARGE: Will be dictated in a second
addendum.
DISCHARGE STATUS: Will be dictated in a second addendum.
CONDITION AT DISCHARGE: Will be dictated in a second
addendum.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern4) 98138**]
MEDQUIST36
D: [**2123-11-30**] 17:44
T: [**2123-11-30**] 15:51
JOB#: [**Job Number **]
RP [**2123-12-6**]
|
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[
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|
30254, 31284
|
38054, 38163
|
2493, 2730
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198, 1601
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,620
| 104,903
|
40007
|
Discharge summary
|
report
|
Admission Date: [**2141-9-12**] Discharge Date: [**2141-9-20**]
Date of Birth: [**2078-2-12**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
collapse, transfer from OSH in coma
Major Surgical or Invasive Procedure:
tPA, cerebral angiography, c/b groin/femoral hematoma, resolved
with pressure, pressure-dressing
History of Present Illness:
[**Known firstname 87998**] [**Known lastname **] is a 62 yo man working today on [**Hospital3 635**] as a
landscaper when he suddenly collapsed around 1pm. He was
initially brought to [**Hospital3 **] Hospital and found to be in Afib.
SBP on arrival was in the 160s-180s. GCS was 3; he was
subsequently intubated and sedated. CT head showed possible
edema of the posterior fossa. CTA was then obtained and
demonstrated basilar artery thrombus as well as thrombus in the
left vertebral artery. IV tPA was given and the patient was
life
flighted to [**Hospital1 18**] for further care. On arrival here. A repeat
CT
of the head was showed evolution of a left cerebellar infarct
and
a hyper density in the left vertebral artery. The patient was
taken immediately to the Angio suite for clot retrieval. There,
off of propofol, his pupils where pinpoint and non-reactive;
there was no spontaneous movement. Angiography demonstrated a
clear basilar with clots in the bilateral PCAs and these where
successfully removed.
Past Medical History:
Have documents from pts pharmacy in [**Location (un) 15158**] NY
(Kraupner Pharmacy- [**Telephone/Fax (1) 87999**]). This documents listed [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 88000**], MD as his PCP (Phone: ([**Telephone/Fax (1) 88001**]) and was able to
receive the following information. Pt was last seen in her
office in [**2141-3-2**]. Her past medical history for the
patient was noted as:
- Gunshot wound [**2115**] with bowel injury
- Hypertension
- Hyperlipidemia (last cholesterol 167) simvastatin LDL
- Atrial Fibrillation on Coumadin (last INR by PCP in [**Name9 (PRE) 547**] was
therapeutic at 2.2)
- No known surgeries, implants.
No known allergies
Social History:
Pt was working as a landscaper. In speaking with
is niece, he has been living on [**Location (un) 945**] since [**Month (only) 958**] or [**Month (only) 547**].
It is unclear if he has been seen by a PCP or as continued to
take his medications. He is married, wife is [**Name (NI) 88002**] [**Name (NI) **] and
has 2 daughters, [**Name (NI) **] [**Name (NI) **] (who consented to the procedure
today)
and [**Female First Name (un) 88003**], all of whom live in NY.
Family History:
nc
Physical Exam:
(on admission, just prior to angiography procedure)
Extremely limited. This exam was with the patient off propofol
for 20minutes during prep for angio.
Pupils pinpoint, non-reactive. No spontaneous movements, no
withdrawal. Unable to test brainstem reflexes further.
<<See scanned inpatient notes in OMR for progression of
physical/neurologic examination during his 1wk stay in the ICU
[**9-12**] - [**9-20**]>
Pertinent Results:
>>
[**2141-9-12**] 10:05PM WBC-13.5* RBC-4.86 HGB-15.2 HCT-46.1 MCV-95
MCH-31.3 MCHC-33.0 RDW-14.2
[**2141-9-12**] 10:05PM PLT COUNT-233
[**2141-9-12**] 08:46PM %HbA1c-6.0* eAG-126*
[**2141-9-12**] 06:57PM TYPE-ART PO2-333* PCO2-43 PH-7.40 TOTAL
CO2-28 BASE XS-1
[**2141-9-12**] 06:57PM GLUCOSE-139* LACTATE-1.7 NA+-141 K+-4.0
CL--101
[**2141-9-12**] 06:57PM HGB-15.1 calcHCT-45
[**2141-9-12**] 06:57PM freeCa-1.10*
[**2141-9-12**] 05:45PM GLUCOSE-116* UREA N-19 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2141-9-12**] 05:45PM estGFR-Using this
[**2141-9-12**] 05:45PM cTropnT-<0.01
[**2141-9-12**] 05:45PM WBC-14.4* RBC-4.75 HGB-15.1 HCT-45.2 MCV-95
MCH-31.7 MCHC-33.3 RDW-14.1
[**2141-9-12**] 05:45PM NEUTS-86.5* LYMPHS-9.5* MONOS-2.7 EOS-0.9
BASOS-0.4
[**2141-9-12**] 05:45PM PLT COUNT-223
[**2141-9-12**] 05:45PM PT-15.8* PTT-46.5* INR(PT)-1.4*
CT brain without contrast on [**2141-9-12**]:
IMPRESSION:
1. Hypodensity within left cerebellar hemisphere may reflect
acute infarct,
although MRI would be more sensitive for this evaluation.
2. Mucosal thickening and air-fluid levels in the sinuses
secondary to
patient's intubated status.
[**2141-9-12**]
Conventional angiogram:
IMPRESSION:
Mr. [**Known firstname 87998**] [**Known lastname **] underwent diagnostic cerebral angiogram, which
demonstrated embolic occlusion of the proximal bilateral P2
segments of the posterior cerebral arteries. The basilar artery
and left vertebral artery were widely patent at the time of the
exam. After discussion with the stroke team, the decision was
made to perform intervention with direct intra-arterial
injection of TPA and mechanical thrombectomy. Post intervention
left vertebral artery angiogram demonstrated widely patent right
PCA and partial recanalization of left PCA.
Due to failure of angioseal device, direct pressure was
necessary for 3-1/2 hours, during which time a large right groin
hematoma formed. Vascular surgery was consulted at the beginning
of the direct pressure procedure and was made aware of the groin
hematoma. The right groin hematoma was stable in size for the
last hour and half of the procedure. The patient was taken to
the ICU and closely monitored by the ICU staff prior to and
after hemostasis.
CT brain on [**2142-9-18**]:
IMPRESSION:
1. Worsening of obstructive hydrocephalus with complete
effacement of the
fourth ventricle and interval dilation of the third and lateral
ventricles
with transependymal flow.
2. Tonsillar herniation.
3. No new hemorrhage identified.
Brief Hospital Course:
Mr. [**Known lastname **] was thought on admission to our Neurology service (in
SICU-B) to have a presentation suggestive of top-of-the-basilar
syndrome, most likely due to cardioembolism from AFib and
subtherapeutic INR. He was given IV/IA tPA and close
neurological monitoring. MRI/DWI confirmed extensive infarction.
He was never extubated, and his exam did not improve and
although he was producing spontaneous respirations while
intubated on a ventilator, his Neurological status, especially
his extensive brainstem infarction and poor airway/secretions
clearance, did not permit extubation. He was maintained on 3%
NaCl IV to minimize intracranial pressure with anticipated
brainstem swelling from his extensive posterior circulation
infarct and reperfusion after tPA. His family was reluctant to
withdraw artificial life support, and a decision re.
tracheostomy was delayed. He developed sepsis and hypotension
overnight 11/2-3, and became pulseless (PEA arrest) [**9-20**]
mid-morning requiring CPR/ACLS as his family had requested that
he remain full-code. He was coded (CPR-ACLS) for roughly 30min
without return of pulse, and I declared death that morning at
8:58am. The family did not request autopsy.
Medications on Admission:
Last documented medications:
- Warfarin 5mg/7.5
- Flomax 0.4
- Amlodipine 2.5mg
- Enalapril 10mg daily
- Simcor 500/20
Discharge Medications:
died [**2141-9-20**]
Discharge Disposition:
Expired
Discharge Diagnosis:
died [**2141-9-20**] in SICU-B with brainstem swelling ([**12-20**] brainstem
stroke) and septic shock
Discharge Condition:
died [**2141-9-20**]
Discharge Instructions:
n/a (died)
Followup Instructions:
n/a (died)
Completed by:[**2142-3-16**]
|
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"33.24",
"88.48",
"38.91",
"39.74",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
7187, 7196
|
5758, 6973
|
349, 447
|
7342, 7364
|
3166, 5735
|
7423, 7464
|
2712, 2716
|
7142, 7164
|
7217, 7321
|
6999, 7119
|
7388, 7400
|
2731, 3147
|
274, 311
|
475, 1497
|
1519, 2212
|
2228, 2696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,325
| 146,591
|
23930
|
Discharge summary
|
report
|
Admission Date: [**2135-11-16**] Discharge Date: [**2135-11-24**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is 82 yo f with COPD (on 2L home O2) s/p admission [**10-14**]
requiring intubation with end of prednisone taper [**10-31**], h/o
CHF, DM, h/o DVT/PE, who presented from rehab with 2 days of
SOB, lethargy, and reports of increased LE edema. Pt reportedly
had been less participatory at PT per rehab team along with her
2 days of SOB. A CXR done yesterday at rehab reportedly showed
bilateral infiltrates, so she was given a dose levofloxacin. Pt
also had hx of FS of 546 at rehab, was given 6 U reg insulin,
and FS improved to 200's.
.
In the [**Name (NI) **], pt had fever to 101.1 (rectal) and was tachypnic to
40's. She was given Lasix 40mg IV, combivent nebs x 3, Meropenem
1g IV, Levofloxacin 500mg IV, tylenol, ASA 325mg PO, solumedrol
125mg IV x 1, and was placed on a nitro gtt. Her breathing
improved after Lasix, nebs, and nitro. She then had SBP in
80's-90's, which improved to 90's to 100's after NS 250cc x 3.
CXR showed new RLL PNA. She was admitted to the [**Hospital Unit Name 153**] for further
monitoring of resp status and BP.
.
Pt currently denies CP/SOB, F/C, N/V, diarrhea, headache, back
pain, hematochezia, or hematemesis.
Past Medical History:
- COPD on 2L home O2, required intubation during [**2135-10-14**]
admission, s/p recent course of Vanc/CTX and prednisone taper
- RUL lung nodule, followed by Dr. [**Last Name (STitle) 60991**] at [**Location (un) 5700**] (pulmonary)
- h/o CHF - ?takatsubo's cardiomyopathy with positive CK/trop,
[**3-13**] TTE w/ EF=25-30%, most recent TTE with EF>55% ([**10-14**]), cath
[**3-13**] with no significant disease
- h/o RP bleed
- HTN
- h/o adnexal mass seen on [**5-14**] MRI
- h/o Group B strep bacteremia, MRSA in sputum, and C.dif
- h/o L4/L5 osteo/discitis s/p course of CTX, followed by course
of Ancef
- h/o guaiac positive stools and coffe ground emesis [**3-13**],
unclear if followed up as outpatient (no scopes in OMR)
- DM- type II, on repaglinide
- History of DVT, h/o PE '[**34**], on coumadin
- Breast ca s/p left mastectomy [**2127**]
- PUD
- Borderline pulmonary HTN
8. Borderline pulmonary HTN
10. Clean cath [**3-13**]
Social History:
lives at [**Hospital3 **], previous tobacco use from her teenage
years until age 60, no EtOH or illicits.
Family History:
non-contributory
Physical Exam:
Vitals: T 98.8 BP 94/32 HR 93 RR 31 O2 97% 4L
Gen: frail appearing, mild resp distress with minimal talking,
but comfortable at rest
HEENT: R surgical pupil minimally reactive, L pupil reactive
Neck: JVP flat
Cardio: distant heart sounds, RRR
Resp: barrel chest, poor air movement BL, RLL crackles, no
wheeze
Abd: soft, nt, nd, +BS. No rebound/guarding
Ext: 1+ BL LE edema
Back: no back or CVA tenderness
Neuro: A&Ox3
Pertinent Results:
[**2135-11-16**] 12:15PM WBC-8.6 RBC-2.77* HGB-8.8* HCT-25.9* MCV-94
MCH-32.0 MCHC-34.2 RDW-14.4
[**2135-11-16**] 12:15PM NEUTS-87.4* LYMPHS-9.4* MONOS-2.8 EOS-0.3
BASOS-0
[**2135-11-16**] 12:15PM PLT COUNT-340#
[**2135-11-16**] 12:15PM proBNP-1761*
[**2135-11-16**] 12:25PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2135-11-16**] 12:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2135-11-16**] 12:30PM GLUCOSE-216* LACTATE-1.6 NA+-141 K+-4.6
CL--98* TCO2-36*
[**2135-11-16**] 06:40PM GLUCOSE-156* UREA N-24* CREAT-1.0 SODIUM-138
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-12
[**2135-11-16**] 09:55PM PT-29.5* PTT-27.7 INR(PT)-3.1*
.
INR 1.4 ON DAY OF DISCHARGE, LMWH: PENDING
ALT 22, AST 16, T BILI 0.3, ALK PHOS 91, LIPASE 53
TROP T < 0.01 X 2
ALBUMIN 2.9, FOLATE 6.4, B12 513, TSH 2.2, SPEP: NEGATIVE, VANCO
11.7
.
URINE CX [**11-23**]: PENDING (URINE CX [**11-18**]: > 100K YEAST)
H PYLORI ANTIGEN: NEGATIVE
BLOOD CX [**11-18**], [**11-16**]: NEGATIVE
URINE LEGIONELLA ANTIGEN: NEGATIVE
.
CXR: Heart normal size with hyperinflated lungs, peripheral
vascular attenuation, and relatively large central pulmonary
vessels. There is a consolidation in the right lower thorax
probably in the lower lobe. Patchy increased markings
bilaterally. Since last exam [**2135-10-25**] the right lower lobe
process has developed and the right IJ line has been removed. A
new right PIC line has its tip in the mid SVC. IMPRESSION:
Severe emphysema and cor pulmonale. New right lower lobe
pneumonia.
.
CT head: No intracranial hemorrhage.
.
EKG: NSR @90, RBBB, LAD, peaked T's in V3-V5, <1mm STE V3-V4 (no
sig change from prior tracings)
.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are patchy
opacities in both lower lobes, right worse than left. There are
small bilateral pleural effusions. There is a hiatal hernia.
There are multiple calcified gallstones in a nondistended
gallbladder. The liver, pancreas, and adrenal glands are
unremarkable. There are several calcified splenic granulomas.
There are several possible tiny nonobstructing stones at the
lower pole of the left kidney. There is atherosclerotic disease
of the aorta. Stomach, small bowel, and large bowel are grossly
unremarkable. There is no intra-abdominal free air. No
pathologically enlarged mesenteric or retroperitoneal lymph
nodes.
CT OF THE PELVIS WITHOUT IV CONTRAST: Note is again made of
small pelvic free fluid. The previously demonstrated right
adnexal mass is not well appreciated on this study, which is
limited due to lack of IV contrast. The bladder, rectum, and
sigmoid colon are unremarkable.
Bone windows demonstrate apparent anterior and lateral
displacement of what appeared to be fragments of a lower lumbar
vertebral body that appear new compared to the previous exam.
Scout images are limited due to underpenetration. These findings
are suggestive of a possible lower lumbar compression fracture
without retropulsion.
IMPRESSION:
1. Bilateral lower lobe patchy opacities may represent pneumonia
or aspiration.
2. Free fluid in the pelvis again demonstrated. The previously
described right adnexal mass is difficult to discern on this
exam that is limited by the lack of IV contrast.
3. Possible lower lumbar compression fracture.
4. Cholelithiasis.
.
MR [**Name13 (STitle) 6452**] WITH AND WITHOUT CONTRAST: There is no significant
interval change in the appearance of the vertebral body and
intervertebral disc changes at the L4-5 level with postcontrast
enhancement consistent with osteomyelitis and discitis, as well
as interval fibrotic reaction. There is no evidence of a
compression fracture. Endplate destructive changes are stable in
appearance. There is no epidural abscess or paraspinal
collection.
Nerve root diverticula seen at nearly all levels from T11-12
through S1-S2 are again identified.
IMPRESSION: Stable appearance of known osteomyelitis/discitis at
L4-5 level with no evidence of compression fracture, new
paraspinal or abnormal epidural fluid collection.
Brief Hospital Course:
# Bacterial pneumonia:
Patient admitted with new right lower lobe pneumonia. She is on
2 L NC at baseline but was requiring 4 liters supplemental O2 on
admission. She was started on vancomycin and cefepime given
history of MRSA and was quickly able to be weaned to her
baseline 2 L NC with medical management. In addition to IV
antibiotics, she received IV solumedrol for resultant COPD
flare. She was initially diuresed but no evidence of CHF on CXR
and blood pressure did not tolerate this well so this was not
continued. Patient has remained stable on vanc/cefepime and is
now down to 1 L supplemental O2. She has been converted to
advair/spiriva and is receiving albuterol nebs prn. Her
steroids have been weaned, she is currently taking 50 mg po qd
but will be weaned to 40 mg po qd starting tomorrow. She is s/p
pneumovax in '[**34**] but received the influenza vaccine prior to
discharge. PICC placed [**2135-10-26**] for completion of IV antibiotic
course. Urine legionella antigen is negative and speech and
swallow evaluation in [**10-14**] showed no evidence of overt
aspiration.
.
# Epigastric pain:
Patient complains of constant epigastric discomfort with
tenderness to palpation. LFTs are normal and CT abd/pelvis
showed no intraabdominal pathology to explain her symptoms.
Cardiac enzymes negative x 2 despite persistent pain, thus
unlikely cardiac in origin. I suspect her discomfor is GI in
origin, likely GERD. I have increased her protonix to twice
daily. H pylori antibody was negative. Of note she does have
guaic positive stools and thus needs an EGD to complete her
work-up to rule out underlying malignancy or PUD. Patient's
daughter [**Name (NI) 653**] to discuss this test but has not returned my
call. Patient will follow-up with her primary care doctor
within 2 weeks to discuss this further. Thus, exam was not
scheduled prior to discharge.
.
# Anemia: Patient has a history of long-standing anemia. Stool
was guiac positive. I have recommended colonoscopy and EGD for
evaluation. Patient wishes this to be discussed with her
daughter. I am still waiting for her daughter to call back.
Patient will follow-up with Dr. [**Last Name (STitle) 5351**] within 2 weeks to
discuss this further. Of note, labs suggested AOCD in [**4-14**]
given ferritin in the 400s. Folate/B12/TSH this admission were
normal and SPEP negative. Patient did require 2 units of PRBC
this admission but her hematocrit has since been stable since
[**2135-11-18**].
.
# Type 2 diabetes:
Patient's po repaglinide discontinued and she has been managed
on HSSI with lantus for persistently high blood sugars on
prednisone. However, she has had multiple episodes of
hypoglycemia. Thus, her dose of lantus has been significantly
decreased (from 22 units qhs to 5 units qhs given decrease in
prednisone from 50 to 40 mg po qd and BS 33 overnight on 22
units). Would recommend monitoring blood sugar q4h overnight to
monitor for recurrent hypoglycemia and discontinue lantus on
[**2135-11-28**] given further decrease in steroid dose.
.
# Hypertension: Patient's beta blocker has been gradually
increased back to her home dose. Please continue to monitor
blood pressure qshift.
.
# Candiduria:
Asymptomatic. No treatment indicated. Repeat urine culture
pending.
.
# History of DVT and PE:
Patient's INR elevated on admission so her coumadin was held.
She is now subtherapeutic, and was thus started on lovenox to
bridge (qd dosing given poor creatinine clearance, Factor Xa
level pending) until she is again therapeutic. Goal INR [**2-11**].
.
# Rule out compression fx:
Incidental finding of ? new L spine compression fracture on CT
abdomen done for complaints of epigastric pain. MRI L spine
shows no new compression fracture, stable osteomyelitis. Spine
was consulted. No brace or other intervention indicated.
.
# Depression: Patient refused antidepressant. Daughter thinks
she is just anxious. She will follow-up with her regular
primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] for continued care.
.
# Full Code: confirmed with patient and HCP
.
# Dispo: Patient discharged back to [**Hospital3 537**]
Medications on Admission:
Tobramycin-Dexamethasone 0.3-0.1 % eye drops QHS
Latanoprost 0.005 % eye drops QHS
Senna 8.6 mg [**Hospital1 **]
Acetaminophen 325mg q4-6h PRN
Docusate Sodium 100mg [**Hospital1 **]
Artificial Tear with Lanolin 0.1-0.1 % Ointment PRN
Metoprolol Tartrate 50 mg tid
Insulin SS
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Betaxolol 0.25 % eye drops qd
Repaglinide 2 mg tid before meals
Pantoprazole 40 mg qd
Coumadin 2 mg qd
Tiotropium Bromide 18 mcg Capsule, w/inhalation device
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime for 4 days: through [**2135-11-29**] then
DISCONTINUE.
2. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
injection Subcutaneous four times a day: per sliding scale.
3. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic QHS (once a day (at bedtime)).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: max = 2 g per day.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day: hold for sbp < 100 or hr < 55.
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-10**]
Drops Ophthalmic PRN (as needed).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
ADJUST DOSE DAILY BASED ON INR.
16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB
Inhalation Q4H (every 4 hours) as needed for shortness of [**Month/Day (2) 1440**]
or wheezing.
18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day:
PLEASE FOLLOW PREDNISONE TAPER ON PAGE 1.
19. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily): DISCONTINUE ONCE INR > 2 X 2
CONSECUTIVE DAYS.
20. Cefepime 2 g Recon Soln Sig: Two (2) grams Injection Q24H
(every 24 hours) for 7 days: through [**2135-11-30**].
21. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q48H (every 48 hours) for 7 days: through
[**2135-11-30**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
bacterial pneumonia
epigastric pain
COPD exacerbation
type 2 diabetes, poorly controlled
hypoglycemia
guiac positive stool
history of deep vein thrombosis and pulmonary emboli
history of hypertension
Discharge Condition:
fair: stable on 1 L NC, no cough or shortness of [**Location (un) 1440**],
afebrile, low mood - seems depressed
Discharge Instructions:
Please monitor for temperature > 101, hypoglycemia, worsening
shortness of [**Location (un) 1440**], diarrhea, or other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] within 1-2 weeks to
discuss scheduling a colonoscopy and EGD. Phone: [**Telephone/Fax (1) 608**]
|
[
"790.92",
"V10.3",
"491.21",
"518.89",
"428.0",
"V09.0",
"112.2",
"250.80",
"401.9",
"482.41",
"V58.61",
"285.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14186, 14257
|
7119, 11289
|
262, 269
|
14501, 14615
|
3021, 4624
|
14804, 15003
|
2549, 2567
|
11824, 14163
|
14278, 14480
|
11315, 11801
|
14639, 14781
|
2582, 3002
|
182, 224
|
297, 1449
|
4633, 7096
|
1471, 2409
|
2425, 2533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,985
| 131,663
|
30053
|
Discharge summary
|
report
|
Admission Date: [**2146-9-19**] Discharge Date: [**2146-10-7**]
Date of Birth: [**2070-3-24**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Ceftriaxone
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Transferred from [**Hospital **] Hospital with fevers and lower back
pain.
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram [**2146-9-21**]
Femoral line placement [**2146-9-27**]
Hemodialysis [**2146-9-28**]
Transfusion of 2 units of red blood cells [**2146-9-29**]
Intraoperative transesophageal echocardiogram [**2146-9-30**]
Laminectomy of L5-S1 for removal of epidural abscess [**2146-9-30**]
Removal of surgical drain [**2146-10-6**]
History of Present Illness:
The patient is a 76-year-old male with no significant past
medical history who was transferred from an OSH for 6 weeks of
fevers and acute onset lower back pain. In [**Month (only) 216**]/[**Month (only) **], he
was admitted to [**Hospital6 3872**] (MWMC) for work up for
the fevers, and per patient, they were unable to determine the
source and ultimately attributed the fevers to pyelonephritis.
On [**2146-9-18**], he experienced acute onset of lower back pain that
radiated down his left leg to his left toes. He has had similar
episodes of lower back pain in the past, but less severe in
intensity. For associated symptoms, he reported a new onset of
constipation. He also complained of urinary incontinence;
however, this had been going on for several months. He denies
any recent history of trauma.
.
Due to the severity of lower back pain, he presented to MWMC
where he was found to have fevers to 102.4 and a leukocytosis of
19.6. He was also noted to be in renal failure with a creatinine
of 2.1 (baseline unknown), thus an MRI with contrast was not
performed. He was given ceftriaxone and metronidazole and
subsequently transferred to [**Hospital1 18**] for further management.
.
In the Emergency Department, vital signs were T=102.4 rectally,
BP=195/95, HR=122, RR=18, O2sat=97%RA. On examination, he was
noted to have midline spinal tenderness, normal rectal tone, and
preserved sensation/strength on his lower extremities. A
post-void residual was measured at 80cc. Laboratory data was
notable for a leukocytosis to 18.6, renal failure with BUN/Cr
40/2.2, anemia with HCT 30, urinalysis with large blood and [**2-17**]
RBCs. A neurosurgical consult recommended an MRI of the L
spine. An MRI of the lumbar spine was obtained without contrast,
which showed moderate canal stenosis at L4-L5, severe canal
stenosis at L5-S1, and impingement of the L5 nerve root by the
disc. No epidural abscess was seen on this study. A CXR showed
mild pulmonary edema with no pneumonia. The patient was given 1g
IV vancomycin and morphine for pain control. Blood and urine
cultures were sent. After 3L of IVF, tachycardia improved to
108. Reportedly, received 1-2 L at OSH ED.
.
