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24,641
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50349
|
Discharge summary
|
report
|
Admission Date: [**2124-12-9**] Discharge Date: [**2124-12-12**]
Date of Birth: [**2053-5-30**] Sex: M
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: This is a 71-year-old male with
a past medical history of duodenal ulcer bleeding, who
presented with a chief complaint of two days of orthostasis,
fatigue and malaise with dark and tarry stools on [**2124-12-9**] to the [**Hospital1 69**]
Emergency Room. The patient reportedly denied nausea,
vomiting, hematemesis, bright red blood per rectum, or
syncope. The patient, however, did note fatigue, weakness
and orthostasis. The patient reportedly contact[**Name (NI) **] Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2124-12-9**], after realizing that his
symptoms were consistent with a prior episode of duodenal
ulcer bleeding. The patient was subsequently referred to the
[**Hospital1 69**] Emergency Room and
admitted on [**2124-12-9**], for workup of suspected upper
gastrointestinal bleed.
PAST MEDICAL HISTORY: Polycythemia [**Doctor First Name **], coronary artery
disease, hypertension, gout, depression, basal cell and
squamous cell carcinoma, duodenal ulcer with repeated bleeds,
status post splenectomy, status post right coronary artery
stent, status post multiple skin biopsies, status post
appendectomy.
MEDICATIONS AT HOME: Protonix, aspirin, hydroxyurea,
Procardia, fexofenadine, allopurinol.
ALLERGIES: Tetracycline.
PHYSICAL EXAMINATION: Temperature 97.2, blood pressure
112/51, heart rate 57, respiratory rate 16, oxygen saturation
95% on room air. The patient was noted to be normocephalic,
atraumatic, pupils equal, round and reactive to light and
accommodation. The patient had moist mucous membranes and a
clear oropharynx, no lymphadenopathy or jugular venous
distention was noted, and no carotid bruits were noted
bilaterally. Heart examination demonstrated a regular rate
and rhythm, normal S1 S2, and a II/VI systolic murmur.
Respiratory examination demonstrated lungs clear to
auscultation bilaterally, with diminished sounds at the
bases. Abdominal examination was soft, with minimal
protuberance, nontender, no palpable masses. Rectal
examination demonstrated brown stool, strongly guaiac
positive, no palpable masses, and normal tone. Extremities
were warm and well perfused, with no cyanosis, clubbing or
edema. Neurologic examination was alert and oriented x 3,
appropriate.
LABORATORY DATA: White blood cell count 9.1, hematocrit
23.6, platelet count 780. Sodium 134, potassium 5.4,
chloride 103, bicarbonate 20, BUN 47, creatinine 1.6, glucose
46. A previously-drawn Helicobacter pylori test was antibody
negative. PT 12.7, PTT 29.2, INR 1.1.
HOSPITAL COURSE: The patient was admitted to the Blue
Surgery service on [**2124-12-9**], under the direction of
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], with a presumptive diagnosis of upper
gastrointestinal bleeding. The patient was admitted to the
Surgical Intensive Care Unit for close hemodynamic
monitoring, and was immediately transfused two units of
packed red blood cells. An endoscopy conducted the evening
of admission demonstrated a normal esophagus, melena in the
antrum and stomach body, and a single acute cratered bleeding
7 mm ulcer in the distal bulb of the duodenum, with edema of
the surrounding walls and a narrowing of the lumen. Ten 1 cc
epinephrine 1:10,000 injections were applied for hemostasis,
with success. [**Hospital1 **]-cap electrocautery was applied for
hemostasis successfully. The patient was followed with
serial hematocrits every four hours through the evening of
admission, into hospital day number one, during which time
the patient required two additional units of packed red blood
cells to be transfused, resulting in a hematocrit of 27.3 on
the morning of hospital day number one.
Given this inappropriate response to four units of packed red
blood cells transfused, the patient received continuous every
four hour hematocrit checks through hospital day number
three. The patient subsequently required two additional
units of packed red blood cells and was noted to demonstrate
a stable hematocrit of 31.8 on hospital day number three.
Given the stabilization, the patient was subsequently
transferred out of the Intensive Care Unit on the evening of
hospital day number three, with instructions for continued
hematocrit monitoring. Serial studies conducted throughout
the course of hospital day number three and four demonstrated
stabilization of the patient's hematocrit at approximately
31.7.
On hospital day number four, the patient was advanced to a
regular diet. His intravenous fluids were discontinued, and
he was transitioned to oral medications. A follow-up
evaluation by the Gastroenterology service noted the patient
to be doing well, in stable condition, and advised continued
oral Protonix therapy twice daily for at least eight weeks,
with once daily therapy thereafter. The patient was
subsequently cleared for discharge to home, with instructions
for follow up.
CONDITION AT DISCHARGE: Patient to be discharged to home,
with instructions for follow up.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg by mouth twice a day
2. Sucralfate 1 gram by mouth four times a day
DISCHARGE INSTRUCTIONS: The patient is to observe a planned
non-acidic diet, Sucralfate 1 gram by mouth four times a day,
pantoprazole 40 mg by mouth every 12 hours. The patient is
to limit physical exercise, no excessive exertion. The
patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the
outpatient surgical clinic three to four weeks following
discharge. The patient is to call [**Telephone/Fax (1) 18052**] to schedule
an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 28881**]
MEDQUIST36
D: [**2124-12-12**] 21:45
T: [**2124-12-13**] 00:17
JOB#: [**Job Number 104961**]
|
[
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|
[
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]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
361
| 108,205
|
932
|
Discharge summary
|
report
|
Admission Date: [**2121-5-10**] Discharge Date: [**2121-5-12**]
Date of Birth: [**2067-11-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
R IJ central line placement
History of Present Illness:
Briefly, this is 53 yo M s/p DDRT in [**2111**] who was in his usal
state of health until 2 days prior to presentation when he
develped non-bloody diarrhea and non bloody, non-bilious emesis.
No sick contract, no travel, no abnormal food exposure and no
recent antibiotic exposure. He reports lightheadedness and
dizziness and 2 syncopal episodes.
.
In the emergency department he was found to be hypotensive with
BP 70/40 (baseline SBP = 90-110) with HR = 60s-80s with a
leukocytosis of 16K and acute on chronic renal failure with Cr =
4.0 up from his baseline of 1.9-2.3. Code sepsis was initiated
and he received IVF, stress dose steroids and vancomycin 1 gm,
zosyn 2.25 gm.
.
In the ICU, he was hemodynamically stable and his BP normalized
to SBP 110s without additional IVF nor need for pressors.
.
On the floor the pt feels comfortable, he denies any further LH
or dizziness lying in bed and with ambulation. He denies
abdominal pain, fevers, chills and states that he would like to
go home in the morning.
Past Medical History:
ESRD ?[**3-14**] HTN s/p deceased donor renal transplant in [**2111**]
Gout
HTN
Impaired glucose tolerance
Hyperlipidemia
Social History:
Born in [**Country 6257**], moved to US in [**2091**] at about age 23. He had
worked in electronics but is now on disability. No tobacco,
alcohol or IVDU.
.
Family History:
father who died at 78 of kidney disease, mother who is in her
80s and well. There is no history of diabetes or cancer in the
family. He has one brother and two sisters who are well. He also
has two children, ages 23(a daughter) and 17 (a son) who are
well.
Physical Exam:
T 98.6 BP 106/77 P 94, O2 sat 97% RA
HEENT: NC/AT, PERRL, no scleral icterus noted, MMM,
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Ext: No C/C/E bilaterally, 2+ DP b/l
Skin: no rashes or lesions noted.
Pertinent Results:
[**2121-5-10**] 05:20AM WBC-16.1*# RBC-4.89 HGB-15.2 HCT-44.9 MCV-92
MCH-31.1 MCHC-33.9 RDW-14.5
[**2121-5-10**] 05:20AM NEUTS-78.4* LYMPHS-14.3* MONOS-6.7 EOS-0.4
BASOS-0.2
[**2121-5-10**] 05:20AM PLT COUNT-217
[**2121-5-10**] 05:58AM LACTATE-1.4
[**2121-5-10**] 07:30AM ALBUMIN-3.1* CALCIUM-6.7* PHOSPHATE-3.0
MAGNESIUM-1.9
[**2121-5-10**] 01:37PM freeCa-1.19
[**2121-5-10**] 03:36PM TYPE-MIX PO2-41* PCO2-30* PH-7.27* TOTAL
CO2-14* BASE XS--11 COMMENTS-CENTRAL VE
[**2121-5-10**] 01:37PM TYPE-[**Last Name (un) **] PH-7.24*
.
Admission CXR: no acute process. Right IJ line with tip in the
SVC/RA junction.
.
CT Abd/pelvis:
1. Mild fascial thickening posterior to the transplant kidney.
No evidence of hydronephrosis or perinephric fluid collection.
2. Incompletely visualized coronary artery calcifications.
3. Cholelithiasis without evidence of cholecystitis.
.
Renal transplant U/S:
A transplant kidney is seen in the right lower quadrant and
measures 13.2 cm. There is no hydronephrosis or perinephric
fluid collection. Resistive indices in the upper, mid, and lower
poles are 0.64, 0.72, and 0.69 espectively. The main renal
artery and main renal vein are patent with normal waveforms. A
Foley catheter is in the decompressed bladder. IMPRESSION:
Normal renal transplant ultrasound.
.
CT head: No intracranial hemorrhage or mass effect.
.
Cardiac Evaluation:
[**6-/2115**] ETT - 8.5 METs. No anginal symptoms nor EKG changes.
.
Admission EKG: NSR, LAD, poor R wave progression and first
degree av block. No acute ST changes.
Brief Hospital Course:
53 y.o. M with h/o ESRD s/p deceased donor kidney transplant in
[**2111**] on chronic immunosuppression presents with emesis,
diarrhea, hypotension and acute on chronic renal failure.
.
1. Hypotension: Was likely due to volume loss from diarrhea and
vomiting. Elevated WBC with left shift. Etiology most likely
viral given lack of fever, abdominal pain. He was continued on
IVF with bicarbonate. He received Hydrocortisone 50mg Q8h for
one day, then was placed back on his outpatient dose of oral
prednisone. Pt initially received antibiotics in the ED, none
were necessary anymore after that since his BP remained stable
and he also remained afebrile. He was discharged with stable BP
but off his antihypertensives. He should schedule a followup
appointment with Dr. [**Last Name (STitle) **] within one week after discharge.
At this time, it can be decided if he should continue any of his
antihypertensives.
.
2. Diarrhea: Probably infectious, most likely viral, however
atypical bacterial presentation was initially considered. Also
in this immunosuppressed pt need to consider
crytpo/micropsiridia and CMV. CMV was negative in the past. No
recent antibiotic exposure and presentation not suggestive of C
diff. Extensive stool studies were sent but pending upon
discharge. His diet was advanced and his diarrhea resolved
slowly after admission.
.
3. Non Anion Gap Metabolic Acidosis: Probably secondary to
diarrhea, possible component of RTA in the context of worsening
RF, however, the patient has had normal bicarbonate in the past.
He received IVF with HCO3 and his HCO3 came back up to normal
levels.
.
4. Syncopal Episodes: Unlikely to be cardiac/seizure/stroke,
probably due to orthostatic hypotension secondary to
hypovolemia. CT head was negative. Patient was without focal
neurological signs. He was monitored on telemetry for 24 h.
Hypocalcemia was repleted with IV calcium gluconate as needed.
.
5. ESRD s/p DDRT 10 years ago on neoral and imuran and
prednisone. Renal US was wnl w/o signs of rejection. He was
continued on neoral, imuran and prednisone (except for one day
while being on stress dose steroids instead of his PO
prednisone).
.
6. Acute on chronic renal insufficiency: likely secondary to
hypovolemia, quickly improved with IVF. Back to baseline (around
2.0) on [**2121-5-12**].
.
7. Hypocalcemia: no QT prolongation. Probably secondary to
diarrhea. Repleted with IV calcium gluconate.
.
8. Hypertension: Initially hypotensive. Resolved after IVF. Then
remained normotensive. All antihypertensives were held given
hypotension. They should be restarted as an outpatient.
.
9. Prophylaxis: Tolerating POs, pantoprazole while on steroids,
ISSC while on steroids, SQ heparin
.
10. Access: RIJ was placed on [**2051-5-10**], then pulled the next
day. PIV.
.
11. Code: FULL
Medications on Admission:
COLCHICINE 0.6MG po qd prn gout
HYDRALAZINE HCL 50MG po bid
IMURAN 50MG po q day
LOPRESSOR 100MG po qday
NEORAL 50MG [**Hospital1 **]
PREDNISONE 5MG po qday
PROBENECID 500MG--One by mouth twice a day for gout
VASOTEC 10MG--One by mouth every day
Ranitidine 150mg po bid
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
3. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Probenecid 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Gastroenteritis with hypotension, self-limited, likely viral
2. ESRD s/p deceased donor renal transplant
3. Hypertension
Secondary Diagnosis:
1. Gout
2. Hyperlipidemia
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You have suffered from a gastroenteritis which was likely caused
by a virus. Your blood pressure was low and you received
intravenous fluids and briefly antibiotics.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
worsening diarrhea, spontaneous bleeding or any other concerning
symptoms.
.
Please take all your medications as directed. You should hold
your blood pressure medications (lopressor, hydralazine and
vasotec) until your next outpatient visit when it will be
decided if you should be restarted on them or not.
.
Please keep you follow up appointments as below.
Followup Instructions:
We have called to schedule you an appointment with [**First Name4 (NamePattern1) 971**]
[**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]. The office will call you with
your appointment time. You should have your blood checked (CBC,
calcium) and follow up with her on your blood pressure
medications and kidney function.
.
In addition, please keep the following scheduled appointments:
.
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2121-7-11**] 9:30
.
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2121-9-15**] 4:10
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
|
[
"276.52",
"276.2",
"E878.0",
"275.41",
"996.81",
"585.6",
"008.8",
"403.91",
"272.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7483, 7489
|
3983, 6784
|
328, 358
|
7725, 7788
|
2410, 3718
|
8490, 9309
|
1738, 1996
|
7105, 7460
|
7510, 7510
|
6810, 7082
|
7812, 8467
|
2011, 2391
|
277, 290
|
386, 1401
|
3727, 3960
|
7676, 7704
|
7529, 7654
|
1423, 1547
|
1563, 1722
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,551
| 142,414
|
44906
|
Discharge summary
|
report
|
Admission Date: [**2107-11-17**] Discharge Date: [**2107-11-19**]
Date of Birth: [**2030-9-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Urispas / Atorvastatin / Nsaids
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
I guess the blood in my head and my left leg hurts
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Asked to see this 77 year old white female who was on the
[**Hospital Ward Name **] today for Holter monitoring and coagulation clinic.
Pt reports that she is on Coumadin for afib and "a flutter in my
heart". Pt states today that she tripped and stubbed her toe
causing her to fall. She fell forward and rolled to her right
striking her face. She denies syncope before or after the fall.
She was immediately aware of her surroundings. The Holter
monitor is also for dizziness and sob since her afib was
diagnosed 3 yrs ago
Past Medical History:
-paroxysmal atrial fibrillation, not on anticoagulation
-hypertension
-hypercholesterolemia
-hypothyroidism
-low back pain
-depression/anxiety
-history of basal cell carcinoma removed from left cheek
-history of multiple skeletal fractures
-history of left hip fracture, status post left ORIF
Social History:
She lives at home with her husband. She is a former hospital
secretary at [**Hospital1 18**]. She has a distant but brief history of
tobacco use. Denied alcohol or illicit drug use.
Family History:
Multiple family members with cardiac disease.
Physical Exam:
: T:98 BP:138 /60 HR:60 R18 O2Sats100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-12**] EOMi / left cerumen impaction noted /
no battles sign / + right periorbital ecchymosis and swelling /
eye still able to open easily.
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-15**] throughout. No pronator drift
Sensation: Intact to light touch
Pertinent Results:
[**2107-11-17**] 10:05PM GLUCOSE-114* UREA N-22* CREAT-1.5* SODIUM-137
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2107-11-17**] 10:05PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2107-11-17**] 10:05PM WBC-9.6 RBC-3.81* HGB-11.8* HCT-34.9* MCV-92
MCH-30.9 MCHC-33.7 RDW-13.8
[**2107-11-17**] 10:05PM PLT COUNT-244
[**2107-11-17**] 10:05PM PT-16.2* PTT-29.3 INR(PT)-1.4*
[**2107-11-17**] 05:15PM URINE HOURS-RANDOM
[**2107-11-17**] 05:15PM URINE GR HOLD-HOLD
[**2107-11-17**] 05:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2107-11-17**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR
[**2107-11-17**] 05:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2107-11-17**] 03:00PM GLUCOSE-115* UREA N-28* CREAT-1.7* SODIUM-138
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
[**2107-11-17**] 03:00PM estGFR-Using this
[**2107-11-17**] 03:00PM WBC-13.0*# RBC-4.29 HGB-13.2 HCT-39.3 MCV-92
MCH-30.8 MCHC-33.7 RDW-14.0
[**2107-11-17**] 03:00PM NEUTS-86.4* LYMPHS-9.0* MONOS-2.8 EOS-1.6
BASOS-0.2
[**2107-11-17**] 03:00PM PLT COUNT-260
[**2107-11-17**] 03:00PM PT-24.4* PTT-34.0 INR(PT)-2.3*
Brief Hospital Course:
IPH/SAH:
Patient was admitted to the hospital after a fall (on coumadin
and aspirin) and was found to have a L traumatic SAH and a R
intraparenchymal hemorrhage. Her INR was reversed with 2 doses
of 5 mg of Vitamin K to 1.1 on discharge. She received 6 packs
of platelets. She was transfused w/ one unit of FFP. The first
repeat CT revealed interval progression of the right frontal
IPH. Subseuqent two CTs revealed stabilization of the IPH. She
remained non-focal throughout her hospitalization. She was
cleared by PT for DC with home PT.
Afib:
She was on coumadin for her Atrial Fibrillation. She required
rapid reversal of her INR and was still in AFib on discharge.
She will need to remain off of coumadin and aspirin for one
month due to the intraparenchymal hemorrhage. She will need to
follow-up with her PCP/Cardiologist within 1-2 weeks to discuss
her atrial fibrillation.
Medications on Admission:
Amlodipine 2.5mg Qd
Levothyroxine 88mcg Qd
Metoprolol Tartrate 50mg [**Hospital1 **]
Paroxetine HCl 10mg Qd
Propafenone 225mg TID
Quinapril 20mg [**Hospital1 **]
Warfarin 1-3mg Qd- dependent on INR
ASA 81mg Qd,
Calcium carbonate w/D3
MVI
Omega 3 fatty Acid
Miralax PRN
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. propafenone 225 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. quinapril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Traumatic Right Intraparenchymal hemorrhage
Traumatic Left Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Take your oxycodone as prescribed.
- Exercise should be limited to walking; no lifting, straining,
or excessive bending.
- Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
- Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
- you may safely resume taking your aspirin and coumadin on
[**2107-12-19**] (one month after event).
- please contact your PCP regarding your Atrial Fibrillation and
to let them know that you have stopped taking coumadin and
aspirin.
Followup Instructions:
- Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 4 weeks.
- You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2107-11-19**]
|
[
"V43.64",
"823.01",
"V10.83",
"427.31",
"272.0",
"V15.82",
"300.4",
"E885.9",
"853.01",
"401.9",
"724.2",
"802.6",
"244.9",
"562.10",
"852.01",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6078, 6136
|
3930, 4815
|
348, 355
|
6263, 6263
|
2672, 3907
|
7150, 7468
|
1443, 1490
|
5134, 6055
|
6157, 6242
|
4841, 5111
|
6414, 7127
|
1506, 1778
|
258, 310
|
383, 910
|
2030, 2653
|
6278, 6390
|
932, 1227
|
1243, 1427
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,674
| 107,142
|
26981
|
Discharge summary
|
report
|
Admission Date: [**2118-11-12**] Discharge Date: [**2118-11-20**]
Date of Birth: [**2069-6-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
bilateral PE w/left DVT.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 yo M w/ h/o left ankle injury transferred from [**Hospital1 66318**] for continued management of bilateral PE w/ a
left DVT. Patient states he noticed left leg swelling and SOB
last night and in the morning his wife insisted he go to the
hospital. CTA at OSH w/ bilateral upper lobe PEs and LENI w/
left LE DVT. Patient denies c/o palpitations or dizziness. Over
the past couple days he has noticed considerable increase in SOB
and has noticed pleuritic CP, which is new. No hemoptysis. No
BRBPR since being on heparin. He reports he has been ambulating
and denies any recent surgeries. He has never had a clot in the
past. Mr. [**Known lastname 66319**] has had a cough productive of yellow sputum x 3
weeks. He has also had concurrent rhinorrhea. He has not
received any antibx to date for his sx. He denies h/o F. No
noticable weight loss. ABG at OSH: 7.44/39/68 on 2 L NC. In ED
he received IV heparin, morphine 2 mg IV, and an albuterol neb.
.
Allergies: NKDA
Past Medical History:
## h/o trauma to left ankle 1 yr ago w/ ligamentous tear
## neuropathic pain in left leg due to h/o trauma
## GERD
## h/o pilonidal cyst s/p surgical intervention as a child
## s/p appy as a child
## h/o back pain, s/p discectomy (Dr. [**Last Name (STitle) 66320**] 1.5 yrs ago
Social History:
Mother [**Name (NI) 2419**] h/o CVA at age 72, father w/ h/o pancreatic CA at age
62
Family History:
no etoh
+ tob: 3 ppd x 30 yrs
Unemployed. Married w/ kids.
Physical Exam:
T 100.1 hr 101-113 bp 146/90 rr 26-30 O2 97% on 4L NC
wt 265 lbs
genrl: increased WOB but o/w in nad
heent: perrla, op clear, mmm, upper dentures in place
neck: no JVD
cv: rrr, no m/r/g
pulm: decreased BS at both bases, poor air movement bilaterally,
no wheezes/ronchi
abd: nabs, diffusely tender to palpation w/o rebound/guarding
extr: 1+ pitting edema left leg
neuro: a, ox3, maew
Pertinent Results:
Admission labs:
CBC: WBC-14.3* RBC-5.04 Hgb-14.5 Hct-42.9 Plt Ct-174
Diff: Neuts-74.5* Lymphs-18.2 Monos-5.1 Eos-1.7 Baso-0.4
Coags: PT-13.7* PTT-34.6 INR(PT)-1.3
Chem10: Glucose-107* UreaN-21* Creat-1.1 Na-138 K-4.3 Cl-99
HCO3-27
Calcium-9.3 Phos-4.0 Mg-2.2
ABG: Type-ART pO2-131* pCO2-42 pH-7.39 calHCO3-26 Base XS-0
Cardiac enzymes: troponinT<0.01x3
Iron studies: calTIBC-160* Ferritn-478* TRF-123* Fe-34*
Discharge labs:
CBC: WBC-10.5 RBC-4.67 Hgb-13.1* Hct-39.3* Plt Ct-271
Coags: PT-17.0* PTT-104.6* INR(PT)-2.0
Chem7: Glucose-98 UreaN-20 Creat-1.2 Na-138 K-4.2 Cl-101 HCO3-28
EKG: sinus tach at 100 bpm, normal axis/intvls, new TWI III, +
PVC
Imaging:
OSH left LE U/S: + DVT involving left popliteal v up to mid
femoral v
OSH CTA: small bilateral subsegmental pulmonary emboli involving
upper lobes, small right pleural effusion, and right basilar air
space dz
OSH ECHO: preserved LV function, no note of RV strain
[**Hospital1 18**] CXR: poor inspiration w/ bibasilar atelectasis, bilateral
blunting of costophrenic angles, no obvious infiltrate
Brief Hospital Course:
Assessment: 49 yo man w/ history of left ankle injury 1 yr ago
transferred from an outside hospital for continued management of
bilateral pulmonary emboli with left deep venous thrombosis
without hemodynamic instability.
Hospital course is reviewed below by problem:
1. Bilateral PE w/ left DVT - On admission, he was
hemodynamically stable w/o right heart strain by EKG or OSH
ECHO. He was monitored in the ICU on heparin gtt + coumadin. His
risk factors included obesity, tobacco use, and h/o trauma to
ankle. Would strongly recommend a hypercoagulable workup as an
outpatient, including colonoscopy, PSA, and hypercoagulable
labs. He was discharged when his INR was therapeutic on coumadin
(with goal [**2-10**]) for 2 days. His PCP's office was contact[**Name (NI) **] to
get in touch with him for follow-up.
2. Cough w/ sputum - He was admitted with a cough productive of
sputum and leukocytosis but no fevers. He had a CXR without
obvious infiltrate. His sputum culture grew moraxella, but he
was otherwise asymptomatic. As it was unclear whether this was
colonization vs infection, he was not treated. He did report
chest pain, which was thought to be secondary to his PEs. He was
treated with nebulizers, then inhalers, and acetaminophen with
codeine. He initially needed additional pain medications but had
not taken any for several days prior to discharge.
3. Nicotine dependence - The patient was strongly encouraged
throughout his hospital stay to stop smoking. He was educated on
smoking cessation and given a prescription for the nicotine
patch on discharge. He endorsed the concept of quitting at the
time of discharge.
4. GERD - He was treated with a PPI but discharged without
(return to aciphex).
5. Code status - full
Medications on Admission:
aciphex
[**Doctor First Name 130**]
cymbalta 60 mg po qd (started Friday for neuropathic pain)
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
2. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for 1 weeks.
Disp:*qs ML(s)* Refills:*0*
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation every twelve (12) hours as needed for cough for
2 weeks.
Disp:*qs * Refills:*0*
4. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Acute pulmonary emboli
2) Deep Venous Thrombosis
Secondary:
3) Anemia - unspecified, perhaps iron deficiency or anemia of
chronic disease
4) chronic low back pain with neuropathic pain extending into
left lower extremity, s/p surgery in past
Discharge Condition:
Good; no further chest pain, improved cough, good oxygen
saturation on room air, stable vital signs.
Discharge Instructions:
Take all medications as prescribed below.
Follow up with your primary care provider as scheduled, ask him
to schedule you for a colonoscopy.
Call your doctor or return to the hospital if you have any
shortness of breath, worsening cough, chest pain, new or
worsening leg pain, dizziness or lightheadedness, bright red
blood in your stool or black stools, nausea, vomiting, or any
other concerning symptoms.
Followup Instructions:
You need a colonoscopy and perhaps an EGD to look at your colon
and perhaps your stomach and small intestine to further evaluate
the cause of your anemia (low blood count). It is important to
ensure you have no evidence of colon cancer or other type of
malignancy (cancer).
You must have your blood checked to monitor your coumadin
dosing. It is essential that you call your primary care
physician and get your 'INR' checked this week so that he can
adjust your coumadin as needed.
You should call the [**Hospital **] clinic after discharge to arrange
for a consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 9645**]) to discuss
any further evalution for a predisposition to forming blood
clots.
You have the following appointment scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 20928**], MD ([**Telephone/Fax (1) 1669**]) Date/Time:[**2118-11-29**]
3:00
|
[
"305.1",
"415.19",
"453.41",
"530.81",
"285.9",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5758, 5764
|
3331, 5075
|
340, 346
|
6063, 6166
|
2248, 2248
|
6622, 7578
|
1762, 1822
|
5220, 5735
|
5785, 6042
|
5101, 5197
|
6190, 6599
|
2674, 3308
|
1837, 2229
|
2584, 2658
|
276, 302
|
374, 1343
|
2264, 2567
|
1365, 1644
|
1660, 1746
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,583
| 121,811
|
34465
|
Discharge summary
|
report
|
Admission Date: [**2100-9-1**] Discharge Date: [**2100-9-1**]
Date of Birth: [**2053-10-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Transfer for TIPS evaluation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 79209**] is a 46 year old man with history of cirrhosis
(secondary to NASH) Crohn's disease s/p resection of small bowel
in 70's, diabetes mellitus, presenting to OSH ([**Hospital3 25148**]
Center) with on day of nausea, vomiting of blood and passing of
dark, black colored stools.
On arrival to PMC, Temp 98, HR 83, BP 119/66 and Os Sat of 98%
on rooom air. There he was given 2 units of PRBC and 2 bags of
platelets. Per report, patient underwent intubation for airway
protection and subsequently had esophageal varix banding x 2
(grade I at 39cm, single band, and grade II at 35cm, double
band.), but several fundal non bleeding varices with fresh blood
were noted. IV protonix, octreotide were started. Patient was
emergently trasnferred to [**Hospital1 18**] ED.
In the ED, VS: Temp: 98.1 HR 71 BP 110/50, patient arrived
intubated on FIO2 100% and PEEP of 5. Patient given additional 2
bags of platelets and hepatology team was contact[**Name (NI) **]. Admitted to
MICU for further evaluation.
Primary [**Hospital **] clinic diligently supplied records. On review,
patient had baseline Hct of 29-35, baseline platelet of 20's
40's in the last year.
Past Medical History:
1. Crohn's Disease
-- s/p ileocolic resection 79 (2 ft of small intestine and 1 ft
of large intentine resected)
-- Last c-xope [**2100-3-22**] with mildly active disease
2. End stage Liver Cirrhosis (though to be [**3-13**] NASH)
-- s/p esophageal varix banding x 2
3. Nephrolithiasis s/p stenting
4. Inguinal hernia s/p repair on L ([**2100-8-11**])
5. Thrombosed Splenic Vein (at confluence of SMV and splenic
vein)
6. S/P Appendectomy
7. DM Type 2
8. Thrombocytopenia (though [**3-13**] quinine for leg cramp?)
9. Cholelithiasis
10. Hypertension
11. Chronic Back pain
Social History:
Married, lives with wife and 2 children, no EtOH abuse
Family History:
NC
Physical Exam:
vitals T = 98.4 BP = 116/59 HR= 76 RR= 18 O2= 100%
Ventillated, PS, FIO2 100%, PEEP 5
GENERAL: Intubated, sedated, apears comfortable.
HEENT: Normocephalic, atraumatic. (+) conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Dry . Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Soft rhonchi from upper airway, good air movement
biaterally.
ABDOMEN: NABS. Soft, NT, ND. (+) Splenomegaly
EXTREMITIES: 3+ pitting edema bilaterally, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Sedated, intubated, following commands.
Pertinent Results:
[**2100-9-1**] 06:50AM BLOOD WBC-5.0 RBC-3.04* Hgb-8.4* Hct-24.5*
MCV-81* MCH-27.5 MCHC-34.2 RDW-16.9* Plt Ct-56*
[**2100-9-1**] 12:43PM BLOOD WBC-7.6# RBC-3.13* Hgb-8.4* Hct-24.9*
MCV-80* MCH-26.8* MCHC-33.6 RDW-16.7* Plt Ct-52*
[**2100-9-1**] 06:50AM BLOOD Neuts-74.2* Bands-0 Lymphs-18.0 Monos-6.1
Eos-1.5 Baso-0.2
[**2100-9-1**] 06:50AM BLOOD PT-17.1* PTT-32.6 INR(PT)-1.5*
[**2100-9-1**] 12:43PM BLOOD PT-16.4* PTT-32.1 INR(PT)-1.5*
[**2100-9-1**] 12:43PM BLOOD Plt Ct-52*
[**2100-9-1**] 07:05AM BLOOD Glucose-204* UreaN-38* Creat-1.0 Na-141
K-4.3 Cl-108 HCO3-24 AnGap-13
[**2100-9-1**] 07:05AM BLOOD ALT-25 AST-32 CK(CPK)-36* AlkPhos-94
TotBili-1.7*
[**2100-9-1**] 07:05AM BLOOD Lipase-24
[**2100-9-1**] 07:05AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2100-9-1**] 07:05AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
[**2100-9-1**] 12:05PM BLOOD Type-ART pO2-213* pCO2-37 pH-7.49*
calTCO2-29 Base XS-5
Relevant Imaging:
1)Cxray ([**9-1**]): 1. Widened superior mediastinum likely due to
azygous distention.
2)RUQ Ultrasound ([**9-1**]): Preliminary report: Known splenic vein
thrombosis with extension to the portosplenic confluence, which
appears nonocclusive. The thrombus appears to extend into the
SMV. The main portal vein also displays a nonocclusive thrombus
with the intrahepatic veins and portal system appearing patent
and with normal flows. Cholelithiasis.
Brief Hospital Course:
Mr. [**Known lastname 79209**] is a 46yo male with history of cirrhosis [**3-13**] NASH,
Crohn's disease, diabetes, known esophageal varices, presenting
with hematemesis, intubated and in fair condition.
1)Hematememsis: Patient presented to outside hospital with
bloody vomitus and melanotic stools. He immediately underwent an
upper endoscopy which showed both esophageal varices as well as
gastric varices. His esophageal varices were banded. He was also
noted to have prominent gastric varices that were of concern.
Pictures from his endoscopy are included. He was also started on
IV PPI and octreotride gtt. He was then transferred to [**Hospital1 18**] for
TIPs evaluation. Mr. [**Known lastname 79209**] normally receives his care at the
[**Hospital3 2358**], but no ICU beds were available at this time. Upon
transfer to [**Hospital1 18**], hepatology was consulted. He was then
transferred to the MICU for closer monitoring. Interventional
radiology was also consulted for TIPs evaluation. A RUQ U/S was
also done to evaluate the portal-splenic system. He has a known
splenic thrombus but the ultrasound here showed extension of the
clot into the porto-splenic confluence as well as involvement of
the SMV. Given the ultrasound findings the decision was made to
abort the TIPs procedure. Dr. [**Last Name (STitle) **] from hepatology spoke with
Dr. [**First Name (STitle) 1726**] at the [**Hospital3 **] and felt that the patient should
be transferred to the [**Hospital3 **] for further management since
he gets all his care there. He received 1 unit FFPs and 2 units
of platelets at [**Hospital1 18**].
2)Splenic vein thrombosis: Patient has known splenic vein
thrombosis. Based on ultrasound here there appears to be
extension of the clot into the portal-splenic confluence. After
talking with hepatology, the decision was made to start the
patient on a heparin gtt (no bolus) with goal PTT of 60-70 given
his acute bleed and platelet count.
3)Cirrhosis: Secondary to NASH. Patient is followed closely at
the [**Hospital3 2358**] by Dr. [**First Name (STitle) 1726**]. The Nadolol was held given the
acute loss of blood. He had been on Ceftin on admission, likely
for SBP prophylaxis. This was changed to Ceftriaxone here. He is
being tansferred to [**Hospital1 1774**] for further work-up.
4)Respiratory: Patient was intubated at OSH for endoscopy to
airway protection. His ventilator settings at time of discharge
is: AC TV 550 FI02 0.40 RR 14 Peep 5. He is on Propafol for
sedation.
5)Crohn's disease: Patient stable at this time. He is on
Prednisone 15mg as an outpatient. Given NPO status, this was
changed to Solumedrol 20mg IV daily.
6)Diabetes: Patient with high insulin requirements at baseline.
Given this, he was briefly started on an insulin gtt. This was
stopped and he was placed on an insulin sliding scale.
Medications on Admission:
Nadolol 10mg daily
Levsin PRN
Novolog 20 units TID
Levamir 44 / 40 units
Flexeril 10mg
Oxycodone
Aldactone 50mg [**Hospital1 **]
Lasix 40mg [**Hospital1 **]
Prednisone 15mg [**Hospital1 **]
Vitamin D daily
Flomax 0.4mg daily
Ceftin daily
Discharge Medications:
1. Pantoprazole 40 mg IV Q12H
2. MethylPREDNISolone Sodium Succ 20 mg IV Q12H
3. CeftriaXONE 1 gm IV Q24H
4. Heparin gtt
Please continue heparin gtt with goal PTT between 60-70.
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Octreotide Acetate 100 mcg/mL Solution Sig: Fifty (50)
microgram Injection INFUSION (continuous infusion).
7. Propofol 10 mg/mL Emulsion Sig: [**6-/2042**] micrograms Intravenous
TITRATE TO (titrate to desired clinical effect (please
specify)).
8. Insulin sliding scale
Continue insulin sliding scale
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses:
Hematemesis
Splenic vein thrombosis
Cirrhosis
Thrombocytopenia
Secondary diagnoses:
Type 2 Diabetes
Discharge Condition:
Stable. Intubated.
Discharge Instructions:
1)You were admitted for an upper gastrointestinal bleed and
evaluation for a TIPs procedure. You also had an ultrasound
which showed that you have a blood clot in your veins near the
spleen and liver. As a result, you were started on a blood
thinner called heparin.
2)After speaking with Dr. [**First Name (STitle) 1726**], the decision was made to
transfer you to the [**Hospital3 2358**] since you normally receive your
care there.
3)Please take all medications as listed in the discharge
instructions.
4)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness, abdominal pain, or any other concerning
symptoms, please return to the emergency room.
Followup Instructions:
You are being transferred to the [**Hospital3 2358**] for further
work-up.
|
[
"456.20",
"571.5",
"456.8",
"555.9",
"250.00",
"287.5",
"571.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8073, 8088
|
4321, 7162
|
342, 348
|
8252, 8273
|
2935, 3830
|
9000, 9078
|
2237, 2241
|
7451, 8050
|
8109, 8192
|
7188, 7428
|
8297, 8977
|
2256, 2916
|
8213, 8231
|
274, 304
|
3848, 4298
|
376, 1555
|
1577, 2149
|
2165, 2221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,127
| 183,283
|
41582
|
Discharge summary
|
report
|
Admission Date: [**2157-11-30**] Discharge Date: [**2157-12-9**]
Date of Birth: [**2099-9-15**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14255**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2157-12-1**] deceased donor renal transplant
History of Present Illness:
58 y/o M with long standing ESRD on HD since [**2-/2150**], currently
receiving dialysis through LUE AV graft. Renal disease thought
to be due to history of DM and HTN. Presents today for renal
transplant.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG:
-[**6-/2155**] VFib arrest with CABG at [**Hospital1 112**] for 3vd, 5vessel-CABG with
LIMA to LAD double touchdown with endarterectomy from D1 to
apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA
-[**4-/2157**] CABG Redo sternotomy and coronary artery bypass graft
x3, saphenous vein graft to obtuse marginal 1, 2 and 3.
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2-/2157**] PCI POBA to 70% L main occulsion, POBA 90% in LAD, DES
placed to L circ for 80% prox with 60% mid occlusion
Repeat cath [**5-2**] showed instent restenosis of L circ (extending
to L main)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- ESRD on hemodialysis (at Quality Care [**Location (un) **], Tu,[**Last Name (LF) 5929**],[**First Name3 (LF) **]
overnight dialysis)
- Diabetes mellitus with renal complications
- Neuropathy
- Retinopathy
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
- Cataract
- Charcot foot due to diabetes mellitus
- Hypothyroidism
- Hyperlipidemia
- Obesity s/p Lap Band ([**2154**])
- Hyperparathyroidism [**3-17**] renal
- Renal osteodystrophy
- Pulmonary Nodule (Solitary)
- History of Colonic Adenoma
- Left arm fistula
- s/p Lap Band ([**2154**])
Social History:
Lives in [**Location **] with his wife and sister-in-law. [**Name (NI) **] 3
children who live in the area. Retired 3 years ago. Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies
Family History:
Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.
Physical Exam:
Vitals: 98.3, 92, 81/53, 20, 98%RA
Gen: NAD, AOx3
HEENT: anicteric, EOMI, few missing teath
CV: RRR, no m/r/g, median sternotomy scar
P: CTAB
GI: soft, NTND, ecchymosis from insulin injections, NABS
Ext: Graft in LUE with positive thrill, no c/c/e
Pertinent Results:
[**2157-11-30**] 10:17AM BLOOD WBC-8.0 RBC-4.24* Hgb-14.4 Hct-42.2
MCV-100* MCH-34.0* MCHC-34.2 RDW-15.0 Plt Ct-261
[**2157-12-9**] 05:38AM BLOOD WBC-3.7* RBC-3.17* Hgb-10.1* Hct-29.0*
MCV-92 MCH-31.9 MCHC-34.8 RDW-16.3* Plt Ct-159
[**2157-12-6**] 06:00AM BLOOD PT-11.5 PTT-29.0 INR(PT)-1.1
[**2157-11-30**] 10:17AM BLOOD UreaN-20 Creat-5.4* Na-134 K-4.9 Cl-93*
HCO3-32 AnGap-14
[**2157-12-9**] 05:38AM BLOOD Glucose-139* UreaN-26* Creat-4.6* Na-136
K-3.7 Cl-98 HCO3-31 AnGap-11
[**2157-12-9**] 05:38AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.0
[**2157-12-9**] 05:38AM BLOOD tacroFK-14.6
Brief Hospital Course:
58 year old man with significant CAD s/p multiple CABG and
multiple PCI interventions due to multiple episodes of in stent
restenosis (most recent [**7-26**]), ESRD on HD for over 7 years was
admitted to the Tranplant Service for preop renal transplant
from high risk donor with h/o IV drugs and high risk sexual
behavior. Donor tested negative for HIV and hepatis panel. On
[**2157-12-1**], he underwent deceased donor renal transplant to the
right iliac fossa with [**Doctor Last Name 406**] drain placement and double-J
ureteral stent placed with uretero-vesicular anastomosis. Given
preop chronically low BP (sbp in 90s), Neo-Synephrine was
infused for most of the OR time and was continued in the PACU.
Surgeon was Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. Please refer to operative note
for details. Induction immunosuppression was given which
consisted of solumedrol, cellcept and prograf. Of note,he was
kept on ASA/Plavix for cardiac stents.
Postop, in PACU, urine was negligible and bloody. [**Doctor Last Name 406**] drain
output was bloody with high output (~600cc). Hct decreased to
27.5 from 42.2 (preop). A total of 4 units of PRBC, FFP and
platelets were transfused. There was concern for need to return
to OR. However, renal transplant duplex demonstrated no
hydronephrosis/hematoma, appropriate arterial and venous
vascular signals. Intraparenchymal arterial signals were noted
to have low velocity, however acceleration time was good and
diastolic flow was seen throughout. Flow was not demonstrated in
the subcortical region on color Doppler imaging. Hct remained
stable.
He was transferred to the SICU for management. Blood pressure
continued to be low and Levo was added. He was tachycardic with
MAP of 65. SOB and volume overloaded. Epinephrine was started,
substernal chest pain and numbness radiating down left arm. Pain
was similar to pas anginal pain. EKG showed new ST depressions
in the anterior leads concerning for posterior infarct.
Epinephrine was stopped and morphine given with resolution of
chest discomfort. Repeat EKG showed resolution of ST
depressions. No NTG was administered secondary to hypotension.
Cardiac enzymes were trended and ASA was given. Swan-Ganz
catheter was placed.
Cardiac enzymes were cycled with notation of increased troponins
in setting of renal failure. Cardiology was consulted noting
high risk for stent re stenosis. Cardiac echo showed EF of 65%.
ASA/plavix were restarted. Cardiology felt ST depression was
secondary to demand ischemia due to either surgery/fluid shifts,
tachycardia or epinephrine. Medical management was recommended
(ASA/Plavix/BB/Statin). Transplant was concerned that symptoms
were possibly due reaction to Thymoglobulin. THymoglobulin was
run over a longer period of time after pre-meds (solumedrol,
tylenol and benadryl).
He became hyperkalemic and SOB. Decision was made to start CVVHD
for no urine output. A L IJ temporary HD line was placed and
CVVHD started
Hct dropped from 32 to 27 and he was transfused 2 units PRBCs.
Potassium and calcium continue to trend down. BP improved and
pressors were stopped. Hct remained stable.
On [**12-4**], neo was off and he tolerated volume off. The decision
was made to stop CVVHD and start HD on [**12-6**]. He transferred out
of the SICU.
Diet was advanced and tolerated. Immunsuppression consisted of 4
doses of ATG (150mg doses), steroid taper, Cellcept and prograf
with dose adjustment per trough levels. He did have high
glucoses from steroids and insulin was adjusted. Nephrology
followed closely and adjusted his medications such resumption of
metoprolol and adding tums/vit D for low calcium.
Urine output (bloody) remained low with approximately low 100s.
HD was tolerated via the LUE AVF on [**12-8**]. Left temporary HD
line was removed. JP drain outputs continued to remain high (up
to 400cc) serosanguinous fluid. RLQ incision had serosanguinous
drainage. Hct decreased to 24-25. 2 units of PRBC were given at
HD on [**12-8**] to keep hct high as he was on ASA/Plavix and
JP/incision had sanguinous drainage.
He was assisted OOB and ambulated with PT. PT cleared him for
home. Foley was removed on [**12-8**]. Urine output was less than 100
for 24 hours. He did well with transplant teaching and felt well
enough to go home on [**12-9**]. [**Location (un) 2203**] VNA was set up to
assist/assess him at home.
Plans were to continue HD via AVF at outpatient center. Labs
were to be drawn on [**12-10**] as Prograf dose increased to 17 on
[**12-7**]. 2 doses were held then dose was decreased to 8 for a day
as level was 14.8. On [**12-9**], level was 14.6. PM dose was held
and 5mg was ordered for [**12-10**].
He was discharged to home on [**12-9**]. R CVL was removed prior to
discharge.