On morning of [**2146-9-19**], the patient was noted to be in
respiratory distress. Wheezes were appreciated in both lung
fields and CXR showed mild pulmonary edema. Pt was found to
have O2 sat of 86% RA and he was subsequently placed on 4-6L NC.
He was given furosemide, morphine, metoprolol, and aspirin.
EKG was significant for ST depression of <1mm in leads V4-V5. Pt
was transferred to MICU for management of respiratory distress
and flash pulmonary edema.
.
In the MICU, he was started on a nitro gtt, placed on NIPPV, and
effectively diuresed. Serial cardiac enzymes were elevated,
ruling the patient in for NSTEMI. Cardiology consult suggested
NSTEMI likely secondary to demand ischemia. The patient was
placed on heparin for 24 hours and metoprolol for blood pressure
control. ACEi, hydralazine, and isosorbide mononitrate was also
recommended for blood pressure control, but ACEi was held as pt
was in acute renal failure. Cath was deferred since he was
febrile and infected. Cardiology recommends a stress test prior
to any surgery.
.
Pt continued to have back pain and was found to have
enterococcus faecalis in his blood. TTE was negative and TEE
showed an aortic valve vegetation. In [**Month (only) 956**], pt had
transurethral resection of the prostate (TURP) or prostate Bx,
which could have led to endocarditis. Bacterial sensitivities
were completed and pt was started on a course of Ceftriaxone and
Ampicillin.
.
In addition to lower back pain, he has been having worse
strength in left toes and sensation loss. MRI L-spine with and
without contrast shows pt has multiple epidural abscesses. IR
and Neurosurgery were consulted, surgery is being held for now
as pt pain has been improving. Back pain is currently an issue,
for which he's on Dilaudid PCA, Neurontin, and Valium. However,
he has not been using his dilaudid PCA. He received a WBC scan
to look for other sources of infection.
.
On arrival to the floor, pt was initially alert and oriented.
Pt had been encouraged by family and staff to use Dilaudid PCA
for pain control. Pt complained of decreased rectal tone and
saddle anesthesia, but not confirmed by neurosurgery consult.
Neurosurgery will reconsider surgery if pt clinical picture
worsens, recommend NPO after MN in case needs surgery tomorrow.
Over afternoon, pt actively used PCA, on floor received about 2
mg over 4 hours. RN noticed pt had difficulty swallowing pills
and had mild aspiration. In the evening, pt was somnolent and
oriented to the year but unable to report name and location.
Somnolence likely secondary to gabapentin and dilaudid dose.
ABGs were taken for concern about hypercapnia.
Past Medical History:
Asthma
Cataracts
Gout
Benign prostate hypertrophy
(Prostate biopsy [**2143**], TURP [**2144**], cystoscopy/transrectal US
[**6-/2146**])
Chronic kidney disease (baseline 1.5-2.0)
Social History:
Born in [**Location (un) 6847**]. Lives with his wife, has 3 children and many
grandchildren. Retired but frequently helps out at family
restaurant. Denies any IVDU or alcohol use. Quit smoking 25
years ago.
Family History:
Non-contributory.
Physical Exam:
On admission to the medical ICU
VS: T 38.2 HR 123 BP 187/96 26 96% CPAP
GEN: on noninvasive, tachypneic
HEENT: EOMI, aicteric
CHEST: diffuse wheezes
CV: tachycardic, no m/r/g
ABD: NDNT, soft, NABS
BACK: TTP over low spine process, paraspinal tenderness
EXT: no c/c/e
NEURO: A&O
DERM: no rashes
.
On admission to the medicine floor:
Vitals: T 99.4 BP 182/86 T 91 RR 16 02 sat 97% RA
GENERAL: Somnolent, arousable.
HEENT: Normocephalic, atraumatic. Left pupil 2mm, right pupil 4
mm. EOMI. No scleral icterus. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No m/r/g.
LUNGS: Diffuse expiratory wheezes.
ABDOMEN: NABS. Soft, NT, ND. No HSM.
EXTREMITIES: No edema. 2+ dorsalis pedis/posterior tibial
pulses.
SKIN: Ecchymoses. No rashes/lesions.
NEURO: A&Ox1 (year). BUE [**4-19**], RLE [**4-19**], LLE -[**4-19**] secondary to
pain, L PF [**3-20**], L toes [**3-20**].
Pertinent Results:
[**2146-9-18**]
BLOOD
PT-13.9* PTT-30.6 INR(PT)-1.2*
PLT COUNT-358
NEUTS-87.8* LYMPHS-7.4* MONOS-4.5 EOS-0.1 BASOS-0.2
WBC-18.6* RBC-3.64* HGB-10.1* HCT-30.7* MCV-85 MCH-27.8
MCHC-32.9 RDW-13.8
GLUCOSE-111* UREA N-40* CREAT-2.2* SODIUM-137 POTASSIUM-3.6
CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
LACTATE-1.4
.
[**2146-9-19**]
URINE
AMORPH-FEW
RBC-[**2-17**]* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0
BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
EOS-NEGATIVE
MUCOUS-RARE
GRANULAR-2* HYALINE-2*
RBC-149* WBC-12* BACTERIA-FEW YEAST-NONE EPI-1
BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR
COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
CREAT-121 SODIUM-64 TOT PROT-69 PROT/CREA-0.6*
.
[**2146-9-19**]
BLOOD
07:15AM RET AUT-1.8
07:15AM PLT COUNT-356
07:15AM NEUTS-84.9* LYMPHS-10.0* MONOS-4.6 EOS-0.1 BASOS-0.4
07:15AM WBC-24.4* RBC-3.70* HGB-10.5* HCT-32.6* MCV-88
MCH-28.5 MCHC-32.4 RDW-13.8
07:15AM calTIBC-174* FERRITIN-910* TRF-134*
07:15AM CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-1.9 IRON-13*
07:15AM GLUCOSE-110* UREA N-36* CREAT-2.1* SODIUM-140
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-19* ANION GAP-19
.
03:32PM PTT-75.7*
03:32PM MAGNESIUM-2.0
03:32PM GLUCOSE-145* UREA N-38* CREAT-2.2* SODIUM-139
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
10:37PM PTT-52.4*
.
Cardiac Enzymes [**2146-9-19**]
07:15AM CK-MB-23* MB INDX-6.6* cTropnT-0.29* proBNP-3681*
07:15AM CK(CPK)-347*
03:32PM CK-MB-13* MB INDX-6.4* cTropnT-0.36*
03:32PM CK(CPK)-203*
10:37PM CK-MB-10 MB INDX-6.3* cTropnT-0.32*
10:37PM CK(CPK)-160
.
Microbiologic Data:
[**2146-10-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-10-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-9-30**] ABSCESS GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL INPATIENT
[**2146-9-30**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL INPATIENT
[**2146-9-30**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL INPATIENT
[**2146-9-29**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-29**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-26**] URINE URINE CULTURE-FINAL INPATIENT
[**2146-9-26**] BLOOD CULTURE NOT PROCESSED INPATIENT
[**2146-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2146-9-25**] URINE URINE CULTURE-FINAL INPATIENT
[**2146-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-23**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-23**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +} INPATIENT
[**2146-9-21**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2146-9-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2146-9-20**] URINE URINE CULTURE-FINAL INPATIENT
[**2146-9-19**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Antigen Screen-FINAL; Respiratory Viral Culture-FINAL
INPATIENT
[**2146-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECALIS, ENTEROCOCCUS FAECALIS}; Anaerobic Bottle
Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2146-9-19**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2146-9-19**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
INPATIENT
[**2146-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2146-9-19**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2146-9-18**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL
.
[**2146-9-18**] 11:20 pm BLOOD CULTURE
**FINAL REPORT [**2146-9-22**]**
Blood Culture, Routine (Final [**2146-9-22**]):
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..
SENSITIVE TO Daptomycin AT MIC 1.5MCG/ML, Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2146-9-19**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 2205 ON [**2146-9-19**].
Aerobic Bottle Gram Stain (Final [**2146-9-20**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
.
Imaging Studies:
.
RUQ ultrasound ([**10-3**]):
INDICATION: 76-year-old man with epidural abscess, now post-op
day #3. LFTs are elevated. Please assess for any abnormalities.
COMPARISON: CT of the abdomen of [**2146-9-26**].
FINDINGS: The liver is normal in echotexture without focal
lesions. The main portal vein is patent with appropriate
direction of flow. The gallbladder demonstrates sludge. There is
no intra- or extra-hepatic biliary dilatation. The distal
pancreas is not well seen due to overlying bowel gas. Visualized
portions of the pancreas are within normal limits.
IMPRESSION: Gallbladder sludge. No signs of cholecystitis.
Normal liver.
.
Left LE ultrasound ([**10-5**]):
INDICATION: 76-year-old man with asymmetric lower extremity
edema. Evaluate for DVT in left leg.
COMPARISON: None available.
FINDINGS: Grayscale and Doppler images were acquired of the left
common femoral, superficial femoral, popliteal, tibial and
peroneal veins. Doppler images of the right common femoral vein
were also obtained. Normal
compression, augmentation, and flow in the vessels.
IMPRESSION: No evidence of DVT.
.
MRI C-T-L spine w/ contrast ([**9-28**]):
1. Some interval improvement in the overall appearance of the
infectious
process involving the lower lumbosacral spine with fewer
loculated epidural "microabscess" at the L5-S1 level. The
largest of these, measuring 12 x 7 mm, continues to exert
significant mass effect on the caudal thecal sac with some
crowding of the traversing nerve roots within, and abuts the
left dorsolateral aspect of the traversing right S1 nerve root
sheath. There is also some evidence of intervening L5-S1
discitis, as well as anterior subligamentous phlegmon, as
before.
2. No definite evidence of noncontiguous involvement of the
remainder of the spine, with stable hyperintensity within the
L1-2 disc, which may be on a degenerative basis, as there are no
other signs of infection at this level.
3. Normal overall appearance of the spinal cord and conus
medullaris, with no pathologic leptomeningeal, intramedullary or
nerve root enhancement.
4. Extensive degenerative changes involving, particularly, the
mid-cervical spine, with ventral canal and neural foraminal
narrowing and cord flattening from the C4-5 through C6-7 levels.
However, there is no definite abnormality of intrinsic signal
within the cervical spinal cord.
5. T2-3: Left paracentral disc protrusion-osteophyte complex
effaces the
ventral CSF, barely contacting, without indenting, the upper
thoracic spinal cord.
.
MRI Brain w/o contrast ([**9-25**]):
1. A few, tiny foci of restricted diffusion in the cerebral
hemispheres, on both sides, in the ACA, MCA, and PCA
distributions as described above, likely embolic infarcts.
Assessment for enhancing lesions is limited due to lack of IV
contrast.
2. Patent major arteries of the anterior and the posterior
circulation, as
described above, with a few normal variants and probably
diminutive left
vertebral artery, which is not seen after the origin of the
posterior inferior cerebellar artery. If there is concern for
better assessment of the intracranial arteries, CTA can be
considered given the artefacts related to the calcifications on
the present study for the vertebral and the carotidarteries. A
small focus of negative susceptibility adjacent to the left
vertebral artery is of uncertain nature (series 8, image 108)
and it is unclear if this relates to the orientation of the
vessel or a focus of calcification; less likely a focus of
aneurysm and this can be better assessed with CT angiogram.
.
MRI Brain w/o contrast ([**10-3**]):
IMPRESSION: Evolving deep white matter infarcts without evidence
for new
infarct or other acute findings when compared to the most recent
MRI one week prior. Given the patient's history, it is possible
the infarcts relate to underlying infection, and a repeat
examination with gadolinium could be considered as indicated
clinically to look for evidence of meningitis.
.
EEG ([**9-27**]):
IMPRESSION: Normal EEG in the waking and drowsy states.
Occasionally,
the excessive drowsiness can be the sign of an early
encephalopathy.
Nevertheless, acceptable background rhythms were reached at
times.
There were no areas of prominent focal slowing, and there were
no
epileptiform features.
.
Transesophageal echocardiogram ([**9-20**]):
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Right ventricular chamber size and free wall motion are
normal. Extensive complex, non-mobile plaque in descending aorta
and arch to 35cm from the incisors. Mildly thickened aortic
valve (3 leaflets) with 6mm echodensity on the LVOT side of
non-coronary leaflet with some mobile components c/w a
vegetation. An eccentric jet of mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Probable aortic valve endocarditis with mild aortic
regurgitation. Preserved biventricular systolic function (EF
>55%). Complex atheroma in arch and descending aorta.
.
Transesophageal echocardiogram ([**9-30**]):
The left atrium is normal in size. No spontaneous echo contrast
is seen in the left atrial appendage. Moderate to severe
spontaneous echo contrast is seen in the body of the right
atrium. The right atrial appendage ejection velocity is
depressed (<0.2m/s). A probable thrombus is seen in the right
atrial appendage The estimated right atrial pressure is
0-10mmHg. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. There are three aortic valve
leaflets. There is a small vegetation on the aortic valve. Mild
(1+) aortic regurgitation is seen. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen. No
masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality. No
masses or vegetations are seen on the pulmonic valve, but cannot
be fully excluded due to suboptimal image quality.
********** OPERATIVE REPORT **********
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] C.
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 71680**]
Service: NSU Date: [**2146-9-30**]
Date of Birth: [**2070-3-24**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 71681**]
PREOPERATIVE DIAGNOSIS: L5-S1 epidural abscess.
POSTOPERATIVE DIAGNOSIS: L5-S1 epidural abscess.
INDICATION: This is a 76-year-old gentleman who presented
with several weeks of back pain associated with fever.
Ultimately the patient underwent an MRI that demonstrated an
L5-S1 epidural abscess. The patient was taken to the
operating room for evacuation of this abscess.
PROCEDURE PERFORMED: L5 laminectomy and S1 laminectomy and
epidural abscess evacuation under microscopic visualization.
DESCRIPTION OF PROCEDURE: After informed consent and
preoperative laboratory values were verified, the patient was
brought into the operating room and he underwent general
anesthesia and intubation without difficulty. As the patient
was intubated the patient underwent a TEE. The results of
this TEE will be described elsewhere by the anesthesiologist.
After the TTE was complete, the patient was then turned into
a prone position onto [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 732**] frame. All pressure points
were padded.
Based on the iliac crest the L4-L5 interspinous process was
marked. Based on this mark an incision was planned in order
to expose the L5 and S1 lamina. This area was then prepped
and draped in a sterile manner.
The planned incision was initially infiltrated with local
anesthetics with dilute epinephrine. The incision was then
opened using a scalpel. The subcutaneous dissection was done
using electrocautery. The fascial layer was developed in
order to facilitate closure and subsequently the fascia was
incised using electrocautery. Periosteal dissection was
carried out to define the L5 and S1 lamina.
A lateral x-ray of the lumbar spine was obtained to verify
the localization. After the localization was verified the
microscope was brought in in order to facilitate the L5
laminectomy and the S1 laminectomy. The laminectomy was
performed using a combination of drills, curettes and
Leksell, revealing the epidural space. There were several
epidural collections identified that were tightly adherent to
the dura. This was carefully dissected off the dura using
microdissection techniques and under microscope
visualization. This process continued until the entire
epidural collection was dissected off the dura.
To ensure complete decompression I followed the lumbar nerve
roots out to the foramen and decompressed the posterior bony
elements bilaterally. After this was achieved the wound was
amply irrigated with approximately 500 mL of bacitracin-
containing irrigant. Two Hemovacs were then inserted and
anchored.
The muscle layers were then closed with 0 Vicryl as was the
fascial layer. The subcutaneous layers were closed with a
combination of 2-0 and 3-0 Vicryl. The skin was then closed
with 3-0 Monocryl. The incision was overlaid with Dermabond.
The EBL was less than 100 mL.
Specimen sent included the epidural abscess.
I was present and performed the key portions of the
procedure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 71682**]
Dictated By:[**Last Name (NamePattern1) 71683**]
Brief Hospital Course:
The patient is a 76-year-old male with a past medical history of
benign prostate hypertrophy, gout, and chronic kidney disease,
who presented from [**Hospital6 1109**] for workup of 6
weeks of fevers and acute onset of lower back pain.
.
# Enterococcal Bacteremia / Aortic Valve Endocarditis
The patient's subacute history of fevers was concerning for
endocartidis, and blood cultures on the day of transfer grew
gram positive cocci ultimately speciated as enterocccus faecalis
that was vanc/amp sensitive. Transesophageal echocardiogram
showed a vegetation on the non-coronary cusp of the aortic
valve. He was initially on vancomyin that was changed to
ampicillin and ceftriaxone for synergy. He underwent
transesophageal echocardiogram intraoperatively (during the
epidural abscess drainage) that showed persistent vegetation on
aortic valve, with mild (1+) aortic regurgitation. Please see
full report above for details. Infectious disease service was
involved and recommended for six-week course of antibiotics with
ampicillin and ceftriaxone starting from the day of surgery
([**9-30**]). This course of antibiotics will end on [**11-11**].
Blood cultures taken during the last two weeks (since [**9-21**]) have
been negative. Cultures from [**Date range (1) 23927**] are still pending at
the time of discharge (they may be followed through Medical
Records at ([**Telephone/Fax (1) 39110**]).
.
# L5 Epidural Abscesses
The patient's complaint of back pain prompted additional imaging
with tagged wbc scan and ultimately MRI with gadolinium that was
positive for several small epidural abscesses around the area of
L5 with some thecal sac impingement on the right side, and
possible L5-S1 discitis. The patient's neurologic exam was
notable for decreased strength left>right in dorsiflexion
>plantar flexion. This was examined serially in the ICU by the
medical and neurosurgical teams and felt to be stable. A
discussion regarding surgical intervention was made between
neurosurgeons, patient and family, and given his recent
NSTEMI/demand ischemia event surgery was felt to be an option of
last resort. However, the patient's pain continued to increase
and he showed evidence of worsening sensory/motor deficits in
his left lower extremity. He was taken to the OR on [**2146-9-30**] for
laminectomy of L5-S1 with washout of the area (see OR report for
further information). He tolerated the procedure well. Tissue
and fluid samples were sent for gram stain, culture and
pathology, but did not yield the identity of the causative
organism (sterile after prolonged treatment with ampicillin and
ceftriaxone). The patient should follow-up with Dr. [**First Name (STitle) **] in
neurosurgery clinic.
.
# Pain Control:
Post-operatively patient was treated with Dilaudid PCA for pain
control. This was weaned to oral medications as his overall
status improved. His current pain regimen consists of oxycodone
5 mg four times daily (standing dose). His symptoms have been
adequately controlled on this regimen.
.
# Probable Right Atrial Appendage Thrombus:
This was visualized on intraoperative transesophageal
echocardiogram. The finding was confirmed after review by the
cardiology service. Anticoagulation was deferred immediately
post-operatively due to the risk of bleeding at the surgical
site. Now that his drains have been removed, patient can begin
anticoagulation. Neurosurgery has confirmed that anticoagulation
can be started at rehab facility with heparin drip transitioned
to coumadin. Cardiology has recommended for 2 months of
anticoagulation with follow-up in cardiology clinic and repeat
transesophageal echocardiogram at that time. As the
post-operative drain was pulled yesterday [**2146-10-6**], the patient
has not yet started anticoagulation. He should begin heparin gtt
today titrated to PTT of 60-90, and begin coumadin 5 mg PO today
titrated to goal INR of [**1-18**].
.
# NSTEMI / Demand Ischemic Event
The patient was transferred to the medical ICU in the setting of
hypertensive emergency with SBPs > 200, pulmonary edema
requiring bipap, and a rise in CK/CK-MB/troponin with question
of lateral ECG changes/ST depressions. Echocardiogram showed
mild apical hypokinesis. Cardiology was consulted and the
consensus was that this was likely demand ischemia in the
setting of hypertensive urgency. He was managed with heparin for
24 hours and aspirin. He was on a nitroglycerin infusion and
weaned to oral metoprolol. Statin was stopped due to slight
transaminitis. Aspirin has not been restarted yet as he is only
one week post-op.
.
# MRSA Positive Sputum
In the ICU, patient was noted to have MRSA positive sputum. CXR
did not show evidence of pneumonia and patient was asymptomatic.
Nevertheless, he was treated with 10-days of intravenous
vancomycin. The vancomycin was stopped on [**10-6**].
.
# Acute-on-Chronic Kidney Disease
The patient had a creatine of 2.0-2.5 during recent admission,
with baseline estimated at 1.5-low 2s with h/o BPH, h/o TURP and
obstructive symptoms. Sediment showed granular casts, felt to be
consistent with low grade GN related to the endocarditis. His
creatinine at time of discharge is ~2.0, consistent with
previous baseline. Throughout the admission, efforts were made
to avoid nephrotoxins. A temporary right femoral line was placed
for hemodialysis following the MRI with gadolinium to prevent
nephrogenic systemic fibrosis. He underwent two cycles of
hemodialysis following the MRI.
.
# Upper Extremity Tremor
The neurology service was consulted when patient developed upper
extremity tremors/myoclonic jerks one week into the
hospitalization. He underwent EEG that was negative for seizure
activity. He had a brain MRI that showed areas of restricted
diffusion in the deep white matter that could represent embolic
infarcts. A follow-up MRI showed evolution of these infarcts but
no new lesions. Overall, his tremors and upper extremity jerks
were felt to be secondary to a toxic-metabolic state from the
underlying infection. The symptoms resolved as his infection was
treated, and have not been a problem for several days prior to
discharge.
.
# Anemia
This was felt to be secondary to his acute inflammatory state.
During this admission he received 2 units of packed red blood
cells prior to surgery. His hematocrit at time of discharge was
29 and remained stable in the high 20s post-operatively.
.
# Gout
Patient has a history of gout. This was stable during this
admission. We held his colchicine during this admission.
.
# BPH
The patient has had a foley catheter in place for most of this
admission. His home medications were held, but may consider
restarting in the appropriate clinical context.
.
# Elevated LFTs
Patient was noted to have LFTs post-operatively. A liver US was
negative for any pathology. This phenomenon is felt to be
related to dual-beta lactam therapy, which is needed to treat
the patient's endocarditis/abscess - therefore, the current plan
is to continue to monitor LFTs and as long as no significant
change, to continue with the treatment course. The alternative
would be to exchange ceftriaxone for gentamicin, but this may
place the patient in danger of permanent renal failure and cause
need for hemodialysis. High-dose statin, which was started in
context of troponin leak in the ICU, was stopped in the setting
of elevated LFTs as it too may have been a contributing factor.
.
# Fevers
Patient has had fever throughout this admission.
Post-operatively, he had several high fevers to > 102, which
were felt to be related to disruption of infectious material in
his epidural space. He has continued to spike daily fevers
(recently low grade; 24-hour Tmax at discharge = 100.5), but
fever curve is trending down. Vancomycin (started for
MRSA-positive sputum) was stopped as patient had no evidence of
PNA and antibiotics may have been contributing. At the present
time, it is expected that low-grade fevers may persist, but this
should not prompt change in medication regimen.
Medications on Admission:
Proscar 5 mg PO daily
Flomax 0.4 mg PO daily
Avodart 0.5 mg PO daily
Albuterol inhaler PRN
Discharge Medications:
1. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours): Please complete a six-week course
as specified in discharge summary.
2. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): Please complete a
six-week course as specified in discharge summary. .
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain: leave on for 12 hours, remove for 12
hours.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Hold for oversedation/RR < 10.
.
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing / SOB.
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever: Please limit to 2 g per day while
LFTs are elevated unless instructed otherwise by your doctor.
15. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Heparin (Porcine) in D5W Intravenous
17. Outpatient Lab Work
Please check patient's CBC with differential, BUN, Cr, ALT, AST,
total bilirubin, and alkaline phosphatase at least weekly, and
ESR/CRP at least monthly. Monitor PTT Q 6 hours while on heprain
gtt, and INR ~weekly while on coumadin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Enterococcal Aortic valve endocarditis
Epidural Abscess on L5 nerve
Acute-on-Chronic Renal Failure
Thrombus in right atrial appendage
NSTEMI (in setting of demand ischemia)
Secondary:
Gout
Asthma
Benign Prostate Hypertrophy
Discharge Condition:
Stable vitals, fever curve trending down, not yet ambulating.
Discharge Instructions:
You were transferred from [**Hospital6 **] to the [**Hospital1 1535**] for workup of your six weeks of
fevers and your acute lower back pain. A blood culture showed
you were growing bacteria in your bloodstream. A
transesophageal ultrasound showed you had a vegetation on your
heart valve (endocarditis) which was likely the source of the
bacteria in your blood. You were started on intravenous
antibiotics and subsequent blood tests showed you were no longer
growing bacteria in your bloodstream. You will complete a six
week course of the following antibiotics: ampicillin and
ceftriaxone. Please followup with your infectious disease
physician [**Name Initial (PRE) 7928**].
While you were in the ICU, you had an episode of low blood
pressure that triggered chest pain and damage to the muscle
cells of the heart. You had no further problems with chest pain
after you left the ICU. This may have happened because of some
underlying coronary artery disease - you should discuss the best
medical management of this issue with your primary care doctor
and Dr. [**Last Name (STitle) 696**] of cardiology.
On an MRI, you were found to have abscess in your spinal
epidural space (the layer covering your spine). This was likely
the source of your left lower back pain and leg pain. You
underwent a neurosurgical procedure where the abscess was
removed. You completed the surgery without any complications.
MRI of your brain shows several small lesions that may represent
bacteria that have traveled to the brain. You are already on
antibiotics that should treat any infection. Please followup
with Dr. [**First Name (STitle) **] as specified below.
.
During an echocardiogram of your heart, you were found to have a
blood clot in your right atrium. You will be started on heparin
(an IV blood thinner) at rehab, and transitioned onto warfarin
(an oral blood thinner).
We have made the following changes to your medication regimen:
- BEGIN TAKING Ampicillin (last day = [**11-11**])
- BEGIN TAKING Ceftriaxone (last day = [**11-11**])
- BEGIN TAKING Coumadin (last day [**12-7**] or as directed by Dr.
[**Last Name (STitle) 696**]
- BEGIN TAKING metoprolol for high blood pressure
- BEGIN TAKING amlodipine for high blood pressure
- CONSIDER TAKING medications to treat constipation, pain, and
SOB as needed (these will be provided for you at the rehab
facility)
- STOP TAKING medications for gout and BPH until directed to do
so by your physician(s)
Please keep/arrange the follow up appointments as outlined
below.
Followup Instructions:
WHILE YOU ARE IN REHAB, you should have your CBC, chem 7, LFTs
checked at least weekly, and your ESR/CRP should be checked
monthly.
1. Neurosurgery - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 3231**] - secretary [**Location (un) 3230**]
- Please call to schedule a follow up appointment with Dr. [**First Name (STitle) **].
You may need to have another MRI of your lumbar spine with and
without contrast prior to this appointment (check with [**Location (un) 3230**]
about scheduling this).
- You still have sutures in your back. They are made of a
dissolvable material so they do not need to be removed. You may
get them wet after [**2146-10-8**].
- If you have any questions or concerns about your spine, please
contact Dr.[**Name (NI) 9399**] office.
2. Nephrology - Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] / Dr. [**Last Name (STitle) 4090**]
[**Telephone/Fax (1) 721**]
Thursday, [**10-27**], 1:00 PM
3. Cardiology - Dr. [**Last Name (STitle) 696**]
[**12-1**], 8:40 AM
[**Telephone/Fax (1) 62**]
[**Hospital Ward Name 23**] 7, [**Hospital Ward Name 516**]
- You will need a follow-up TEE (transesophageal echocardiogram)
study in approximately 3 months. Dr. [**Last Name (STitle) 696**] will help you to
schedule this. Additionally, he will address any cardiac issues
or make necessary changes in medication related to your troponin
leak that occurred while you were in the hospital.
4. Infectious disease - Dr. [**First Name8 (NamePattern2) 7810**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 457**]
Wednesday, [**2148-10-18**]:30 AM
[**Last Name (NamePattern1) **]., [**Hospital Ward Name 517**]
5. Primary Care Provider [**Name Initial (PRE) **] [**Name10 (NameIs) 71684**] [**Name11 (NameIs) 71685**]
[**Telephone/Fax (1) 58931**]
Monday [**10-24**], 1:30 PM
[**Location (un) 47**] Office
- Dr. [**Last Name (STitle) 71685**] will wish to review your medications
with you, to check your PTT/INR for treatment of your blood
clot, and to monitor your liver and kidney function.
Completed by:[**2146-10-7**]
|
[
"410.71",
"041.12",
"V45.11",
"466.0",
"585.6",
"285.9",
"263.9",
"041.04",
"790.7",
"518.4",
"421.0",
"600.00",
"333.2",
"584.9",
"324.1",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.95",
"03.09",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
33771, 33845
|
23546, 31528
|
361, 709
|
34123, 34187
|
6974, 13394
|
36762, 38860
|
6034, 6053
|
31669, 33748
|
33866, 34102
|
31554, 31646
|
34211, 36739
|
6068, 6955
|
246, 323
|
737, 5586
|
5608, 5788
|
5804, 6018
|
13411, 23523
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,021
| 122,731
|
45371
|
Discharge summary
|
report
|
Admission Date: [**2101-5-5**] Discharge Date: [**2101-5-17**]
Date of Birth: [**2047-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2101-5-12**] - CABG X 2 (LIMA->LAD, Vein to obtuse marginal), Mitral
valve replacement (25mm Mosaic Porcine Valve)
[**2101-5-9**] - Cardiac Catheterization
[**2101-5-6**] - Stress Test
History of Present Illness:
53 yo F with diastolic CHF, CAD, DM, Hep C, presents with
progressive dyspnea on exertion and chest pain. The patient has
been having progressive dyspnea over the past 3-4 weeks. The
symptoms are worsened by even mild activity such as sweeping the
floor. She also has been having intermittent L chest pain with
out radiation or diaphoresis. This pain worsens with activity
and improves with rest. Furthermore the patient has been having
a productive cough with brown sputum. Patient is a difficult
historian.
.
Denies fevers, chills, nausea, vomiting, diarrhea. Reports no
change in her chronic abdominal pain or chronic orthopnea.
Patient speaks slowly with a flat affect.
.
In the ED patient was given 60mg IV lasix, levoflox 500mg IV.
Agree with Nightfloat admission note. The patient is not able to
provide a fully consistent history. She mentions feeling more
ill over the past several weeks, which has included increased
SOB as well as intermittent chest pain. She believes the CP
radiates to both arms is described as sharp rather than
sqeezing. She has noted increased SOB when performing her daily
activities, she is highly sedentery recently, no stairs or walks
outside of the home. She is currently chest pain free. No
fevers, chills, no cough or wheezing.
Past Medical History:
1. CAD - pMIBI ([**2100-7-14**] negative EKG changes, no CP, no
perfusion
defects, EF 70%)
2. Diastolic CHF, 2+ MR
3. hypertension
4. diabetes mellitus type II
5. hepatitis c - untreated
6. cervical cancer - s/p TAH/BSO/peritoneal washing for adnexal
masses
7. abdominal aortic aneurysm repair in [**2085**] with
8. s/p chole [**2088**]
9. PVD: aorto/fem bypass then with Thrombectomy and patch
angioplasty of common femoral arteries in [**2091**]
10. iv drug abuse - quit methadone program. actively using now.
11. asthma/chronic obstructive pulmonary disease / emphysema
12. total body pain
13. abdominal pain with adhesions
Social History:
smokes [**1-17**] ppd x 35 yrs
denies etoh
history of heroin use, on methadone
Family History:
No diabetes; MI (dad-?age); heart disease (brother - quintuple
bypass); HTN (dad); cancer (breast-aunt; lung-brother);
depression (mom, dad).
Physical Exam:
VS T 97.6 P 86 BP 116/63 R 16 O2 97 on 2L
Gen - flat affect, tired, Ox3
HEENT - EOMI, PERRL, OP clear
Neck - supple, No LAD, no JVD
Cor - RRR, sys murmur at apex
Chest crackles at bases bilat
Abd - diffusely tender, large healed scar down center
Ext- w/wp no c/c/e, 1+ DP
Pertinent Results:
[**2101-5-5**] 11:27PM URINE HOURS-RANDOM
[**2101-5-5**] 11:27PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2101-5-5**] 11:27PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2101-5-5**] 11:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2101-5-5**] 08:55PM GLUCOSE-79 UREA N-8 CREAT-0.6 SODIUM-141
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
[**2101-5-5**] 08:55PM ALT(SGPT)-15 AST(SGOT)-23 CK(CPK)-66 ALK
PHOS-227* AMYLASE-31 TOT BILI-0.5
[**2101-5-5**] 08:55PM LIPASE-14
[**2101-5-5**] 08:55PM cTropnT-<0.01
[**2101-5-5**] 08:55PM proBNP-4555*
[**2101-5-5**] 08:55PM ALBUMIN-3.9
[**2101-5-5**] 08:55PM WBC-10.3 RBC-4.76 HGB-12.8 HCT-38.8 MCV-82
MCH-26.9* MCHC-33.0 RDW-14.6
[**2101-5-5**] 08:55PM NEUTS-61.7 LYMPHS-29.6 MONOS-6.3 EOS-1.7
BASOS-0.6
[**2101-5-5**] 08:55PM MICROCYT-1+
[**2101-5-5**] 08:55PM PLT COUNT-223
[**2101-5-5**] ECHO
1. The left atrium is moderately dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. The left ventricular cavity
is unusually small. Left ventricular cavity size could not be
determined. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.]
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal. Abnormal septal position consistent with RV
pressure/volume overload.
4. The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. There is
moderate mitral stenosis. Mild to moderate ([**1-17**]+) mitral
regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen.
7.There is moderate pulmonary artery systolic hypertension.
8.There is no pericardial effusion
[**2101-5-6**] Stress Test
This 53 year old type 2 IDDM woman was referred to
the lab for evaluation of chest discomfort and shortness of
breath. Due
to PVD, the patient was infused with 0.142 mg/kg/min of
dipyridamole
over 4 minutes. No arm, neck, back or chest discomfort was
reported by
the patient throughout the study. There were no ST segment
changes
during the infusion or in recovery. The rhythm was sinus with
frequent
isolated vpbs. Appropriate hemodynamc response to the infusion.
The
dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
[**2101-5-9**] Cardiac Catheterization
1. Selective coronary angiography showed a co-dominanat system
with
calcified Left Main Coronary Artery. The LAD had a 50%
mid-vessel hazy
lesion. LCX had a severe 90% lesion at its origin and a 50% OM
lesion.
RCA was chronically totally occluded proximally but was a
smaller vessel
with an acute marginal branch and modest L->R collaterals.
2. Left ventriculography showed preserved ejection fraction
(58%) which
is depressed given the degree of mitral regurgitation (3+).
Inferior
wall was hypokinetic.
3. Hemodynamic assessment showed a 9 mmhg gradient across the
mitral
valve consistent with moderate mitral stenosis. There was no
gradient
across the aortic valve. Pulmonary pressures were moderately to
severely
elevated with Pap 85/38. PCWP was 35 mm Hg.
[**2101-5-14**] CXR
Right internal jugular vascular sheath remains in standard
position. There is stable [**Month/Day/Year **] widening of the cardiac
and mediastinal contours. Vascular engorgement and perihilar
haziness is again demonstrated. Bibasilar atelectasis and
pleural effusions, small on the left and moderate on the right
are without change. Overall, there has not been a significant
change allowing for technical differences.
Brief Hospital Course:
Mrs. [**Known lastname 39008**] was admitted to the [**Hospital1 18**] on [**2101-5-5**] for evaluation
of chest discomfort and dyspnea. A stress test was performed
which was normal however the nuclear images revealed a
reversible defect in the left anterior descending artery
territory. Plavix was started and her lipitor was increased.
Lasix and an ace inhibitor were started for congestive heart
failure symptoms. She developed another episode of chest pain
which suggested the possibility of unstable angina. A cardiac
catheterization was performed which was significant for three
vessel coronary artery disease, mixed mitral valve stenosis and
regurgitation and left ventricular ejection fraction of 58%. An
echocardiogram was performed which showed a dilated left atrium,
a normal left ventricular ejection fraction, 1+ aortic
regurgitation, moderate mitral valve stenosis, moderate mitral
valve regurgitation and moderate pulmonary hypertension. Heparin
was started and her plavix was stopped. Given these findings,
the cardiac surgery service was consulted for surgical
evaluation. Mrs. [**Known lastname 39008**] was worked-up in the usual preoperative
manner. On [**2101-5-12**], Mrs. [**Known lastname 39008**] was taken to the operating room
where she underwent coronary artery bypass grafting to two
vessels and a mitral valve replacement with a 25mm mosaic
porcine valve. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. She had a short run
of ventricular tachycardia which was self limited. On
[**Known lastname **] day one, Mrs. [**Known lastname 39008**] awoke neurologically intact
and was extubated. Methadone was resumed given her history of
heroin abuse. Beta blockade, statin therapy and aspirin were
started. On [**Known lastname **] day two, she was transferred to the
cardiac surgical step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
[**Known lastname **] strength and mobility. Mrs. [**Known lastname 39008**] continued to
make steady progress and was discharged to her home with a
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] day five. She will follow-up
with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician
as an outpatient.
Medications on Admission:
Xanax 1mg qid
Trazodone 300mg qhs (?per patient)
Methadone 70mg qday
lipitor 10mg qday
Lasix 80mg qday
ASA 81mg qday
Lisinopril 10mg qday
Prilosec
mvi
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily): patient has prescription for methadone.
Disp:*0 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day.
Disp:*30 patches* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
MR
[**First Name (Titles) **]
[**Last Name (Titles) 96870**]
HTN
COPD
PVD
Chronic pain
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) 665**] in [**2-18**] weeks
with Dr. [**First Name (STitle) 437**] in [**2-18**] weeks ([**Telephone/Fax (1) 13786**]
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2101-5-17**]
|
[
"394.2",
"493.20",
"070.70",
"250.00",
"428.0",
"998.11",
"428.30",
"788.20",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.53",
"36.11",
"37.23",
"35.23",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10991, 11049
|
6932, 9293
|
307, 497
|
11184, 11191
|
3016, 6909
|
11363, 11588
|
2565, 2709
|
9494, 10968
|
11070, 11163
|
9319, 9471
|
11215, 11340
|
2724, 2997
|
248, 269
|
525, 1802
|
1824, 2453
|
2469, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,589
| 129,695
|
33721
|
Discharge summary
|
report
|
Admission Date: [**2172-11-11**] Discharge Date: [**2172-11-26**]
Date of Birth: [**2138-8-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Invasive thymoma type B1 s/p chemo admitted for radical
thymectomy
Major Surgical or Invasive Procedure:
s/p Clamshell radical thymectomy , trach/PEG([**11-18**])
History of Present Illness:
The patient is a 34-year-old
female who was recently diagnosed with an invasive thymoma,
the biopsy of which showed type B1 according to the WHO
classification. The patient underwent preoperative
chemotherapy and a repeat CT scan showed involution in the
size of the thymic mass.
Past Medical History:
Oncologic history (per OMR):
- Admitted to [**Hospital1 18**] [**3-/2172**], rx afib/aflutter with metoprolol and
warfarin; no CXR performed
- Developed palpitations [**5-/2172**], found to have rapid afib; CXR
showed large mediastinal mass; subsequent CT showed large
anterior mediastinal mass (no clear evidence of pericardial
involvement)
- Mediastinal biopsy performed at [**Hospital1 1474**], non-diagnostic
- [**2172-6-22**] Dr. [**Last Name (STitle) **] performed bronchoscopy and biopsy,
revealing lymphocyte-[**Doctor First Name **] thymoma.
- Port placed [**2172-7-13**]
- Received neoadjuvant CAP (Cytoxan/Adriamycin/Platinum) on [**7-14**]
(as inpatient; she was hospitalized at that time for afib/RVR
- Second cycle CAP [**8-4**], Neulasta [**8-5**]
- Third cycle CAP [**9-1**]; admitted [**Date range (1) 74440**] with fever and
neutropenia (no clear source). Digoxin stopped on that
admission.
- Fourth cycle CAP [**9-21**]; admitted to OSH [**2172-9-25**] for hydration,
monitoring.
.
PMH:
1. Abnormal LFTs: s/p liver biopsy without definitive cause.
Possibly part of an autoimmune phenomenon associated with
thymoma. Outpatient liver center follow up appointment was not
kept.
2. Atrial flutter: likely related to/exacerbated by mediastinal
mass. Difficult to rate control due to low BP. At the last
hospitalization, she would have BP 80s/50s but would be
asymptomatic. HR tends to be 100-110s.
3. High grade cervical SIL
4. Low back pain
5. Depression/anxiety
Social History:
Previously worked as a case manager for a home care company, out
of work since diagnosis. Lives with her mother in [**Name (NI) 701**].
History of social alcohol use, none current. No tobacco or
illicits.
Family History:
Sister has atrial fibrillation and elevated liver enzymes,
unknown cause. Father - diabetes [**Name2 (NI) **], HTN,
hypercholesterolemia. Mother - Gerd.
Physical Exam:
General: Frail, thin female, quite and occas withdrawn.
HEENT: alopecia s/p chemo. trach #6 portex.
Chest: course breath sounds which clear somewhat w/ coughing and
sxn'ing. left double port port a cath. Clamshell incision well
healed.
COR: RRR S1, S2 w/ III/VI SEM
ABd: soft, flat , NT, +BS Peg tube site benign
Extrem: no edema LE. right upper extremity: full thickness burn
at medial aspect of elbow d/t hot pack. Presently 5x4 cm w/
yellow escar.
Neuro: awake alert, mouths words. Tends to become easily anxious
and overwhelmed.
Pertinent Results:
PORTABLE CHEST [**2172-11-23**] AT 09:16.
COMPARISON STUDY: [**2172-11-20**].
CLINICAL INFORMATION: Status post clamshell procedure and
radical thymectomy,
evaluate for interval changes.
FINDINGS:
Tracheostomy is positioned in the midline. Sternal wires are
present. Left
subclavian catheter terminates at the cavoatrial junction. There
is a small
left pleural effusion with left lower lobe atelectasis. The
remainder of the
lungs are clear. Compared to the prior study, left pleural
effusion and left
lower lobe atelectasis have increased since the prior study.
Multiple clips
are present in the mediastinum.
IMPRESSION:
Increased left lower lobe atelectasis and small left pleural
effusion since
the prior study.
Brief Hospital Course:
Pt was admitted and taken to the OR for Clamshell incision with
radical
thymectomy, toilette bronchoscopy for excision of
invasivethymoma type B1.
An epidural was placed for pain control at the time of surgery.
2 bilat chest tubes and 2 [**Doctor Last Name **] drains were also placed for
pleural and mediastinal drainage.
Post operatively, pt remained intubated and was admitted to the
surgical ICU for ongoing monitoring and ventilator support.
Initially required pressors and volume resusitation.
POD#1 chest tubes wer eplaced to water seal. Attempting to wean
from vent support but became tacypneic.
POD#2 febrile to 101.8; pan cultured. HCT 20- transfused 1UPRBC
for post op anemia.
POD#3 BAL w/ GNR- empirically started on levaquin then changed
to vanco/zosyn.
Chest tubes d/c'd and blakes remained inplace. Tube feeds
started via dobhoff.
POD#4 diuresis begun. ID was consulted-/ ? PNA
POD#5 failing to wean from vent d/t agitation off propfol.
Epidural d/c'd d/t persistant fever>101.5
POD#6 Pt sustained burn on right medial aspect of upper
extremity d/t hot pack. Wound care was consulted and recommended
plastic surgery consult. Pt found to have full thickness burn.
Xeroform gauze was recommended but he possiblity of surgical
debridement might be rquired in the future.
POD#7 failure to wean from the vent. Taken to the OR for trach
and peg done. [**Doctor Last Name 406**] drains d/c'd in the OR.
POD#8 dobhoff d/c'd and tube feeds initiated via peg. Bronch
done at bedside for moderate amount of scecretions- BAL
wasobtained.
POD#9 trach collar trials to wean from vent. Eval for passey
muir valve but unable to [**Last Name (un) 1815**]. Vanco d/c'd and zosyn continued
for PNA.
POD#10 Psych was consulted for agitation. Recommended zyprexa or
haldol for agitation. intermittant rapid afib- treated
successfully w/ lopressor. has a history of afib/aflutter.
POD#11 Transferred from ICU to floor. Failed swallow study-
remains NPO on tube feeds. requires q 3-4 hr suctioning. seen by
PT and rehab recommended.
POD#12 wound care re- consu;[**Male First Name (un) **] for right upper extrem burn-
Santyl recommended- allegry to sulfa so, no silvadine. [**Last Name (un) **]
tube feeds replete w/ fiber cycled over 14 hrs at 85cc/hr.
Medications on Admission:
Digoxin 250 mcg, lorazepam 0.5 q6h prn, Metoprolol 12.5 mg [**Hospital1 **]
mirtazipine 15 qhs, zyprexa , ambien, Aspirin 325 mg, Docusate
Sodium 100 mg [**Hospital1 **]
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): via feeding tube.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
via feeding tube or suppository form.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed: elixir via feeding tube.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): via feeding tube.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day).
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mls PO Q4H (every
4 hours) as needed.
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
14. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) dose Intravenous Q8H (every 8 hours) for 3 days.
17. port a cath
Sodium Chloride 0.9% Flush 10 mL IV Q8H:PRN line flush
Heparin Flush (10 units/ml) 5 mL IV PRN
to port
18. wound care
santyl [**Hospital1 **] to right elbow burn
19. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for severe agitation, anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
invasive type B1 thymoma s/p cycle 4 of CAP (cytoxan,
adriamycin, cisplatin)
s/p Clamshell radical thymectomy
failure to wean from vent resulting in trach/PEG([**11-18**])
Discharge Condition:
deconditioned
Discharge Instructions:
Trach care per policy
Currently NPO after failed bedside swallow and video swallow
[**2172-11-26**] - repeat swallow eval to assess readiness for PO's.
Passey muir valve as [**Last Name (un) 1815**].
Burn care to right arm
Followup Instructions:
You have a follow up appointment with the plastic surgery office
for the burn on your right arm. [**2172-12-4**] at 3pm with Dr. [**First Name (STitle) 3228**]
[**Hospital Ward Name **] [**Hospital Ward Name **] clinical center [**Location (un) 470**] [**Telephone/Fax (1) 4652**].
You have follow up appointments on [**12-10**] on the [**Hospital Ward Name **]
[**Hospital Ward Name 23**] clinical center [**Location (un) **].
2:00 pm Dr. [**Last Name (STitle) 3274**],
2:30 pm Dr. [**Last Name (STitle) **],
3:00 pm Dr. [**Last Name (STitle) **].
Please arrive at 1:15pm and report to the [**Location (un) 470**] radiology
for a chest XRAY prior to your appointments.
Completed by:[**2172-12-1**]
|
[
"E873.5",
"512.1",
"164.0",
"427.32",
"458.29",
"724.2",
"518.5",
"300.4",
"276.4",
"E878.8",
"427.31",
"997.09",
"957.1",
"997.31",
"943.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"33.24",
"31.1",
"96.6",
"43.11",
"33.22",
"96.72",
"07.82",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8243, 8315
|
3938, 6187
|
356, 417
|
8532, 8548
|
3192, 3915
|
8819, 9522
|
2470, 2624
|
6410, 8220
|
8336, 8511
|
6214, 6387
|
8572, 8796
|
2639, 3173
|
249, 318
|
445, 727
|
749, 2231
|
2247, 2454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,844
| 126,384
|
16366
|
Discharge summary
|
report
|
Admission Date: [**2172-10-30**] Discharge Date: [**2172-12-12**]
Date of Birth: [**2143-7-2**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Gleevec / Cefepime Hcl / Clindamycin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Endotracheal intubation
Paracentesis x 2
Arterial line
Liver biopsy
History of Present Illness:
CC - abdominal pain
.
HPI - This is a 29 y/o male with a complicated onc history -
diagnosed with AML in [**2169**] s/p [**Year (4 digits) 3242**] in [**4-/2170**] with failed
complete remission and subsequent remission in [**2170**]. He was
treated with multiple chemo regimens and had a cell boost in
3/[**2171**]. His clinical course was complicated by GVHD involving
the GI tract and liver, and is on multiple immunosuppresants.
The patient reports that he has had severe, [**9-28**] abdominal pain
beginning earlier today, presenting as a "tight band acoss his
abdomen and constipation pain." His last BM was earlier the
morning of admission and was [**12-22**] diarrhea and [**12-22**] constipation -
normally he has just diarrhea. [**1-23**] nights ago, he had a large
meal his mother cooked and had severe diarrhea following this,
so he took Immodium and increased his narcotics dose.
Denies any fevers, nausea or vomiting. He was seen by his
primary oncologist today who referred him to the ED. CT of the
abd/pelvis in the ED confirmed a large amount of stool in the
colol with fecalization of the small bowel and ?colitis. Was
given Levo and Flagyl in the ED. Seen by surgery, who are
following with serial abd exams and recommend IVF, NPO, and abx.
Past Medical History:
PMH - AML diagnosed in [**12/2169**] with a white blood cell count of
130,000. He was shown by immunophenotyping to have biclonal
leukemia. Cytogenetics revealed multiple abnormalities including
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5622**] chromosome 9:22 translocation. This was initially
treated on an ALL regimen and then received multiple
chemotherapy regimens including ALL and AML-based regimens
finally responding to hyper CVAD regimen. He had achieved
partial remission but never complete remission. At the time of
his transplant in [**4-/2170**], he had still not achieved complete
remission. His former blood type was B positive and he was CMV
positive. His donor transplant course was complicated by grade 1
graft versus host disease of the skin which resolved with
steroids. He had some relapse of his disease in [**7-/2171**] and was
treated with multiple chemo regimens including hyper CVAD and
did respond. He underwent a stem cell boost in [**2-/2172**] with
clinical remission since. He has had continued graft versus host
disease of the liver. He has been on multiple immunosuppressants
including Neoral, CellCept, and prednisone. He had a liver
biopsy in the past, which revealed graft versus host disease of
the liver. He has also had an acidosis in the past relating to
cyclosporine and was on oral sodium bicarbonate in the past. He
has had a perianal fistula/abscess in [**6-/2172**] that responded to
antibiotics. He has had coag-negative staph bacteremia in the
past as well in the setting of a line-associated infection that
was treated with daptomycin on an extended basis. He has had
several blood cultures in early [**Month (only) 216**], which were no growth to
date. His most recent bone marrow biopsy was [**2172-8-31**] , which
did not reveal any evidence of leukemia and showed normal
trilineage hematopoiesis.