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Novolog scale
Insulin NPH 20 bedtime
synthroid 300 mcg daily
toprol XL 12.5 [**Hospital1 **]
Nephrocaps 1 tab daily
Sevelamer 2400 before meals
Zocor 40mg at bedtime
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Calcium Carbonate 1000 mg PO TID:PRN indigestion
5. Calcium Carbonate [**2145**] mg PO HS
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. HYDROmorphone (Dilaudid) 0.5-1 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 0.5-1 tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
9. NPH 10 Units Breakfast
NPH 30 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
10. Levothyroxine Sodium 300 mcg PO 5X/WEEK (MO,TU,WE,TH,FR)
11. Metoprolol Tartrate 12.5 mg PO BID
12. Mycophenolate Mofetil 1000 mg PO BID
13. Nephrocaps 1 CAP PO DAILY
14. Nystatin Oral Suspension 5 ml PO QID
15. Omeprazole 40 mg PO DAILY
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Tucks Hemorrhoidal Oint 1% 1 Appl PR TID
18. ValGANCIclovir 450 mg PO 2X/WEEK (TU,FR)
19. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit [**Unit Number **]
capsule(s) by mouth once a week Disp #*12 Capsule Refills:*0
20. Tacrolimus 0 mg PO ONCE Duration: 1 Doses
do not take pm of [**12-9**]
21. Tacrolimus 5 mg PO ONCE Duration: 1 Doses
take am [**12-10**] after prograf level drawn at 9am at [**Hospital Ward Name 1826**] 7
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
ESRD
s/p deceased donor renal transplant
Delayed graft failure
anemia
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Location (un) 2203**] VNA arranged. They will call you to schedule home visit.
Please call the [**Hospital 1326**] clinic [**Telephone/Fax (1) 673**] if you have any
of the following:
temperature of 101 or greater, chills, nausea, vomiting,
inability to eat/drink or take ANY of you medications, increased
abdominal pain, incision redness/increased drainage or bleeding,
increased "JP" drain output or fluid appears more bloody,
increased urine output or urine output stops, constipation or
diarrhea, malfunction of left arm AVF
-continue hemodialysis 3x per week
-Prograf level has been too high (goal level about 10); You will
need to have blood drawn Saturday [**12-10**] for lab monitoring at
[**Hospital Ward Name **], [**Hospital Ward Name 1826**] 7 th Floor at 9am then twice weekly as
directed
-You may shower with soap & water, pat incision dry, cover drain
and incision with dry gauze
-Empty your drain and record all fluid out.
-no heavy lifting ( nothing heavier than 10 pounds)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-12-15**] 2:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2157-12-15**] 3:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-12-19**] 1:00
Completed by:[**2157-12-9**]
|
[
"285.1",
"V45.11",
"V12.53",
"V45.86",
"250.40",
"E878.0",
"357.2",
"250.50",
"250.60",
"588.0",
"585.6",
"414.00",
"272.4",
"788.5",
"996.81",
"411.89",
"403.91",
"244.9",
"V45.81",
"V45.82",
"276.7",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"55.69",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9655, 9706
|
3329, 8112
|
310, 360
|
9824, 9824
|
2723, 3306
|
10995, 11424
|
2300, 2440
|
8367, 9632
|
9727, 9803
|
8138, 8344
|
9975, 10972
|
2455, 2704
|
702, 1299
|
266, 272
|
388, 597
|
9839, 9951
|
1330, 1906
|
619, 682
|
1922, 2284
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,178
| 122,231
|
50437
|
Discharge summary
|
report
|
Admission Date: [**2134-12-3**] Discharge Date: [**2134-12-11**]
Date of Birth: [**2065-5-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
EGD [**2134-12-10**]
History of Present Illness:
Ms. [**Known lastname 919**] is a 69 year-old female with grade III infiltrating
ductal carcinoma of the right breast, ER/PR positive and Her-2
neu negative on arimidex, hypertension and obstructive sleep
apnea who presented to the emergency room with nausea, vomiting
and abdominal pain after eating [**Holiday 1451**] dinner. Per notes,
prior to eating the meal she felt well but afterwards she
experienced acute-onset abdominal pain, nausea and vomiting. She
was not experiencing hematemasis. The date of her last bowel
movement is unclear. She was not experiencing fevers or chills.
She was experiencing a sensation of pressure in her chest which
she has noticed before after eating. She was not experiencing
diarrhea. The persistent vomiting has never happened to her
before.
.
In the ED, initial vitals: 97.9 (98.8), 95, 110/80, 18, 97% on
RA. Labs were notable for hypokalemia (2.8) and a WBC count of
19,000 w/ a left-shift. UA trace positive. CT abdomen w/o acute
pathology although it did show a large hiatal hernia such that
her entire stomach is above her diaphragm. CXR without
infiltrates but with large hiatal hernia. EKG without acute
changes. Emesis in the ER was guaiac positive. ASA 325 and CE
were sent. EKG unchanged from [**2133**]. She received aspirin 325 mg
and potassium. She also received Zofran and ativan for nausea.
She received levofloxacin 500 mg IV and flagyl 500 mg IV x1.
.
On the floor the patient's antibiotics were discontinued as she
had no obvious source of infection. During the day of the 29th
she was noted to be 95 on 2L nasal cannula. She had persistent
small amounts of emesis throughout the day. The attending was
called to evalute the patient at approximately 5 AM for
desaturations to 86% on 5L NC. ABG peformed at that time was
7.45/51/62/37. Repeat CXR showed a new right sided opacity. She
was placed on a 100% non-rebreather with saturations initially
in the low 90s. On initial evaluation she was speaking full
sentences and appeared comfortable without accessory muscle use.
The decision was made to transfer the patient to the [**Hospital Unit Name 153**].
.
On arrival to the [**Hospital Unit Name 153**] the patient was hypoxic to 83% despite
100% non-rebreather. The decision was made to intubate the
patient. Post-intubation the patient vomitted large amounts of
clear liquid with digested food. An NGT was placed to suction.
She was hypotensive in the setting of receiving bolus sedation
and transiently required peripheral dopamine but this resolved
with the administration of 2 L NS bolus.
Past Medical History:
1. Grade III infiltrating ductal carcinoma of the right breast
diagnosed in [**12/2132**], ER/PR positive, Her-2/neu negative,
metastatic work-up negative. S/p dose-dense Cytoxan, Adriamycin
followed by 12 weekly cycles of Taxol. On [**2133-7-31**], she
underwent a right partial mastectomy with axillary sampling. She
was found to have residual invasive ductal carcinoma, 1.7 cm,
grade 3, EIC negative, LVI positive with 0/11 nodes positive for
metastatic disease. Her margins were negative. She went on to
receive postoperative adjuvant
radiation therapy, which was completed on [**2133-11-13**]. Now on
Arimidex (started in 12/[**2133**]).
2. Gastritis
3. Hypertension
4. Hiatal hernia
5. Diverticulosis
6. Colon polyps ([**2132**] was last colonoscopy)
7. OSA (hasn't used her CPAP recently)
Social History:
She lives alone, her daughter lives close by. She functions
independently w/ ADLs and still drives. She has a 20-pack-year
smoking history. She rarely drinks. She is divorced from her
first husband and her second husband died. She is retired from
airline reservations. She has a daughter who works at [**Hospital1 105095**].
Family History:
Shows her father died at 94 of kidney problems,
her mother at 83 with a CVA. She had a brother die of
complications of spinal cord injury at age 59 and a sister in
her
70s with multiple problems.
Physical Exam:
Vitals: T: 96.5 HR: 102 BP: 124/59 O2: 100%
General: Intubated, heavily sedated, does not open eyes to voice
HEENT: PERRL, sclera anicteric, MM moist
Neck: no bruits
CV: RRR, s1 + s2, no murmurs, rubs, gallops
Resp: Clear to auscultation anteriorly and laterally, previously
decreased breath sounds on left base
GI: soft, non-tender, non-distended, hypoactive bowel sounds, no
organomegaly appreciated
GU: foley draining clear yellow urine
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
[**2134-12-3**] 02:35PM WBC-19.5*# RBC-5.00# HGB-13.6 HCT-39.9
MCV-80* MCH-27.2 MCHC-34.0 RDW-14.9
[**2134-12-3**] 02:35PM NEUTS-89.9* LYMPHS-3.9* MONOS-5.7 EOS-0.2
BASOS-0.3
[**2134-12-3**] 02:35PM PLT COUNT-322
[**2134-12-3**] 02:35PM GLUCOSE-115* UREA N-23* CREAT-1.0 SODIUM-143
POTASSIUM-2.5* CHLORIDE-98 TOTAL CO2-31 ANION GAP-17
[**2134-12-3**] 02:35PM ALT(SGPT)-39 AST(SGOT)-50* CK(CPK)-342* ALK
PHOS-133*
[**2134-12-3**] 02:35PM LIPASE-20
[**2134-12-3**] 02:35PM cTropnT-<0.01
[**2134-12-3**] 02:35PM CK-MB-16* MB INDX-4.7
[**2134-12-3**] 02:35PM ALBUMIN-4.9*
[**2134-12-3**] 05:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2134-12-3**] 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2134-12-3**] 05:40PM URINE RBC-0-2 WBC-[**3-10**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2134-12-3**] 02:35PM PLT COUNT-322
PA AND LATERAL CHEST, [**2134-12-3**] AT 1814 HOURS
.
FINDINGS: The lungs remain clear without consolidation or edema.
Again noted is a massive hiatal hernia with essentially an
intrathoracic stomach and a large air-fluid level. The aorta is
mildly tortuous. The cardiac silhouette is borderline enlarged
but stable. No effusion or pneumothorax is seen. The visualized
osseous structures again demonstrate a slight levoconcave
curvature of the thoracic spine.
.
IMPRESSION: Stable radiograph with no acute pulmonary process.
Massive
hiatal hernia with intrathoracic stomach.
.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST:
IMPRESSION:
1. Large hiatal hernia.
2. Cholelithiasis.
3. Small bilateral pleural effusions.
4. Peripheral areas of low attenuation in the right kidney with
cortical
defects, likely reflecting areas of scarring from a prior
episode of
pyelonephritis on [**2133-2-28**].
.
EKG: Sinus rhythm. Compared to tracing #1 there is no
significant diagnostic
change.
.
Brief Hospital Course:
Impression: Mrs. [**Known lastname 919**] is a 69 year old female with grade III
infiltrating ductal carcinoma of the right breast, hypertension
and obstructive sleep apnea who presented to the emergency room
with nausea, vomiting and abdominal pain. On day two of
admission the patient was transferred to the [**Hospital Unit Name 153**] for hypoxic
respiratory failure in the setting of aspiration and witnessed
aspiration during intubation. S/p Extubation [**12-6**].
.
Hypoxic Respiratory Failure/Aspiration: Patient with respiratory
failure in the setting of nausea, vomiting, leukocytosis and
likely aspiration pneumonia on CXR. Hypoxia despite
non-rebreather on the floor. Patient required intubation and
ventilation x 1day and was later extubated. Etiology of
respiratory failure is unclear and likely multifactorial realted
to her pneumonia, aspiration and possibly mucous plugging
acutely. Patient has known large hiatal hernia that may be her
etiology of aspiration. PAtient passed a speech a swallow
evaluation. Patient was pput on a GERD diet. She was
insttructed to eat all meals upright to avoif future aspiration.
Patient was given Levaquin and Flagyl for aspiration pneumonia
and was instructed to complete a full course.
.
Nausea/Vomiting: Patient with known large hiatal hernia.
Differential diagnosis includes viral syndrome, gastric outlet
obstruction, or gastritis. KUB with no evidence of free air,
dilated bowel loops. Patietn had EGD on [**2134-12-10**] that showed
gastritis. Patient was already on a [**Hospital1 **] ppi. Carafate was
added to her regimen. GI recommended UGI series to look for
paraesophageal hernia, which will be done as an outpatient next
Wednesday. The patient clinically improved and had no more
n/v/abd pain for multiple days. Patient was instructed to
follow up with gastroenterology and her PCP. [**Name10 (NameIs) **] patient can
later be referred to surgery for consideration of surgical
correction of the hernia if she is a candidate.
.
Hypertension: Stable on home regimen.
.
Breast cancer: Currently in remission. Continued arimdex
.
Depression: Continued sertraline, wellbutrin and ativan
.
Hypothyroidism: Continued levothyroxine
.
Prophylaxis: Heparin SC, IV PPI
.
Code: Full (discussed with patient, HCP)
.
Dispo: Consider transfer to the floor today
.
Communication: w/ patient and daughter [**Name (NI) 402**] [**Name (NI) 919**] (HCP)
Medications on Admission:
Arimidex 1 mg PO daily
Bupropion 200 mg SR [**Hospital1 **]
Restasis eye drops [**Hospital1 **]
Esomeprazole 20 mg daily
Levothyroxine 88 mcg daily
Lorazepam 0.5 mg QHS:PRN
Nifedipine 60 mg SR daily
Potassium 20 meq daily
Sertraline 200 mg QAM
Simvastatin 80 mg daily
Triamterene-HCTZ 37.5-25 mg daily
Aspirin 81 mg daily
Calcium 1000 mg daily
Thera tears PRN
Multivitamins daily
Discharge Medications:
1. oxygen
3L continuous pulse dose for portability.
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
4. Bupropion 200 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
5. Sucralfate 100 mg/mL Suspension Sig: One (1) PO four times a
day.
Disp:*1 bottle* Refills:*2*
6. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
7. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
13. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
15. M-Vit 27-1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
-Nausea/vomiting likely secondary to hiatal hernia/gastritis
-Aspiration pneumonia
Discharge Condition:
Good
Discharge Instructions:
-Take antibiotics for 4 more days
-Take Nexium TWICE a day and carafate to treat your gastritis.
-Eat all your meals while sittting upright to prevent reflux of
gastric contents. Try to minimize/avoid foods that may
exacerbate reflux.
-Continue oxygen at home. VNA nursing will continue to evaluate
you and determine when you do not need it anymore.
-Ask your PCP to arrange [**Name Initial (PRE) **] follow up CXR for 4 weeks from now to
follow up on your pneumonia.
-Follow up with your PCP and gastroenterology. Please call on
Monday and make these appointments.
-Call PCPs office or return to ED if you experience worsening
nasea/vomiting, abdominal pain, shortness of breath,
fevers/chills or other worrisome signs/symptoms.
Followup Instructions:
-Provider: [**Name10 (NameIs) 326**] UPPER GI (HOSPITAL) RADIOLOGY [**Hospital Ward Name 23**] building
[**Location (un) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2134-12-15**] 9:00
-Please call the [**Hospital **] clinic on Monday to arrange a follow up
appointment with Dr. [**Last Name (STitle) 6220**] regarding your hiatal hernia and
gastritis. He should follow up on the results of your upper GI
series.
-Please call your PCPs office on monday to arrange a follow up
appointment for 1-2 weeks from now.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2134-12-14**]
|
[
"E915",
"553.3",
"V12.72",
"401.9",
"V10.79",
"V10.3",
"327.23",
"562.10",
"574.20",
"933.1",
"285.9",
"535.40",
"507.0",
"311",
"276.51",
"276.3",
"276.8",
"458.29",
"518.81",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.07",
"38.93",
"45.16",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10962, 11013
|
6790, 9209
|
332, 355
|
11140, 11147
|
4844, 6767
|
11929, 12622
|
4117, 4315
|
9640, 10939
|
11034, 11119
|
9235, 9617
|
11171, 11906
|
4330, 4825
|
277, 294
|
383, 2938
|
2960, 3758
|
3774, 4101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,799
| 109,875
|
36453+58088
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-11-15**] Discharge Date: [**2118-11-22**]
Date of Birth: [**2044-8-14**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
74M w/bilateral renal masses
Major Surgical or Invasive Procedure:
[**11-15**] PROCEDURES: Left laparoscopic radical nephrectomy and left
laparoscopic para-aortic lymph node dissection.
[**11-16**] PROCEDURE: Open splenectomy for splenic rupture
History of Present Illness:
1. Peripheral vascular disease.
2. 2.5 cm right renal mass.
3. 3.2 and 1.6 solid left renal masses.
4. [**1-18**] MRI left kidney: 3.1 and 2.1 solid lesion suspicious
for papillary RCC, right kidney: 1.9-cm solid lesion in the mid
kidney suspicious for RCC.
5. [**9-18**] MRI, significant increase in mass, 4.9 cm with
perinephric nodules.
Past Medical History:
PMH: HTN, bilateral renal masses, HLD
PSH: splenectomy [**2118**], lap left radical nephrectomy [**2118**], R CEA
([**Doctor Last Name **]) [**2116**], hernia repair x 2
Social History:
He is a senior project coordinator for the Department of Mental
Health, specializes in [**Doctor First Name **] networks. He has a 50-pack-year
smoking history, continues to smoke one pack per day, occasional
alcohol, no drug use.
He drinks rare alcohol. He is retired but still works two days
a week.
Family History:
Not available at time of dictation
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, appropriately tender along incisions
Incisions c/d/i w/out evidence hematoma, infection
Foley catheter in place, urine yellow/clear
JP to [**Doctor Last Name 14837**] bulb in place.
Extremities w/out edema or pitting and no report of calf pain
Pertinent Results:
[**2118-11-21**] 3:25 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2118-11-22**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2118-11-22**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2118-11-8**] 11:00 am URINE Site: CLEAN CATCH CLEAN CATCH.
**FINAL REPORT [**2118-11-9**]**
URINE CULTURE (Final [**2118-11-9**]): <10,000 organisms/ml.
[**2118-11-21**] 05:20AM BLOOD WBC-17.9* RBC-2.90* Hgb-9.0* Hct-26.3*
MCV-91 MCH-31.0 MCHC-34.2 RDW-13.5 Plt Ct-555*
[**2118-11-20**] 03:06AM BLOOD WBC-18.5* RBC-3.04* Hgb-9.0* Hct-27.6*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.4 Plt Ct-549*
[**2118-11-19**] 03:47AM BLOOD WBC-18.8* RBC-2.82* Hgb-8.5* Hct-25.4*
MCV-90 MCH-30.2 MCHC-33.4 RDW-13.8 Plt Ct-371
[**2118-11-21**] 05:20AM BLOOD Glucose-151* UreaN-14 Creat-1.0 Na-134
K-4.0 Cl-97 HCO3-29 AnGap-12
[**2118-11-20**] 03:06AM BLOOD Glucose-75 UreaN-18 Creat-1.1 Na-137
K-4.1 Cl-98 HCO3-28 AnGap-15
[**2118-11-19**] 03:47AM BLOOD Glucose-81 UreaN-15 Creat-1.2 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
[**2118-11-20**] 03:06AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 82579**] was admitted to Urology after undergoing
laparoscopic Left nephrectomy. There was splenic bleeding
intra-op with 50-100cc extravasation, controlled with packing
and dry at the end of the case. Post-operatively Mr. [**Known lastname 82579**]
had hypotension, poor urine output, and 10-point drop in Hct
over 3 hours, so he was taken for emergent splenectomy. Total
received 3u PRBC and 2L crystalloid resuscitation. Excellent
hemostasis at the end of splenectomy but had 350cc bloody JP
output immediately post-op. Remained asymptomatic and JP output
slowed. The patient received perioperative antibiotic
prophylaxis. The patient was transferred to the intensive care
unit from PACU in stable condition. On POD1 he was hydrated for
urine output >30cc/hour, provided with pneumoboots and incentive
spirometry for prophylaxis. He was monitored with serial
hematocrits. He was eventually transferred from the ICU to the
general surgical floor where he made a gradual recovery and was
advanced with diet. Basic metabolic panel and complete blood
count were checked, pain control was transitioned from PCA to
oral analgesics, diet was advanced to a clears/toast and
crackers diet. Abdominal drain output was monitored and checked
for creatinine and amylase and at discharge was left in place.
Urethral foley was removed on day prior to discharge but he
failed the voiding trial so it was replaced. Diet was slowly
advanced but by discharge he was on a regular house diet. The
remainder of the hospital course was relatively unremarkable.
The patient was discharged in stable condition, eating well,
ambulating independently, and with pain control on oral
analgesics. On exam, incision was clean, dry, and intact, with
no evidence of hematoma collection or infection. The patient was
given explicit instructions to follow-up in clinic with Dr.
[**Last Name (STitle) 3748**] for trial of Void and staple removal and with Dr. [**Last Name (STitle) **]
for abdominal drain removal.
Medications on Admission:
Metoprolol 25 mg PO bid
Simvastatin 20 mg PO qhs
Vitamin b12 1000 mcg PO daily
ASA 325 mg PO daily
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. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): DO NOT SMOKE WHILE CONCURRENTLY
WEARING PATCH.
Disp:*14 Patch 24 hr(s)* Refills:*2*
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: DO
NOT RESUME until cleared by Dr. [**Last Name (STitle) 3748**] &/or Dr. [**Last Name (STitle) **].
11. Outpatient Lab Work
-Please empty and MEASURE AND RECORD the daily output of the
drain and be prepared to share these findings with Dr. [**Last Name (STitle) **] at
your appointemnt.
Discharge Disposition:
Home
Discharge Diagnosis:
[**11-15**]: Renal Cell Carcinoma
[**11-16**]: Splenic Rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please also refer to the provided written instructions on
post-operative care, instructions and expectations made
available from Dr. [**Last Name (STitle) 3748**]??????s office.
-The DRAIN will remain in place until your follow-up appointment
with Dr. [**Last Name (STitle) **] and the Foley will be removed when you see Dr.
[**Last Name (STitle) 3748**] later this week.
-Please empty and measure AND RECORD the daily output of the
drain and be prepared to share these findings with Dr. [**Last Name (STitle) **] at
your appointemnt.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-DO NOT RESUME your pre-admission dose of ASPIRIN 325mg PO DAILY
until explicitly cleared by Dr. [**Last Name (STitle) 3748**] &/or Dr. [**Last Name (STitle) **]
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Resume all of your pre-admission/home medications except as
noted. Do not take Aspirin or Non-steroidal anti-inflammatories
(ibuprofen, etc.) unless advised to do so.
-Call your Urologist's office today to schedule/confirm your
follow-up appointment in 3 weeks AND if you have any questions.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-If you have been prescribed IBUPROFEN (the ingredient of Advil,
Motrin, etc.) , you may take this and Tylenol together
(alternating) for additional pain control---please try TYLENOL
FIRST and take the narcotic pain medication as prescribed if
additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark tarry stools)
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
-Please call Dr.[**Name (NI) 11306**] office to arrange for TRIAL OF VOID
and surgical skin clip removal for Thursday this week;
[**2118-11-24**].
-The DRAIN will remain in place until your follow-up appointment
with Dr. [**Last Name (STitle) **]. Your appointment has been made for [**2118-11-29**] at
10:30 AM.
-Call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for follow-up AND if
you have any urological questions. Dr. [**Last Name (STitle) 3748**]??????s Nurse
Practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] may be reached at the same
number.
Completed by:[**2118-11-25**] Name: [**Known lastname 13208**],[**Known firstname 33**] Unit No: [**Numeric Identifier 13209**]
Admission Date: [**2118-11-15**] Discharge Date: [**2118-11-22**]
Date of Birth: [**2044-8-14**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3840**]
Addendum:
This addendum reflects notation of the vaccines provided prior
to discharge.
The following three vacines were provided prior to discharge.
PNEUMOcoccal Vac Polyvalent 0.5 mL IM
Influenza Virus Vaccine 0.5 mL IM NOW X1
MENINGOcoccal Conj Vaccine (Menactra) 0.5 mL IM ONCE
Duration: 1 Doses
Major Surgical or Invasive Procedure:
[**11-15**] PROCEDURES: Left laparoscopic radical nephrectomy and left
laparoscopic para-aortic lymph node dissection.
[**11-16**] PROCEDURE: Open splenectomy for splenic rupture
Discharge Disposition:
Home
Discharge Diagnosis:
[**11-15**]: Renal Cell Carcinoma
[**11-16**]: Splenic Rupture
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3843**] MD [**MD Number(2) 3844**]
Completed by:[**2118-12-9**]
|
[
"577.9",
"289.59",
"272.4",
"458.29",
"788.20",
"285.1",
"E878.6",
"998.11",
"305.1",
"189.0",
"443.9",
"401.9",
"998.2",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"55.51",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
11093, 11099
|
3035, 5041
|
10887, 11070
|
6618, 6618
|
1801, 3012
|
9534, 10849
|
1425, 1461
|
5191, 6482
|
11120, 11342
|
5067, 5168
|
6769, 9511
|
1476, 1782
|
267, 297
|
546, 895
|
6633, 6745
|
917, 1089
|
1105, 1409
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,651
| 124,949
|
43429
|
Discharge summary
|
report
|
Admission Date: [**2167-4-30**] Discharge Date: [**2167-5-3**]
Date of Birth: [**2120-2-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
T9-L2 fusion with vertebrectomies T10/L2
History of Present Illness:
47-year-old gentleman who unfortunately has been diagnosed with
a lung carcinoma. He suffered metastasis to the T10-L1
vertebral bodies. He is relatively asymptomatic but on serial
FDG PET scan, the metastasis is still metabolically active. The
volume of the lesion is significant and does suggest
potential instability. He denies any difficulty with bowel,
bladder, or gait. He has no positional symptoms at present. He
has undergone CK to the area and now presents for spinal
stabilization.
Past Medical History:
1. NCSLC, stage IV, as described above, diagnosed in [**12-14**],
complicated by diffuse metastatic disease to left adrenal, right
mandible, sternum, left sacrum, left femoral head, right lesser
trochanger, destructive lesions of the T10 and L1 vertebra with
possible spinal canal extension, now on cyberknife treatment for
vertebral lesions, after poor response to carboplatin and
pemetrexed, now awaiting treatment with erlotinib.
2. Hodgkin's disease, stage IIa, diagnosed in [**2141**], treated with
radiation, then with relapse in [**2146**], treated with chemotherapy.
3. S/p splenectomy
Social History:
The patient is married and has three children, [**8-20**]. He works
previously worked in software, now not working. He enjoys
playing the violin. He has never smoked. He drinks alcohol
occasionally.
Family History:
From OMR: The patient's mother is 75 years old and has diabetes
and obesity. His father is 76 years old and is well. The
patient's maternal grandmother is 101. [**Name2 (NI) 93448**] of his
grandparents have malignancies. The patient's mother has one
brother, and the patient's father had two brothers and two
sisters, none of whom have a history of cancer. The patient has
one brother, age 49, who is well.
Physical Exam:
On examination, his motor strength is [**4-8**] in hip
flexion,extension, quadriceps, hamstrings, dorsiflexion, and
plantar flexion bilaterally. His sensory examination was intact
with respect to the modality of light touch. His reflexes were
normal and symmetric. The straight leg raise was negative
bilaterally as was the [**Doctor Last Name **] maneuver. His back was flat
and nontender.
Pertinent Results:
PATHOLOGY REPORTS ARE STILL PENDING AT THE TIME OF THIS SUMMARY
Radiology Report CHEST (PORTABLE AP) Study Date of [**2167-4-30**] 5:59
PM
[**Doctor First Name **] [**2167-4-30**] 7:38 PM
Final Report
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Status post posterior fusion T10-L1.
Comparison is made with prior study dating back [**2167-2-8**].
Cardiac size is normal. ET tube is in standard position 4.8 cm
above the
carina. Right IJ catheter tip is in the upper right atrium.
Multifocal
opacities in the right lung greater on the upper lobe have
improved.
Unchanged fullness of the right hilum and right paratracheal
stripe due to patient's known lymphadenopathy.
Hardware is seen in the thoracolumbar region
There is no pneumothorax or large pleural effusion.
The study and the report were reviewed by the staff radiologist.
Radiology Report T-SPINE Study Date of [**2167-5-2**] 11:45 AM
Final Report
THORACIC SPINE, [**2167-5-2**]
CLINICAL INFORMATION: Fusion T9-L2.
Standing radiographs obtained demonstrating fusion hardware from
T9 through L2 with pedicle screws, posterior fusion rods and
interbody fusion devices. An IVC filter and multiple surgical
clips are present. Alignment is maintained. There is some loss
of disc height at several levels. Surgical drain is present.
Staples are present along the midline posteriorly. There is
mildly dilated small bowel, likely secondary to ileus. Continued
observation recommended.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2167-5-3**] 05:54 12.6* 2.96* 8.8* 26.5* 89 29.8 33.3 18.6*
223
Source: Line-Right IJ
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2167-5-3**] 05:54 223
Source: Line-Right IJ
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2167-4-30**] 07:30 448*
LAB USE ONLY
[**2167-5-3**] 05:54
Source: Line-Right IJ
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2167-5-3**] 05:54 122*1 5* 0.6 137 3.5 107 22 12
Source: Line-Right IJ
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2167-4-30**] 17:18 Using this1
Source: Line-aline
Using this patient's age, gender, and serum creatinine value of
0.4,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 40-49 is 99 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2167-4-30**] 19:30 19 30 170 69 102* 0.6
Source: Line-arterial
OTHER ENZYMES & BILIRUBINS Lipase
[**2167-4-30**] 19:30 19
Source: Line-arterial
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2167-5-3**] 05:54 9.0 2.3* 1.8
Source: Line-Right IJ
Brief Hospital Course:
Pt was admitted electively and brought to OR where under general
anesthesia he underwent posterior fusion. He tolerated this
well, was brought to PACU intubated and was safely extubated 3
hours post-op.Post op exam should full motor strength. Postop
his pain was managed and titrated to PO meds. His diet and
activity were advanced. He had JP drain placed intraop which was
monitored and removed [**2167-5-2**]. Foley was removed [**5-2**]. He
continued to do well and his Hct remained stable. He was
cleared for d/c to home by PT. It was noted that he had
tachycardia for most of his hospital course. He stated this was
the norm for him and he remains asymptomatic. He agree's with
the plan for d/c to home.
Medications on Admission:
Ambien 5 mg po qhs prn
Tessalon perles prn
Oxycodone 5 mg po prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: BE SURE NOT TO TAKE MORE THAN
4000MG OF TYLENOL PER DAY .
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) AS PREVIOUSLY
PRESCRIBED Subcutaneous Q12H (every 12 hours): please contact
dr [**Last Name (STitle) **] if your weight has changed - this may change the
dose of this medication .
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no BM >24hr.
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
Disp:*135 Tablet(s)* Refills:*0*
12. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Tarceva 150 mg Tablet Sig: One (1) Tablet PO once a day: you
may now restart this medication.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic lesions to spine with instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2167-5-3**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
* You may resume yout tarceva upon discharge.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**9-17**] DAYS FROM THE DATE OF YOUR
SURGERY FOR REMOVAL OF YOUR STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2167-5-3**]
|
[
"V10.72",
"198.7",
"198.5",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"81.05",
"80.99",
"81.04",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
7827, 7833
|
5473, 6190
|
328, 371
|
7922, 7922
|
2591, 5450
|
8969, 9273
|
1750, 2160
|
6306, 7804
|
7854, 7901
|
6216, 6283
|
8073, 8946
|
2175, 2572
|
279, 290
|
400, 899
|
7937, 8049
|
921, 1517
|
1533, 1734
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,414
| 142,003
|
26069
|
Discharge summary
|
report
|
Admission Date: [**2167-2-23**] Discharge Date: [**2167-3-1**]
Date of Birth: [**2110-5-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic w/ syncopal episode
Major Surgical or Invasive Procedure:
Aortic Valve Replacement w/ 29mm CE Pericardial Tissue Valve
[**2167-2-23**]
History of Present Illness:
Pleasant 56 y/o male with known Aortic Stenosis folllowed by
serial echo's for approximately 10 yrs. In [**2165-5-11**] he had
syncopal episode alond with Atrial Fibrillation (which converted
to SR). In [**12-15**] he had another episode of AFib which converted
to SR on it's own. His last Echo now shows a critical Aortic
Valve area of 0.55 cm2 and presents for surgery.
Past Medical History:
Aortic Stenosis
Hypertension
h/o Atrial Fibrillation
Congestive Heart Failure
Hepatitis C
Anxiety/OCD
Social History:
Retired. Lives with wife.
Quit smoking 20 yrs ago after 1/2ppd
Drinke [**3-14**] alcoholic beverages/day
Family History:
Non-Contributory
Brief Hospital Course:
Mr. [**Known lastname 32624**] had usual pre-operative work-up approximately 1
week prior to surgery. He was a same day admit and on [**2167-2-23**]
was brought directly to the operating room where he underwent an
Aortic Valve Replacement. Please see operative note for surgical
details. He was transferred to the CSRU in stable condition.
Later on op day pt was weaned from sedation and awoke
neurologically intact. He was then extabed. By post-op day one
he was weaned off of Neo-synephrine for BP support and was
started on B blockers, Aspirin, and diuretics. During his
post-operative period he was gently diuresed towards his
pre-operative weight. He was transferred to the cardiac surgery
step down unit on post op day one. His chest tubes were removed
on post op day two. CXR revealed no pneumothorax, but possible
left pneumonia with tiny bilateral effusions. On post-op day two
he was anemic, with a HCT of 21.9. Repeat bloodwork revealed a
HCT of 26.1. Patient was asymptomatic and transfusion was held.
On post op day three his HCT continued to be low, 20, with
repeat showing an HCT of 22. His platelet count was also
trending down and a HIT screen was done which was negative. He
also developed a fever between post-op day two and three, at one
point approximately 103. WBC was normal and urine and blood
cultures were negative. On post-op day four his platelets
increased and his epicardial pacing wires were removed. He
continued to remain anemic with HCT of 20.8. Pt refused blood
transfusion statinng he felt good. The patient's hematocrit
remained stable, and his platelet count was 165 upon discharge.
The patient was discharged on post-op day #6 in stable condition
and fever-free for >24hours.
Medications on Admission:
Celexa 40mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
9. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 45673**]Hospice
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Hypertension
h/o Atrial Fibrillation
Congestive Heart Failure
Hepatitis C
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incision with water and gentle soap.
Gently pat dry. Do not apply lotions, creams, ointments or
powders to incision. Do not take bath.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
Please contact office immediately if you notice signs of
sternal/chest drainage or develop fever greater than 101.5
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 45670**] in [**2-13**] weeks
Dr. [**Last Name (STitle) 64714**] in [**1-12**] weeks
|
[
"428.0",
"780.6",
"424.1",
"287.5",
"282.49",
"427.31",
"285.9",
"070.70",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
3941, 3999
|
1136, 2852
|
353, 431
|
4161, 4167
|
1095, 1113
|
2917, 3918
|
4020, 4140
|
2878, 2894
|
4191, 4540
|
4591, 4746
|
281, 315
|
459, 832
|
854, 957
|
973, 1079
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,901
| 125,875
|
51113
|
Discharge summary
|
report
|
Admission Date: [**2158-3-15**] Discharge Date: [**2158-4-4**]
Date of Birth: [**2100-8-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Ascites
Major Surgical or Invasive Procedure:
Dobhoff tube placement
Multiple paracenteses
Colonoscopy
Endoscopy
Hickman line placement
History of Present Illness:
57 yo M with cirrhosis due to hepatitis C decompensated with
ascites, encephalopathy, varices, and mild jaundice referred by
his hepatologist Dr. [**Last Name (STitle) **] for TIPS evaluation for refractory
ascites. Patient has had hepatitis C for over 30 years but over
the past 2 months developed increasing ascites not responsive to
escalating doses of lasix and aldactone. Per report, last
paracentesis was four days ago, he reports 'a lot of fluid
removed' and was negative for SBP. Ascites has re-accummulated
rapidly since then so patient was referred to [**Hospital1 18**] for further
evaluation after seeing his PCP [**Name Initial (PRE) 3011**] (initially presented to
[**Hospital3 7571**]Hospital and then was transferred here). Patient
denies any fevers or chills, but reports chronic abdominal pain
over all of his belly (which he attributes to the ascites) and
worsening shortness of breath due to fluid accumulation in this
abdomen. Denies hemoptysis or rectal bleeding. Does have a
history of encephalopathy, but does not stool more than once per
day on his current lactulose regimen. He also reports an EGD at
[**Hospital3 7571**]Hospital one year ago where he was told he had
varices (unsure of grade).
.
In ED VS were 98.4 93 117/69 97% on RA. Labs sig for Na of 127,
Cre of 1.7, Tbili of 1.8, INR of 1.5. WBC of 11.6. CXR showed no
focal pneumonia. Guiac negative. Liver attending was consulted
who recommend admission to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] with paracentesis and
U/S in AM.
.
On the floor, patient had a run of SVT which broke
spontaneously. Unable to get an EKG at the time. Patient denies
any chest pain or palpitations at the time and stated he had
gotten up to go to the bathroom at the time and had been 'lying
down' all day. Has never had a tachycardia before.
Past Medical History:
Cirrhosis due to Hepatitis C/EtOH (no treatment)
- has had disease for 30 years without treatment
- unknown genotype
- decompensated with ascites, encephalopathy, mild jaundice,
varices
- [**Location (un) **] records indicate ? GI bleed, small volume hematemesis
- EGD on [**2158-2-25**] with mild to moderate gastritis, 1+ nonbleeding
esophageal varices and mild erosive reflux esophagitis
h/o previous EtOH abuse (quit in [**1-/2158**])
PVD s/p aortobifemoral bypass graft in [**2150**]
Social History:
Currently unemployed. Previous EtOH abuse, quit 2 months ago.
used to drink 'a lot' of EtOH for many years, declined to
elaborate. Current smoker > 60 pack year history. Denies current
IVDU, does have history of IVDU.
Lives with wife and 2 teenage children - son and daughter.
Family History:
Mother died of pancreatic cancer
Physical Exam:
Admission physical exam:
VS: 97.1 117/69 94 20 96% on RA
GA: elderly M AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. +scleral
icterus nad sublingual jaundice.
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: distended, +BS. midline abd vertical scar well healed.
+fluid shift. + caput medusa. no g/rt. unable to palpate spleen.
neg [**Doctor Last Name 515**] sign. No TTP.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no jaundice.
Neuro/Psych: no asterixis.
.
Pertinent Results:
Admission labs:
[**2158-3-14**] 09:35PM WBC-11.6* RBC-3.08* HGB-10.7* HCT-31.9*
MCV-104*# MCH-34.8* MCHC-33.6 RDW-15.7*
[**2158-3-14**] 09:35PM NEUTS-79.3* LYMPHS-12.1* MONOS-7.4 EOS-0.9
BASOS-0.3
[**2158-3-14**] 09:35PM PT-16.8* PTT-32.8 INR(PT)-1.5*
[**2158-3-14**] 09:35PM ALBUMIN-2.5* CALCIUM-7.9* PHOSPHATE-4.5
MAGNESIUM-2.0
[**2158-3-14**] 09:35PM LIPASE-35
[**2158-3-14**] 09:35PM ALT(SGPT)-26 AST(SGOT)-37 ALK PHOS-89 TOT
BILI-1.8*
[**2158-3-14**] 09:35PM GLUCOSE-154* UREA N-23* CREAT-1.7*#
SODIUM-127* POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-12
[**2158-3-15**] 03:08PM ASCITES WBC-109* RBC-39* POLYS-4* LYMPHS-10*
MONOS-7* MESOTHELI-4* MACROPHAG-71* OTHER-4*
[**2158-3-15**] 03:08PM ASCITES TOT PROT-1.3 LD(LDH)-68 ALBUMIN-LESS
THAN
[**2158-3-15**] 04:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
[**2158-3-15**] 04:41PM URINE OSMOLAL-474
[**2158-3-15**] 04:41PM URINE HOURS-RANDOM CREAT-366 SODIUM-<10
POTASSIUM-73 CHLORIDE-<10
.
Abd U/S:
IMPRESSION:
1. Patent hepatic and portal veins, with slow flow through the
portal vein.
Hepatofugal flow is seen in the left portal vein.
2. Cirrhotic liver with moderate amount of ascites without any
evidence of
concerning focal lesion.
.
[**3-16**] Echo:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 75-80%). Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The mitral valve leaflets are
elongated. There is borderline/mild bileaflet mitral valve
prolapse. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion
.
Renal U/S: Normal left and right kidney with normal waveforms.
.
EGD:
Trace varices at the lower third of the esophagus, non-bleeding
Normal mucosa in the whole stomach
Normal mucosa in the whole duodenum
.
Colonoscopy:
Abnormal mucosa was noted from rectum to length of colon
examined. There was erythema, friability, hyperemia and edema,
consistent with ischemic colitis.
Brief Hospital Course:
57 y.o. male with alcohol and hep C cirrhosis presenting for
TIPS but with course complicated by end stage renal failure, GI
bleed, and multisystem organ failure transitioned to comfort
care and subsequently expired at 8:27 PM on [**2158-4-4**] with chief
cause of death ischemic colitis (week) and secondary cause
respiratory failure (minutes) with contributing causes of
alcoholic cirrhosis, hepatitis C cirrhosis, and hepato-renal
syndrome.
# EtOH/Hepatitis C cirrhosis: Child's Score of 10, class C. MELD
of 18 on admission.
Decompensated with ascites, grade I varices, recent
encephalopathy and mild jaundice. HCV VL was 64,200. Admitted
for evaluation for TIPS given refractory ascites. Recent
paracentesis 4 days prior to admission negative for SBP. RUQ
ultrasound not suggestive of Budd-Chiari. Patient received
diagnostic and therapeutic paracentesis [**2158-3-15**], with removal of
3L ascites. Peritoneal fluid not suggestive of SBP. SAAG > 2.2,
so unsurprisingly suggestive of portal hypertension. Patient
received another therapeutic paracentesis on [**2158-3-17**]. The plan
was to prepare patient for TIPS procedure on [**2158-3-21**], but [**Last Name (un) **]
and intractable nausea necessitated his transfer to the
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for additional care. On the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
service, lactulose was continued for encephalopathy. Dobhoff
tube was placed for poor nutrition and insufficient calorie
intake. HRS was treated as below. The patient was seen by SW who
found that the patient had had recent EtOH intake - 6 weeks PTA
- and was therefore, not a transplant candidate at this time.
Part of his transplant evaluation was initiated, however this
was not completed. Hyponatremia was managed as below.
.
# Hepatorenal syndrome: The patient was admitted with a Cr of
1.8. Call to OSH revealed a baseline Cr of 0.9. He gave a
history of multiple recent paracenteses without albumin
administration. He had also been on spironolactone and lasix.
Urine sediment revealed hyaline casts. Urine Na < 10, Uosm
365-474. Cr rapidly worsened up to 8.7. Urine output declined -
was < 500 cc's for 3 days and then patient became anuric. Renal
was consulted. Treatment for HRS was begun early in the Cr
decline with aggressive albumin administration, max dose
octreotide and midodrine without effect. Unfortunately, the
patient was anuric for several days necessitating hemodialysis.
Initially, a temporary dialysis line was placed, which was
changed to a tunnelled Hickman line. HD was continued. Renal U/S
showed normal kidneys with normal waveforms.
.
# Anemia: On presentation, patient was anemic with Hct 31.5, MCV
= 102. Likely from alcohol and AOCI. After placement of the
temporary dialysis catheter, the patient had uncontrollable
oozing from the site, serial Hcts were checked and went as low
as 20.9. The patient was transfused with 4U of PRBC with
appropriate response.
.
# Hyponatremia: Na on admission was 127. Thought to be
hypervolemic hyponatremia in setting of cirrhosis and
hyper-[**Male First Name (un) 2083**]/high-ADH state. Urine Na <10, with urine Osm 474.
Water restriction to 2L was enacted along with low salt diet and
Na improved to 138.
.
# History of EtOH use: Patient reports substantial EtOH abuse
history in the past, but denies any EtOH use for the past two
months - his son reported recent alcohol use 6 weeks PTA.
Continued MVI, thiamine, folate. Patient not a transplant
candidate given substance use history though patient did report
willingness to participate in relapse prevention program.
.
# Malnutrition: Nutrition was consulted on transfer to ET
service. Calorie counts revealed insufficient intake. A Dobhoff
was placed and tube feeds were started.
.
# SVT: Patient with narrow-complex tachycardia on telemetry on
morning after admission, asymptomatic (was standing at the
time). Returned to [**Location 213**] sinus rhythm without intervention. He
had a repeat episode of Afib w/ RVR on [**3-27**] and again on [**3-30**] in
HD. Was treated with IV diltiazem and IV metoprolol. His
pressures dropped briefly into SBP of 80s but the decrease was
not sustained.
.
#. Ischemic Bowel: On the evening of [**3-30**], the patient had the
acute onset of BRBPR and altered mental status, he was
transferred to the ICU. Was intubated the morning of [**3-31**] and
underwent EGD and flex-sig, which revealed ischemic colitis.
Patient evaluated by transplant surgery team, but was not felt
to be surgical candidate given underlying liver and renal
disease. He was managed conservatively with close monitor of
HCT and hemodynamics, with transfusions as needed for recurrent
bleeding. Patient had left IJ trauma line placed [**3-31**] for
access. Given rising WBC and concern for intrabdominal
infection, patient on antibiotics with zosyn.
.
#. Hypotension: Patient developed hypotension while in ICU, in
setting of acute blood loss from ischemic colitis, sedation in
setting of intubation, underlying cirrhosis, and possible sepsis
in setting of ischemic colitis, leukocytosis and concern for
intraabdominal process. Patient initially on levophed for
pressor support, though switched to dopamine on [**4-1**] given
desire to minimize vasocontriction given ischemic bowel.
Patient also fluid bolused as needed. Lactate levels closely
monitored, and were trending down.
.
# Goals of care: On [**4-3**] family meeting was held and HCP decided
to transition goals to comfort. Patient was terminally extubated
and started on a morphine drip. He was transitioned back to the
floor on [**4-3**]. Pt expired on [**2158-4-4**] at 8:27PM, wife was
present.