Social History:
He is not working. He is not married. He has a significant
other. He has no children. He does not smoke tobacco or drink
alcohol. He lives in [**Location **], [**State 350**]. His primary care
physician is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Family History:
non-contributory
Physical Exam:
VS: 97.7, 106/60, HR 100, RR 22
General: Frail-appearing male, jaundiced, NAD
HEENT: Scleral icterus
Chest: CTA-B, no w/r/r
CV: RRR, s1 s2 normal, no m/g/r
Abd: distended, no bowel sounds, +tympany; pain with deep
palpation, no peritoneal signs
Ext: 1+ edema b/l, no c/c; pulses 2+ b/l
Skin: jaundiced
Pertinent Results:
[**2172-10-29**] 12:00PM PT-14.0* PTT-32.7 INR(PT)-1.3
[**2172-10-29**] 12:00PM PLT COUNT-70*
[**2172-10-29**] 12:00PM NEUTS-86* BANDS-1 LYMPHS-7* MONOS-2 EOS-1
BASOS-0 ATYPS-2* METAS-0 MYELOS-0 PROMYELO-1* NUC RBCS-3*
[**2172-10-29**] 12:00PM WBC-5.3 RBC-3.08* HGB-10.9* HCT-33.2*
MCV-108* MCH-35.5* MCHC-32.9 RDW-25.3*
[**2172-10-29**] 12:00PM ALBUMIN-2.5* CALCIUM-8.2* MAGNESIUM-1.8 URIC
ACID-4.5
[**2172-10-29**] 12:00PM ALT(SGPT)-177* AST(SGOT)-81* LD(LDH)-191 ALK
PHOS-558* TOT BILI-22.6* DIR BILI-16.5* INDIR BIL-6.1
[**2172-10-29**] 12:00PM GLUCOSE-112* UREA N-58* CREAT-2.0* SODIUM-137
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-17* ANION GAP-18
[**2172-10-30**] 10:30AM GRAN CT-3340
[**2172-10-30**] 10:30AM PLT COUNT-60*
[**2172-10-30**] 10:30AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-2+ TEARDROP-1+
PAPPENHEI-1+
[**2172-10-30**] 10:30AM WBC-4.2 RBC-2.80* HGB-10.6* HCT-30.3*
MCV-108* MCH-37.8* MCHC-34.9 RDW-26.8*
[**2172-10-30**] 10:30AM CALCIUM-8.2* PHOSPHATE-6.3*# MAGNESIUM-1.9
URIC ACID-5.2
[**2172-10-30**] 10:30AM ALT(SGPT)-169* AST(SGOT)-79* LD(LDH)-181 ALK
PHOS-621* TOT BILI-22.9* DIR BILI-17.3* INDIR BIL-5.6
[**2172-10-30**] 10:30AM UREA N-74* CREAT-2.4* SODIUM-133
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-14* ANION GAP-20
[**2172-10-30**] 04:20PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2172-10-30**] 04:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-1 PH-6.5 LEUK-NEG
[**2172-10-30**] 04:20PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2172-10-30**] 04:23PM LACTATE-1.8
Brief Hospital Course:
He initially presented to this hospital on [**2172-10-30**] with severe,
[**9-28**] abdominal pain beginning that day, presenting as a "tight
band acoss his abdomen and constipation pain." CT of the
abd/pelvis done on the day of admission confirmed a large amount
of stool in the colon with fecalization of the small bowel and
?colitis. The patient given Levo and Flagyl in the ED. He was
seen by surgery, who are following with serial abd exams and
recommended IVF, NPO, and abx. He was started on Zosyn for
possible colitis. He was also noted to be in acute renal failure
with a creatinine of 2.4 up from a baseline of 1.2. This was
thought to be pre-renal and the patient was started on fluids.
He had a transaminitis that was stable but his bilirubin was 24
which is up from 22 and alkaline phosphatase that was also
significantly elevated.
.
Patient was continued on prophylactic acyclovir. He was
continued on voriconazole, started in [**1-25**] for treatment of lung
nodules presumed to be fungal. Of note galactomannin was
negative. The lung nodules have resolved on voriconazole. He is
also getting inhaled pentamidine for PCP [**Name Initial (PRE) 1102**]. He was
continued on cellcept, solumedrol and cyclosporin as well as
photophoresis.
.
During this admission patient developed progressively worsening
LFTs and encephalopathy. He has also developed vomiting. An NG
tube was placed [**11-1**] with return of 600 cc of brown liquid.
Imaging was been consistent with a partial small bowel
obstruction. Patient removed NGT which was complicated by
prolonged epistaxis. He was subsequently was found to have a
large hematoma in the oropharyx. His hospital stay has been
complicated by elevated INR (likely from liver dysfunction)
requiring FFP and vitamin K.
.
Due to worsening LFTs, patient underwent a liver ultrasound to
rule out portal vein thrombosis which showed no thrombosis.
Patient developed worsening renal failure with urine sodium >
20, thus not consistent with HRS. Voriconazole was stopped due
to progressive liver failure. Liver failure was thought to be
due to cyclosporine toxicity vs GVHD. Patient underwent
photopheresis on [**11-3**]. Patient has been guiac positive from
above and below. He was seen by ID who recommended stopping
zosyn due to thrombocytopenia, stopping voriconazole due to
liver failure, obtaining CT chest and starting levofloxacin for
SBP coverage. Liver recommended changing csa to rapamycin and
obtaining biopsy.
.
On the morning of his transfer to the ICU the patient was
hypertensive to 170/108 and heart rate was 60. He was
unresponsive but arousable and disoriented. He underwent head CT
to r/o bleed that was negative. Sinus CT showed hemorrhage from
the nasal cavity to the nasopharynx. CT chest showed worsened
consolidation in the right upper lobe with cavitation.
Temperature later that morning was 95.5. ID recommended adding
ambisome, meropenem and daptomycin. Patient had liver biopsy to
evaluate cause of worsening liver function. After returning to
the floor the intern was called for SBP of 50. Patient was
unresponsive. He received blood, saline. Repeat BP was elevated
at 170/100. Emergent US showed liver laceration with venous
bleed. Patient was transfered to the MICU.
.
In the MICU pH was 7.23/27/128/12. Lactate was 12. O2 sat was
100% on RA. BP was 120s/60s. HR was 120-130. Patient was
answering questions appropriately and following commands.
Patient was given 7 units of PRBC, one bag of FFP, 2 bags of
platelets, 5 liters of saline, 2 liters of LR and 550 cc of D5W
HCO3. Lactate improved to 3.9 and hematocrit to 43. Patient was
seen by angiography and they felt bleeding had self tamponaded
and wanted to watch overnight.
.
His MICU course was complicated by abdominal compartment
syndrome secondary to worsening ascites, ileus, and
hemoperitoneum s/p liver bx. Surgery was consulted and felt the
patient was too high-risk for a surgical decompression. He had a
5 L and 3.5 L paracentesis with some reduction in abdominal
pressures. Course was also complicated by respiratory failure,
secondary to narcotics, increased abdominal pressure, and liver
failure. He was intubated while in the ICU and attempts to wean
towards extubation were unsuccessful. His course was also
complicated by liver failure, presumed to be secondary to GVHD
and was continued on immunosuppresants with minimal change in
LFTs. Other cx included persistent anemia and thrombocytopenia,
thought to be [**1-22**] TTp vs [**Doctor First Name **] from malignant HTN. The
plasmapheresis did not seem to help with his platelet count or
hematocrit. Plasmapheresis was d/c'd on [**11-16**]. Because he
continued to have severe liver disease from presumably GVHD, he
was restarted photopheresis soon. In addition, he was
intermittently hypothermic and hemodynamically unstable,
requiring pressors. Etiology was unclear, and patient was
continued on broad-spectrum abx.
.
Given the patient's declining status and worsening prognosis, it
was decided that the patient be CPR not indicated by the team
and family. Aggressive care was continued, including ventilatory
support and pressors, however the patient's status declined
precipitously despite the efforts of the team, and he expired on
[**2172-12-12**].
Medications on Admission:
MEDS AT HOME-
1. Acyclovir 400 mg q8
2. CSA 100 mg q12
3. Cell-cept [**Pager number **] mg [**Hospital1 **]
4. Prednisone 40 mg qd
5. Ursodiol 300 mg [**Hospital1 **]
6. Voriconazole 200 mg q12
.
MEDS ON TRANSFER -
Budesonide 3 mg tid
Ursodiol 300 mg [**Hospital1 **]
Diphenhydramine 25 mg prn
Acyclovir 400 mg IV q8
Methylprednisolone 40 mg IV q24
Mycophenolate Mofetil 750 mg IV bid
Cyclosporine 50 mg IV q12
Phenylephrine 1%
Oxymetazoline 1
Pantroprazole 40 IV q12h
Meropenem 1000 mg IV q8h
Daptomycin 300 IV q 24
Lidocaine jelly
Lactulose 300 mg PR tid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2173-9-28**]
|
[
"996.85",
"572.2",
"401.0",
"285.1",
"560.9",
"998.2",
"584.9",
"284.8",
"486",
"427.5",
"V58.65",
"428.0",
"518.81",
"286.6",
"038.9",
"868.03",
"570",
"E870.5",
"204.00",
"276.52",
"995.92",
"283.19",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.91",
"00.17",
"96.72",
"33.24",
"00.14",
"99.71",
"99.88",
"96.07",
"38.93",
"96.04",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
11802, 11811
|
5911, 11166
|
324, 393
|
11862, 11871
|
4242, 5888
|
11924, 11959
|
3886, 3904
|
11773, 11779
|
11832, 11841
|
11192, 11750
|
11895, 11901
|
3919, 4223
|
270, 286
|
421, 1684
|
1706, 3574
|
3590, 3870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,629
| 132,678
|
27335
|
Discharge summary
|
report
|
Admission Date: [**2171-5-24**] [**Month/Day/Year **] Date: [**2171-6-3**]
Date of Birth: [**2113-2-16**] Sex: M
Service: SURGERY
Allergies:
Adefovir
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
liver [**First Name3 (LF) **] [**2171-5-24**]
History of Present Illness:
58yo male presenting for admission pre-operatively for an
orthotopic liver [**Month/Day/Year **] on [**2171-5-24**]. His recent health has
been complicated by multiple episodes of hepatic encephalopathy,
portal venous thrombosis, esophageal varices, ascites, portal
HTN
requiring admission. Notably, the patient has a left thyroid
nodule that was biopsied and suggestive of papillary carcinoma
being followed by Dr [**Last Name (STitle) 5182**] (please refer to his OMR notes
for details) and a cardiac evaluation in [**2171-3-28**], that
cleared
him for potential liver transplantation.
Past Medical History:
1. DM-insulin dependent -> very labile in setting of ESLD and
followed at [**Last Name (un) **] with recent FSG's varrying from 2 to 300.
2. ESLD awaiting [**Last Name (un) **]: [**1-29**] hep B, hepatic encephalopathy
and recurrent ascites, esophageal varices (grade III
[**2168**]),portal hypertension and known portal vein thrombosis not
on anticoagulation.
3. History of tuberculosis s/p 6 months INH
4. GERD
5. HTN
6. History of E. Coli septicemia in [**12-1**]
7. Hx of Acute renal failure thought [**1-29**] Hepsera in [**3-4**]
8. Grade III esophageal varices-[**7-/2169**]
10. hx seizures
11. hx osteoperosis based on low bone density d/t GSW L-forearm
and bullet in lung from [**Country 3992**] war
12. s/p inguinal hernia repair (3x Left, 2x Right)
13. Liver [**Country **] [**2171-5-24**]
14. Exploratory laparotomy, revision of
hepatic artery anastomosis x2. Liver biopsy. [**2171-5-28**]
Social History:
He and his wife own a hair salon. They live in [**Location (un) 686**] and
have 4 children. He does not smoke, drink, or use illicit drugs.
Family History:
No family history of hepatocellular carcinoma or cirrhosis. 4
adult children, all in good health.
Physical Exam:
97.7 77 118/70 20 100RA
General - AOx3, NAD
HEENT - normocephalic, atraumatic, trachea midline
CV - RRR, S1/S2 noted, no R/M/G appreciated
Chest - CTAB
Abdomen - soft, nontender, nondistended, normal bowel sounds in
pitch and frequency; bilateral well-healed lower abdominal
surgical incisions
GU - deferred
Ext - skin intact, BLE 1+ pitting edema; left forearm well
healed
surgical incision
Labs:
Na-132, K-3.7, Cl-98, HCO3-31, BUN-16, Cr-1.2, glc-280
Ca-8.3, Mg-2.0, P-2.9
WBC-2.3, Hct-27.2, plt-21
PT-17.5, PTT-36.7, INR-1.6, fibrinogen-150
UA - leuk: sm, RBC>50, nitr: neg, bact: occ, glu: 1000, prot: 25
CXR: pending final read
Pertinent Results:
[**2171-6-3**] 11:32AM BLOOD WBC-3.7* RBC-3.05* Hgb-9.7* Hct-29.0*
MCV-95 MCH-31.6 MCHC-33.3 RDW-20.4* Plt Ct-21*
[**2171-6-2**] 05:55AM BLOOD PT-12.6 PTT-25.1 INR(PT)-1.1
[**2171-6-2**] 05:55AM BLOOD Glucose-64* UreaN-35* Creat-1.3* Na-135
K-4.8 Cl-102 HCO3-28 AnGap-10
[**2171-6-2**] 05:55AM BLOOD ALT-224* AST-67* AlkPhos-86 TotBili-3.8*
[**2171-6-2**] 05:55AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.7
[**2171-6-2**] 05:55AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
[**2171-6-3**] 11:32AM BLOOD tacroFK-11.3
Brief Hospital Course:
On [**2171-5-24**], he underwent orthotopic liver [**Date Range **] for chronic
hepatitis B infection that had resulted in end-stage liver
disease, encephalopathy, and 2 hepatic lesions suspicious for
HCC. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Induction immunosuppression
was given as well as HBIG that was given during the anhepatic
phase. Per the operative report, the arterial anastomosis was
donor common hepatic artery to recipient common hepatic artery
anastomosis created end-to-
end fashion with several areas that required repair sutures for
hemostasis
after unclamping. Once complete, the liver reperfused well. Two
[**Doctor Last Name 406**] drains were placed, one posterior to the right lobe and
one behind the portal anastomoses. A piece of Surginet was left
in the retroperitoneal space behind the right lobe of the liver.
Please refer to operative note for complete details. Postop, he
was transferred to the SICU for management.
On postop day 1, liver duplex demonstrated patent hepatic
vasculature with normal portal and venous waveforms. There were
low left hepatic arterial resistive indices and borderline right
hepatic arterial resistive indices with normal main hepatic
arterial indices. A right hepatic subcapsular hematoma was noted
measuring 3.6 x 2.4 cm. LFTs increased and a repeat duplex was
done on [**5-26**] showing patent venous vasculature. The hepatic
artery was patent with low resistive indices, decreased in the
main hepatic artery. There was normal upstroke in the main
hepatic artery with delayed and blunted upstroke in the left and
right hepatic artery, and high diastolic flow. This raised
concern for anastamotic stenosis. The main portal vein velocity
was much higher than intrahepatic portal velocities,raising
concern for of a portal vein stenosis. LFTS further increased.
Given elevated LFTs and duplex studies, a CTA was done to
evaluate the vasculature. This showed compromised arterial flow
to the liver due to arterial stenosis. Given these findings, he
was taken back to the OR on [**5-26**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
exploratory laparotomy, revision of hepatic artery anastomosis
x2 and liver biopsy. Postop, he returned to the SICU where he
was extubated. LFTs trended down. He received a total of 5 days
of HBIG for h/o HBV. Hepatitis B antibody titers were positive
and the HBSAg remained negative. He received HBIG again on
postop day 7 per protocol.
He was transferred out of the SICU to the med-[**Doctor First Name **] unit on
postop day 4 where his diet was gradually advanced and
tolerated. He had required an insulin drip for hyperglycemia due
to steroids. [**Last Name (un) **] was consulted and NPH insulin with sliding
scale was switched to improve glucose control. Bowel function
was sluggish and he required dulcolax suppositories to help him
move his bowels.
JP drain outputs were non-bilious. Both were removed by the time
he was discharged to home. He did fair with medication teaching
despite having a Vietnamese interpreter during teaching
sessions. VNA services were arranged with Suburban Nursing.
Immunosuppression consisted on Cellcept 1gram [**Hospital1 **] which was well
tolerated. Steroids that were tapered to 20mg daily per protocol
and prograf. Prograf was started on [**5-25**] and was adjusted by
trough levels to 1mg [**Hospital1 **].
Insulin was switched back to the patients home regimen of 75/25
qam and pre supper on the day of [**Hospital1 **] to facilitate home
management given h/o hypoglycemic episodes with insulin.
He was ambulatory with stable vital signs at time of [**Hospital1 **]
to home.
Medications on Admission:
ENTECAVIR - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth once weekly for 8 weeks and then every other
week thereafter
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25 KWIKPEN] -
(Dose adjustment - no new Rx) - 100 unit/mL (75-25) Insulin Pen
-
64 in the morning and 36 at night each day
INSULIN LISPRO [HUMALOG KWIKPEN] - (Prescribed by Other
Provider) - 100 unit/mL Insulin Pen - as per sliding scale
LACTULOSE - 10 gram/15 mL Solution - 30cc by mouth TID
LISINOPRIL - (record) - 5 mg Tablet - 1 Tablet(s) by mouth
daily
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
RIFAXIMIN [XIFAXAN] - 200 mg Tablet - 2 (Two) Tablet(s) by mouth
3 times a day
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
TRAMADOL [ULTRAM] - (record) - 50 mg Tablet - 1 Tablet(s) by
mouth once daily as needed for headache
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - use one four
times per day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - 500 mg (1,250
mg)-400 unit Tablet, Chewable - 1 Tablet(s) by mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by
Other Provider) - 400 unit Tablet - two Tablet(s) by mouth daily
INSULIN NEEDLES (DISPOSABLE) [PEN NEEDLE] - 31 gauge Needle - 1
Needle(s) twice a day For use with humalog 75/25 KwikPen
MAGNESIUM OXIDE - 400 mg Tablet - 1 Tablet(s) by mouth twice a
day
Allergies: adefovir
[**Hospital1 **] Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
ML PO DAILY (Daily).
3. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
taper per schedule.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
13. 75/25 Sig: Thirty Four (34) units every morning: Insulin
subcutaneous injection.
14. 75/25 Sig: Twenty Four (24) units pre-supper: insulin
subcutaneous injection.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO every
other week.
16. Hepatitis B Immune Globulin
per protocol
you will receive this per protocol schedule in clinic
[**Hospital1 **] Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
[**Location (un) **] Diagnosis:
HBV
DM
s/p liver [**Location (un) **]
arterial anastomosis stenosis, repaired
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Location (un) **] Instructions:
Please call the [**Location (un) 1326**] Office [**Telephone/Fax (1) 673**] if you have any
of the warning signs listed below
You will need to come back to [**Last Name (NamePattern1) 439**] Lab every
Monday and Thursday am for labs
You may shower
No heavy lifting/straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2171-6-6**] 1:10
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2171-6-13**]
2:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2171-6-13**] 3:10
Completed by:[**2171-6-4**]
|
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"996.74",
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"530.81",
"070.22",
"452",
"789.59",
"V58.67",
"E878.0",
"572.3",
"V12.51",
"155.2",
"571.5",
"287.5",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"50.11",
"39.49",
"99.14",
"50.4"
] |
icd9pcs
|
[
[
[]
]
] |
3354, 7055
|
283, 331
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2830, 3331
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10840, 11300
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2055, 2155
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10159, 10234
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8741, 10129
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10540, 10817
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359, 951
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10393, 10505
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973, 1880
|
1896, 2039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,268
| 144,218
|
51950
|
Discharge summary
|
report
|
Admission Date: [**2197-3-23**] Discharge Date: [**2197-3-29**]
Date of Birth: [**2124-12-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Doxycycline
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Surgical Wound Infection
Major Surgical or Invasive Procedure:
Incision and Drainage of the Left Above the Knee Amputation
stump
History of Present Illness:
72F with PMH HTN, HLP, OA of the knee s/p multiple TKR
complicated by wound infection and subsequent AKA presents from
her rehab facility with 4d of pain, erythema, and purulent
drainage from her AKA stump.
She was intially given Moxifloxacin by her NH staff.
The patient was then brought to the [**Hospital1 18**] ED where initial VS
were:
97.2 126 111/71 16 100%
She was seen by the Orthopedics team who determined that her
wound required surgical incision and drainage. Laboratory
evaluation was notable for a normal WBC count, but a lactate of
2.1. IV Vancomycin was started. The patient was thought to be
too medically complex at the time to be admitted to the
Orthopedic Surgery floor, and so the patient was admitted to the
Medicine service.
On the floor the patient is comfortable. Not in any pain.
Admits to recent chills and night sweats, but no recent fevers.
Noticed that her stump began to "pink up" about 4 days ago.
Since then it has gotten progressively worse. She denies any
other symptoms.
Past Medical History:
PMH:
Dementia, HTN, HL, Depression, Dementia, organic brain
syndrome; unknown etiology; SDH
requiring surgical intervention, osteoarthritis
PSH: Total knee replacement on [**6-/2196**] Displaced fracture of
left knee one month later surgically repaired on [**2196-8-17**] by Dr.
[**Doctor Last Name 3646**] ([**Hospital3 **]) Re-rupture of patellar tendon. Failed
conservative approach given patella became more prominent in
skin and concern for breakdown; was admitted on [**2196-10-17**] and
underwent repair of left patellar fracutre by Dr. [**First Name (STitle) 3646**] ([**Hospital1 **]). Multiple readmissions and reoperations on the L knee
for infection and dislocation leading to eventual AKA in 3/[**2196**].
Social History:
Lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] nursing home currently but originally [**Location (un) 107544**]. No Etoh or tobacco currently.
Family History:
non-contributory
Physical Exam:
ADMISSION:
96.5 86 152/70 20 100% RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: LLE AKA stump with 12cm area of circumferential erythema,
2 sites of purulent drainage along prior staple line.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
.
Discharge:
VS - 96.5, HR: 78 (73-95), BP: 123/48 (118-157/40-80), RR: 21,
O2: 97%RA
GENERAL - A&Ox3, appears uncomfortable, shifting in bed,
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Decreased bs at bases, rales at bases, no respiratory
distress
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obese, soft/ND, LLQ tenderness to palpation, no masses
or HSM, no rebound/guarding
EXTREMITIES - LLE AKA stump is surgically dressed, R LE with
pneumoboot, 1+ edema, cool feet; fullness in UE, cool hands, JP
drain on L stump with minimal sanguinous output
NEURO - lethargic but conversational, A&Ox3, moves both legs and
good hand grip bilaterally, EOMI
Pertinent Results:
LABS:
[**2197-3-23**] 03:30PM BLOOD WBC-7.4 RBC-3.09* Hgb-9.0* Hct-27.3*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.2* Plt Ct-347
[**2197-3-25**] 05:56AM BLOOD WBC-8.9 RBC-2.72* Hgb-8.2* Hct-23.9*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.8* Plt Ct-295
[**2197-3-29**] 04:47AM BLOOD WBC-8.0 RBC-3.36* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.7* Plt Ct-269
.
BMP:
[**2197-3-23**] 03:30PM BLOOD Glucose-120* UreaN-19 Creat-1.1 Na-136
K-4.5 Cl-103 HCO3-24 AnGap-14
[**2197-3-24**] 02:31PM BLOOD Glucose-129* UreaN-17 Creat-0.8 Na-135
K-4.6 Cl-107 HCO3-20* AnGap-13
[**2197-3-25**] 05:32PM BLOOD Glucose-110* UreaN-18 Creat-0.9 Na-129*
K-4.9 Cl-102 HCO3-23 AnGap-9
[**2197-3-29**] 04:47AM BLOOD Glucose-104* UreaN-11 Creat-0.9 Na-140
K-4.2 Cl-106 HCO3-28 AnGap-10
[**2197-3-24**] 06:42AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
[**2197-3-25**] 05:32PM BLOOD Calcium-8.2*
[**2197-3-28**] 06:12AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.8 Iron-39
[**2197-3-29**] 04:47AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7
.
VANCO:
[**2197-3-28**] 09:04AM BLOOD Vanco-14.8
###########################################################
MICRO:
[**2197-3-23**] 5:30 pm ABSCESS
**FINAL REPORT [**2197-3-28**]**
GRAM STAIN (Final [**2197-3-23**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
WOUND CULTURE (Final [**2197-3-28**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
PSEUDOMONAS AERUGINOSA. RARE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 16 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>2 R
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>8 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 4 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- 16 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>8 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2197-3-27**]): NO ANAEROBES ISOLATED.