Medications on Admission:
Thiamine 100 mg PO daily
Folice Acid 1 mg PO daily
Lactulose 15 mg PO daily
Prilosec 20 mg PO BID
Aldactone 100 mg PO daily
Lasix 80 mg PO daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"263.9",
"276.1",
"V66.7",
"443.9",
"276.52",
"276.2",
"427.31",
"070.44",
"785.50",
"571.2",
"584.9",
"275.42",
"303.93",
"585.6",
"572.4",
"518.81",
"285.9",
"789.59",
"305.1",
"427.89",
"V49.86",
"557.9",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"45.13",
"38.91",
"38.95",
"45.23",
"54.91",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12071, 12080
|
6163, 11843
|
312, 404
|
12131, 12140
|
3704, 3704
|
12196, 12206
|
3081, 3115
|
12039, 12048
|
12101, 12110
|
11869, 12016
|
12164, 12173
|
3155, 3685
|
265, 274
|
432, 2257
|
3720, 6140
|
2279, 2770
|
2786, 3065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 155,919
|
22410
|
Discharge summary
|
report
|
Admission Date: [**2129-3-10**] Discharge Date: [**2129-3-15**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly this is a 23 year old female with a past medical
history of
type I diabetes with > 20 admissions for DKA over the past four
years who presents from home with elevated blood sugars and
chest tightness. The patient reports that she has felt well
recently. On the day of admission she checked her blood sugar
at 4 PM and it was 200. At approximately five PM she noticed
the onset of chest tightness. The pain was well localized in
her epigastric region. It was non-radiating. It was associated
with a sensation of not being able to get enough air. It was
not pleuritic. At its worst it was a [**5-10**] and resolved
completely within 15 minutes. She has had this pain once in the
past when she heard that her son was in a car accident. She is
physically active and does not get chest pain with exertion.
She checked her blood sugar after experiencing this pain and it
was crtically high so she presented to the emergency room. She
reports that she last saw her [**Last Name (un) **] provider in [**Name9 (PRE) 404**] but has
since missed appointments. She reports that she has been
compliant with her insulin regimen.
In the ER her FS was noted to be critially high and was 706 on
chemistries. Her gap was noted to be 21. She was treated with 14
units of humalog and 0.5 mg of dilaudid x2 for backpain. She was
eventually started on an insulin gtt at 5 units/hr. UA, urine
hcg and CXR were negative. An EKG demonstrated tachycardia but
no ST changes and one set of CEs was negative. She received 2L
of IVFs. She was admitted to the ICU for DKA. FSBG prior to txfr
was 405.
In the ICU she was seen by the [**Last Name (un) **] consult service who
adjusted her insulin regimen. She received aggressive IV
hydration (5800 cc positive during her MICU stay). Her anion
gap closed and her insulin drip was discontinued. She was
restarted on lantus with a humalog sliding sacle.
On review of systems she currently denies feves, chills,
lightheadedness, dizziness, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, diarrhea, constipation,
dysuria, hematuria, leg pain or swelling. She did not some
vaginal pruritis in the emergency room. She has not experienced
any further episodes of chest pain. She reports back pain which
is chronic.
Past Medical History:
Past Medical History:
-Diabetes Type I: diagnosed age 16 in [**2120**] after her first
pregnancy. Most recent Hgb A1C 12.7 % ([**7-/2128**]), followed at
[**Last Name (un) **] but concern for compliance.
-stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- H. Pylori [**6-/2128**]
- Hyperlipidemia
- S/P MVA [**5-4**] - lower back pain since then. Per patient
received oxycodone from her primary provider
[**Name Initial (PRE) **] [**Name10 (NameIs) 58252**]
[**Name Initial (NameIs) **] G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
shots
- Genital Herpes
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own appartment. She is currently unemployed and received
disability. She has a 5 year old son. [**Name (NI) **] mother and sisters
live nearby. She denies tobacco, alcohol or illicit drug use.
Family History:
Her grandmother had type I diabetes. Otherwise
non-contributory.
Physical Exam:
VS: T: 98.9 HR: 110 BP: 100/51 RR: 14 O2 sat: 97%RA FSBG 382
Gen: well appearing, NAD
HEENT: anicteric sclera
Resp: CTAB, no w/r/r
Cardio: tachy with regular rhythm, nl S1 S2, no m/r/g
Abd: soft, NT, ND, +BS
Ext: no edema, 2+ DP pulses b /l
Neuro: A&Ox3, moves all extremities
Pertinent Results:
Chemistries:
[**2129-3-10**] 07:00PM BLOOD Glucose-706* UreaN-24* Creat-1.3* Na-125*
K-7.4* Cl-90* HCO3-14* AnGap-28*
[**2129-3-10**] 08:50PM BLOOD Calcium-9.8 Phos-5.3* Mg-2.0
[**2129-3-10**] 08:50PM BLOOD Acetone-LARGE
[**2129-3-10**] 08:32PM BLOOD K-4.9
[**2129-3-15**] 04:55AM BLOOD Glucose-100 UreaN-12 Creat-0.7 Na-136
K-4.1 Cl-101 HCO3-28 AnGap-11
[**2129-3-15**] 04:55AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.8
[**2129-3-10**] 10:33PM BLOOD D-Dimer-119
Hematology:
[**2129-3-10**] 07:00PM BLOOD WBC-6.1 RBC-4.56 Hgb-13.2 Hct-42.1 MCV-92
MCH-28.9 MCHC-31.3 RDW-12.3 Plt Ct-236
[**2129-3-10**] 07:00PM BLOOD Neuts-66 Bands-0 Lymphs-32 Monos-1* Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2129-3-10**] 07:00PM BLOOD Hypochr-2+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2129-3-15**] 04:55AM BLOOD WBC-6.1 RBC-3.65* Hgb-10.4* Hct-31.1*
MCV-85 MCH-28.4 MCHC-33.4 RDW-12.9 Plt Ct-186
Cardiac Enzymes:
[**2129-3-10**] 07:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-3-10**] 07:00PM BLOOD CK(CPK)-103
[**2129-3-11**] 03:22AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2129-3-11**] 03:22AM BLOOD CK(CPK)-62
Urinalysis:
[**2129-3-10**] 06:34PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.032
[**2129-3-10**] 06:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Blood Gas:
[**2129-3-11**] 04:29AM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-35* pCO2-47*
pH-7.26* calTCO2-22 Base XS--6 Intubat-NOT INTUBA
Comment-PERIPHERAL
EKG: sinus tachycardia, with rate of 126, TWF in AVL is old, no
acute ST changes
CXR: FINDINGS: The lungs are well expanded and clear. The
mediastinum is unremarkable. The cardiac silhouette is within
normal limits for size. No effusion or pneumothorax is evident.
The visualized osseous structures are unremarkable.
Brief Hospital Course:
3 year old female with a past medical history of type I diabetes
with > 20 admissions for DKA over the past four years who
presents from home with elevated blood sugars and chest
tightness.
Diabetic Ketoacidosis: The patient presented with hyperglycemia
with evidence of diabetic ketoacidosis with an elevated anion
gap at 21 and positive serum acetone and urine ketones. The
etiology of her hyperglycemia is unclear. She denies any signs
or symptoms of infection. She had no evidence of cardiac
ischemia. She reported being compliant with her insulin regimen
although she does have a history of non-compliance and has a
high hemoglobin A1C. She was initially treated with aggressive
IV fluids and placed on an insulin drip. Her anion gap closed
and she was transitioned to subcutaneous insulin. Her
electrolytes were monitored closely without severe
abnormalities. She was seen by the [**Last Name (un) **] consult service who
assisted in adjusting her insulin regimen which includes lantus
with a novolog sliding scale. She was discharged with plans to
follow up closely with the [**Last Name (un) **] diabetes center for further
management.
Chest pain: On presentation the patient noted that she had
experienced chest pain on the day of admission. The pain was
atypical for cardiac ischemia. It was well localized, not
associated with exercise or exertion and resolved within fifteen
minutes. It was associated with a subjective sense of dyspnea
but no nausea, vomiting or diaphoresis. Her EKG on admission
had no changes concerning for ischemia. She had a negative
d-dimer making pulmonary embolism unlikely. She had two sets of
negative cardiac enzymes. No further workup was pursued.
Tachycardia: The patient's heart rate was noted to be elevated
in the 100s to 120s on presentation in the setting of diabetic
ketoacidosis. After aggressive IV fluids this improved to the
90s to 100s at rest. The rhythm was noted to be normal sinus
rhythm on EKG without evidence of ischemia. Her low d-dimer
makes pulmonary embolism unlikely. Reviewing her previous
records she has been noted to have sinus tachycardia in the
past. This should be followed as an outpatient when the patient
is less acutely ill.
Acute Renal Failure: The patient's serum creatinine was 1.3 on
admission from a baseline of 0.7. Given her presentation this
was felt to be prerenal secondary to dehydration. Her renal
function quickly improved with IV hydration to her baseline.
Hypertension: The patient's blood pressures ranged from the 90s
to 100s systolic throughout this hospitalization. Her home
lisinopril was initially held but was restarted prior to
discharge.
Hyperlipidemia: No active inpatient issues. She was continued
on her home ezetimibe.
Back pain : The patient has a history of chronic low back pain
for which she is treated with oxycodone by her primary care
physician. [**Name10 (NameIs) **] continued to experience back pain during this
admission and was treated initially with IV pain medications and
ultimately transitioned back to an oral regimen. She was not
provided with any additional narcotics at the time of discharge
and will need to follow up with her primary care physician.
Medications on Admission:
Aspirin 81 mg daily
Lisinopril 10 mg daily
Zetia 10 mg daily
Protonix
Lantus 31 units qhs
Novolog sliding scale
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 33
Subcutaneous at bedtime.
6. Novolog 100 unit/mL Cartridge Sig: One (1) units Subcutaneous
four times a day: Please use sliding scale as provided. .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1) Diabetic Ketoacidosis
2) Type I Diabetes Mellitus
3) Chest pain
Discharge Condition:
stable
Discharge Instructions:
You were evaluated in the hospital for very elevated blood
sugars. You were found to be in diabetic ketoacidosis and
treated with fluids and insulin for this. You improved and were
discharged home. You were seen by the doctors from the [**Name5 (PTitle) **]
clinic who recommended changes to your insulin dosing.
The following changes were made to your medications:
1. Please take lantus 33 units at night
2. Please use the novolog insulin sliding scale we have provided
you until you are seen by the [**Hospital **] clinic.
Please keep all your follow up appointments as scheduled.
Please call your doctor or return to the ER if you have chest
pain, shortness of breath, dizziness, lightheadedness, sweating,
blood sugars >350 or less than 80.
Followup Instructions:
Please call and schedule an appointment to be seen at the [**Last Name (un) **]
Diabetes center in [**12-1**] weeks. Their number is [**Telephone/Fax (1) 2384**].
Please call your primary care physician at [**Name9 (PRE) 17377**] [**Name9 (PRE) **] Health
Center to schedule an appointment. We have not provided you
with any pain medications and you will need to see your doctor
for this. Their phone number is [**Telephone/Fax (1) 58253**].
|
[
"724.2",
"584.9",
"250.43",
"338.29",
"300.01",
"054.10",
"V58.67",
"583.81",
"276.51",
"311",
"564.00",
"427.89",
"250.13",
"786.59",
"240.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9802, 9808
|
5874, 9085
|
292, 298
|
9938, 9947
|
3975, 4927
|
10746, 11195
|
3592, 3659
|
9247, 9779
|
9829, 9829
|
9111, 9224
|
9971, 10723
|
3674, 3956
|
4944, 5851
|
239, 254
|
327, 2602
|
9848, 9917
|
2646, 3285
|
3301, 3576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,510
| 140,952
|
41440
|
Discharge summary
|
report
|
Admission Date: [**2141-4-24**] Discharge Date: [**2141-5-25**]
Date of Birth: [**2064-2-6**] Sex: F
Service: MEDICINE
Allergies:
Doxycycline
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Pheresis catheter placement, Right neck
Plasmapheresis
History of Present Illness:
77 F with a medical history of DM, HTN, and distant history of
breast cancer. She presents with acute altered mental status of
1 day duration. The history is obtained through the family as
the patient is acutely altered. Patient had episode of diarrhea
this morning and family needed to carry her back to her bed. She
was confused, sleepy and disoriented. Episode of diarrhea was
reported as dark with possible blood. Additionally patient
complained of left lower quadrant abdominal pain ([**5-16**]). Family
deny patient complaining of headache, vision difficulty, chest
pain, SOB or urinary symptoms. Patient's baseline mental status
is alert and independent of all ADLs. Family additionally report
episode of feeling "a little more confused" this past Wednesday
which resolved and yesterday more fatigue but otherwise her
usual state of health. Family deny new medications.
On arrival to the ED VS T 94.6, BP 152/80, HR 88, RR 16, 92%
NRB. Tmax 100.9. BP ranged 124-154/81-82. Patient given
levaquin, vancomycin, zosyn. Patient started on a heparin drip
due to elevated troponin. She was admitted to the MICU for
altered mental status.
In the MICU, the diagnosis of TTP was made. She was started on
daily plasma exchange on [**4-25**]. Her mental status improved and
she was transferred to the floor.
Past Medical History:
Diabetes
Hypertension
Peptic ulcer disease
Shingles
Carpal tunnel
Breast cancer: she breast cancer in [**2100**], and it sounds like
there were lymph nodes removed. She has not had any problems
since then. She did have a mastectomy.
Questionable history of discoid lupus
Social History:
She never smoked, no alcohol use. She lives with her son and
daughter in law. She was a systems analyst.
Family History:
No early coronary artery disease. No other cancers.
Physical Exam:
Admission Physical Exam:
GEN: Holding head in pain. Disoriented - unable to name name,
place, date or family. Unable to hold conversation.
HEENT: PERRL, dryMM, op without lesions, no jvd.
RESP: Anterior - CTA b/l with good air movement throughout
CV: Tachycardic, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Disoriented. Moving all extremities. Strength intact
throughout. Unable to follow commands for complete physical
exam.
RECTAL: Trace guaiac positive in ED
Pertinent Results:
Admission labs:
[**2141-4-24**] 02:55PM WBC-5.7 RBC-3.26* HGB-10.0* HCT-28.0* MCV-86
MCH-30.6 MCHC-35.7* RDW-18.8*
[**2141-4-24**] 02:55PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL TARGET-OCCASIONAL
SCHISTOCY-2+ BITE-OCCASIONAL ACANTHOCY-2+
[**2141-4-24**] 02:55PM NEUTS-46* BANDS-12* LYMPHS-28 MONOS-8 EOS-0
BASOS-0 ATYPS-4* METAS-2* MYELOS-0
[**2141-4-24**] 02:55PM PLT SMR-RARE PLT COUNT-23*
[**2141-4-24**] 02:55PM GLUCOSE-238* UREA N-55* CREAT-2.1* SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-23 ANION GAP-16
[**2141-4-24**] 02:55PM ALBUMIN-3.0* CALCIUM-8.7 PHOSPHATE-5.7*
MAGNESIUM-1.6
[**2141-4-24**] 02:55PM ALT(SGPT)-32 AST(SGOT)-132* LD(LDH)-3550*
CK(CPK)-265* ALK PHOS-72 TOT BILI-2.4* DIR BILI-0.3 INDIR
BIL-2.1
[**2141-4-24**] 03:03PM PT-12.7 PTT-29.6 INR(PT)-1.1
Pertinent labs:
[**2141-4-28**] 08:09AM BLOOD ACA IgG-3.6 ACA IgM-4.1
[**2141-4-28**] 08:09AM BLOOD Lupus-NEG
[**2141-4-28**] 08:09AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:320
[**2141-4-25**] 05:15PM BLOOD HIV Ab-NEGATIVE
[**2141-4-25**] 01:04AM BLOOD ADAMTS13 EVALUATION- <5
Hepatitis B ab positive
HBV Viral Load (Final [**2141-5-11**]):
HBV DNA not detected.
[**5-5**]:
SJOGREN'S ANTIBODY (SS-A) 5.3 POS A
RNP ANTIBODY 6.7 POS A
SM ANTIBODY <1.0 NEG
Discharge labs:
Imaging:
CT A/P on admission: Limited evaluation due to the lack of
contrast. Diffuse stranding in the retroperitoneum and along the
lateral ascending colon is of uncertain etiology. A repeat CT
after hydration and repeat creatinine is recommended with IV
contrast (paque for the high creatinine) and oral contrast to
further help to determine the cause.
CT Head: No acute intracranial process.
CXR on admission: The lung volumes are slightly low, but no
focal consolidation, pleural effusion or pneumothorax is seen.
The cardiomediastinal and hilar contours are within normal
limits. Small
extrapulmonary calcific density adjacent to the right lateral
third rib
overlying the scapula is seen, question an osteochondroma
arising from the
scapula versus the rib, unchanged.
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2141-4-28**]
IMPRESSION: Penetration with thin liquids. Otherwise, no gross
aspiration or penetration.
[**2141-5-24**] 06:40AM BLOOD WBC-9.1 RBC-3.16* Hgb-9.8* Hct-29.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-16.9* Plt Ct-223
[**2141-5-24**] 06:40AM BLOOD Glucose-45* UreaN-36* Creat-1.7* Na-141
K-3.3 Cl-102 HCO3-29 AnGap-13
Brief Hospital Course:
Patient is a 77 yo woman with hypertension and diabetes who
presented with TTP on [**2141-4-24**].
1. TTP, complicated by renal failure, hemolytic anemia, and
acute encephalopathy:
She was intially admitted to the ICU and a pheresis line was
placed. She was started on daily plasma exchange on [**4-25**] and
high-dose steroids. Rheumatology, Hematology, and the Pheresis
team followed closely. Her mental status improved, and her
platelet count began to recover with this treatment, but
plateaued. She was started on weekly rituximab due to slow
improvement. With rituximab, her platelets improved and her
last dose of plasma exchange was on [**5-19**]. She requires 1
additional dose of rituxan on [**2141-5-29**] and then she will
follow-up with hematology as an outpatient. She will be
discharged on a slow steroid taper with bactrim and PPI
prophylaxis as well as new insulin because of elevated blood
sugars while on prednisone. At the time of discharge, her renal
dysfunction had improved from a Cr peak of 3.4 back to 1.7 where
it appears to have plateaued. Her anemia is stable with Hct of
29 without signs of ongoing hemolysis. During her
hospitalization she did require multiple blood transfusions. Her
platelets rebounded to >200.
.
Rheumatology was consulted as there was concern about a possible
history of lupus, and it was unclear if this may have been
contributing to her resistance to treatment. Further
clarification with her outpatient providers revealed that she
does NOT have a history of lupus, but instead had a history of
relapsing polychondritis and possible pulmonary vasculitis.
Several rheum markers were positive, including SSa and RNP, but
she had no other evidence of systemic rheumatologic illness.
She was evaluated by Rheumatology consult service and would like
to transition her care to [**Hospital1 18**]. She will follow-up as an
outpatient with her [**Last Name (un) **] opthalmologist and then Rheumatology
for further management including timing of re-initiation of
plaquenil.
.
The patient's hypertension was poorly controlled off of
lisinopril and atenolol (due to renal failure). She was changed
to metoprolol with hydralazine and imdur in addition to her home
amlodipine. Her bp medications require further titration as an
outpatient.
.
Diabetes mellitus, uncontrolled without known complications.
Blood sugars were elevated in the setting of high dose steroids,
and holding of Januvia. Insulin was started and will continue
while the patient receives steroids.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day
SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth
daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 1,000 unit Tablet,
Chewable - 1 Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS [FISH OIL] - 1,000 mg Capsule - 1 Capsule(s)
by mouth daily
Discharge Medications:
1. alcohol swabs Pads, Medicated Sig: One (1) Topical four
times a day.
Disp:*1 Box* Refills:*2*
2. Glucometer test strips
Please dispense 1 box (120) glucometer test strips for the
Contour glucometer. Refills: 2.
3. Lancets
Please dispense 120 lancets for blood sugar testing. Refills: 2.
4. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Eighteen
(18) units Subcutaneous at bedtime: Dose according to insulin
regimen.
Disp:*4 pen* Refills:*2*
5. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: Dose according to sliding scale.
Disp:*20 pens* Refills:*3*
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
8. prednisone 10 mg Tablet Sig: Per taper Tablet PO DAILY
(Daily): 5 tabs daily for 7 days, then 4 tabs daily for 7 days
then 3 tabs daily for 7 days then 2 tabs daily for 7 days then 1
tab daily for 7 days.
Disp:*105 Tablet(s)* Refills:*0*
9. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
11. Omega 3 Fish Oil 684-1,200 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Take this while on prednisone.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
15. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
TTP
Acute renal failure
Hemolytic anemia
Left eye conjunctivitis
Hypertension
Uncontrolled type 2 diabetes without complications
Relapsing polychondritis and pulmonary vasculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low platelets due to TTP. You were
treated with steroids, plasma pheresis, and Rituxan. You
required multiple blood transfusions. Your platelet count
improved and is now stable. Continue on a slow prednisone taper
as prescribed. You require an additional dose of rituxan as
scheduled at the hematology clinic.
While on prednisone, you must take bactrim prophylaxis and
insulin as prescribed.
Please follow-up with the opthalmologist and then your
rhematologist to consider when to restart your plaquenil.
You were found to have high blood pressure and new medications
were added. You were started on hydralazine and Imdur. Your
atenolol was changed to metoprolol.
Followup Instructions:
[**2141-5-29**] 9:00AM [**Hospital **] clinic [**Hospital Ward Name 23**] Center, [**Location (un) 24**]
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for Rituxan dose.
Department: Ophthalmology
Name: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
When: Monday [**2141-6-19**] at 2;30 PM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Department: [**Hospital3 249**]
When: THURSDAY [**2141-6-1**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2141-6-8**] at 1:30 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2141-6-8**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: THURSDAY [**2141-6-15**] at 11:15 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20135**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"401.1",
"275.2",
"782.4",
"250.02",
"446.6",
"276.0",
"283.9",
"348.30",
"733.99",
"V10.3",
"790.4",
"584.9",
"276.8",
"417.8",
"372.30",
"275.3",
"780.60",
"V12.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.71",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
10236, 10242
|
5300, 7815
|
292, 349
|
10465, 10465
|
2770, 2770
|
11333, 13138
|
2118, 2172
|
8294, 10213
|
10263, 10444
|
7841, 8271
|
10616, 11310
|
4138, 4154
|
2212, 2751
|
231, 254
|
377, 1684
|
4503, 4539
|
2786, 3608
|
4553, 5277
|
10480, 10592
|
3624, 4121
|
1706, 1979
|
1995, 2102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,990
| 146,046
|
49275
|
Discharge summary
|
report
|
Admission Date: [**2175-2-8**] Discharge Date: [**2175-3-10**]
Date of Birth: [**2098-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Losartan
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Fever, Altered Mental Status
Major Surgical or Invasive Procedure:
Left femoral central venous line placement ([**2-8**])
.
Temporary HD catheter placement on [**2175-2-15**], [**2175-2-21**], [**2175-3-2**]
.
Tunneled HD catheter placement on [**2175-3-8**]
.