.
[**2197-3-24**] 11:00 am TISSUE (L) STUMP.
**FINAL REPORT [**2197-3-28**]**
GRAM STAIN (Final [**2197-3-24**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2197-3-27**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2197-3-24**] 11:00 am FLUID,OTHER LEFT STUMP.
**FINAL REPORT [**2197-3-28**]**
GRAM STAIN (Final [**2197-3-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2197-3-24**] @
740 PM.
FLUID CULTURE (Final [**2197-3-27**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 321-1508F [**2197-3-24**].
ANAEROBIC CULTURE (Final [**2197-3-28**]): NO ANAEROBES ISOLATED.
.
[**2197-3-26**] 4:34 pm URINE Source: Catheter.
**FINAL REPORT [**2197-3-28**]**
URINE CULTURE (Final [**2197-3-28**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2197-3-26**] Blood cultures: pending
[**2197-3-26**] Blood cultures: pending
#
#
#
#
#
#
#
################################################################
IMAGING:
[**2197-3-24**] CXR:
FINDINGS: In comparison with study of [**2-13**], the patient has
taken a somewhat better inspiration. Cardiac silhouette is
within normal limits and the lungs are essentially clear except
for some retrocardiac atelectasis. No definite vascular
congestion.
.
[**2197-3-27**] ECHO: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified. Compared with the
prior study (images reviewed) of [**2197-2-8**]
Brief Hospital Course:
72F with PMH of multiple L knee infections, hx MRSA, presents
with a surgical wound infection of the L AKA stump.
# Wound infection: She presented with 4 days of the patient was
seen by ortho, started on Vancomycin and brought to the OR for
debridement of the wound on her left stump. After the surgery
she was transiently hypotensive and was brought to the Intensive
Care Unit for monitoring. While in the ICU, her vancomycin
trough was very elevated and the medication was held for 2 days
while it trended down. Her dose was also lowered to 500mg IV
Q12H. The wound also also cultured and growing MRSA. After
speaking with ID it was determined she will need Abx for a
prolonged period of time and so a PICC line was placed and she
was discharged on vancomycin until [**2197-4-7**] and ceftrizone until
[**2197-4-3**].
.
# UTI: patient had rising white count and found to have UTI
growing Proteus. She was initially started on ciprofloxacin,
but sensitivities showed resistance and so was switched to
ceftriaxone. She will need a 7 day course of ceftriaxone and
was send to [**Hospital1 1501**] with a prescription for 5 more days of therapy.
.
# Atrial tachycardia: Had some bouts of tachycardia in the
intensive care unit and was started on metoprolol tartate 12.5mg
PO BID. She was transferred to the floor and monitored on
telemetry overnight and had no events. Telemetry was
disconitnued and the patient remained asymptomatic. She was
discharged on metoprolol succinate 25mg PO Daily
.
# HTN: initially lisinopril was held after hypotensive episode,
but was restarted once BP was stabilized. She remained
normotensive on home meds.
.
3) GERD: continued home prilosec
.
4) HLP: continued home simvastatin
.
5) Dementia: continued outpt abilify and paxil
6) Anemia: Patient had hct drop from oozing from wound site.
She was transfused total 3 units pRBC over the course of her
stay and H/H has since stabilized with control of patient's
bleeding.
.
TRANSITIONAL ISSUES:
- Follow up blood culture
- continue Abx (vancomycin until [**2197-4-7**], ceftriaxone until
[**2197-4-5**])
- wound care
- once antibiotic course is completed please discontinue PICC
line
Medications on Admission:
Abilify 5 mg qhs
ASA 325 mg qday
Colace/Dulcolax
Lisinopril 5 mg qday
MVI
Omeprazole 20 mg qday
Paxil 20 mg qday
Senna
Simvastatin 20 mg qday
Vitamin C 500 mg ER [**Hospital1 **]
Klonopin 0.5 mg TID prn
Discharge Medications:
1. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours).
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
13. Vitamin C 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO twice a day.
14. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
15. ceftriaxone 1 gram Recon Soln Sig: One (1) gm Intravenous
once a day for 5 days: last dose [**2197-4-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Surgical Wound Infection of the L AKA stump
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted to the [**Hospital1 18**] for management of your surgical
wound infection. You were given antibiotics and then taken to
the OR for incision and drainage by the Orthopedic Surgery team.
Unfortunately while you were waking up from Anesthesia your
heart went into an abnormal rhythm and your blood pressure
dropped very low. You were then observed in the Intensive Care
Unit. You did well and were transferred back to the floor for
further management. You were also found to have a urinary tract
infection and we are treating you for that as well. You also
had some fast heart rate an started on a low dose beta blocker.
You continued to be managed well with the antibiotics given to
you and you are ready for discharge.
.
The following medication was STARTED:
metoprolol succinate 25mg by mouth daily
Vancomycin 500mg IV every 12 hours until [**2197-4-7**].
Ceftriazone 1gm [**Last Name (un) **] 24 hours for 7 days (last dose [**2197-4-5**])
.
Please take your other medications as prescribed.
.
You will have labs drawn in one week to make sure that your
infection is improving and to make sure your kidneys and liver
are safe on these medications.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2197-5-9**] at 2:25 PM
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 [**2197-5-9**] at 2:45 PM
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
|
[
"E878.8",
"997.62",
"310.9",
"427.89",
"E849.7",
"041.6",
"285.29",
"274.00",
"311",
"041.12",
"E878.5",
"682.6",
"E849.8",
"998.51",
"458.29",
"401.9",
"599.0",
"530.81",
"041.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93",
"84.3"
] |
icd9pcs
|
[
[
[]
]
] |
14564, 14637
|
10766, 12734
|
314, 382
|
14725, 14725
|
3800, 10743
|
16130, 16690
|
2384, 2402
|
13199, 14541
|
14658, 14704
|
12971, 13176
|
14901, 16107
|
2417, 3781
|
12755, 12945
|
250, 276
|
410, 1428
|
14740, 14877
|
1450, 2178
|
2194, 2368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,249
| 186,567
|
38043
|
Discharge summary
|
report
|
Admission Date: [**2135-8-25**] Discharge Date: [**2135-8-31**]
Date of Birth: [**2074-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **]
CC:[**CC Contact Info 84965**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname **] is a pleasant 61 yo with no PMH, hx etoh, icu stays for
withdrawal and currently in AA, who recently went on binge for
last 2 wks drinking 40-50 beers/day, now presents to [**Hospital1 18**] for
withdrawal, seizures. Pt states that he stopped drinking on
[**8-25**], at which time he had two seizures and was taken to the ED
by a friend. [**Name (NI) **] also states that he has had auditory and visual
hallucinations, N/V/D, no hematematis, no coffee ground emesis.
He has not had any food in the last week due to his excessive
EtOH consumption.
.
In the ED, he was given 30 IV diazepam and 10 PO diazepam,
fluids, thiamine and folate. Pressures were in the 100s-130s,
HR 80s-90s.
.
On arrival on the floor, pt was comfortable, with no new
complaints other than outlined above
Past Medical History:
Alcohol Abuse
- Has had multiple admissions for alcohol withdrawal, per
records
- c/b seizures, DT's
- Recurrent patter after short periods of sobriety.
Hepatitis C - followed at [**Hospital6 **]
Depression
Scoliosis
Social History:
Alcohol abuse as above. 40 pack year smoking history, quit 2
years ago. Denies a history of IV drug use. Has one tattoo
from age 16 done at home. No blood transfusions.
Family History:
Father with alcoholism
Physical Exam:
Vitals: T:98.3 BP:117/58 P:72 R: 18 O2:96%
General: Alert, oriented, tremulous, mildy diaphoretic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
mild TTP in LUQ
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs [**3-11**] intact, 5/5 strength throughout, 2+ biceps and
patellar reflexes
Pertinent Results:
[**2135-8-25**] 09:40PM URINE HOURS-RANDOM
[**2135-8-25**] 09:40PM URINE HOURS-RANDOM
[**2135-8-25**] 09:40PM URINE GR HOLD-HOLD
[**2135-8-25**] 09:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2135-8-25**] 09:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2135-8-25**] 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-6.5 LEUK-NEG
[**2135-8-25**] 09:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2135-8-25**] 09:40PM URINE HYALINE-0-2
[**2135-8-25**] 06:00PM GLUCOSE-123* UREA N-8 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19
[**2135-8-25**] 06:00PM estGFR-Using this
[**2135-8-25**] 06:00PM ALT(SGPT)-484* AST(SGOT)-632* LD(LDH)-325*
ALK PHOS-89 TOT BILI-1.0
[**2135-8-25**] 06:00PM ALBUMIN-4.6
[**2135-8-25**] 06:00PM ASA-NEG ETHANOL-197* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2135-8-25**] 06:00PM WBC-8.2 RBC-4.53* HGB-14.3 HCT-41.0 MCV-91
MCH-31.6 MCHC-34.9 RDW-13.3
[**2135-8-25**] 06:00PM NEUTS-71.7* LYMPHS-22.8 MONOS-4.3 EOS-0.8
BASOS-0.4
[**2135-8-25**] 06:00PM PLT COUNT-159
.
RUQ U/S [**2135-8-26**]:
1. Diffusely increased hepatic echogenicity, findings most
suggestive of
fatty deposition. More severe forms of hepatic disease including
fibrosis and
cirrhosis cannot be excluded based on this study.
2. Cholelithiasis.
3. Punctate echogenic foci within the left kidney, findings
which likely
represent small non-obstructing renal calculi
.
CT Head w/o Contrast: No acute intracranial abnormality.Sinus
disease as above. Near total opacification of the right
maxillary sinus is new
from the previous study.
Brief Hospital Course:
1. EtOH intoxication. The patient had elevated blood EtOH
levels in the setting of known alcoholism with recent relapse
and seizures on the day prior to admission. He did not have
hemodynamic instability but was having visual hallicinosis.
After treatment with diazepam via CIWA protocol, he improved.
Social work was consulted given his relapse. He deferred detox.
He was discharged on thiamine, folate, and close PCP follow up
2. Seizure: The patient had two witnessed seizures prior to
admission. The patient was unclear on the details of these
events but states that he may have hit his head. A CT scan of
the head showed no acute process/bleed. Likely related to
alcohol withdrawal. Stable for the duration of his hospital
stay
3. Transaminitis. Known hepatitis C and alcohol use. RUQ
ultrasound showed fatty liver. LFTs trended down during
admission.
Medications on Admission:
None. Patient left AMA off of meds
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute alcohol withdrawal
alcohol dependence
Hepatitis due to alcohol use
Anemia of chronic disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with alcohol intoxication and withdrawal.
With valium your symptoms improved. Your liver also showed
damage, most likely due to your alcohol use. It is VERY
important that you stop using alcohol. Please follow up closely
with your primary doctor and take all medications as prescribed
Followup Instructions:
Name: [**Month/Day/Year **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] COMMUNITY HEALTH CENTER
Address: [**State **], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**0-0-**]
Appointment: Wednesday, [**9-7**], 2PM
|
[
"311",
"287.5",
"303.01",
"780.39",
"291.81",
"787.91",
"V64.2",
"263.9",
"285.29",
"V45.82",
"070.70",
"571.0",
"790.4",
"737.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5424, 5430
|
4149, 5019
|
474, 481
|
5573, 5573
|
2391, 4126
|
6054, 6334
|
1761, 1785
|
5104, 5401
|
5451, 5552
|
5045, 5081
|
5724, 6031
|
1800, 2372
|
276, 436
|
509, 1316
|
5588, 5700
|
1338, 1556
|
1572, 1745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,357
| 150,393
|
22947
|
Discharge summary
|
report
|
Admission Date: [**2109-4-29**] Discharge Date: [**2109-5-6**]
Date of Birth: [**2082-1-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
pericardectomy [**2109-4-29**]
History of Present Illness:
27 yo male with history of rhabdomyosarcoma s/p XRT, chemo and
surgery at age 5. Has been in remission since then. Syncope
resulted in recent cath. This revealed hemodynamics consistent
with constrictive pericarditis.
Past Medical History:
- Rhabdomyosarcoma age 5 s/p surgery and XRT x 2 yrs, in
remission
- h/o CMP with biventricular dysfunction
- h/o syncope first in [**2098**] when crouching under a tree, [**11-28**]
had second syncopal episode after running up 3 flights of
stairs, third event again in [**11-28**] after doing jumping jacks
- URI's in the past
- Palpitations in the past
- bony spurs
- GERD
Social History:
Grad student studying psychology, has a girlfriend, family
involved. No smoking, etoh, drugs.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Maternal grandfather with heart disease.
Paternal grandfather with MI.
Physical Exam:
5'9" 136#
HR 72 RR 16 left BP 106/72
NAD
skin unremarkable
EOMI, PERRL, NC/AT, OP benign
neck supple with full ROM, , no JVD
CTAB, with right chest wall defect and muscle atrophy
soft, NT, ND, + BS
warm, well-perfused, no edema or varicosities
neuro grossly intact, alert and oriented x3, MAE, non-focal
2+ bil fem/DP/PT/radials, no carotid bruits
Pertinent Results:
[**2109-5-6**] 06:50AM BLOOD WBC-10.1 RBC-4.84 Hgb-15.2 Hct-45.9
MCV-95 MCH-31.3 MCHC-33.0 RDW-15.0 Plt Ct-389
[**2109-5-6**] 06:50AM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3*
[**2109-5-6**] 06:50AM BLOOD Plt Ct-389
[**2109-5-6**] 06:50AM BLOOD Glucose-99 UreaN-26* Creat-0.9 Na-133
K-4.8 Cl-93* HCO3-32 AnGap-13
[**2109-4-29**] 12:03PM BLOOD ALT-26 AST-44* AlkPhos-238* TotBili-1.3
DirBili-0.5* IndBili-0.8
Cardiology Report ECHO Study Date of [**2109-5-3**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Right ventricular
function. S/p pericardiectomy.
Height: (in) 69
Weight (lb): 137
BSA (m2): 1.76 m2
BP (mm Hg): 96/46
HR (bpm): 111
Status: Inpatient
Date/Time: [**2109-5-3**] at 12:09
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W028-0:35
Test Location: West Other
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 0.7 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm)
Aorta - Descending Thoracic: 1.7 cm (nl <= 2.5 cm)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A Ratio: 2.33
Mitral Valve - E Wave Deceleration Time: 118 msec
TR Gradient (+ RA = PASP): *40 to 46 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2109-5-1**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
False LV tendon
(normal variant). Severely depressed LVEF.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall
hypokinesis. [Intrinsic RV systolic function likely more
depressed given the
severity of TR]. Abnormal septal motion/position consistent with
RV
pressure/volume overload.
AORTA: Normal aortic diameter at the sinus level. Normal
descending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm).
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Overall left ventricular systolic
function is severely
depressed. The right ventricular cavity is moderately dilated
with severe
global free wall hypokinesis. [Intrinsic right ventricular
systolic function
is likely more depressed given the severity of tricuspid
regurgitation.] There
is abnormal septal motion/position consistent with right
ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is
no mitral valve prolapse. Moderate [2+] tricuspid regurgitation
is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial
effusion. The pericardium may be thickened.
Compared with the prior study (images reviewed) of [**2109-5-1**],
findings are
similar (The LVEF was likley overestimated on the prior study).
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2109-5-3**]
15:35.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J.
([**Numeric Identifier 59273**])
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2109-5-6**] 10:34 AM
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
27 year old man with s/p Pericardiectomy and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
AP CHEST 10:51 A.M. [**5-6**]
HISTORY: Pericardiectomy and chest tube removal.
IMPRESSION: PA and lateral chest compared to [**4-23**] through [**4-30**]:
Since [**4-30**] following removal of bilateral pleural and midline
drains small right pneumothorax with apical and basolateral
components has increased slightly, small left apical
pneumothorax is stable. Bilateral hilar enlargement is stable
and diffuse mild interstitial pulmonary abnormality is
unchanged. Overall diameter of the cardiac silhouette is top
normal and along with borderline distention of the azygos vein,
unchanged since preoperative study on [**2109-4-23**] prior to
sternotomy.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2109-5-6**] 3:07 PM
Brief Hospital Course:
Admitted [**4-29**] and underwent pericardectomy with Dr. [**First Name (STitle) **].
Transferred to the CSRU in stable condition on epinephrine and
propofol drips. Extubated the next day and levophed drip
required for pressor support. Echo repeat and epinephrine and
milrinone weaned off on POD #3.Beta blockade titrated and
natrecor started and then discontinued on POD #4. Transferred to
the floor on POD #6. Chest tubes removed on POD #7. He had a
repeat CXR and was cleared for discharge to home with services
on POD #7. Pt. is to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
carvedilol 6.25 mg [**Hospital1 **]
enalapril 5 mg daily
ASA 81 mg daily
albuterol prn
MVI daily
lasix 20 mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Enalapril Maleate 5 mg Tablet Sig: 0.5 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 Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p Pericardectomy
PMH: CMP w/biventricular dysfx, Rhabomyosarcoma s/p chemo/rads,
URI's, Bone spurs, Syncope, GERD
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
take all medications as prescribed
call for any fever, redness or drainage from wounds
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) 7772**] in 4 weeks, pt to call for appt [**Telephone/Fax (1) 1504**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2109-6-5**] 12:20
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2788**] INTERNAL MEDICINE (NHB)
Date/Time:[**2109-5-10**] 9:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2109-5-8**]
|
[
"V10.89",
"530.81",
"V15.3",
"424.0",
"425.4",
"423.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
8311, 8360
|
6636, 7230
|
326, 359
|
8520, 8527
|
1672, 2131
|
8727, 9309
|
1133, 1286
|
7396, 8288
|
5712, 5768
|
8381, 8499
|
7256, 7373
|
8551, 8704
|
2157, 5447
|
1301, 1653
|
279, 288
|
5797, 6613
|
387, 606
|
5479, 5675
|
628, 1005
|
1021, 1117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,211
| 172,261
|
34472
|
Discharge summary
|
report
|
Admission Date: [**2169-3-7**] Discharge Date: [**2169-3-12**]
Date of Birth: [**2136-9-5**] Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin / Aspirin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Living unrelated kidney transplant for ESRD secondary to
calcineurin induced toxicity
Major Surgical or Invasive Procedure:
[**2169-3-8**]: Living unrelated kidney transplant
History of Present Illness:
32F s/p OLT in [**2154**] for Budd Chiari and subsequently
developed Budd Chiari in her transplanted liver necessitating
the
need for splenorenal shunt. She now presents with renal
insufficiency secondary to calcineurin inhibitors for her OLT
and
will undergo a living unrelated transplant from a friend. She
reports feeling well and denies fevers, chills, nausea,
vomiting,
diarrhea, rhinorrhea, dysuria or BRBPR. She does report however
some recent fatigue as well a cough which is chronic and
believed
to be from her ACE inhibitor. She was last sick 2 years ago when
she developed pneumonia. She has been off her Coumadin since
Sunday.
Past Medical History:
Diabetes mellitus, hypertension, obesity
PSH: PSH: OLT '[**54**] c/b Budd Chiari requiring splenorenal shunt,
tubal ligation, appendectomy, exlap
Social History:
Does no work, occasional EtOH, no smoking, no illicit drugs
Family History:
Mother - fibromyalgia, sarcoid
Father - no contact
Physical Exam:
T 98.0 P 82 BP 130/93 RR 18 O2 100RA
PE: Gen - A&O x 3
CV - RRR
Pulm - CTAB
Abd - Obese, Well healed Chevron and lower midline
incisions, soft, nontender, nondistended
Ext - No edema
Pertinent Results:
On Admission: [**2169-3-7**]
WBC-8.4 RBC-3.71* Hgb-11.4* Hct-33.9* MCV-91 MCH-30.7 MCHC-33.6
RDW-13.6 Plt Ct-297
PT-16.2* PTT-30.3 INR(PT)-1.5*
Glucose-200* UreaN-61* Creat-3.7* Na-138 K-4.9 Cl-110* HCO3-16*
AnGap-17
ALT-29 AST-32 AlkPhos-200* TotBili-0.5
Albumin-4.4 Calcium-10.0 Phos-4.8* Mg-2.3
On Discharge: [**2169-3-12**]
WBC-8.4 RBC-3.25* Hgb-9.8* Hct-29.5* MCV-91 MCH-30.0 MCHC-33.0
RDW-14.0 Plt Ct-198
PT-15.9* PTT-46.4* INR(PT)-1.4*
Glucose-247* UreaN-24* Creat-1.0 Na-139 K-4.2 Cl-109* HCO3-23
AnGap-11
ALT-27 AST-22 AlkPhos-142* TotBili-0.7
Calcium-9.1 Phos-2.3* Mg-1.5*
tacroFK-15.0
Brief Hospital Course:
32 y/o female s/p OLT with splenorenal shunt, now with renal
insufficiency secondary to drug toxicity here for living
unrelated kidney transplant. She has been off her coumadin for 3
days and was started on heparin pre-op as a bridge.
The patient was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Routine
induction immunosuppression to include ATG 125 mg ( for 3 total
doses) cellcept and solumedrol with prednisone taper was given.
The kidney had to be placed upside down as the renal vein would
not reach to the common iliac vein. The donor ureter was
anastomosed end-to-side to the native ureter as in the upside
position of the kidney, the ureter was unable to reach the
bladder. This anastomosis was completed over a 6-French double-J
stent.
It was noted that the kidney, while making urine on the table,
did respond to SBPs less than 130 by appearing slightly ischemic
on one pole. Due to this finding, she was admitted to the SICU
post op for maintenance of her BPs > 130 with neo. In addition
it was felt that the ATG may have caused some hypotension, so it
was run in slower.
She stayed overnight in the ICU and was transferred the
following day with stable blood pressures, excellent urine
output and a creatinine down to 1.0 by day of discharge. Liver
enzymes took a small bump but were back within normal limits by
discharge.
She was discharged to home with the JP drain. She was tolerating
diet, ambulating without difficulty and pain was well managed.
Medications on Admission:
Amlodipine 10mg Daily, Nexium 20mg Daily, Lantus 22 units
QHS, Humalog SS, Lisinopril 20mg Daily, Prograf 1mg Daily,
Coumadin 2.5mg Daily, Oscal 500mg/400units
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*10 Tablet(s)* Refills:*1*
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours) for 2 doses.
5. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO ONCE (Once)
for 1 doses.
Disp:*5 Tablet(s)* Refills:*0*
6. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day.
9. Pantoprazole 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*
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO once a day.
11. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Eighteen
(18) units Subcutaneous at bedtime.
12. Humalog 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous four times a day.
13. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD s/p LURT
Discharge Condition:
Good
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or visit ER if you experience any of the
following: Temp>101.5, chest pain, shortness of breath, severe
abdominal pain, drainage or redness from your incision, severe
nausea/vomiting, inability to tolerated food or any other
symptom that is concerning to you.
Do not drive while on pain medication
Keep incision clean and dry. Do not soak in tub however you may
shower.
Please record daily drain outputs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2169-3-17**] 12:50
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2169-3-17**] 1:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2169-3-21**] 2:40
Completed by:[**2169-3-14**]
|
[
"453.0",
"585.6",
"250.00",
"E878.0",
"278.00",
"E947.8",
"996.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.92"
] |
icd9pcs
|
[
[
[]
]
] |
5242, 5248
|
2270, 3782
|
366, 419
|
5306, 5313
|
1650, 1650
|
5800, 6246
|
1351, 1404
|
3993, 5219
|
5269, 5285
|
3808, 3970
|
5337, 5777
|
1419, 1631
|
1962, 2247
|
241, 328
|
447, 1088
|
1664, 1948
|
1110, 1258
|
1274, 1335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,249
| 124,041
|
20097
|
Discharge summary
|
report
|
Admission Date: [**2176-12-22**] Discharge Date: [**2176-12-22**]
Service: TRAU [**Doctor First Name **] SV
DEATH SUMMARY
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is an unfortunate
84-year-old woman who was involved in a motor vehicle
accident earlier this afternoon. She was a restrained driver
that was T-boned by another vehicle with extensive damage to
the passenger side. There was prolonged extrication time
with initial GCF of five to six on the scene. The patient
was intubated for airway protection and initially brought to
the [**Hospital6 5016**]. At that time, as part of the
initial trauma series obtained, she was found to have
multiple rib fractures as well as a pelvic fracture. She was
transferred to [**Hospital1 69**] for
further evaluation and treatment. Upon being transferred and
en route via [**Location (un) **], she dropped her blood pressure to the
90s but responded adequately with fluid resuscitation. Once
the patient arrived to the emergency room trauma bay, a chest
x-ray revealed bilateral subcutaneous emphysema, raising a
high suspicion for pneumothoraces, given the history of the
rib fractures as well. It was decided to place bilateral
chest tubes in the trauma bay, obtaining about 100 cc of
bloody drainage total. The patient's blood pressure was
about 130/palp and upon being rolled up and after the
adequate labs were obtained, she was transferred to CT scan
and head, neck, check, abdomen and pelvis CT were obtained.
The findings can be summarized as follows:
1. She had bilateral, small, subarachnoid hemorrhages that
were not causing any compression or shifts.