Excision of left upper arm arteriovenous graft.
.
History of Present Illness:
Mrs. [**Known lastname 103090**] is a 76 year old female with a PMH significant for
DM 2, ESRD on MWF HD, dCHF, CVA admitted from her nursing home
with 2 days of fever, altered mental status, and hyperkalemia
with ECG changes. Per review of records, the patient had a fever
at her NH with a Tmax of 102.9 today with a CXR performed at her
nursing home that demonstrated increased congestion without
consolidation per report. A urinalysis She was also reported to
have altered mental status from her baseline. Of note, the
patient appears to have relatively frequent admissions for
altered mental status and fever, most recently in [**10-19**] with
another admission in [**12-19**] for bleeding AVF.
In the [**Hospital1 18**] ED, VS 100.6 (Tmax to 102 in ED) 142/72 88 96%RA.
Labs were notable for a serum potassium of 6.9 with an ECG
demonstrating peaked T waves, for which the patient received
calcium, insulin, and bicarbonate with a repeat serum potassium
of 6.0. Other notable labs at the time of initial presentation
included a lactate of 4. The patient received vancomycin,
cefepime, meropenem, and acyclovir prior to transfer. The
patient also had a left femoral CVL after being unable to place
a LIJ, RIJ, or right femoral CVL. CXR demonstrated pulmonary
edema but no acute consolidation. CTAP was notable for a wall
thickening and pericolonic fat stranding in the left colon. The
patient was also evaluated by Renal, with plan for emergent HD
upon admission to the MICU.
The patient was then transferred to the MICU for further
management.
ROS: Unable to obtain secondary to AMS.
Past Medical History:
1. Type 2 Diabetes [**Hospital1 **]
2. ESRD on Hemodialysis
3. Vascular Dementia
4. Hypertension
5. Osteoarthritis
6. Cataracts
7. Hypothyroidism
8. Anemia
9. Pre-existing Stage 3 Decubitus Ulcer
10. Congestive Heart Failure, diastolic
11. s/p CVA
Social History:
Home: lives in [**Hospital3 2558**]
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
Sister - Diabetes [**Name (NI) **], hypertension, hypercholesterolemia
Physical Exam:
PHYSICAL EXAM:
VS: 100 98 182/62 15 98%RA
Gen: Minimally responsive moaning female
HEENT: Eyes possible deviated to right, although unclear
secondary to patient cooperation after patient closed her eyes
and would not re-open.
CV: Nl S1+S2, II/VI systolic murmur throughout the precordium
Pulm: Crackles to anterior auscultation bilaterally
Abd: S/NT/ND. hypoactive BS.
Ext: No c/c/e
Skin: Stage 1-2 sacral decubitus ulcer
Neuro: Unable to assess cranial nerves. Exam otherwise
non-focal.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-3-10**] 12:26PM 6.9 2.98* 9.1* 29.2* 98 30.5 31.1 16.9*
356
[**2175-3-8**] 06:03AM BLOOD WBC-5.3 RBC-2.52* Hgb-7.8* Hct-24.7*
MCV-98 MCH-31.0 MCHC-31.6 RDW-16.8* Plt Ct-438
[**2175-3-6**] 05:33AM BLOOD WBC-5.9 RBC-2.67* Hgb-8.3* Hct-26.1*
MCV-98 MCH-31.0 MCHC-31.8 RDW-16.6* Plt Ct-480*
[**2175-2-25**] 06:51AM BLOOD WBC-8.8 RBC-2.85* Hgb-9.0* Hct-28.1*
MCV-99* MCH-31.5 MCHC-32.0 RDW-16.6* Plt Ct-346
[**2175-2-22**] 07:15AM BLOOD WBC-11.4* RBC-3.03* Hgb-9.2* Hct-28.8*
MCV-95 MCH-30.3 MCHC-31.8 RDW-16.9* Plt Ct-382
[**2175-2-21**] 06:05AM BLOOD WBC-13.2* RBC-3.21* Hgb-9.9* Hct-30.6*
MCV-95 MCH-31.0 MCHC-32.5 RDW-16.8* Plt Ct-394
[**2175-2-20**] 06:30AM BLOOD WBC-16.1* RBC-3.20* Hgb-9.9* Hct-31.2*
MCV-97 MCH-31.0 MCHC-31.9 RDW-16.8* Plt Ct-365
[**2175-2-18**] 06:30AM BLOOD WBC-10.6 RBC-3.28* Hgb-10.2* Hct-32.1*
MCV-98 MCH-31.0 MCHC-31.7 RDW-16.9* Plt Ct-297
[**2175-2-17**] 03:32AM BLOOD WBC-8.2 RBC-3.00* Hgb-9.5* Hct-28.5*
MCV-95 MCH-31.6 MCHC-33.3 RDW-17.1* Plt Ct-265
[**2175-2-16**] 06:41PM BLOOD Hct-28.7*
[**2175-2-16**] 09:45AM BLOOD Hct-28.8*
[**2175-2-15**] 04:08AM BLOOD WBC-10.3 RBC-3.15* Hgb-10.0* Hct-28.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-18.2* Plt Ct-264
[**2175-2-14**] 11:39PM BLOOD WBC-14.7*# RBC-3.46*# Hgb-10.9*#
Hct-31.8* MCV-92# MCH-31.6 MCHC-34.4# RDW-18.0* Plt Ct-284
[**2175-2-14**] 06:53PM BLOOD WBC-9.6 RBC-2.65* Hgb-8.1* Hct-26.6*#
MCV-101* MCH-30.7 MCHC-30.5* RDW-16.3* Plt Ct-213
[**2175-2-14**] 05:57PM BLOOD WBC-13.7* RBC-1.97*# Hgb-6.0*# Hct-20.9*#
MCV-106* MCH-30.5 MCHC-28.7* RDW-14.3 Plt Ct-235
[**2175-2-14**] 04:15PM BLOOD WBC-12.6* RBC-3.38* Hgb-10.8* Hct-35.6*
MCV-105* MCH-31.9 MCHC-30.3* RDW-14.2 Plt Ct-208
[**2175-2-13**] 07:00AM BLOOD WBC-9.3 RBC-3.48* Hgb-11.3* Hct-37.2
MCV-107* MCH-32.5* MCHC-30.4* RDW-13.9 Plt Ct-235
[**2175-2-11**] 06:25AM BLOOD WBC-6.8 RBC-3.59* Hgb-11.7* Hct-37.4
MCV-104* MCH-32.5* MCHC-31.2 RDW-14.2 Plt Ct-226
[**2175-2-8**] 01:10PM BLOOD WBC-10.0# RBC-3.75* Hgb-12.2 Hct-39.1
MCV-104* MCH-32.5* MCHC-31.1 RDW-14.4 Plt Ct-199
[**2175-2-24**] 07:25AM BLOOD Neuts-75.7* Lymphs-17.5* Monos-4.5
Eos-2.0 Baso-0.3
[**2175-3-4**] 07:30AM BLOOD PT-13.6* PTT-30.9 INR(PT)-1.2*
[**2175-2-8**] 01:10PM BLOOD PT-13.7* PTT-28.6 INR(PT)-1.2*
[**2175-2-16**] 03:30AM BLOOD Fibrino-445*
[**2175-2-15**] 04:08AM BLOOD Fibrino-297
[**2175-2-14**] 06:53PM BLOOD Fibrino-292
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-3-10**] 12:26PM 164*1 18 4.9*# 137 4.3 95* 32 14
[**2175-3-8**] 06:03AM BLOOD Glucose-80 UreaN-23* Creat-5.1*# Na-138
K-4.5 Cl-92* HCO3-33* AnGap-18
[**2175-3-7**] 05:32AM BLOOD Glucose-124* UreaN-31* Creat-6.7*#
Na-127* K-6.4* Cl-89* HCO3-24 AnGap-20
[**2175-2-25**] 06:51AM BLOOD Glucose-126* UreaN-20 Creat-4.3*# Na-139
K-4.6 Cl-96 HCO3-29 AnGap-19
[**2175-2-15**] 04:08AM BLOOD Glucose-172* UreaN-58* Creat-9.5* Na-140
K-4.0 Cl-99 HCO3-25 AnGap-20
[**2175-2-14**] 11:39PM BLOOD Glucose-219* UreaN-57* Creat-9.3* Na-140
K-4.1 Cl-98 HCO3-27 AnGap-19
[**2175-2-14**] 06:53PM BLOOD Glucose-277* UreaN-54* Creat-9.2*# Na-142
K-4.3 Cl-101 HCO3-22 AnGap-23*
[**2175-2-14**] 05:57PM BLOOD Glucose-188* UreaN-46* Creat-8.0*# Na-143
K-4.0 Cl-104 HCO3-21* AnGap-22*
[**2175-2-14**] 04:15PM BLOOD Glucose-159* UreaN-58* Creat-10.3*#
Na-135 K-5.4* Cl-90* HCO3-23 AnGap-27*
[**2175-2-12**] 06:40AM BLOOD Glucose-156* UreaN-22* Creat-5.3*# Na-142
K-4.3 Cl-95* HCO3-34* AnGap-17
[**2175-2-10**] 06:00AM BLOOD Glucose-160* UreaN-23* Creat-4.9* Na-140
K-4.9 Cl-93* HCO3-30 AnGap-22*
[**2175-2-8**] 01:10PM BLOOD Glucose-183* UreaN-43* Creat-7.5*# Na-140
K-6.9* Cl-92* HCO3-31 AnGap-24*
[**2175-2-9**] 04:53AM BLOOD Glucose-140* UreaN-26* Creat-5.4*# Na-139
K-4.4 Cl-91* HCO3-36* AnGap-16
[**2175-3-1**] 05:00AM BLOOD CK(CPK)-83
[**2175-2-21**] 06:05AM BLOOD CK(CPK)-102
[**2175-2-20**] 06:30AM BLOOD ALT-21 AST-24 AlkPhos-97 TotBili-0.3
[**2175-2-17**] 03:32AM BLOOD ALT-25 AST-34 LD(LDH)-273* AlkPhos-65
TotBili-0.4
[**2175-2-15**] 04:08AM BLOOD ALT-44* AST-78* LD(LDH)-342* CK(CPK)-848*
AlkPhos-61 TotBili-0.8
[**2175-2-14**] 11:39PM BLOOD CK(CPK)-1067*
[**2175-2-14**] 06:53PM BLOOD ALT-55* AST-93* CK(CPK)-708* AlkPhos-52
TotBili-0.2
[**2175-2-9**] 04:53AM BLOOD ALT-26 AST-41* LD(LDH)-269* AlkPhos-92
TotBili-0.5
[**2175-2-8**] 09:40PM BLOOD ALT-26 AST-43* LD(LDH)-268* AlkPhos-94
Amylase-44 TotBili-0.5
[**2175-2-14**] 06:53PM BLOOD Lipase-19
[**2175-2-16**] 03:30AM BLOOD cTropnT-0.37*
[**2175-2-15**] 06:08PM BLOOD cTropnT-0.37*
[**2175-2-14**] 11:39PM BLOOD CK-MB-11* MB Indx-1.0 cTropnT-0.39*
[**2175-2-14**] 06:53PM BLOOD CK-MB-4 cTropnT-0.21*
[**2175-2-8**] 01:10PM BLOOD cTropnT-0.23*
[**2175-3-8**] 06:03AM BLOOD Calcium-8.8 Phos-5.4*# Mg-2.2
[**2175-2-24**] 05:59AM BLOOD Calcium-9.3 Phos-5.7* Mg-1.9
[**2175-2-15**] 04:08AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.9*
[**2175-2-14**] 06:53PM BLOOD Albumin-2.6* Calcium-8.7 Phos-7.9*
Mg-3.2*
[**2175-2-8**] 09:40PM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.1 Mg-2.2
[**2175-2-9**] 04:53AM BLOOD VitB12-1436*
[**2175-2-10**] 06:00AM BLOOD TSH-3.4
.
.
[**2175-3-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2175-3-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2175-3-6**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2175-3-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2175-3-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2175-3-3**] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL {STAPH AUREUS
COAG +}; ANAEROBIC CULTURE-FINAL INPATIENT
[**2175-3-3**] TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY {STAPH
AUREUS COAG +, STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL
INPATIENT
[**2175-3-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2175-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-28**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-26**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-25**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-23**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-23**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-22**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-21**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2175-2-20**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2175-2-20**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2175-2-20**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2175-2-19**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-19**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-18**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-17**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-17**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-16**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-15**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-14**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-13**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-11**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2175-2-11**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2175-2-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-10**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2175-2-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-9**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2175-2-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2175-2-8**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +, STAPHYLOCOCCUS, COAGULASE NEGATIVE,
STAPHYLOCOCCUS, COAGULASE NEGATIVE, CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS)}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2175-2-8**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)}; Aerobic
Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
.
.
[**2175-3-3**] 4:05 pm TISSUE PROXIMAL GRAFT LEFT.
GRAM STAIN (Final [**2175-3-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
REPORTED BY PHONE TO DR [**Last Name (NamePattern4) 103279**] [**2175-3-4**] 1PM.
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.
Please contact the Microbiology Laboratory ([**8-/2471**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SULFA X TRIMETH sensitivity testing performed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITY TO Daptomycin AND VANCOMYCIN REQUESTED BY
DR. [**Last Name (STitle) **].
SENSITIVE TO Daptomycin AT MIC 0.25 MCG/ML, Sensitivity
testing
performed by Etest.
SENSITIVE TO VANCOMYCIN AT MIC 1.5 MCG/ML, Sensitivity
testing
performed by Etest.
STAPH AUREUS COAG +. SPARSE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES TO Daptomycin AND VANCOMYCIN REQUESTED BY
DR.
[**Last Name (STitle) **].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- I
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2175-3-7**]): NO ANAEROBES ISOLATED.
.
.
.
**FINAL REPORT [**2175-2-13**]**
Blood Culture, Routine (Final [**2175-2-13**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Please contact the Microbiology Laboratory ([**8-/2471**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. days after initiation of
therapy.
Testing of repeat isolates may be warranted days after
initiation
of therapy. Testing of repeat isolates may be
warranted.
Please contact the Microbiology Laboratory ([**8-/2471**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
SENSITIVITIES PERFORMED ON CULTURE # 288-3782M.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R <=0.12 S
OXACILLIN------------- =>4 R <=0.25 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=1 S 2 S
Anaerobic Bottle Gram Stain (Final [**2175-2-9**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier **] [**2175-2-9**] AT
0855.
Aerobic Bottle Gram Stain (Final [**2175-2-9**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
.
CT abd/pelvis
Final Report
IMPRESSION:
1. Finding likely suggesting mild enterocolitis, which could be
infectious,
inflammatory or ischemic in etiology. Early obstruction can not
be excluded.
Evaluation of colon is significantly limited particularly the
transverse colon
due to underdistention. Close clinical follow-up and if needed
further
evaluation with oral contrast should be considered. The above
findings were
discussed with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Emergency Radiology.
3. Extensive SMA and [**Female First Name (un) 899**] calcifications, potentially increasing
risk for
ischemia, although no signs specific for ischemia are
identified.
4. Changes of chronic pancreatitis, stable.
5. Multiple abdominal wall collaterals and small collaterals
along the GE
junction, of uncertain etiology for which considerations might
include a
central venous stenosis or portal hypertension. Clinical
correlation is
recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name (STitle) 8913**] SUN
Approved: [**Doctor First Name **] [**2175-2-9**] 10:41 AM
.
.
.
CXR
Final Report
INDICATION: Fever.
COMPARISON: Chest radiograph [**2174-10-31**].
PORTABLE AP VIEW OF THE CHEST: Mild cardiomegaly persists. The
mediastinal
and hilar contours are stable. There is mild perihilar haziness
with mild
vascular indistinctness, which appears slightly improved when
compared to the
prior study, suggestive of mild volume overload. Mitral annular
calcifications appear to be noted. No focal consolidation,
pleural effusion
or pneumothorax is seen. There is no acute skeletal abnormality.
IMPRESSION: Moderate cardiomegaly with mild volume overload.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2175-2-8**] 11:49 PM
.
.
.
CT head
Final Report
INDICATION: 66-year-old woman with altered mental status and
some focal
signs.
COMPARISON: CT of the head without contrast from [**2174-10-11**].
TECHNIQUE: MDCT images were acquired from the vertex to the 1st
cervical
vertebrae without contrast.
FINDINGS:
Mild hypoattenuation of the periventricular white matter is
likely secondary
to chronic small vessel ischemic disease. There is calcification
of the
vertebral artery. No acute masses, infarct or bleed is present.
No midline
shift is present. No fracture is present and the visualized
sinuses and
mastoid air cells are well aerated. The ventricles and sulci are
normal in
caliber and configuration.
IMPRESSION:
No acute bleed, infarct or mass present.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: [**Doctor First Name **] [**2175-2-9**] 5:26 PM
.
.
.
CT Abd/pelvis
Final Report
HISTORY: Fever and altered mental status. Question of colitis on
prior CT.
Repeat with p.o. contrast.
TECHNIQUE: CT through the abdomen and pelvis performed after
administration
of oral and IV contrast. Multiplanar reformats were performed.
COMPARISON: [**2175-2-8**].
FINDINGS:
ABDOMEN: There is bibasilar dependent atelectasis. There is
interlobular
septal thickening suggestive of mild CHF. There is a 5 mm nodule
in the right
lower lobe. The liver and gallbladder appear normal. Again the
pancreas is
diffusely calcified with dilated pancreatic duct and pancreatic
atrophy
consistent with chronic pancreatitis. The spleen and adrenal
glands are
unremarkable. The kidneys are atrophic bilaterally. There is a
small
fat-containing umbilical hernia. There is extensive
atherosclerotic disease
of the aorta and the ostium of the mesenteric vessels. However,
the SMA and
celiac axis appear patent. The [**Female First Name (un) 899**] is difficult to visualize
given its small
size, but does appear patent. The small bowel loops are
unremarkable. Again
noted are numerous prominent collaterals throughout the anterior
abdominal
wall.
PELVIS: The colon is now more distended and fills with oral
contrast. There
is no evidence of bowel wall thickening or inflammatory process
to suggest
colitis. There is no evidence of bowel obstruction. A calcified
uterus is
noted, likely related to fibroids. A Foley is seen within the
decompressed
bladder. There is no free fluid.
There are degenerative changes in the spine including a
transitional left
L5-S1 vertebra. The bones are slightly dense suggestive of renal
osteodystrophy.
IMPRESSION:
1. No evidence of colitis or other acute inflammatory process in
the abdomen
or pelvis.
2.Stable appearance of chronic pancreatitis.
3. Stable appearance of multiple abdominal wall collaterals,
likely related to
venous obstruction in the chest.
4. 5 mm nodule in the right lower lobe. Attention on follow up
imaging
recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2175-2-9**] 6:25 PM
.
.
.
Final Report
HISTORY: Difficulty placing jugular line.
FINDINGS: Duplex and color Doppler demonstrate wide patency of
both internal
jugular veins.
The patient also underwent interrogation of her left AV fistula
for question
of a fever. The fistula is widely patent with expected areas of
mild
aneurysmal dilatation involving the draining vein. There is no
fluid
collection adjacent to the fistula.
IMPRESSION:
1. Patent jugular veins bilaterally.
2. Normal assessment of left upper extremity arteriovenous
fistula.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: MON [**2175-2-13**] 8:40 PM
.
.
.
TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with infero-lateral
hypokinesis. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. There is moderate thickening of the
mitral valve chordae. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2173-8-16**], no
change (regional LV systolic dysfunction was present - but not
reported- on the prior study).
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2175-2-9**] 10:55
.
.
The TEE probe could not be passed into the esophagus due to
patient agitation/uncooperativeness. Patient extracted probe
from her mouth twice and communicated that she did not wish to
continue with the study.
IMPRESSION: Unsuccessful esophageal intubation. Procedure
aborted secondary to patient comfort/preference.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3766**] was notified by telephone on [**2175-2-14**] at
1:30 p.m.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2175-2-14**] 17:59
.
.
.
CXR
Final Report
HISTORY: 76-year-old woman with PE at rest. Status post
intubation. Please
assess for airway placement.
COMPARISON: [**2175-2-9**].
CHEST RADIOGRAPH, PORTABLE AP VIEW:
Interval placement of endotracheal tube ending 1.2 cm above the
carina. The
nasogastric tube extends into the stomach, with the tip out of
view. Mild
patchy opacities at lower lungs are unchanged. Increased right
moderate
pleural effusion. Mild cardiomegaly is unchanged. The
mediastinal and hilar
contours are normal.
A vascular guidewire ascends from the IVC to the stented left
brachiocephalic
vein.
IMPRESSION:
1. Interval placement of endotracheal tube ending 1.2 cm above
the carina.
2. Increased moderate right pleural effusion and unchanged mild
bibasal basal
opacities.
3. Retained venous guidewire.
These findings were discussed with the IR team by Dr. [**Last Name (STitle) 12330**]
by phone on
[**2175-2-15**] at 3:40pm.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2175-2-15**] 8:27 PM
.
.
.
CXR
Final Report
HISTORY: 75-year-old woman with PEA arrest, status post
intubation, evaluate
for ET tube placement and cardiopulmonary process.
COMPARISON: Radiograph [**2175-2-14**] at 20:11.
CHEST RADIOGRAPH PORTABLE AP VIEW: Interval withdrawal of
endotracheal tube
now ending 4.7 cm above the carina. Nasogastric tube extending
into the
stomach with the tip out of view. Bibasilar mild lung patchy
opacities are
unchanged. Right moderate pleural effusion is unchanged. There
is no
pnemothorax. Stable mild cardiomegaly. The mediastinal and hilar
contours are
normal.
Unchanged position of the venous guidewired ending in a stent in
the left
brachiocephalic vein.
IMPRESSION:
1. Interval withdrawal of endotracheal tube ending 4.7 cm above
the carina.
2. Stable bilateral mild lung opacities and right moderate
pleural effusion.
3. Guidewire retained in stented left brachiocephalic vein.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2175-2-15**] 8:27 PM
.
.
.
Temp Line / wire removal report:
IMPRESSION:
1. Occlusion of the bilateral distal internal jugular veins and
right
subclavian vein with multiple chest wall collaterals precluding
placement of a
hemodialysis catheter.
2. Uncomplicated placement of a 20 cm double-lumen temporary
hemodialysis
catheter VIP via the right common femoral access with the tip
terminating in
the IVC. The catheter is ready to use.
3. Successful removal of an indwelling vascular guidewire which
was
identified extending from the left common femoral central venous
catheter.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Name (STitle) **]
Approved: [**First Name8 (NamePattern2) **] [**2175-2-21**] 8:34 AM
.
.
.
Tagged WBC scan
Final Report
RADIOPHARMACEUTICAL DATA:
439.0 uCi In-111 WBCs ([**2175-2-22**]);
HISTORY: 76 year-old female with persistent MRSA bacteremia and
rising WBC
count; recent AVF ligation.