2. She had a cervical II fracture, categorized as a type III
odontoid fracture.
3. She had left posterior aspect rib fractures from the 2nd
to the 7th rib.
4. She had right posterior and anterior rib fractures on the
1st through the 4th rib.
5. She had a left acetabular anterior wall fracture with
associated superior and inferior pubic rami fracture as well
as a small contiguous hematoma.
6. She had a mediastinum hematoma without any obvious
extravasation of contrast but significant mediastinal
hematoma.
7. Cervical subcutaneous emphysema that also raised the
question of a potential phaco injury.
The patient remained hemodynamically stable as these studies
were obtained and urgent Neurosurgery and Orthopedics Spine
consults were obtained. TLS films were also obtained in the
ER prior to moving the patient to the Trauma SICU. By this
time, the initial labs came back and revealed a white count
of 27,000, hematocrit 31, platelets 307,000. Her sodium was
136, potassium 3.8, chloride 109, CO2 19, BUN 25, creatinine
0.8, glucose 155. Her INR was 1.2, PT 13.4, with a PTT of 27
and a lactate of 1.4. Her gas was 7.50, CO2 24, O2 268,
bicarbonate 19, with a base excess of -2. The patient was
transferred to the Trauma Surgical Intensive Care Unit and
arrived to this location about 3:45 p.m. At that time the
Orthopedics team was present to evaluate the patient. Dr.
[**First Name (STitle) 1022**] and his resident were seeing the patient as well as the
Neurosurgical team performing evaluation. A left subclavian
triple-lumen was placed without any complication as an
accessory line and the placement was verified by the chest
x-ray, as well as repositioning of the ET tube that was
pulled about 3.0 cm out as it was placed too close to the
carina in the prior film. The next serial hematocrit, about
half an hour later, came back at 26 and the patient was
transfused two units of packed red blood cells. Up until
then, the pressure was still at the 110s or so. The nursing
staff noticed that the left chest tube had about 300 cc of
bloody drainage into the canister. The pressure was still
not high. An additional right femoral Cordis was placed and
the patient dropped her blood pressure to the 70s systolic.
She was placed emergently in Trendelenburg position and
bolused with IV fluids as well as the remainder of the packed
red blood cells. The CT Surgical team was contact[**Name (NI) **] once
again and made aware of this increase in the CT drainage. At
that point, the left chest tube had drained about 900 cc of
blood and was still draining bright red blood into the
canister. A new hematocrit was obtained, as well as
coagulation studies which revealed a hematocrit of 26 despite
about five units of packed red blood cells that were already
infused. An INR was 1.4, PT 14.8, PTT 33.0, with fibrinogen
of 101. The cardiothoracic fellow was present and at that
time was discussing the case with Dr. [**Last Name (STitle) 70**] and Dr. [**Last Name (STitle) **]
over the phone. Upon reviewing the patient's case, the blood
pressure of this unfortunate woman dropped once again to the
70s and this time, despite positioning changes and an
additional five units of packed red blood cells for a total
of ten, and one unit of fresh frozen plasma, the patient's
blood pressure did not recover. CPR and ACLS protocol was
initiated. The recommendation from the CT Surgical team was
unanimous in not doing any heroic maneuvers as no potential
repair could have been done in light of the patient's
neurosurgical injury. The thoracotomy kit was ready in the
room and the team full-gowned but upon reviewing the
situation it was decided not to proceed with the emergent
thoracotomy. After 20 minutes of active coding, performing
CPR as well as providing medications, there was still no
blood pressure and the O2 saturations were in the low 60s
despite full ventilatory support on 100 percent FIO2. The
patient was pronounced dead at about 6:44 p.m. The family
was updated every fifteen minutes as they were present in the
family waiting room. They were very grateful and satisfied
with the team's efforts. Dr. [**Last Name (STitle) **] was made aware and the
patient was presented to the medical examiner who accepted
the case. The postmortem was pending.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2176-12-22**] 20:11
T: [**2176-12-23**] 03:51
JOB#: [**Job Number 54076**]
|
[
"808.2",
"852.05",
"808.0",
"958.7",
"E813.0",
"805.02",
"901.0",
"807.08"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"99.07",
"99.04",
"99.60",
"38.93",
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,178
| 173,333
|
27086
|
Discharge summary
|
report
|
Admission Date: [**2145-2-16**] Discharge Date: [**2145-2-23**]
Date of Birth: [**2098-12-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2145-2-16**] Mitral valve replacement 29mm [**Company 1543**] Mosaic Porcine
History of Present Illness:
Mr. [**Known lastname 66530**] is a 46 year old man with known mitral
regurgitation, now presenting with palpitations and worsening
mitral valve prolapse and mitral regurgitation. He came to [**Hospital1 1535**] for surgical evaluation.
Past Medical History:
Anxiety/panic disorder
Developmental delay
Inguinal hernia repair
Social History:
Unemployed, denies tobacco use and alcohol. He lives with his
mother.
Family History:
non-contributory
Physical Exam:
VS: 85 12 160/80 96%RA 64" 148#
Gen: Anxious 46 y/o male
Skin: Psoriasis noted on entire body.
HEENT: NC/AT, PERRL, EOMI, Anicteric, OP benign
Neck: Supple, FROm, -JVD
Chest: CTAB -w/r/r, thoracic scoliosis
Heart: RRR, [**4-6**] sys. murmur with diastolic [**2-6**]
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses
throughout
Neuro: MAE, non-focal, A&O x 3
On discharge today he isin no acute distress. He is awake,
alert, and oriented. Upon ausculation of his chest no cardiac
murmurs were appreciated and his lungs were clear bilaterally.
His abdomen was soft, non-tender, and non-distended. No
erythema or drainage was noted at his mediastinal incision and
the sternum was stable. His extremities were warm and 1+ edema
was noted.
Pertinent Results:
[**2145-2-16**] Echo: PRE-BYPASS: The left atrium is markedly dilated.
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
0-5mmHg. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is 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 atherosclerotic plaque.
The aortic valve is bicuspid. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
myxomatous. There is moderate/severe mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. There is no pericardial
effusion. Dilated coronary sinus with (+ve) bubble contrast
study through the left arm vein = consistent with left sided
SVC. POST BYPASS: Normal biventricular systolic function.
Bioprosthesis is visualized in the mitral position. Well seated
and mechanically stable. Trace mitral regurgitation. Due to the
tilted posiiton of the mitral prosthesis, and appearance of a
strut of the supporting structures of the bioprosthesis, LVOT
was interrogated with PWD and 3-D. PWD interrogation of the left
ventricular loutflow tract demonstrated no significant gradient
and 3-D reconstruct showed a patent LVOT and no significant
obstruction.
[**2145-2-22**] CXR: Cardiomediastinal contours are stable in the
postoperative period. Bibasilar atelectasis and pleural
effusions have improved with residual patchy and linear
atelectasis, most prominent in the left mid and lower lung
region and periphery of right lung base. Small residual pleural
effusions are present. There is no pneumothorax.
[**2145-2-16**] 10:02AM BLOOD WBC-4.2 RBC-2.79*# Hgb-9.4*# Hct-27.1*#
MCV-97 MCH-33.6* MCHC-34.5 RDW-12.3 Plt Ct-83*#
[**2145-2-17**] 03:43AM BLOOD WBC-7.9 RBC-2.35*# Hgb-7.8*# Hct-22.8*
MCV-97 MCH-33.3* MCHC-34.4 RDW-12.6 Plt Ct-144*
[**2145-2-22**] 10:30AM BLOOD WBC-8.0 RBC-3.22* Hgb-10.6* Hct-31.1*
MCV-97 MCH-32.9* MCHC-34.0 RDW-13.2 Plt Ct-274#
[**2145-2-16**] 10:02AM BLOOD PT-15.1* PTT-50.0* INR(PT)-1.4*
[**2145-2-22**] 10:30AM BLOOD PT-12.8 PTT-25.1 INR(PT)-1.1
[**2145-2-16**] 10:45AM BLOOD UreaN-18 Creat-0.7 Cl-117* HCO3-20*
[**2145-2-22**] 10:30AM BLOOD Glucose-128* UreaN-24* Creat-0.9 Na-135
K-4.6 Cl-100 HCO3-24 AnGap-16
[**2145-2-22**] 10:30AM BLOOD Calcium-8.6 Phos-3.2 Mg-3.0*
Brief Hospital Course:
On [**2145-2-16**] Mr. [**Known lastname 66530**] was brought to the operating room and
underwent a mitral valve replacement with a 29mm [**Company 1543**]
Mosiac porcine valve. Please see operative report for surgical
details. The patient tolerated this procedure well and was
transferred in to the CSRU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. He did require some blood
products post-operatively for a decreased HCT/bleeding. He was
weaned off of pressors on post-op day one and was started on
beta blockers and diuretics. He was gently diuresed towards his
pre-op weight. On post-op day two he was transferred to the
telemetry floor. His chest tubes and epicardial pacing wires
were removed on this day as well. Throughout post-op course he
had intermittent atrial fibrillation, which was treated
appropriately with amiodarone and EP recommendations. He
continued to progress well with PT assisting with strength and
mobility. On post-op day seven he was discharged home with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
atenolol 50 mg [**Hospital1 **], KCl 20 mg [**Hospital1 **], ativan 5 mg, aspirin 81 mg,
lisinopril 5 mg
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 2 tabs(400mg) [**Hospital1 **] for 7 days then decrease to 2
tabs(400mg) QD for 7 days then decrease to 1 tab(200mg) for
indefinite.
Disp:*120 Tablet(s)* Refills:*2*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: please take with KCL.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days: Please take with Lasix.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
10. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral valve replacement
PMH: developmentally delayed, anxiety/panic disorder, s/p
Inguinal hernia repair
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see your PCP [**Name9 (PRE) 391**] [**Name9 (PRE) **] ([**Telephone/Fax (1) 66531**] in [**2-2**] weeks.
Please see your cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 26917**] in [**2-2**]
weeks.
Please see your surgeon [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 11763**] in [**5-7**]
weeks.
Completed by:[**2145-3-5**]
|
[
"300.01",
"319",
"424.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
7078, 7140
|
4326, 5455
|
335, 416
|
7314, 7320
|
1699, 4303
|
7648, 8076
|
876, 894
|
5610, 7055
|
7161, 7293
|
5481, 5587
|
7344, 7625
|
909, 1680
|
283, 297
|
444, 683
|
705, 772
|
788, 860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,574
| 100,208
|
36829
|
Discharge summary
|
report
|
Admission Date: [**2170-6-1**] Discharge Date: [**2170-6-11**]
Date of Birth: [**2090-4-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Sulfa (Sulfonamide Antibiotics) / Tegretol /
Statins-Hmg-Coa Reductase Inhibitors / Morphine / Plavix /
Codeine / Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
[**2170-6-1**] Cardiac catheterization
[**2170-6-6**] Coronary artery bypass graft x4 (saphenous vein graft >
left anterior descending, saphenous vein graft > obtuse marginal
1 > obtuse marginal 2, saphenous vein graft > posterior
descending artery)
History of Present Illness:
80 year old female with a history of HTN, hyperlipidemia, prior
tobacco abuse, s/p left [**Last Name (LF) **], [**First Name3 (LF) **], and PVD, with a 2 month
history of exertional chest tightness and upper chest discomfort
that she describes as "pins and needles",
along with mild shortness of breath, which is relieved by rest.
This usually occurs with climbing a flight of stairs and
occurred once while walking 50 yards following her thallium.
She was referred for catheterization. Cardiac surgery consulted
for revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Prior tobacco abuse
PVD
Gout
Spinal Stenosis
S/p right amaurosis fugax/[**First Name3 (LF) **] [**2167**]
Arhtritis
History of C-Diff [**2167**]
Scarlet fever
PNA
Kidney stone
s/p Back surgery
s/p Right [**Year (4 digits) **] [**2167**]
s/p Bilateral Cataract surgery
Social History:
partial with a few native lower teeth
Lives with:her son live with her in [**Name (NI) 620**] Heights
Occupation:retired
Tobacco:smoked 1 pack per week for 30 years and quit in [**2147**]
ETOH:denies
Family History:
non contributory
Physical Exam:
Pulse:59 Resp:18 O2 sat:100/RA
B/P Right:135/87 Left: 140/94
Height:5'5" Weight:135 lbs
General:NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] I-II/VI systolic Murmur best heard
at 2nd RICS
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right:+1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:0
Carotid Bruit Right:+ brunit Left:+ bruit
Pertinent Results:
[**2170-6-1**] 02:40PM BLOOD WBC-6.1 RBC-3.36* Hgb-9.9* Hct-28.6*
MCV-85 MCH-29.5 MCHC-34.6 RDW-15.2 Plt Ct-278
[**2170-6-1**] 02:40PM BLOOD Plt Ct-278
[**2170-6-1**] 02:40PM BLOOD PT-14.0* INR(PT)-1.2*
[**2170-6-6**] 12:41PM BLOOD Fibrino-247
[**2170-6-1**] 02:40PM BLOOD Glucose-173* UreaN-8 Creat-0.6 Na-137
K-2.8* Cl-103 HCO3-26 AnGap-11
[**2170-6-1**] 02:40PM BLOOD ALT-12 AST-17 Amylase-64 TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2170-6-6**] 06:17PM BLOOD cTropnT-1.00*
[**2170-6-7**] 01:45AM BLOOD cTropnT-0.47*
[**2170-6-2**] 06:15AM BLOOD Albumin-3.9 Mg-2.1 Cholest-211*
[**2170-6-1**] 02:40PM BLOOD %HbA1c-5.3 eAG-105
[**2170-6-2**] 06:15AM BLOOD Triglyc-165* HDL-45 CHOL/HD-4.7
LDLcalc-133*
Chest CT
FINDINGS: Multiple bilateral solid and ground-glass pulmonary
nodules are new or increased from prior examination, measuring
up to 5 mm. Biapical and peripheral pleuro-parenchymal scarring
persist, with associated ground-glass opacities, suggestive of
interstitial lung disease. There is no focal consolidation. The
central airways are patent to the subsegmental levels.
Evaluation of intrathoracic vasculature is suboptimal without
intravenous
contrast, but there has been interval progression of diffuse
atherosclerotic calcifications. At the origin of the right
brachiocephalic artery, a 1.5-cm segment of severe stenosis now
demonstrates near-complete luminal occlusion.
Moderate orificial stenosis of the left common carotid artery
also appears
more prominent. In the proximal left subclavian artery, a 1.4 cm
segment of moderate stenosis now demonstrates near-complete
luminal occlusion. Extensive calcifications are also noted
involving the aortic arch and root, three coronary arteries, and
posterior descending artery.
Thoracic aorta is normal in caliber, measuring 3.3 cm at the
level of the main pulmonary artery, 2.7 cm at the arch, and 2.5
cm in the descending portion.
Central pulmonary arteries are unremarkable. The heart is normal
in size,
without pericardial effusion.
Prominent left axillary lymph node measures 9 mm, with fatty
hilum.
Intrathoracic lymph nodes are stable, measuring up to 5 mm in
the superior
paratracheal region, 7 mm in the precarinal region, and 7 mm in
the subcarinal
region.
Note is made of mild pectus excavatum.
Examination is not tailored for subdiaphragmatic evaluation, but
reveals dense calcification of the abdominal aorta with severe
celiac artery stenosis.
Bilateral non-obstructing renal stones are present.
Calcifications in the
region of the porta hepatis are likely vascular.
The bones are diffusely mottled and sclerotic, with mild
multilevel
degenerative changes.
IMPRESSION:
1. Progression of severe atherosclerosis.
2. Interstitial lung disease, with multiple new pulmonary
nodules measuring
up to 5 mm. Recommend followup CT in [**6-10**] months, depending on
patient's risk
factors.
3. Bilateral non-obstructing renal stones.
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.2 m/s
Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 3.8 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Stroke Volume: 71 ml/beat
Left Ventricle - Cardiac Output: 4.25 L/min
Left Ventricle - Cardiac Index: 2.53 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 2 mm Hg
Aortic Valve - LVOT VTI: 25
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *2.3 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.8 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.17
Mitral Valve - E Wave deceleration time: *257 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA size. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous
hypertrophy of the interatrial septum. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. 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. Mildly thickened
aortic valve leaflets (3). No AS. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild to moderate ([**12-31**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] 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.
Conclusions
The left atrium is normal in size. The left atrium is elongated.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
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 (3)
are mildly thickened but aortic stenosis is not present. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-31**]+) mitral regurgitation is seen. There is no pericardial
effusion.
Post Bypass: Patient is Apaced and intermittently AV paced, on
phenylepherine infusion at 0.5 mcg/kg/min. Preserved
biventricular function, LVEF >55%, no wall motion abnormalities.
Mrremains mild to moderate. Aortic contours intact. Remaining
exam is unchanged. Cardiac output 5.0 LPM at HR 80. All findings
discussed with surgeons at the time of the exam.
Brief Hospital Course:
Ms.[**Known lastname 83206**] presented for cardiac catheterization which
revealed significant coronary artery disease. Cardiac surgery
was consulted and she underwent preoperative evaluation which
included CT scan of chest that recommends follow up CT scan in 6
months to evaluate pulmonary nodules. On [**6-6**] she was brought to
the operating room for coronary artery bypass graft surgery, see
operative report for further details. That evening she was
weaned from sedation, awoke neurologically intact and was
extubated without complications. On post operative day one she
was weaned off phenylephrine and started on lasix for diuresis.
That evening she was started on betablockers/ statin/aspirin and
diuresis. Chest tubes and epicardial wires were removed per
protocol. She continued to progress and was transferred to the
step down unit for further monitoring. Physical therapy worked
with her on strength and mobility. By post-operative day #5 she
was ready for discharge to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] rehab. All follow-up
appointments were advised.
Medications on Admission:
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
(One) Tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s) by
mouth
daily
NITROGLYCERIN [NITROSTAT] - (Prescribed by Other Provider) -
0.4
mg Tablet, Sublingual - [**1-1**] Tablet(s) sublingually q 5 minutes
as
needed
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet - 1 (One) Tablet(s) by mouth
daily
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 1
(One) Tablet(s) by mouth daily
IBUPROFEN [ADVIL] - (OTC) - 200 mg Tablet - 1 (One) Tablet(s)
by
mouth as needed for back pain
IBUPROFEN-DIPHENHYDRAMINE [ADVIL PM] - (Prescribed by Other
Provider) - 200 mg-38 mg Tablet - 2 (Two) Tablet(s) by mouth
daily at HS
MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other
Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet - 1
(One)
Tablet(s) by mouth daily
NIACIN - (OTC) - 500 mg Tablet - 1 (One) Tablet(s) by mouth
daily
POTASSIUM GLUCONATE - (OTC) - Dosage uncertain
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. niacin 250 mg Capsule, Extended Release Sig: Two (2) Capsule,
Extended Release PO DAILY (Daily).
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
9. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/temp.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Hyperlipidemia
Peripheral vascular disease
Gout
Spinal Stenosis
Arhtritis
Kidney stone
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**7-5**] at 1:00pm
Cardiologist: Dr [**Last Name (STitle) 8579**] on [**7-10**] at 10:45am
Pulmonary nodules on preoperative CT scan - recommended Chest CT
in 6 months
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 58623**] in [**4-3**] weeks [**Telephone/Fax (1) 58624**]
**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:[**2170-6-11**]
|
[
"447.1",
"518.89",
"V70.7",
"414.01",
"413.9",
"V15.82",
"274.9",
"401.9",
"443.9",
"272.4",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.44",
"88.53",
"88.47",
"88.56",
"36.14",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12772, 12894
|
9365, 10474
|
428, 680
|
13071, 13282
|
2544, 9342
|
14205, 14803
|
1799, 1817
|
11580, 12749
|
12915, 13050
|
10500, 11557
|
13306, 14182
|
1832, 2525
|
366, 390
|
708, 1245
|
1267, 1565
|
1581, 1783
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,118
| 159,194
|
5365
|
Discharge summary
|
report
|
Admission Date: [**2153-3-31**] Discharge Date: [**2153-4-4**]
Date of Birth: [**2093-10-2**] Sex: F
Service: MEDICINE
Allergies:
Lidocaine / Lipitor / Lovastatin
Attending:[**First Name3 (LF) 15237**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 59 yo F with a 80 PYHx of tobacco (quit 4 yrs ago),
COPD, CAD s/p MI, prolonged PNA admission in [**3-20**], who presents
today from home with hemoptysis of 15-30cc of blood x 1 day. She
was admitted on [**3-22**] for hemoptysis and at that time was found
to have a 8x8x9cm mass in the RUL displacing segmental bronchi
of the RML but no clear invasion. CT guided biopsy showed SCLC.
She had a PET and an MRI and found to have a T7 likely
metastatic lesion and started on decadron last nght. She states
since her last admission last week, her hemoptysis stopped (2
episodes the size of a quarter). She states she started decadron
yesterday and awoke at 6am and started to have hemoptysis again.
She states that it was 1 tablespoon at the most at that time and
maybe 1 additional tablespoon since she's been in the ICU for
the past 4 hours. No chest pain, shortness of breath, +
hemoptysis, no fevers/chills. No abdominal pain. No back pain,
urinary incontinence/stool incontinence, parasthesias.
Past Medical History:
-Diverticular bleeds, most recently in [**2152-9-16**].
-Strep pneumoniae pneumonia and sepsis and a prolonged intensive
care unit stay complicated by difficulty extubating, delirium,
and right internal carotid artery cannulization.
-HTN
-COPD
-CAD with a MI infarction in [**2144**]. - EF 55% based on echo [**3-20**]
- hypothyroidism
Social History:
She is retired from working in [**Company 2486**]. She smoked two
packs per day for 40 years and quit four years ago. She does
not use alcohol. She has trouble getting to her appointments
here as she has no car and the taxi from [**Location (un) 686**] is quite
expensive. Her husband passed away several years ago, and his
end of life medical care required her to sell their home and
many belongings. She moved here from [**Doctor First Name 5256**] while he was
ill and has not found many frineds she believes she can count on
in the area.
Family History:
She has no siblings. Her mother passed away at
age 76 of osteoporosis and severe emphysema. Her father died at
age 56 of lung cancer, though he was a nonsmoker. She has no
children. She is widowed.
Physical Exam:
96.9, 122/80, 94-101, 13, 96% on 4L
GEN- lying in bed in NAD, AAOx3
Neck - no adenopathy appreciated
HEENT- PERRL, EOMI
CV- tachycardic, regular, no M
CHEST- decreased breath sounds in RUL, wheezing bilaterally
ABD- soft, NT/ND, +BS
EXT- trace edema bilaterally, +2DP pulses bilaterally, +clubbing
Back - no spinal tenderness
NEURO- moving all extremities, CN 2-12 intact
Pertinent Results:
PET scan: Intense FDG uptake associated with the right upper
lobe mass is consistent with biopsy proven NSCLC. The contiguity
of the mass with the right hilum makes nodal disease likely, but
poorly evaluated due to uptake from the primary tumor. Uptake in
right mediastinal nodes is mild and not definitive for disease
involvement and there is no evidence of contralateral nodal
disease.
Intense uptake associated with thoracic spine lesion is
suspicious for an epidural metastasis as hemangiomas are not
generally FDG avid. There is mass effect upon the adjacent
thecal sac and further evaluation with MRI is advised.
.
MRI T-spine:
T7 vertebral body hemangioma and adjacent soft tissue mass
eroding through the posterior cortex of the vertebral body and
causing moderate compression of the thecal sac. The appearance
of this soft tissue mass, lack of vertebral collapse, and lack
of hemorrhage would be atypical for a hemangioma. Given the
patient's known lung mass and involvement of the left pedicle,
this most likely represents a metastasis. Collision tumor given
the presence of hemangioma should be considered.
.
CXR- large RUL mass
.
Labs
WBC 4.9 Hgb 11.1* Hc 34.6* MCV 81*
diff N 72.2* L 24.5 2 B .4 E 0.4 M 0.5
.
[**2153-4-4**] 07:15AM BLOOD WBC-7.7 RBC-3.89* Hgb-10.1* Hct-31.3*
MCV-81* MCH-26.0* MCHC-32.3 RDW-16.3* Plt Ct-431
[**2153-4-3**] 07:05AM BLOOD WBC-7.6 RBC-3.73* Hgb-10.1* Hct-30.2*
MCV-81* MCH-27.0 MCHC-33.4 RDW-16.3* Plt Ct-485*
[**2153-4-2**] 07:16AM BLOOD WBC-8.2 RBC-3.76* Hgb-9.7* Hct-30.6*
MCV-81* MCH-25.9* MCHC-31.9 RDW-16.2* Plt Ct-445*
[**2153-4-4**] 07:15AM BLOOD Plt Ct-431
[**2153-4-3**] 07:05AM BLOOD Plt Ct-485*
[**2153-4-2**] 07:16AM BLOOD Plt Ct-445*
[**2153-4-3**] 07:05AM BLOOD PT-11.9 PTT-21.3* INR(PT)-1.0
[**2153-4-4**] 07:15AM BLOOD Glucose-113* UreaN-13 Creat-0.5 Na-138
K-4.5 Cl-100 HCO3-27 AnGap-16
[**2153-3-31**] 05:59PM BLOOD ALT-11 AST-21 LD(LDH)-325* AlkPhos-255*
TotBili-0.2
[**2153-4-4**] 07:15AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname 7474**] is a 59 yo F with newly diagnosed NSCLC with likely
T7 metastasis who presents with hemoptysis.