INTERPRETATION: Following the injection of autologous white
blood cells labeled
with In-111, images of the whole body were obtained at 24 and 48
hours.
These images show a small focus of increased tracer uptake in
the left upper arm
near the elbow which may correlate with her history of a left
upper extremity
AVF ligation and likey represents an area of inflammation versus
infection. No
increased tracer uptake is seen tracking up the arm; there are
no other foci of
increased tracer uptake.
IMPRESSION: 1. Small focal tracer uptake in the left upper arm
near the elbow,
likely representing an area of inflammation versus infection. 2.
No other
evidence of inflammatory/infectious foci.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**], M.D.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D.
Approved: [**First Name8 (NamePattern2) **] [**2175-2-28**] 2:34 PM
.
.
.
TTE
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with mild hypokinesis of the inferior and
inferolateral hypokinesis. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. There is moderate
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate mitral regurgitation. No vegetation or
abscess seen. Mild inferior/inferolateral hypokinesis. Mild
pulmonary artery systolic hypertension.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2175-2-9**],
the estimated pulmonary artery systolic pressures are lower. The
other findings are similar.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2175-2-23**] 13:20
.
.
.
Final Report
TWO VIEW CHEST, [**2175-3-2**]
COMPARISON: [**2175-2-15**].
INDICATION: Preoperative assessment for AV fistula revision.
FINDINGS: Cardiac silhouette is mildly enlarged, but may be
accentuated by AP
technique. Mild pulmonary vascular congestion. New airspace
consolidation has
developed within the right middle and right lower lobes as well
as mild
associated volume loss. Small right pleural effusion has
slightly increased in
size and appears partially loculated laterally. There is no left
pleural
effusion. Skeletal structures are unchanged.
IMPRESSION:
1. New right middle and right lower lobe airspace opacification
concerning
for pneumonia with possible parapneumonic effusion. Findings
discussed by
phone with Dr. [**Last Name (STitle) 3766**] on [**2175-3-2**].
2. Mild pulmonary vascular congestion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**First Name8 (NamePattern2) **] [**2175-3-2**] 5:28 PM
.
.
CT chest/abd/pelvis
IMPRESSION:
1. Small to moderate right pleural effusion and small left
pleural effusion
are simple in nature. Associated bibasal compressive atelectasis
is greater
on the right than left lung.
2. No evidence of abscesses or infections in the chest, abdomen,
and pelvis.
3. Findings suggestive of chronic pancreatitis are stable.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: SAT [**2175-3-4**] 10:58 AM
.
.
.
Final Report
PA AND LATERAL CHEST, [**3-6**]
HISTORY: Question abscess on previous chest radiograph, does not
seem to have
pneumonia.
IMPRESSION: PA and lateral chest compared to [**3-2**] and
[**3-4**]:
The right perihilar lung has cleared at least radiographically
since [**3-4**], [**2175**], probably due to decreasing moderate-sized right
pleural effusion.
The right hilus is still mildly enlarged, probably due to
adenopathy and
should be followed. Left hilus is normal. Heart is mildly
enlarged. No left
pleural effusion. No pneumothorax. There is no evidence of
pneumonia.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2175-3-6**] 3:44 PM
.
.
.
Brief Hospital Course:
# Fevers / bacteremia / infected AV fistula:
76 year old female with DMII, ESRD on HD, dCHF, CVA, dementia
who was initially admitted to the MICU for fever and
hyperkalemia with ECG changes. She underwent HD and was called
out to the medical floor with improvment of her K. At baseline
she is disoriented to person, place, mumbling speech, ambulating
with walker; [**Name8 (MD) **] NP altered from baseline AND in setting of
fever and elevated lactate strongly suggests underlying
infectious etiology; initally, most likely etiology thought to
be colitis apparent on CT abdomen; patient high risk for diff
colitis given past history of recent antibiotic use. She was
noted to be bacteremic with MRSA, coag negative staph and
corynebacerium on [**2-8**]. She was started on vancomycin on
[**2-9**]. Initially there was also a concern for intra-abominal
process and so she was started on cipro/flagyl. C. diff was
negative and CT abd/pelvis was without infectious etiology.
Cipro/flagyl were d/c'd on [**2175-2-10**]. Lung also possible but
initial CXR unremarkable. Urine less likely source give anuric.
CNS possible source given fever and AMS although less likely
with CT findings and absence of meningeal signs on PEx. Sacral
decub possible source although no signs around area of
infection. Endocarditis possible source given murmur, but no
embolic phenomena visualized and murmur is not acute; TTE was
unremarkable. Reports of difficulty threading wire in ED through
IJ and concern for clot raises concern of septic thrombus.
Throughout hospitalization, her graft site was determined to be
the likely site of infection. For the work up of her
fevers/baceremia she then underwent a TTE which was unrevealing
and an U/S of her fistula/graft and stent in her left IJ which
were also unrevealing. The pt could not tolerate a TEE despite
attempts twice by cardiology.
Patient was scheduled to go to HD on [**2175-2-14**] but, the HD team did
not feel comfortable using her fistula due to oozing.
Transplant sugery was contact[**Name (NI) **] and planned to put her on the OR
schedule that night. On the floor at approximately 1730 that
day, she was found by nursing to be in a pool of blood and was
bleeding from her fistula site. Her SBP at that time was 54. A
code blue was called and she was intubated while she still had a
pulse. Normal saline was infused and while surgery was
attempting femoral access she lost her pulse and went into PEA
arrest. ACLS was started and her pulse returned after 8
minutes. During that time, transplant surgery cut down the
fistula and tied the brachial artery and some veins off and
packed the antecubital fossa with gauze and wrapped an ACE
bandage around her arm. She was transferred to the MICU for
further care where she had received the massive blood
transfusion protocol including 5U pRBC, 2U platelets, 2U FFP.
Arctic cooling protocol was discussed after her PEA arrest but
deferred given patient's improved/return to baseline mental
status shortly after the event. It was also noted that a
guide-wire from an emergent femoral a-line was mistakenly left
in place and migrated to the abdominal aorta during the code and
noticed afterwards while the patient was in IR for a HD catheter
placement. This guide-wire was removed by IR without any
complications.
During her MICU stay, her hypovolemic shock was stabilized and
her HD access issues were addressed with renal, ID, and
transplant surgery. A temporal femoral VIP line was placed and
used for dialysis for two sessions. Transplant surgery
recommended to continue dressing changes and no OR at that time.
She was transferred back to the floor on daptomycin at this
point but still growing positive blood cultures with Staph
aureus. Repeat TTE on [**2-23**] was negative for vegetations. A WBC
scan showed small tracer uptake at the graft site, without any
other source in the body. Surgical revision was re-discussed and
the transplant team agreed to perform a surgical revision to
remove infected graft material, which pathology/micro showed to
be growing Staph aureus. Since that time her blood cultures have
remained negative and she was able to have a tunneled HD
catheter placed for long term HD access. There was minimal
bleeding over 24 hrs at the catheter tunneled site which IR
injected with thrombin and achieved hemostasis, the patient
should not be weight bearing for 12 hours after this. She is to
have 6 weeks of vancomycin (her graft MRSA was sensitive to
vanc) starting from 6 weeks after removal of infected graft
material, dated from [**3-3**], to end [**4-14**].
# Diabetes [**Month/Day (1) **] type II. She was continued on humalog
insulin sliding scale. She was placed on a diabetic diet.
# Diastolic CHF, chronic. She has diastolic HF based on prior
TTE and CXR with signs of mild fluid overload, but no signs of
respiratory distress. We continued HD for fluid removal. BB was
held initially given concern of evolving sepsis. This was
restarted prior to discharge. Aspirin and statin were also
restarted prior to discharge on the patient stabilized.
# Dementia. Her baseline mental status is poor in setting of
vascular dementia. Per discussion with NH staff, patient
receives psychotropics for agitation (trazodone, citalopram, and
olanzapine), as well as prn olanzapine. The psychotropics were
held this admission due to her altered mental status.
Citalopram, risperdone prn were continued while we held
trazadone, olanzapine.
# Hypertension. Initially her BP meds were held in the acute
setting, however upon discharge she was on hydralazine,
amlodipine, labetalol with good BP control.
# Hypothyroid. We continued her home Synthroid. TSH was 3.4
during this admission.
# Anemia. Baseline hematocrit of 30-35, likely secondary to
ESRD. Her hematocrit returned to baseline s/p massive
transfusion protocol for her hypovolemic shock/PEA arrest and
continued to remain stable throughout the rest of her hospital
admission.
# CVA. Aspirin was held when she was in the MICU in the setting
of acute bleed.
# Hyperlipidemia. We restarted her home statin.
# Code: Full code (confirmed)
# Contact: [**Name (NI) **] [**Name (NI) 103090**] (daughter) [**Telephone/Fax (1) 103094**] (c) /
[**Telephone/Fax (1) 103280**] (h)
Medications on Admission:
HISS
Omeprazole 20 mg daily
Amlodipine 2.5 mg daily
Cinacalcet
B complex vitamin
Vitamin D
Colace 100 mg po bid
Labetalol 300 mg po tid
Calcium
Hydralazine 50 mg po QID
Simvastatin 40 mg daily
Levothyroxine 75 mcg daily
Citalopram 5 mg daily
Nephrocaps daily
Olanzapine 5 mg qhs and prn for agitation
Trazodone 50 mg qhs
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Memantine 5 mg Tablet Sig: One (1) Tablet PO Daily () as
needed for dementia.
5. Risperidone 1 mg/mL Solution Sig: 0.5 mg PO HS (at bedtime)
as needed for insomnia/agitation.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for Pain.
10. Heparin (Porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
11. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
12. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily).
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): should be stopped on
[**2175-4-14**].
15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
17. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
Hyperkalemia with EKG changes
Bacteremia with MRSA
AV fistula graft infection
.
Secondary Diagnoses
End-stage renal disease on hemodialysis
Type II diabetes [**Location (un) **]
Vascular Dementia
Hypertension
Osteoarthritis
Cataracts
Hypothyroidism
Anemia
Diastolic congestive heart failure
S/p cerebrovascular accident
Discharge Condition:
afebrile, stable vitals, tolerating POs
.
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital for treatment of high
potassium levels in the blood and bacteria in your blood. Your
potassium normalized with dialysis. An extensive workup was
conducted throughout your body and it was determined that the
bacteria was coming from an infection in your AV fistula/graft.
Initially, we could not perform a surgery on this site to remove
the infectious nidus; however, the graft led to a serious bleed
which required multiple blood products. You had a guide wire
left in your aorta as well but this was succesfully found and
retrieved without any complications. You continued to have
positive blood cultures despite being on IV antibiotics after
this time and ultimately had a graft revision by transplant
surgery after which time your blood cultures remained negative.
You had placement of a tunneled HD catheter for dialysis which
initially had small amounts of bleeding which was ultimately
controlled.
.
The following changes were made to your medicines:
- Please take vancomycin for 6 weeks after removal of infected
graft material, dated from [**3-3**], to end [**4-14**].
- Please take amlodipine 10mg daily
- Please take hydralazine 50mg every 8 hrs
- Please stop taking Aspirin 81mg due to concerns for bleeding
around your HD catheter site
- Please stop taking olanzapine and trazodone
There were no other changes to your medicines.
.
Please attend all appointments.
Please do not hesitate to return to the hospital for any
concerning symptoms at all.
.
Followup Instructions:
Please follow up with the following appointments:
.
Transplant surgery: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**]
Date/Time:[**2175-3-29**] 10:00
.
Infectious Disease:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2175-4-5**] 10:10
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icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.04",
"38.93",
"39.43",
"96.71",
"39.95"
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icd9pcs
|
[
[
[]
]
] |
41965, 42035
|
33577, 39840
|
328, 574
|
42418, 42460
|
3174, 33554
|
44151, 44514
|
2579, 2651
|
40211, 41942
|
42056, 42397
|
39866, 40188
|
42631, 44128
|
2681, 3155
|
260, 290
|
602, 2195
|
42474, 42607
|
2217, 2466
|
2482, 2563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,784
| 150,384
|
28064
|
Discharge summary
|
report
|
Admission Date: [**2145-9-6**] Discharge Date: [**2145-9-13**]
Date of Birth: [**2068-2-24**] Sex: F
Service: TRA
ADMISSION DIAGNOSIS: Polytrauma.
DISCHARGE DIAGNOSES:
1. Closed head injury with intracranial hemorrhage.
2. Cervical spine injury with associated spinal cord injury.
3. Multiple rib fractures.
4. Status post splenectomy.
5. Right wrist fracture.
6. Right grade 3C tibia and fibula fracture.
7. Comminuted left acetabular fracture.
8. Supracondylar right femur fracture.
9. L2 spine fracture.
10. Traumatic injury to the T6-T7 disc of the spinal cord.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old female
status post 50 mile per hour head on motor vehicle collision
who was pinned in her vehicle. Her initial [**Location (un) 2611**] coma scale
was 15 and the patient was moving all 4 extremities. The
[**Location (un) 2611**] coma scale deteriorated to 8 at [**Hospital 12017**] [**Hospital 12018**]
Hospital. The patient was intubated. In transit the patient
developed hypotension with systolic blood pressure in the
80s. She has received 2 units of packed red blood cells and 5
liters of crystalloid at the outside hospital.
On arrival in the emergency department the patient was with
an initial blood pressure of 60/palp, but subsequently rose
to the 110s/60s post resuscitation and subsequent heart rate
of 60.
PHYSICAL EXAMINATION: She had ecchymoses over the right eye
as well as ecchymosis to the left of the umbilicus in the
left hip. She had decreased rectal tone and an open grade 3
right tibia and fibula fracture, initially cool but recovered
pulses on reduction of the fracture. She also had deformity
of the right wrist.
She remained stable on the trauma bed and was taken to the CT
scanner for CT scan of the head, C-spine and torso. At this
point she also received a tetanus shot as well as antibiotic
coverage for her open fractures. Her CT scan was significant
for intracranial hemorrhage as well as cervical spine injury
at the C2-C3 level. She also had bilateral old fractures. Her
abdominal CT scan revealed splenic laceration with
extravasation. She also had a comminuted left acetabular
fracture.
HOSPITAL COURSE: She went from emergency room to the
operating room for exploratory laparotomy and open reduction
internal fixation of the right lower extremity as well as
angiography of the right lower extremity. She received 8
units of packed red blood cells, 6 units of fresh frozen
plasma, 2 units of platelets and 1 unit of cryo-precipitate.
During the laparotomy, gross amount of hemoperitoneum was
identified and the spleen was removed. There was also repair
of a left diaphragmatic traumatic hernia and left chest tube.
She subsequently underwent a right lower extremity angiogram
which revealed patency of arterial supply to the right lower
extremity. At this point an external fixator was applied to
the right lower extremity and she was transferred to the
intensive care unit on norepinephrine for maintenance of her
blood pressure.
On postoperative day 2 however the norepinephrine was weaned
off. Repeat head CT demonstrated worsening intracranial
hemorrhage and further neurological evaluation was consistent
with incomplete spinal cord injury. An epidural hematoma was
seen on MRI without compromise.
Over the next couple of days, the patient underwent several
further operations including placement of a halo for
stabilization of her C2-dens fracture on [**2145-9-7**].
She also underwent open reduction internal fixation of
supracondylar right femur fracture on [**9-9**] as well as
open reduction internal fixation of a comminuted left
acetabular fracture on [**9-10**]. On [**9-10**], she also
underwent open reduction internal fixation of her right wrist
fracture. The patient maintained a good cardiovascular and
renal function throughout this perioperative period. Her main
issue however centered about her closed head injury and
partial spinal cord injury. She was never observed moving
anything but her left toes. Because she had a poor
neurological prognosis based on the combination of her brain
and spinal cord injury, family decided to make her comfort
measures only. She was extubated and expired on [**2145-9-13**], at 5 a.m.
DIAGNOSES AT THE TIME OF DEATH:
1. Polytrauma.
2. Closed head injury with intracranial hemorrhage.
3. Unstable C2 spine fracture with spinal cord injury.
4. Hemoperitoneum status post exploratory laparotomy with
splenectomy and repair of left diaphragmatic hernia.
5. Open reduction internal fixation of right wrist fracture.
6. External fixation of right tibia and fibula fracture
right lower extremity arteriography.
7. Open reduction internal fixation of left acetabular
fracture.
8. Open reduction internal fixation of right femur fracture.
9. Thoracic and lumbar spine injury.
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Last Name (NamePattern4) 25081**]
MEDQUIST36
D: [**2145-10-1**] 00:01:12
T: [**2145-10-1**] 01:37:41
Job#: [**Job Number 68288**]
|
[
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"805.4",
"852.05",
"958.4",
"862.0"
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icd9cm
|
[
[
[]
]
] |
[
"79.26",
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"99.04",
"34.82",
"88.72",
"79.36",
"02.94",
"41.5",
"99.07",
"79.02",
"99.05",
"79.32",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
191, 599
|
2196, 5150
|
1393, 2178
|
157, 170
|
628, 1370
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,992
| 188,943
|
2808+55410
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-3-6**] Discharge Date: [**2153-3-18**]
Date of Birth: [**2074-11-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Recurrent gastrointestinal stromal tumor.
Major Surgical or Invasive Procedure:
Resection of recurrent gastrointestinal stromal tumor.
History of Present Illness:
Mrs [**Known lastname 13755**] is s/p GIST resection in [**2143**] and was subsequently
treated with Gleevec [**Date range (1) 13756**], [**7-19**]-present. Recently she
has had some evidence of tumor
recurrence on a CT performed in [**2151-6-14**]. This was treated
with increasing doses of Gleevec, which she tolerated
marginally. The growth has enlarged to some degree and options
were discussed the patient and she ultimately elected to undergo
surgery to have this removed.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- . Paroxysmal Atrial Fibrillation on coumadin
- . Heart Failure with preserved EF
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
.
1. CVA in [**2136**]
2. TIA in [**2138**]
3. Hypertension
4. Hypothyroidism
5. Abdominal mass - GIST (diagnosed [**2143**]) s/p surgery, on
Gleevec therapy, follows Dr. [**Last Name (STitle) 13754**] in Heme/Onc.
.
PAST ONCOLOGIC HISTORY:
- Mrs. [**Known lastname 13755**] initially presented [**2143-9-2**] with abdominal
pain. At that time, she was found to have a large mass in her
abdomen.
- On [**2143-9-6**], she underwent an incomplete resection of this
tumor. It was found to be increasing in size and she was treated
on Gleevec from [**1-/2145**] to 12/[**2146**]. At that time, she stopped it
as she was having some side effects from this therapy, most
notably severe cramping. On the Gleevec, her tumor had decreased
in size. However, the mass grew while she was off the Gleevec
and she was restarted on it again in 07/[**2149**]. She was restarted
at 200mg daily to avoid issues with cramping.
- On [**2151-6-29**] she had a CT scan which showed new liver lesions
which were concerning. An ultrasound was obtained [**2151-7-13**] which
showed these lesions and raised concern for metastatic disease.
- She was increased from Gleevec 200mg daily to 400mg daily on
[**2151-9-8**].
- She had stable CT scans and the liver lesions were determined
to be cysts, she was decreased from 400mg daily to 200mg daily
due to nausea on [**2152-4-5**].
-CT scan [**10/2152**] there was increase in size of a right upper
mesenteric nodule with no other enlarging disease. Her case was
discussed previously and surgery is an option. At this time she
is interested in trying 400mg Gleevec to see if this
controls/shrinks this mass. If the mass continues to enlarge she
would consider surgery.
Social History:
Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history: negative
-ETOH: negative
-Illicit drugs: negative
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
Gen: NAD, AOx3
CVS: RRR, no m/r/g
Resp: CTAB
Abd: soft, non distended, appropriately tender over surgical
incision. Incision c/d/i
Ext: WWP
Pertinent Results:
[**2153-3-14**] 04:23AM BLOOD WBC-8.3 RBC-3.73* Hgb-11.3* Hct-34.6*
MCV-93 MCH-30.4 MCHC-32.7 RDW-16.4* Plt Ct-243
[**2153-3-15**] 05:15AM BLOOD WBC-5.4 RBC-3.02* Hgb-9.2* Hct-28.5*
MCV-95 MCH-30.3 MCHC-32.1 RDW-16.0* Plt Ct-212
[**2153-3-17**] 05:04AM BLOOD WBC-5.8 RBC-3.35* Hgb-10.3* Hct-31.4*
MCV-94 MCH-30.9 MCHC-33.0 RDW-15.5 Plt Ct-243
[**2153-3-18**] 05:05AM BLOOD WBC-5.9 RBC-3.65* Hgb-11.0* Hct-34.7*
MCV-95 MCH-30.1 MCHC-31.7 RDW-15.4 Plt Ct-274
[**2153-3-17**] 05:04AM BLOOD PT-12.8 PTT-24.6 INR(PT)-1.1
[**2153-3-17**] 05:04AM BLOOD Plt Ct-243
[**2153-3-18**] 05:05AM BLOOD PT-14.6* PTT-26.2 INR(PT)-1.3*
[**2153-3-18**] 05:05AM BLOOD Plt Ct-274
[**2153-3-15**] 05:15AM BLOOD Glucose-122* UreaN-25* Creat-1.3* Na-141
K-4.2 Cl-103 HCO3-32 AnGap-10
[**2153-3-16**] 04:32AM BLOOD Glucose-110* UreaN-24* Creat-1.4* Na-139
K-4.5 Cl-103 HCO3-30 AnGap-11
[**2153-3-17**] 05:04AM BLOOD Glucose-139* UreaN-19 Creat-1.1 Na-141
K-4.0 Cl-101 HCO3-34* AnGap-10
[**2153-3-18**] 05:05AM BLOOD Glucose-103* UreaN-18 Creat-1.2* Na-142
K-4.1 Cl-100 HCO3-36* AnGap-10
[**2153-3-7**] 11:57AM BLOOD CK(CPK)-135
[**2153-3-7**] 03:39PM BLOOD CK(CPK)-136
[**2153-3-7**] 11:39PM BLOOD CK(CPK)-145
[**2153-3-15**] 05:15AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2
[**2153-3-16**] 04:32AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1
[**2153-3-17**] 05:04AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
[**2153-3-18**] 05:05AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Brief Hospital Course:
The patient was admitted to the west 3 surgery service with
abdominal pain secondary to intraperitoneal hemorrhage from
recurrent GIST. She was managed in the ICU upon admission. Her
initialy HCT upon admission was 21.6 and patient was given
2units of PRBCs and HCT increased to 25.4. The patient went to
IR for angiography to look for bleeding source, but this showed
no extravasation of blood from branches of the GDA. Serial HCTs
were monitored, which were stable. Patient was hemodynamically
stable and transferred to the floor on [**2153-3-9**]. On [**2153-3-10**],
patient was noted to have a diffuse, erythematous blanching rash
over her entire body, with confluence in several areas of the
trunk, face, and arms. Dermatology was consulted and recommended
a combination of benadryl, atarax, and clobetasol ointment. The
patient's rash improved dramatically over the next several days.