[**Hospital Unit Name 13533**]:
She was admitted to the [**Hospital Unit Name 153**] for overnight monitoring.
Hemoptysis was found to be only a few teaspoons over the course
of 24 hours and her hematocrit remained stable. Bronchoscopy was
therefore not indicated. Radiation oncology was called and will
see the patient on Monday, as they had already been planning to
begin spinal radiation at that time. They will consider possible
chest radiation as well given new hemoptysis. She was kept on
decadron [**Hospital1 **] for her spinal mass.
We held her aspirin until hemoptysis stopped, and continued her
outpatient beta blocker, ACE inhibitor and statin. The patient
has no HCP and no family. She also states that she has no
frineds she trusts. She needs help with resources including
transportation to and from her appointments, as she lives in
[**Location 686**] and must pay for expensive taxi rides to [**Hospital1 18**]. She
will be seen by SW and CM during her stay.
She was called out to the floor hte day after admission as she
was stable.
.
On the floor she remained stable; she underwent two rounds of
XRT withouth incident and was discharged on her present dose of
decadron with a plan for followup with rad onc day post
discharge and with Dr. [**Last Name (STitle) **] in [**1-19**] weeks for onc care.
Medications on Admission:
Metoprolol 50 mg p.o.b.i.d. (was 100 mg po bid)
Imipramine 50 mg p.o. q.h.s.
Citalopram 20 mg p.o. qd
Levothyroxine 75 mcg p.o. daily,
Ipratropium nebulizer,
albuterol nebulizer
Docusate 100 mg p.o. b.i.d.
Simvastatin 40 mg p.o. qd
Aspirin 81 mg qd
Dexamethasone 4mg po bid
Lisinopril 10 mg po qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: Two (2)
Inhalation every six (6) hours as needed.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) Inhalation
four times a day.
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
non small cell lung cancer
hemoptysis
Discharge Condition:
good
Discharge Instructions:
You should contact Dr. [**Last Name (STitle) **] or your PCP or come to the ED if you
have cough up any bright red blood, feel lightheaded, or
experience any chest pain, light headedness, dizziness, nausea,
vomiting. You should call Dr.[**Name (NI) 21829**] office to schedule an
appointment in [**1-19**] weeks. You should take all your medications
as directed and keep all your appointments. You should hold on
taking your aspirin until you discuss this further with Dr. [**Last Name (STitle) **]
at your appointment
Followup Instructions:
Call Dr. [**Last Name (STitle) **] for an appointment tomorrow that is convenient for
you; you should be seen in [**1-19**] weeks. His phone number is ([**Telephone/Fax (1) 21830**]
|
[
"412",
"244.9",
"V15.82",
"414.01",
"162.3",
"493.90",
"228.09",
"786.3",
"272.4",
"401.9",
"198.5",
"300.4",
"V45.82",
"336.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
7862, 7868
|
4916, 6365
|
304, 311
|
7950, 7957
|
2895, 4893
|
8527, 8713
|
2283, 2487
|
6712, 7839
|
7889, 7929
|
6391, 6689
|
7981, 8504
|
2502, 2876
|
254, 266
|
339, 1346
|
1368, 1705
|
1721, 2267
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,373
| 121,302
|
30956
|
Discharge summary
|
report
|
Admission Date: [**2158-6-24**] Discharge Date: [**2158-6-29**]
Date of Birth: [**2091-1-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
None
Major Surgical or Invasive Procedure:
Right IJ, A-line, Intubation.
Brief Hospital Course:
The patient was admitted intubated from an OSH. The patient
required persistent ventilator support. His vent settings were
changed for ARDS treatment, specifically pressure control with
reduced tidal volumes (goal 450), reduced driving pressure (goal
14). The patient required high FiO2 (60%) to maintain his oxygen
pressure. He was continued on high dose steroids. The patient's
IV access from the outside hospital was removed and the patient
underwent right IJ line placement as well A-Line placement.
.
The [**Hospital 228**] hospital course was complicated by a pneumothorax.
It is unknown if the pneumothorax was due to prior trauma (the
patient had a pneumothorax at the OSH prior to admission), a
complication from central line placement or volu/[**Doctor Last Name **] trauma
from mechanical ventilation. The patient underwent chest tube
placement with successful reduction of his pneumothorax. The
patient had a persistent air leak from the right sided chest
tube. The patient required large doses of sedation and continued
to have dyssynchrony from the vent. The patient failed a trial
of APRV. Ultimately the patient showed no improvements in his
respiratory status. Upon dicussion with the family it became
clear that the patient's wish was to never be ventilator
dependent for any protracted period of time (by the family's
account, the patient specifically stated a desire for no
mechanical ventilation beyond 2 days). In accordance with the
patient's stated wishes prior to intubation as well as the
family's wishes, the patient was extubated on [**2158-6-29**]. He
expired within 2 hours of extubation.
.
Of note, the patient had 1+ GNR on gram stain of his sputum and
out of concern for a possible ventilator-associate pneumonia he
was started on broad spectrum antibiotics. Ultimately sputum
cultures grew only oropharyngeal flora. In addition, the patient
grew coag negative staph - a likely contaminent - in 1 out of 4
bottles of blood from his A-line.
Discharge Disposition:
Expired
Discharge Diagnosis:
ARDS
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"515",
"512.8",
"280.9",
"486",
"276.7",
"518.81",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2371, 2380
|
374, 2348
|
320, 351
|
2429, 2439
|
2492, 2500
|
2401, 2408
|
2463, 2469
|
276, 282
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,871
| 175,709
|
33393
|
Discharge summary
|
report
|
Admission Date: [**2145-3-12**] Discharge Date: [**2145-3-22**]
Date of Birth: [**2080-10-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
CABGx4(LIMA-LAD, SVG-OM1, SVG-Diag, SVG-PDA)[**3-15**]
History of Present Illness:
64yoM with 3 week history of chest tightness. Positive ETT at
cardiologists office. Followed by cardiac cath at [**Hospital1 **]
which showed multivessel disease then referred to cardiac
surgery
Past Medical History:
DM
^chol
HTN
sleep apnea
excision of precancerous lesion(nose)
Social History:
Lives with wife
[**Name (NI) 1403**] as machinist
Remote tobacco- quit 15 years ago
Remote ETOH- quit 5 years ago
Family History:
non contributory
Physical Exam:
Admission:
VS T 98 HR 71 BP 142/62 RR 18 O2sat..
Ht 5'[**47**]" Wt 205lbs
Gen NAD
Skin unremarkable
Neuro grossly intact
HEENT unremarkable, neck supple
Pulm CTA-bilat
CV RRR
Abdm soft, NT/ND/+BS
Ext warm, well perfused w/bilat varicosities
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77495**]Portable TTE
(Focused views) Done [**2145-3-18**] at 2:45:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2080-10-21**]
Age (years): 64 M Hgt (in): 71
BP (mm Hg): 127/48 Wgt (lb): 205
HR (bpm): 68 BSA (m2): 2.13 m2
Indication: Focused study to evaluate for pericardial effusion
ICD-9 Codes: 423.9
Test Information
Date/Time: [**2145-3-18**] at 14:45 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: Limited Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W006-1:34 Machine: Vivid [**7-18**]
Echocardiographic Measurements
Results Measurements Normal Range
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: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
TR Gradient (+ RA = PASP): *34 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Overall normal LVEF
(>55%).
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2145-3-18**] 15:34
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2145-3-17**] 12:36 PM
CHEST (PORTABLE AP)
Reason: eval ptx s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
64 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p CT d/c
HISTORY: Chest tube removal, to assess for pneumothorax.
FINDINGS: In comparison with study of [**3-15**], all of the tubes
have been removed. No evidence of pneumothorax or acute
pneumonia.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
[**2145-3-21**] 09:12AM BLOOD WBC-8.8# RBC-2.93* Hgb-9.3* Hct-26.6*
MCV-91 MCH-31.8 MCHC-35.1* RDW-14.5 Plt Ct-195
[**2145-3-19**] 04:10AM BLOOD PT-11.6 PTT-31.1 INR(PT)-1.0
[**2145-3-21**] 09:12AM BLOOD Glucose-224* UreaN-35* Creat-1.1 Na-136
K-4.5 Cl-99 HCO3-25 AnGap-17
Brief Hospital Course:
Mr [**Known lastname 7739**] was transferred from [**Hospital1 **] MC for coronary bypass
grafting after cardiac catheterization which showed multivessel
coronary disease with normal EF and valve function. He was
brought to the operating room on [**3-15**] where he had coronary
bypass x4, please see OR report for details. In summary had
CABGx4 with LIMA-LAD, SVG-Diag, SVG-OM1, SVG-PDA his bypass time
was 86 minutes with a crossclamp of 68 minutes. He tolerated the
operation well and was transferred to the cardiac surgery ICU in
stable condition. He did well in the immediate post-op period
but because he was a difficult intubation he remained sedated
and ventilated until the morning of POD1 at which point he was
extubated without difficulty. Later on POD1 he was transferred
to the step down floor for continued post-op care. On POD2 he
was noted to be oliguric with a rise in creatine and drop in
hematocrit. He was transferred back to the ICU for monitoring,
with tranfusion oliguria resolved and creatinine corrected. He
was monitored in ICU for additional 24 hours then transferred
back to step down floor. Over the next several days he advanced
his activity and endurance.
He was discharged to home in stable condition on POD#8.
Medications on Admission:
Lisinopril 10'
Pravachol 40'
ASA 81'
Actos 30'
Glyburide 10"
Metformin 1000"
Gemfibrozil 600"
B12
Garlic
Flax seed oil
Cod liver oil
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): 20mg [**Hospital1 **] x 7days then
20mg QD x 10days.
Disp:*24 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): 20mEq [**Hospital1 **] x 7days then
20mEq QD x 10days.
Disp:*24 Packet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 7days then
200mg QD.
Disp:*37 Tablet(s)* Refills:*1*
11. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
s/p CABGx4(LIMA-LAD, SVG-Diag, SVG-OM1, SVG-PDA)[**3-15**]
PMH: CAD, DM, ^chol, HTN, OSA
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) **] in [**2-14**] weeks
Dr [**First Name (STitle) 1075**] in 4 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Vascular surgeon( referal per Drs [**Name5 (PTitle) **]/Love)
Patient to call for all appointments
Completed by:[**2145-3-22**]
|
[
"V58.67",
"327.23",
"584.9",
"443.9",
"454.9",
"V15.82",
"414.01",
"427.31",
"250.52",
"272.0",
"360.43",
"433.10",
"411.1",
"285.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"39.64",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7268, 7320
|
4357, 5601
|
301, 358
|
7453, 7462
|
1116, 3644
|
7664, 7952
|
815, 833
|
5784, 7245
|
3681, 3706
|
7341, 7432
|
5627, 5761
|
7486, 7641
|
848, 1097
|
246, 263
|
3735, 4334
|
386, 582
|
604, 668
|
684, 799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,503
| 118,804
|
32513
|
Discharge summary
|
report
|
Admission Date: [**2135-7-16**] Discharge Date: [**2135-7-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Fevers, dMS
Major Surgical or Invasive Procedure:
LIJ placement, a-line
History of Present Illness:
[**Age over 90 **]yo [**Age over 90 595**] only speaking female with dementia, DM2, CAD, HTN,
hyperlipidemia presents from NH with fevers and hypotension.
Per ED call in, she reportedly has frequent aspiration events
and was recently started on IM ceftriaxone for aspiration
pneumonia. Today, however, she was noted to be persistently
febrile and hypotensive to the 80s systolic. Additionally, her
right foot appeared ischemic. Beyond son's report of generally
feeling unwell this week with increased confusion, specific
localizing sx of infection are unknown. In the setting of
fevers and dMS, she was transferred to the ED for further
evaluation.
.
In the ED, initial vitals were T: 97.1 BP: 78/33 HR: 71 RR: 19
O2sat: 97%RA. Initial labs were notable for ARF with creatinine
elevated to 2.6, potassium of 6.0, lactate of 2.2. UA was
positive for many bacteria, 11-20 WBCs ([**3-23**] squams). CXR showed
bilateral opacities concerning for aspiration. Physical exam
was notable for faint femoral pulse on RLE, absent popliteal
pulse and absent DP/PT; she had ischemic, blue toes. Vascular
surgery was consulted and recommended amputation however felt
she was too unstable for OR. CT head was obtained due to
increased somnolence which was negative for acute intracranial
process. She had a CT chest/abdomen/pelvis which revealed ? of
diverticulitis, marked intra- and extrahepatic ductal
dilatation, and bilateral lung opacities concerning for acute on
chronic aspiration. She received IV zosyn and vancomycin.
Additionally she received 5L NS, however SBPs remained 70s-80s;
thus CVL was placed and she was started on levophed.
.
ROS: Unable to obtain given patients confusion (even with
[**Name6 (MD) 595**] speaking RN) and beyond son reporting patient was "ill",
specific localizing sx not clear.
Past Medical History:
DM II
h/o aspiration pneumonia
Systolic CHF; EF 35% on TTE from [**12-25**]
Dementia
Hep C
Left BKA [**2067**]
Hypothyroidism
Frequent falls
Right foot neuropathic pain
HTN
CAD s/p MI
Hyperlipidemia
Transaminitis
DJD
Anemia
Constipation
Social History:
Lives in [**Location **] at [**Hospital **] health center. She is
incontinent of bowel and bladder. Wheelchair bound. Son
reports able to converse and oriented to person and place at
baseline however frequently becomes more confused in setting of
infections and illness.
Family History:
NC
Physical Exam:
VS: T: 99.6 BP: 94/48 HR: 92 RR: 21 O2sat: 99%3L NC
GEN: moans and speaks nonsensical words per both [**Hospital 595**]
speaking [**Name6 (MD) **] and RN
HEENT: Squeezes eyes closed tightly when attempts made to exam
pupils
CV: Borderline sinus tachy, no mrg appreciated
PULM: rhonchorus anteriorly, no wheezes, unable to examine
posteriorly as uncooperative with exam
ABD: +BS, soft, TTP diffusely however without rebound/guarding
EXT: RLE with faint femoral pulse, absent popliteal pulse,
absent DP/PT; ischemic, blue toes, pressure ulcer on heel,
pressure ischemia on posterior aspect of right calf. Toes
appear NTTP however markedly TTP posterior calf, no drainage
appreciated. S/P Left BKA.
NEURO: Moves all 4s spontaneously however RLE limited [**2-19**] pain.
Pertinent Results:
EKG: NSR at rate 72, nml axis, RBBB, TWI II, aVF, TW flattening
V3-V6. Old EKG dated [**2134-12-25**] with TW flattening inferior and
V4-V6.
.
STUDIES:
.
[**2135-7-16**] CT abd/pelvis:
1. Wall thickening and surrounding inflammatory stranding in the
sigmoid colon which may represent diverticulitis vs colon
cancer. Wall thickening of the rectum with inflammatory change.
Colonoscopy recommended.
2. Diffuse intra and extrahepatic ductal dilitation to the level
of the ampulla. No pancreatic duct dilitation. Recommend further
eval with ERCP/MRCP.
3. Small bilateral pleural effusions with diffuse intersitial
and parenchymal opacities in the lungs in which acute on chronic
aspiration is in the differential. Patulus esophagus with
material within the upper third.
.
[**2135-7-16**] CXR:
1. New left IJ central venous catheter with tip in appropriate
position.
2. Bilateral pulmonary patchy opacities, which are suggestive of
underlying pneumonia/aspiration and pulmonary edema.
.
[**2135-7-16**] CT head: No acute intracranial process.
Brief Hospital Course:
[**Age over 90 **]yoF with h/o dementia, CAD, HTN, hyperlipidemia p/w fever and
dMS with ischemic RLE and multiple sources of infection in
septic shock. The pt. expired due to sepsis.
.
# Septic shock: Multiple sources including urinary source,
diverticulitis and probable aspiration pneumonia. Although not
clearly infected on exam, ischemic RLE also concerning.
Additionally concerning are her markedly dilated intra- and
extrahepatic ducts and elevated transaminases and alk phos
concerning for ascending infection (appears to be s/p ccy by
exam and on CT per radiology); t. bili was normal. Pt. continued
to deteriorate and was in significant discomfort, despite
aggressive pain control. A family meeting was held and a
decision was made to focus on comfort.
.
# Ischemic RLE: Vascular was consulted and felt her ischemia
was chronic in nature however may have acutely worsened in
setting of infection and hypotension. She was deemed a poor
operative candidate due to her significant comorbidities. Her
pain was controlled with dilaudid and morphine.
.
# Elevated LFTs: Has h/o hep C, status largely unknown.
However, in review of past labs, has never had elevated
transaminases nor alk phos. Now with elevated transaminases and
elevated alk phos; t. bili normal. Thought to be a result of
shock liver.
# Altered mental status: Per son, pt. frequently becomes
confused like this in setting of acute illness. CT head in ED
without acute process. Suspect as above due to metabolic
abnormalities and infection on baseline dementia. No nuchal
rigidity on exam to suggest CNS infection.
.
# Hypoxia: Maintained good O2 sats (mid to high 90s) on 3L NC.
Chest CT calling bilateral opacities concerning for aspiration
pneumonia. Must also consider volume overload as well as
developing ARDs in setting of septic shock. Treated with broad
coverage antibiotics.
.
# CAD/Elevated troponin: Elevated at presentation. CK's trended
down during stay.
.
# CHF: EF 35-40% per [**2134**] TTE. Does have interstitial
opacities on CT chest with concern for pneumonia but also c/f
volume overload. As above, currently maintaining O2 sats on NC.
.
# DM2: Elevated BS to 300s. Started on insulin gtt and
transitioned to SSI.
.
# Anemia: Chronic with BL hct appears to be high 20s to low
30s; hct is currently above this range and is stable and likely
was hemoconcentrated on presentation.
Medications on Admission:
Lasix 20mg PO daily
Lisinopril 10mg once daily
MVI
Ferrous sulfate 325mg daily
ASA 81mg PO daily
Colace 100mg [**Hospital1 **]
Ipratropium-Albuterol nebs [**Hospital1 **]
Senna 8.6 mg daily
Gabapentin 300mg PO daily
Simvastatin 10mg daily
Glyburide 10mg daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
expired
Completed by:[**2135-7-22**]
|
[
"715.90",
"038.9",
"250.00",
"428.0",
"785.52",
"412",
"785.4",
"V12.09",
"244.9",
"272.4",
"728.88",
"401.9",
"562.11",
"787.6",
"458.9",
"584.9",
"294.8",
"V49.75",
"707.07",
"995.92",
"414.01",
"428.20",
"285.9",
"276.7",
"788.30",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7317, 7326
|
4584, 5909
|
274, 297
|
7377, 7387
|
3519, 4519
|
7440, 7479
|
2709, 2713
|
7285, 7294
|
7347, 7356
|
7001, 7262
|
7411, 7417
|
2728, 3500
|
223, 236
|
325, 2142
|
4529, 4561
|
5925, 6975
|
2164, 2402
|
2418, 2693
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,052
| 148,169
|
17454
|
Discharge summary
|
report
|
Admission Date: [**2192-1-26**] Discharge Date: [**2192-2-14**]
Date of Birth: [**2157-7-10**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
Nasointestinal tube placement (now removed)
Intubation
Central line placement (now removed)
History of Present Illness:
34 yF with longstanding DM-I c/b severe gastroparesis, autonomic
neuropathy, and ESRD who is s/p LURT [**11/2189**] and PAK [**2190-9-26**].
She subsequently underwent re-exploration for intraabdominal
hemorrhage. She presented to OSH and was found to have a
bibasilar pneumonia and was placed on 100% NRB and
received 1 dose of levaquin. Upon arrival to the ED, she was
sat'ing in the mid 80's to 90's on 100%NRB and 99-100% on bipap.
She received 1g of Vancomycin and 1L of crystalloid before
admission to SICU.
Past Medical History:
s/p HITT from [**3-/2191**] admission: HIT Ab positive, but SRA
negative
Status post Pancreas transplant [**2190-9-26**]
Status post Living unrelated renal transplant [**11/2189**]
End-stage renal disease secondary to Type 1 diabetes mellitus
Gastroparesis
Autonomic neuropathy
Diabetic retinopathy and peripheral neuropathy
Osteopenia
Depression
R vitrectomy
Left antecubital arteriovenous fistula on [**2192-1-4**]
Social History:
Social History:
Married, no children, denies alcohol, IVDU and tobacco. Her
husband was the donor for her kidney transplant in [**2188**].
Family History:
There is no history of DM in her family. Her father died of
lymphoma and her mother has HTN.
Physical Exam:
Vitals: 99.4 109 142/82 17 100% CPAP
General: + labored breathing, awake alert and oriented x 3
HEENT: mucous membranes dry, no LAD, neck supple
CVS: tachycardic, no arrhythmias, no m/r/g
Chest: bibasilar crackles, labored breathing
Abdomen: soft, nontender, + tympany to percussion, no HSM, NABS
Extremities: no c/c/e
Rectal: no masses, guaiac negative
Pertinent Results:
[**1-26**] CXR
Moderately severe pulmonary edema, not appreciably changed since
earlier in the day, the lung volumes have improved. Bibasilar
consolidation, presumably represents coalescent edema and
atelectasis. Small bilateral pleural effusions are present.
Heart size normal. ET tube and nasogastric tube, and right PIC
catheter in standard placements respectively. No pneumothorax.
[**1-29**] CXR
Previous severe pulmonary edema has improved substantially.
Consolidation is largely restricted to the lower lungs which may
be a combination of edema and atelectasis, not necessarily
pneumonia.
Heart size is normal. Pleural effusions if any are small and
there is no pneumothorax. Tip of the endotracheal tube is
partially obscured but appears to be more than a centimeter
above the upper margin of the clavicles and 7 cm from the
carina, and should be advanced 3-4 cm. Nasogastric tube ends in
the lower stomach and an esophageal manometer in the upper.
Right jugular line ends in the upper right atrium.
[**1-30**] Nasointestinal tube placement
Successful placement of post-pyloric feeding tube with tip in
the distal duodenum
.
Labs on Admission: [**2192-1-26**]
WBC-16.9* RBC-2.70* Hgb-6.7* Hct-22.7* MCV-84 MCH-24.8*
MCHC-29.4* RDW-16.0* Plt Ct-263
PT-25.2* PTT-40.9* INR(PT)-2.5*
Glucose-144* UreaN-69* Creat-2.6*# Na-137 K-3.5 Cl-110* HCO3-13*
AnGap-18
ALT-19 AST-40 AlkPhos-133* Amylase-45 TotBili-0.5 Lipase 12
Albumin-2.2* Calcium-7.3* Phos-3.7 Mg-1.5*
.
Labs on Discharge:[**2192-2-14**]
[**2192-2-14**] 05:33AM BLOOD WBC-7.2 RBC-2.84* Hgb-8.1* Hct-25.6*
MCV-90 MCH-28.4 MCHC-31.5 RDW-19.6* Plt Ct-364
[**2192-2-14**] 05:33AM BLOOD Glucose-84 UreaN-67* Creat-2.3* Na-142
K-3.9 Cl-113* HCO3-17* AnGap-16
[**2192-2-14**] 05:33AM BLOOD Calcium-8.6 Phos-4.5 Mg-1.9
Brief Hospital Course:
The patient was admitted to Transplant Surgery as a transfer
from an outside hospital for management of her bilateral
pneumonias. Upon arrival to the ED, she was transfered
immediately to the ICU.
# Neuro - The patient was sedated with propofol and versed
throughout initial period of intubation. Pain was adequately
controlled during hospitalization.
# Pulmonary - Upon arrival to the SICU, she was intubated and
bronchoscopied. Pulmonary was consulted. On HD 6 ([**1-31**]) the
patient was successfully extubated without complications.
# Cardiovascular - Upon arrival to the SICU, she was started on
pressors for hemodynamic instability and transfused 1u PRBC. By
HD2, she was weaned off of pressors but eventually required
another 2 units of PRBC.
# Renal - The patient required aggressive diuresis with
furosemide after she was hemodynamically stable. Creatinine 2.6
on admission and 2.5 on discharge with mild variations during
hospitalization. Followed by Renal, no biopsy at this time
# Infectious diseases - Upon arrival, she was started on IV
vanco/zosyn/cipro. Infectious diseases service was consulted.
BAL revealed no organisms on gram stain or culture. PCP stains
were all negative but the patient was switched from inhaled
pentamidine to bactrim for prophylaxis. Vanco was d/c'd on HD5
CMV Viral load was found to be positive with initial result of
922 copies. She was started on IV gancyclovir. She [**First Name8 (NamePattern2) **] [**Last Name (un) 7387**]
on IV prophylaxis as an outpatient for 2 weeks post discharge
due to concerns that PO dosing will not be appropriately
absorbed.
# Endocrine - the patient's glucose was initially labile and
required an insulin drip. Followed by [**Last Name (un) **] while hospitalized,
she will resume Lantus and Humalog upon discharge.
# FEN/GI - Nasointestinal tube was placed via fluoroscopy on
[**1-30**] to start tube feeds which were d/c'd by [**2-1**].
# Immunosuppression - She was maintained on her cyclosporin but
required several modifications to her dosages. She also was
placed on IV Solumedrol until she was able to take adequate po
and was switched to Prednisone 40mg. This was subsequently
tapered and she will be discharged home on 5 mg daily.
Upon discharge, the patient was afebrile with all vitals stable,
tolerating po feeds, ambulating but requiring assistive devices
which were provided for home use through [**Hospital1 5065**], and with pain
controlled on po pain medication.
Medications on Admission:
ALBUTEROL 90 mcg--1 pf in prn with pentamidine treatments
ATIVAN 0.5 mg--1 tablet(s) by mouth as needed
Alendronate 35 mg--1 tablet(s) by mouth qweek
Aranesp (Polysorbate) 40 mcg/mL--once per week weekly
BENADRYL 25 mg--1 capsule(s) by mouth as needed
CALCITRIOL 0.25 mcg--1 capsule(s) by mouth once a day
CELLCEPT [**Pager number **] mg--1 capsule(s) by mouth three times a day
CELLCEPT [**Pager number **] mg--500 tablet(s) by mouth three times a day
Domperidone (Bulk) --10mg prn 10-20mg tid with meals
Ergocalciferol (Vitamin D2) 50,000 unit--1 capsule(s) by mouth
qmonth x6months
FLUOXETINE 20 mg--3 capsule(s) by mouth once a day
Florinef 0.1 mg--1 tablet(s) by mouth as needed for low bp
GENGRAF 100 mg--3 capsule(s) by mouth twice a day
METOPROLOL SUCCINATE 50 mg--1 tablet(s) by mouth twice a day
PREDNISONE 5 mg--1 tablet(s) by mouth once a day
Pentamidine 300 mg--300 mg ih once per month may give albuterol
pre and post treatment
Discharge Medications:
1. Ganciclovir Sodium 500 mg Recon Soln Sig: Sixty (60) mg
Intravenous once a day for 3 weeks.
Disp:*18 * Refills:*0*
2. PICC line care
Avoid heparin Products
[**Month (only) 116**] flush with 10 cc NS following use
Flush Daily and PRN
3. Normal Saline
0.9% Normal Saline
1000 ml Bag
[**Month (only) 116**] infuse 1-2 Liters daily as needed for hydration
Dispense # 40 (forty) (4 boxes of 10 bags)
Refills 2(two)
4. PICC line care
PICC line dressing kit
Change dressing q 3 days and as needed per agency protocol
Dispense # 10 (Ten)
Refills 2 (Two)
5. Home Oxygen Therapy
Oxygen via Nasal Cannula at 2L
Maintain Sats > 92%
Diagnosis: Pulmonary CMV infection with O2 sats documented less
than 88%
Disp : QS for maintenance of 2L O2
6. Outpatient Physical Therapy
Please provide wheelchair for patient use at home
Diagnosis: Pulmonary CMV infection/weakness
7. Commode
Please provide Bedside Commode
Diagnosis: Pulmonary CMV infection, weakness
8. Glucose test strips
Accucheck Aviva glucose test strips
Dispense # 3 (Three)
Refills: 6 (Six)
9. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
Disp:*2 bottles* Refills:*2*
10. Insulin Lispro 100 unit/mL Solution Sig: as directed per
sliding scale Subcutaneous four times a day.
Disp:*2 bottles* Refills:*2*
11. Insulin Syringe MicroFine 0.3 mL 28 x [**12-7**] Syringe Sig: One
(1) syringe Miscellaneous 5 times daily.
Disp:*1 box* Refills:*5*
12. Outpatient Lab Work
Biweekly cbc with diff, chem 7, ast, alt, alk phos, t.bili, and
trough cyclosporine level.
Fax to [**Telephone/Fax (1) 697**] (transplant office) and [**Telephone/Fax (1) 432**]
(Infectious Disease)
13. Outpatient Lab Work
Weekly CMV viral load
fax to [**Telephone/Fax (1) 432**] attn Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (Infectious Disease)
14. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
18. Aranesp (Polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1)
Injection once a week.
19. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
21. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
22. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
23. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
24. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
25. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
26. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours).
Disp:*1200 ML(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 45673**]Hospice
Discharge Diagnosis:
Pulmonary CMV infection
s/p kidney transplant with elevated creatinine
Discharge Condition:
Fair/Stable
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] if you
experience fever > 101, chills, increased difficulty with
breathing, increased cough or sputum production.
Monitor for nausea/vomiting/diarrhea
Wear O2, goal is to maintain sats> 92% on 2L nasal cannula
PICC line inplace, maintain hydration at 1-2 L NS daily as
needed
Use Commode and wheelchair as needed.
You will be receiving home PT
Have labwork drawn per transplant clinic guidelines
Followup Instructions:
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2192-2-24**] 8:00
PFT,INTERPRET W/LAB NO CHECK-IN PFT INTEPRETATION BILLING
Date/Time:[**2192-3-20**] 9:00
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2192-3-20**]
9:00
Follow up with Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 575**] (Pulmonologist) [**2192-3-20**] at 10:00
Please schedule follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**Telephone/Fax (1) 673**]
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2192-3-20**] 2:00
Completed by:[**2192-2-22**]
|
[
"996.81",
"250.63",
"136.3",
"287.5",
"584.9",
"078.5",
"276.51",
"337.1",
"518.81",
"484.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"38.93",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10380, 10438
|
3855, 6327
|
306, 400
|
10553, 10567
|
2053, 3194
|
11076, 11845
|
1560, 1655
|
7321, 10357
|
10459, 10532
|
6353, 7298
|
10591, 11053
|
1670, 2034
|
257, 268
|
3541, 3832
|
428, 946
|
3208, 3523
|
968, 1387
|
1419, 1544
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,132
| 149,351
|
49755
|
Discharge summary
|
report
|
Admission Date: [**2198-7-24**] Discharge Date: [**2198-7-31**]
Date of Birth: [**2143-11-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pericardiocentesis
[**2198-7-27**] Right video-assisted thoracoscopy and creation of
pericardial window.
History of Present Illness:
Ms. [**Known lastname 104012**] is a 54 yo female with metastatic breast cancer
s/p right mastectomy and XRT who presents with shortness of
breath over approximately the past week. The patient reports
this may have been going on for a few weeks at most but that it
has been most obvious over approximately the past week when she
has been unable to sleep at night due to an inability to lie
flat without shortness of breath. If patient did fall asleep
recumbent she would wake up gasping for breath. She reports
that she called the clinic who thought this was most likely
secondary to anxiety so she was given "something to sleep" that
didn't work well. She also reports she would have dyspnea on
exertion so that on climbing a single flight of stairs she would
become short of breath. Also she has generally been more
fatigued over the last month or so, but says this may have been
related to recent chemotehrapy. Patient has a longstanding
cough since last fall that briefly improved with PPI and speech
and swallow consult but has worsened again recently. Usually
non-productive but occasionally associated with thick, white
sputum. She denies any night sweats or frank fevers though she
reports "low grade" fevers to 99. No night sweats. She has
lost approximately 60 lbs over the last two years as she has
dealt with her metastatic carcinoma. She denies any chest pain,
palpitations, leg swelling, pre-syncope, or syncope. Because of
her recurrent respiratory symptoms a chest radiograph was
checked at the outpatient clinic and showed possible worsening
of her right sided pleural effusion as well as an enlarged
cardiac silhouette so the patient was referred for outpatient
TTE on day of admission. After this echo showed a large
pericardial effusion she was sent to the ED to be seen by
cardiology.
.
On arrival in the ED, HR 120's, BP 150/100's, RR 30's. She was
seen by cardiology who took her for pericardiocentesis. In the
cath lab 670 cc's of serosanguinous fluid was drained.
Post-procedure TTE showed only slight residual effusion.
.
On arrival to floor patient reports less dyspnea and generally
feeling well except for mild pain at drain site.
.
ROS
----
On review of symptoms, she denies any history of coronary artery
disease or problems with her heart though she has been on
lisinopril in the past. She self discontinued this because of
cough. She denies any hemoptysis. No nausea/vomiting/diarrhea.
She denies any melena, hematochezia, or noted increase in the
size of her abdomen. She denies lower extremity edema. She has
some mild tingling in her feet that was worse when she was
receiving chemotherapy and has now improved.
Past Medical History:
1) Metastatic breast adenocarcinoma: Breast cancer diagnosis in
[**2185**] s/p mastectomy and CA chemotherapy. Recurrence in neck in
[**2189**] with XRT. In [**2192**] known metastatic disease to spine,
supraclavicular node, and right hip. She has tried and failed
multiple chemotherapy regimens, now cycle 1, day 16 of
Herceptin/Xeloda
2) Anxiety
3) Hypertension (has been on lisinopril but stopped on own)
4) s/p appendectomy
5) Hypothyroidism
Social History:
Social history is significant for no tobacco since [**2165**]. The
patient drinks socially and quite infrequently with no history
of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father died of a AAA rupture. There is a
history of cancer in multiple family members.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.8 , BP 162/84, HR 116, RR 29, O2 99 % on 4L
Gen: Well attired, appropriately groomed middle aged woman in
NAD
HEENT: NC,AT; Sclera anicteric, PERRL, EOMI; conjunctivae
non-injected; oropharynx benign without pallor, petechiae, or
exudates
Neck: Supple with no JVD appreciated, Port-a-cath noted in Left
chest, site is non-tender and C/D/I
CV: PMI located in 5th intercostal space, midclavicular line;
Tachycardic but regular rhythm with normal s1 and s2, no m/r/g
Chest: Respirations unlabored without accessory muscle use; on
auscultation there are no wheezes, rhonchi, or rales but there
are decreased breath sounds at the right base
Abd: Obese, soft, NT, ND; No HSM or masses appreciated. No
abdominial bruits.
Ext: No C/C/E. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; DP 2+
Left: Carotid 2+ without bruit; DP 2+
.
.
Pertinent Results:
MEDICAL DECISION MAKING
EKG demonstrated sinus tachycardia with rate of 123 with normal
intervals and axis and no ST or T wave abnormalities appreciated
but overall low voltage. The tachycardia and low voltage are
new when compared with prior dated from [**2185**].
.
TELEMETRY demonstrated:Sinus tachycardia
.
2D-ECHOCARDIOGRAM performed on [**2198-7-24**] demonstrated:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thickness and cavity size are normal with mild-moderate
global hypokinesis (LVEF=?40%). The right ventricular cavity is
unusually small with normal free wall contractility. The aortic
valve leaflets appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is a
large circumferential pericardial effusion measuring 2-3cm
anterior to the right ventricle and 1.5-2.5cm around the apical
and lateral left ventricle and 1.5cm inferior to the left
ventricle. There is right atrial and right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology.
IMPRESSION: Large circumferential pericardial effusion with
evidence of tamponade physiology. Mild-moderate global left
ventricular hypokinesis c/w diffuse process (toxin, metabolic,
etc.)
.
LABORATORY DATA
-----------------
WBC-9.0 RBC-3.87* HGB-11.4* HCT-33.3* MCV-86 MCH-29.4 MCHC-34.2
RDW-15.3
-----------NEUTS-84.5* LYMPHS-7.8* MONOS-6.1 EOS-1.5 BASOS-0.1
GLUCOSE-131* NA+-135 K+-4.2 CL--97* TCO2-22 UREA N-17 CREAT-0.8
CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.3
ALT(SGPT)-52* AST(SGOT)-95* CK(CPK)-100 ALK PHOS-99 TOT BILI-0.7
CK-MB-2 cTropnT-<0.01
.
Pericardial fluid:
WBC-8000* HCT-24.5* POLYS-38* LYMPHS-12* MONOS-20* EOS-3*
BASOS-1* MESOTHELI-9* MACROPHAG-8* OTHER-9*
TOT PROT-6.9 GLUCOSE-49 LD(LDH)-1302 AMYLASE-44 ALBUMIN-4.1
.
Brief Hospital Course:
54 y.o. female with metastatic breast cancer presenting with
shortness of breath and found to have a large pericardial
effusion as well as bilateral pleural effusions.
.
# Cardiac tamponade: The patient had a large (2-3 cm)
pericardial effusion on echo and demonstrated tamponade
physiology. Patient had 670 cc of serosanguinous fluid drained
from her pericardium and a drain left in place on the night of
admission. She tolerated this procedure well with minimal pain
afterward. There was some interval improvement in her shortness
of breath with the procedure, though she continued to be
somewhat dyspneic, probably due to her continued pleural
effusions. Eventually, analysis of the fluid from the
pericardiocentesis revealed malignant cells. With confirmation
that this was a malignant effusion further management was
discussed with her primary oncologist, Dr. [**Last Name (STitle) 2036**], who felt
placement of pericardial window would be reasonable given the
likelihood that this would re accumulate. This was performed on
[**2198-7-27**] by the thoracic surgery service and after which she was
transferred to their service as she had no structural heart
disease and a normal EF and thus no active cardiac issues. On
[**2198-7-28**] the right chest tube was removed. She was started on
Lovenox for the SVC syndrome. Her pain was managed with PO pain
medication.
.
# O2 requirements/Cough: The patient had a persistent oxygen
requirement and cough after having her pericardiocentesis. This
was thought most likely due to continued pleural effusions.
There was interval worsening of these effusions in the hospital
possibly due to fluid resuscitation vs continuing disease. On
[**2198-7-26**] a CT chest was performed which better demonstrated a
large right sided pleural effusion. This was drained by
thoracic surgery at the same time they placed her pericardial
window. Her oxygenation improved and she was sent home without
oxygen supplement.
.
# Breast Cancer: On day 16 of Herceptin/Xeloda at presentation
and on drug holiday. Will continue to hold. Primary oncologist
Dr. [**Last Name (STitle) 2036**] was involved in care and approved decisions of
surgical management.
She continued to make steady progress and was discharged to home
with VNA.
Medications on Admission:
-Xeloda 1000 mg [**Hospital1 **] x 14 days followed by 7 day rest (presented
2 days after finishing cycle started on [**7-9**])
-Levothyroxine 150 mcg 5.5 days a week
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*2*
2. Levoxyl 150 mcg Tablet Sig: One (1) Tablet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**2-25**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 269**] homecare
Discharge Diagnosis:
Primary Diagnoses:
Malignant pericardial effusion
Malignant pleural effusion
Metastatic carcinoma of the breast
.
Secondary Diagnoses
- Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you were short of
breath. This was most likely due to the fluid around your heart
and lungs. You had procedures to drain this fluid and a
permanent window put in the sac around your heart to keep that
from reaccumulating.
.
Your medications have not been changed. Please continue to keep
all medications as prescribed.
Continue Lovenox 70 mg twice daily. Follow-up with Dr. [**Last Name (STitle) 2036**]
Chest tube site remove dressing on Thursday and cover with a
clean bandaid until healed. Should site begin to drain cover
with a clean dry dressing and change as needed to keep site
clean and dry.
You may shower on Thursday. No tub bathing or swimming for 4
weeks
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2198-8-20**] 10:00
Follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], Phone:[**Telephone/Fax (1) 2348**]
Date/Time:[**2198-8-14**] 10:00am on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Completed by:[**2198-8-8**]
|
[
"401.9",
"196.0",
"197.1",
"V10.3",
"197.2",
"459.2",
"198.89",
"584.9",
"244.9",
"198.5",
"423.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.20",
"37.12",
"34.06",
"34.04",
"37.0",
"37.24"
] |
icd9pcs
|
[
[
[]
]
] |
10054, 10131
|
6942, 9214
|
329, 437
|
10326, 10335
|
4930, 6919
|
11102, 11687
|
3793, 3969
|
9432, 10031
|
10152, 10305
|
9240, 9409
|
10359, 11079
|
3984, 3984
|
4006, 4911
|
282, 291
|
465, 3136
|
3158, 3610
|
3626, 3777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,387
| 159,831
|
53753
|
Discharge summary
|
report
|
Admission Date: [**2133-4-21**] Discharge Date: [**2133-4-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Hypoxia, edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a [**Age over 90 **] year old man with baseline dementia who was brought
in by his daughter from home for a distended and painful lower
abdomen, increased pedal edema, shortness or breath, and
decreased urinary output over the past 3 days. The patient lives
at home with around the clock care and his daughter had been
notified of a general functional decline over the past 3 weeks.
The patient had become more withdrawn, almost completely
nonverbal, and unable to feed himself. On the day of admission,
one of his caretakers notified his daughter of the fact that he
seemed uncomfortable, dyspneic, and that his UOP was decreased,
and his daughter brought him to the [**Name (NI) **] for evaluation and
treatment. EMS gave the patient nitro and 40 mg Lasix en route.
In the ED, his vitals were T97, HR in the 70s, BP 140/80, RR 16
and he was satting 98% on 3 L n/c. A Foley was put in and the
patient immediately drained over 1 L tea colored urine. A set of
labs revealed that the patient was hyperkalemic to 6.4, and his
creatinine was 7.8 (we have a value of 0.9 in [**2129**], pt not known
to have RF). His BNP was elevated ( 9553) He was given calcium
gluconate, 10 units insulin, 1 amp D50, and ceftriaxone, and
then transferred to the ICU.
.
He rapidly diuresed with steady improvement in his creatinine,
allowing transfer to the floor [**4-22**] in stable condition. He is
slowly becomine more arousable and appears to be symptomatically
improved. Urology consultation did not appreciate significant
prostate enlargement. Renal ultrasound was essentially normal
with an 8.2cm R renal cyst. The daughter's goal is to get him
home with goal of comfort.
Past Medical History:
CAD, s/p CABG
HTN
Hypercholesterolemia
S/p right parotidectomy
Melanoma (back, resected 27 years ago)
Bilateral Cataracts, s/p resection
Primary Thrombocytopenia
severe dementia
Social History:
The patient has dementia, lives alone with a caretaker around
the clock. His daughter visits him frequently and his health
care proxy. [**Name (NI) **] alcohol, tobacco or drugs.
Family History:
Noncontributory
Physical Exam:
VS T 96.8 HR 71 BP 102/53 RR 16 Sat 99% on 3 L n/c
GENERAL: Frail elderly man in bed, breathing comfortably,
nonverbal.
HEENT: Minimal pupillary reaction to light. Unable to test EOM.
Neck: JVD is present. No masses.
CHEST: Fine crackles both lung bases, decreased respiratory
sounds throughout.
CV: RRR. Normal S1 and S2. A [**2-3**] holosystolic murmur is heard
throughout precordium, radiating to axilla.
ABDOMEN: NTND. BS present.
GU: A Foley is in place. External genitalia grossly normal.
EXT: Edema is present to hip, 3 pitting edema R>L. Also sacral
edema.
NEURO: Patient unable to cooperate
Pertinent Results:
[**2133-4-20**] CXR: Accounting for the poor inspiratory effort on the
exam, no definite pneumonia or CHF.
.
[**2133-4-20**] ECG: Technically difficult study
Regular rhythm consider accelerated idioventricular rhythm
Left axis deviation
IV conduction defect
QT interval prolonged for rate
Lateral ST-T changes
Since previous tracing of [**2128-6-14**], P wave discernible, QRS wider
Clinical correlation is suggested
.
[**2133-4-21**] ECG: Regular rhythm - consider accelerate
idioventricular rhythm
Left axis deviation - possible left anterior fascicular block
Extensive ST-T changes
QT interval prolonged for rate
Since previous tracing of [**2133-4-20**], no significant change
.
[**2133-4-22**] RENAL U/S: 1. No obstruction or stones were seen.
2. Simple cyst in the upper pole of right kidney measuring 8.2
cm in greatest dimension.
.
[**2133-4-21**] 12:30 am URINE Site: CLEAN CATCH
URINE CULTURE (Final [**2133-4-22**]): NO GROWTH.
[**2133-4-21**] 12:30AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2133-4-21**] 12:30AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2133-4-21**] 12:30AM URINE RBC->50 WBC-[**3-2**] Bacteri-FEW Yeast-NONE
Epi-0
[**2133-4-21**] 01:54PM URINE Hours-RANDOM UreaN-649 Creat-67 Na-72
[**2133-4-21**] 01:54PM URINE Osmolal-498
.
[**2133-4-20**] 10:20PM BLOOD WBC-6.9 RBC-3.51* Hgb-12.0* Hct-35.8*
MCV-102* MCH-34.2* MCHC-33.5 RDW-14.6 Plt Ct-203
[**2133-4-20**] 10:20PM BLOOD Neuts-78.0* Lymphs-13.2* Monos-5.3
Eos-2.5 Baso-1.0
[**2133-4-20**] 10:20PM BLOOD Macrocy-2+
[**2133-4-20**] 10:20PM BLOOD Plt Ct-203
[**2133-4-20**] 10:20PM BLOOD PT-11.8 PTT-24.3 INR(PT)-1.0
[**2133-4-20**] 10:20PM BLOOD Glucose-106* UreaN-99* Creat-7.8*#
Na-147* K-6.4* Cl-113* HCO3-24 AnGap-16
[**2133-4-20**] 10:20PM BLOOD CK(CPK)-33*
[**2133-4-20**] 10:20PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2133-4-20**] 10:20PM BLOOD proBNP-9553*
[**2133-4-20**] 10:20PM BLOOD Calcium-8.3* Phos-4.2 Mg-2.9*
.
[**2133-4-21**] 09:10AM BLOOD WBC-5.9 RBC-3.65* Hgb-12.7* Hct-37.2*
MCV-102* MCH-34.8* MCHC-34.1 RDW-13.9 Plt Ct-184
[**2133-4-21**] 09:10AM BLOOD Plt Ct-184
[**2133-4-21**] 09:41PM BLOOD Glucose-88 UreaN-65* Creat-3.9* Na-146*
K-4.0 Cl-109* HCO3-29 AnGap-12
[**2133-4-21**] 05:59PM BLOOD CK(CPK)-26*
[**2133-4-21**] 05:59PM BLOOD CK-MB-4 cTropnT-0.07*
[**2133-4-21**] 09:10AM BLOOD CK-MB-5 cTropnT-0.07*
[**2133-4-21**] 09:41PM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1
[**2133-4-21**] 09:10AM BLOOD %HbA1c-5.7
[**2133-4-21**] 03:00AM BLOOD TSH-2.4
[**2133-4-21**] 03:00AM BLOOD PSA-1.2
[**2133-4-21**] 10:35AM BLOOD Type-ART pO2-168* pCO2-42 pH-7.46*
calTCO2-31* Base XS-6
[**2133-4-21**] 10:35AM BLOOD Na-149* K-4.7 Cl-110
[**2133-4-21**] 10:35AM BLOOD freeCa-1.18
.
Brief Hospital Course:
1) ARF: His baseline creatinine is not known, but the patient
does not have a hx of renal failure. His RF is likely postrenal,
as placement of a Foley resulted in immediate output of >1 Liter
urine. In the unit, postobstructive diuresis yielded>2 Liters
urine output in the first two hours. Urology was consulted and
proscar and finasteride were started for possible BPH. Urology
felt he would need Foley drainage for at least 2 weeks following
his severe retension. He was discharged home with Foley and 24h
care. His Cr was back down to 1.0 on discharge.
2) EDEMA: The edema was likely secondary to his obstructive
renal failure. The patient has been diuresing with no need for
lasix. Edema had almost completely resolved on discharge.
3) HYPOXIA: He does have some fluid overload on CXR, however he
is not dyspneic now and is breathing comfortably on 2 L n/c. No
signs of consolidation. Sats remained stable.
4) ALTERED MENTAL STATUS. The patient has dementia at baseline
and is essentially nonverbal. His functional decline over the
past three weeks was most likely [**1-30**] to uremia in the setting of
his renal failure.
5) CHF. The primary insult seems to have been the renal failure
causing fluid overload. On exam, the patient does not have an
S3.Edema had resolved on discharge.
6) FEN.
- Ground pureed diet, thick liquids.
- All pills crushed.
9) COMMUNICATION
With daughter [**Name (NI) 14880**] [**Telephone/Fax (1) 110324**]
10) DNR DNI: discharged home with 24h care.
Medications on Admission:
Celexa
Levothyroxine
Calcium gluconate
Latanorprost eye drops
Sennakot
Dulcolax
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Disp:*6 Tablet(s)* Refills:*0*
11. Hospital Bed
Semi-Electric Hospital Bed with Half Rails and Mattress
Dispense: 1
12. Mattress
Alternating Pump and Pad Air Mattress
Dispense: 1
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute Obstructive Renal Failure
Severe Dementia
Urinary Tract Infection
Discharge Condition:
stable
Discharge Instructions:
Please continue medications as listed. Please follow up with
your PCP [**Last Name (NamePattern4) **] [**2-1**] weeks. Continue Foley care.
Followup Instructions:
1. Please follow up with your PCP in the next 2-4 weeks.
|
[
"584.9",
"276.7",
"V10.82",
"272.0",
"401.9",
"600.01",
"599.0",
"428.0",
"788.20",
"294.8",
"V45.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8482, 8540
|
5844, 7336
|
277, 283
|
8656, 8665
|
3048, 5821
|
8853, 8913
|
2392, 2409
|
7467, 8459
|
8561, 8635
|
7362, 7444
|
8689, 8830
|
2424, 3029
|
223, 239
|
311, 1979
|
2001, 2180
|
2196, 2376
|
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