The patient went to the operating room on [**2153-3-13**] for an open
GIST tumor resection. (Please see operative report for further
details)
Post operatively:
Neuro: The patient received an epidural with good pain control.
When tolerating oral intake, the patient was transitioned to
oral pain oxycodone with standing tylenol. This regimen was
effective in controlling the patient's pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient has known CHF. During her hospital stay,
fluid balance was closely monitored to minimize fluid overload.
CXRs were performed post-op that showed vascular congestion that
improved during her stay. Home lasix dose was started on POD3.
Initially, patient did complain of more SOB, but this improved
greatly during her hospital course, and she was weaned off
oxygen. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was slowly advanced when appropriate, which was
initially well tolerated and patient was on regular diet.
However, she began to have worsening distension on exam, but was
still passing small amounts of flatus. The patient was made NPO
again on [**2153-3-17**] and a KUB was performed that was consistent with
ileus. The patient began to start having plenty of flatus, so
diet was slowly readvanced, which she tolerated well. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Initially on POD1, the patient's uop
was low and required bolus, and the UOP responded appropriately.
Home lasix dose was started on POD3. Electrolytes were routinely
followed, and repleted when necessary. Foley was d/c'd on [**2153-3-16**]
and patient voided without problem.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection, and there were none. The
patient's wound remained clean, dry, and intact.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required post-op.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible. Home coumadin dose was
restarted on [**2153-3-16**]. Physical therapy evaluated the patient and
determined that short term rehab was necessary to bring patient
back to her baseline.
At the time of discharge on [**2153-3-18**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Gleevec 400', Amiodarone 200', furosemide 80', levothyroxine 200
mcg', imatinib 400', potassium, warfarin with a goal INR of [**2-15**],
zolpidem PRN, docusate/senna prn
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 50 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. clobetasol 0.05 % Ointment Sig: Five (5) Appl Topical [**Hospital1 **] (2
times a day).
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
10. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day.
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: goal
INR [**2-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
recurrent gastrointestinal stromal tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-22**] 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:
Provider: [**Name10 (NameIs) 13757**] [**Name11 (NameIs) 13758**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2153-4-26**] 1:45
Please call the office to schedule an appointment with Dr.
[**Last Name (STitle) **] in [**1-14**] weeks
Completed by:[**2153-3-18**] Name: [**Known lastname 2104**],[**Known firstname 2105**] Y Unit No: [**Numeric Identifier 2106**]
Admission Date: [**2153-3-6**] Discharge Date: [**2153-3-18**]
Date of Birth: [**2074-11-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 203**]
Addendum:
The operative finding of blood in the abdomen was consistant
with a hemoperitoneum.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2153-4-27**]
|
[
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"693.0",
"V58.61",
"276.52",
"V87.41",
"438.89",
"250.00",
"428.0",
"278.01",
"197.6",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.93",
"54.4"
] |
icd9pcs
|
[
[
[]
]
] |
13035, 13276
|
4808, 8663
|
345, 402
|
9974, 9974
|
3367, 4785
|
12277, 13012
|
3121, 3192
|
8884, 9782
|
9911, 9953
|
8689, 8861
|
10157, 11138
|
11764, 12254
|
3207, 3348
|
1019, 1180
|
11170, 11749
|
264, 307
|
430, 912
|
9989, 10133
|
1211, 2913
|
934, 996
|
2929, 3105
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,515
| 194,025
|
38616
|
Discharge summary
|
report
|
Admission Date: [**2180-4-12**] Discharge Date: [**2180-4-18**]
Date of Birth: [**2147-8-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p ~15ft fall
Major Surgical or Invasive Procedure:
None
Physical Exam:
Upon presentation to [**Hospital1 18**]:
HR:80 BP:170 SBP Resp:20 O(2)Sat:95 normal
Constitutional: Appears in pain but no respiratory distress
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation. No crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Tenderness to the right shoulder and clavicle
area
Pertinent Results:
[**2180-4-12**] 10:55AM GLUCOSE-136* LACTATE-2.0 NA+-141 K+-3.6
CL--101 TCO2-24
[**2180-4-12**] 10:40AM UREA N-16 CREAT-1.2
[**2180-4-12**] 10:40AM WBC-8.1 RBC-4.67 HGB-14.2 HCT-40.6 MCV-87
MCH-30.4 MCHC-35.0 RDW-13.3
[**2180-4-12**] 10:40AM PLT COUNT-320
[**2180-4-12**] 10:40AM PT-12.5 PTT-19.4* INR(PT)-1.0
IMAGING:
FAST: negative
CT Head:No acute intracranial process. small right subgaleal
hematoma.
CT Neck: No fractures.
CT chest: Complex right diaphyseal clavicle fracture with bone
fragment in close proximity to right subclavian artery but no
evidence of vascular injury. Multiple right posterior (at
costovertebral junctions) and anterior rib fractures. Small
right pneumothorax. Multiple smaller bilateral lung contusions
and right
small lung laceration.
CT abdomen and pelvis: No acute pathology
Shoulder X ray: Severely comminuted mid diaphyseal right
clavicle fracture. The glenohumeral joint is intact.
Brief Hospital Course:
He was admitted to the Trauma Service for pulmonary care and
pain management. Orthopedics was consulted for the clavicle
fracture which was managed with closed treatment. He will remain
non-weight bearing in a sling and will follow up in 2 weeks in
[**Hospital 5498**] clinic.
He did have significant pain control issues related to his rib
fractures; discussions regarding epidural catheter took place
but patient declined this option. He initially trialed Dilaudid
PCA which was not adequate alone. Oral narcotics and adjunct
treatment with NSAID's were initiated with adequate control of
his pain. His oxygen saturations were in the high 90's on room
air. He will follow up in 2 weeks in Trauma clinic for
evaluation of his rib fractures.
He was ambulating independently and tolerating a regular diet
prior to his discharge to home.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
4. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*100 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours: take with food.
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p ~15 ft Fall
Right rib fractures [**2-28**]
Right pulmonary contusion
Right comminuted clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after sustaining a fall from a
great height. Your ribs and clavicle were fractured as a result.
Your injuries did not require any operations; you were
hospitalized for management of your pain from your rib
fractures. It is important that you take your pain medication as
prescribed; take a stool softner and laxative to avoid
constipation.
Rib fractures can take several weeks to heal. Walking around at
least 4-5 times daily, sitting in chair vs. lying down will help
to keep your lungs in adequate expansion. Use the incentive
spirometer 10x every hour while awake to help exercise your
lungs.
DO NOT bear weight on your right arm; wear the sling for
comfort.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP, in Orthopedic
Trauma
clinic for your clavicle (collar bone) fracture. Call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up next week with Dr. [**Last Name (STitle) **], Trauma Surgery for your rib
fractures. Call [**Telephone/Fax (1) 2359**] for an appointment. You will need a
standing end expiratory chest sray for this appointment.
Completed by:[**2180-6-5**]
|
[
"860.0",
"338.11",
"807.06",
"861.22",
"862.29",
"E882",
"810.02",
"780.97",
"861.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.54"
] |
icd9pcs
|
[
[
[]
]
] |
3217, 3223
|
1723, 2561
|
329, 335
|
3374, 3374
|
768, 1113
|
4246, 4719
|
2620, 3194
|
3244, 3353
|
2587, 2595
|
3524, 4223
|
350, 749
|
275, 291
|
1121, 1700
|
3389, 3500
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,299
| 154,692
|
37801
|
Discharge summary
|
report
|
Admission Date: [**2170-9-20**] Discharge Date: [**2170-9-23**]
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
dyspnea, left shoulder/neck pains
Major Surgical or Invasive Procedure:
Cardiac catheterization.
Angioplasty was performed of LCx stenosis.
History of Present Illness:
89 y/o F with PMHx of CAD s/p LAD stent and in '[**66**] she underwent
2x BMS stenting RCA and taxus stent to proximal RCA, CHF
(unknown EF), HTN, hyperlipidemia, DM-II and Paget's Disease who
was taken to [**Location (un) 620**] [**Hospital1 18**] after developing left sided shoulder,
neck pain and dyspnea overnight. Pt recalled waking up to go to
the bathroom several times and became very short of breath. She
was having trouble breathing while lying flat and was
gasping/panicking per the family.
.
At [**Hospital1 **] [**Location (un) 620**], she was anxious, SOB and diaphoretic with a sinus
tachycardia to 120 range. She was given 325mg ASA and NTG SL
with resolution of her left neck/shoulder discomfort. She was
noted to have diffuse fluid overload on CXR and was given 40mg
IV lasix, 2mg morphine and placed on CPAP with a slow resolution
of her symptoms. Labs revealed a troponin of 0.09 and CK 138 and
CK-MB 9.1. Total lactate elevated slightly at 2.1. Decision was
made for transfer to [**Hospital1 18**] for further care.
.
Upon arrival to [**Hospital1 18**], pt was chest pain free and her SOB was
markedly improved on CPAP. She was still having trouble
breathing with lying flat. EKG showed ST depressions in V4-V6,
I and aVL. She was continued on heparin gtt and given 600mg load
of Plavix in ED in anticipation for late afternoon cardiac
catheterization.
.
In the cath lab, patient complained of CP and SOB while lying
flat. O2 sat dropped to 87% on 4L. She was given lasix, and
started on a nitro gtt. She felt better after the intervention.
Angioplasty was performed of LCx stenosis. RCA appeared totally
occluded and no intervention was performed. On arrival to the
CCU, pt was hypertensive, tachycardic and complaining of
worsening SOB. She was placed on a NRB and given Atrovent nebs,
nitro gtt and Lasix 80mg IV. Her tachypnea improved rapidly as
the BP came down and she was able to weaned from the NRB to 4L
NC. She was denying any chest pain, nausea or lightheadedness.
.
On ROS, pt denies cough, congestion, fevers, chills, changes in
bladder habits, diarrhea, constipation, muscle pain or lower
extremity edema. She denies palpitations, lightheadedness or
chest pressure.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia,
+Hypertension, +PVD, +CAD
.
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: Multiple prior stents
placed in [**State 531**] state, Cath from [**2167-4-13**] with LAD stent,
Cath in [**2167-5-14**] revealed patent stent to LAD and she underwent
2 x BMS to RCA, and taxus to proximal RCA.
-stopped ASA one month ago because of bruising
-PACING/ICD: none
.
3. OTHER MEDICAL HISTORY:
-Paget's Disease
-Glaucoma
-Diabetes mellitus-II
-Hypertension
Social History:
Patient lives alone in [**Location (un) 17004**] [**State 531**], [**State 531**]. Completes all
of her ADLs and ADLs by herself. Denies smoking, alcohol, drugs.
Family History:
Noncontributory.
Physical Exam:
99.1 139/70 89 22 98%4LNC
GEN: Pleasant, poor historian, elderly woman in NAD, AOx3
HEENT: Oropharynx clear, neck pain reproducible by palpation
CV: RRR, no RMG, elevated JVP at 16cm
PULM: Bibasilar rhales and bibasilar decreased breath sounds.
ABD: Soft, NTND, +BS
EXT: No edema, 1+ DP pulses
NEURO: CN 2-12 intact, 5/5 strength of UE and LE, light touch of
UE and LE intact, 1+ patellars, negative Babinski's.
.
Notable exam component on discharge - lungs clear bilaterally.
Pertinent Results:
Pertinent labs on admission:
WBC 11.2
Hb 11.3
Hct 35.6
Plt 270
Na 142
K 4.3
Cl 107
HCO3 23
BUN 44
Cr 1.3
Gluc 180
TropT 0.57
CK 259
CK-MB 24
MB index 9.3
Ca 9.0
Mg 1.7
Phos 4.8
2nd set of cardiac enzymes: CK 363 CK-MB 31 MBindex 8.5
3rd set of cardiac enzymes: CK 287 CK-MB 21 MBindex 7.3
.
Discharge labs pertinent:
WBC 5.5
Hb 10.8
Hct 33.7
Plt 233
Na 137
K 4.0
Cl 96
HCO3 26
BUN 45
Cr 1.2
.
CXR ([**9-20**] at OSH):
AP portable sitting view of the chest. There are bilateral
extensive interstitial opacities with more alveolar-appearing
perihilar opacities, most consistent with severe pulmonary
edema. No large pleural effusions are seen. The heart shadow is
partially obscured. Aortic calcification is seen. Left basilar
retrocardiac opacity is likely related to the pulmonary edema,
although a superimposed consolidation could not be definitively
excluded.
.
CXR [**9-21**]:
IMPRESSION: Improving pulmonary edema which is now moderate on a
background of probable emphysema. Mild cardiomegaly.
.
Echo [**9-21**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with inferior and
inferolateral akinesis. The remaining segments contract normally
(LVEF = 40%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**12-15**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate calcific aortic stenosis. Mild to moderate
mitral regurgitation. Moderate pulmonary hypertension.
.
EKG [**2170-9-20**]: Sinus rhythm and frequent ventricular ectopy. ST
segment depression in leads I, aVL and V4-V6 which may represent
active ischemic process
.
Cardiac catheterization report 10/8/9:
COMMENTS:
1. Selective coronary angiography of this right dominant
circulation
demonstrated two vessel coronary artery disease. The LMCA had
60%
stenosis at the origin. The LAD had a 40% stenosis at the mid
segment
and otherwise no angiographically apparent flow limiting
disease. The
LCX had a 95% stenosis at the proximal segment and a 70%
stenosis at the
mid segement. The RCA was occluded proximally with left to
right
collaterals.
2. Resting hemodynamics demonstrated elevated right sided
filling
pressures (RVEDP 15 mm Hg), severe pulmonary hypertension (PA
64/31 mm
Hg), elevated left sided filling pressures (PCWP 35 mm Hg), low
cardiac
index (cardiac index 2.1 l/min/m2), and systemic systolic
hypertension
(central aortic pressure 161/85 mm Hg).
3. Successful POBA of the LCX with a 2.5x12mm Voyager balloon.
Final
angiography revealed minimal residue stenoses, no
angiographically
apparent dissection and TIMI III flow (see PTCA comments).
4. The procedure was complicated with transient hemodynamic
instability
due to damping of guide in the LMCA with resultant hypotension,
chest
pain and hypoxia that resolved with guide removal.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Acute myocardial infarction, managed by acute ptca. PTCA of
vessel.
Brief Hospital Course:
89-yo woman with h/o multi-vessel CAD with multiple stents from
[**2166**], CHF, HTN, hyperlipidemia, DM-II who was taken to [**Location (un) 620**]
[**Hospital1 18**] after developing left sided shoulder/neck pain and dyspnea
overnight, transferred to [**Hospital1 18**] for catheterization due to
concern for NSTEMI.
Due to the NSTEMI, the patient was taken to the cardiac cath lab
on [**9-20**]/9. Please see below for the cath report details. During
this procedure the patient developed an acute exacerbation of
worsening CHF, with respiratory distress and chest pain. The
patient was made chest pain free and through lasix and oxygen
the patient's respiratory distress resolved shortly after
arriving in the CCU. Following this episode, the [**Hospital 228**]
hospital course consisted primarily of diuresis with lasix. The
patient's oxygen requirement resolved, her
chest/shoulder/back/neck pain did not reoccur, and she improved
enough to be discharge on [**9-23**]/9 (her 90th birthday).
NSTEMI: Likely had an ischemic event (positive cardiac enzymes)
that led to an ischemic ventricular wall that caused acute on
chronic CHF. Possibly related to her stopping aspirin a few
months ago [**1-15**] bruising. Best treatment of her acute heart
failure is to treat the underlying etiology which is ischemic.
Patient had cardiac catheterization on [**9-20**]. Please see cath
report below for details.
CHF: Treat ACS first. Following acute exacerbation consisting of
SOB (respiratory distress) and chest pain in the cath lab,
treated with aggressive diuresis through lasix. Patien's CXR and
symptoms improved with lasix, and her O2 requirement returned to
room air.
PVD: Continued ASA, Plavix.
DM: Changed medication regimen while inpatient as wanted to
avoid metformin in setting of dye load in cath lab, but returned
patient to home metformin upon discharge.
FEN/GI: Cardiac/diabetic diet, repleted lytes PRN, bowel
regimen.
PPX: Heparin SC.
CARDIAC CATHETERIZATION REPORT, 10/8/9:
BRIEF HISTORY:
This is an 89 year old woman with past medical history
significant for
CAD ([**4-/2167**] PCI with stent to LAD, [**5-/2167**] PCI with 2.5 x 24 mm
Taxus to
proxRCA, 3 x 24 mm BMS to midRCA, 3 x 18 mm BMS to midRCA) who
presented to [**Hospital1 **] [**Location (un) 620**] with an NSTEMI complicated by
congestive heart
failure and was transferred to [**Hospital1 18**] for cardiac
catheterization. On
arrival to the catheterization lab, patient was complaining of
chest
pain.
INDICATIONS FOR CATHETERIZATION:
CHF
NSTEMI
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 5 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 5 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Percutaneous coronary revascularization was performed using
balloon
angioplasty.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: 11.3 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} -/14/11
RIGHT VENTRICLE {s/ed} [**2115-11-27**]
PULMONARY ARTERY {s/d/m} 64/31/48
PULMONARY WEDGE {a/v/m} -/45/34
AORTA {s/d/m} 161/85/121
**CARDIAC OUTPUT
HEART RATE {beats/min} 120
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 59
CARD. OP/IND FICK {l/mn/m2} -/2.11
**% SATURATION DATA (NL)
PA MAIN 51
AO 90
**PTCA RESULTS
PTCA COMMENTS:
Initial angiography revealed 95% proximal and 70% mid LCX
stenosis. We
planned to treat this with PTCA only due to significant damping
of the
guide in the LMCA with resultant hemodynamic instability.
Aspirin,
plavix and bivalirudin were given prophlylactically and a
therapeutic
ACT was confirmed. A 6F XB 3.5 guide was a little long and
caused
significant damping in the left main. A choice PT [**Year/Month/Day **] wire
crossed
the stenoses with some difficulty. The stenoses were dilated
with a
2.5x12mm Voyager balloon at 10 and 12atms. Patient became
hemodynamically unstable during the procedure with chest pain,
hypotension and hypoxia which resolved with removal of the guide
from
the LMCA and opening of the LCX. Final angiography revealed mild
residue
stenoses, no angiographically apparent dissection and TIMI III
flow.
Stenting of the lesions were not performed due to good POBA
result and
concern of further hemodynamic compromise with guide insertion.
The
patient left the lab free of angina and in stable condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 7 minutes.
Arterial time = 49 minutes.
Fluoro time = 19 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 140 ml
Premedications:
Fentanyl 100 mcg IV
ASA 325 mg P.O.
Plavix 600 mg
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Bivalirudin 35 mg bolus and 29 mg/hr drip
Nitroglycerine 40 mcg/min drip
Furosemide 20 mg
Cardiac Cath Supplies Used:
.014IN [**Company **], CHOICE PT [**Name (NI) **] 300CM
2.0MM [**Doctor Last Name **], VOYAGER 12MM
2.5MM [**Doctor Last Name **], VOYAGER 12MM
6FR CORDIS, XB 3.5
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
- [**Company **], RIGHT HEART KIT
5FR [**Company **], MULTIPACK
- [**Doctor Last Name **], PRIORITY PACK 20/30
5FR ARROW, BALLOON WEDGE PRESSURE CATHETER 110CM
COMMENTS:
1. Selective coronary angiography of this right dominant
circulation
demonstrated two vessel coronary artery disease. The LMCA had
60%
stenosis at the origin. The LAD had a 40% stenosis at the mid
segment
and otherwise no angiographically apparent flow limiting
disease. The
LCX had a 95% stenosis at the proximal segment and a 70%
stenosis at the
mid segement. The RCA was occluded proximally with left to
right
collaterals.
2. Resting hemodynamics demonstrated elevated right sided
filling
pressures (RVEDP 15 mm Hg), severe pulmonary hypertension (PA
64/31 mm
Hg), elevated left sided filling pressures (PCWP 35 mm Hg), low
cardiac
index (cardiac index 2.1 l/min/m2), and systemic systolic
hypertension
(central aortic pressure 161/85 mm Hg).
3. Successful POBA of the LCX with a 2.5x12mm Voyager balloon.
Final
angiography revealed minimal residue stenoses, no
angiographically
apparent dissection and TIMI III flow (see PTCA comments).
4. The procedure was complicated with transient hemodynamic
instability
due to damping of guide in the LMCA with resultant hypotension,
chest
pain and hypoxia that resolved with guide removal.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Acute myocardial infarction, managed by acute ptca.
PTCA of vessel.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **]
[**Last Name (LF) **],[**First Name3 (LF) **]
[**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Medications on Admission:
-Citalopram 10mg PO qdaily
-Catapres TTS patch - .1mg q24 hours ( 1 patch weekly)
-Atenolol 150mg PO qdaily
-Lasix 40mg PO qdaily
-Lisinopril 40mg PO qdaily
-Simvastatin 80mg PO qdaily
-KCL tabs /crystal particles - 15mEq daily
-Nifedipine ER 90mg PO qdaily
-Trazodone 25mg PO qdaily at 9pm
-Wellbutrin 75mg PO BID
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Isradipine 5 mg Capsule Sig: Two (2) Capsule PO once a day.
11. Pletal 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Nitroglycerin SL 0.3mg PRN chest pain; take up to 2 tablets
and then if chest pain still does not resolve call 911.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. NSTEMI s/p cardiac catheterization with balloon angioplasty
to the circumflex coronary artery
2. Acute exacerbation of CHF
Secondary diagnosis:
Type 2 Diabetes Mellitus
Hypertension
Discharge Condition:
Afebrile, vital signs stable, feeling well.
Discharge Instructions:
You were admitted to the hospital with shortness of breath,
shoulder and neck pain. You were found to be having a type of
heart attack that warranted examination and treatment of the
blood vessels that nourish your heart, during a cardiac
catheterization. One of these vessels was tight and that was
widened by the cardiologist (balloon angioplasty). During this
procedure, you had chest pain and difficulty breathing and this
was likely due to an overload of fluid on your lungs. We used
medication over the next couple of days to take the fluid off
your lungs. Your chest discomfort resolved and your breathing
improved.
.
Please call your doctor or return to the hospital if you have
chest pain, shortness of breath, reoccurence of your
neck/shoulder pain, difficulty breathing, or other symptoms that
concern you.
.
Changes to your medication list include the following:
-Re-start aspirin 81mg daily
-Discontinue atenolol/chlorthalidone
-Start metoprolol tartrate 12.5mg twice a day
-Start lasix (furosemide) 20mg twice a day
-Discontinue crestor
-Start simvastatin 80mg daily
Followup Instructions:
Please follow-up with your cardiologist in [**State 531**], or please
call Dr. [**Last Name (STitle) **] (he gave you his business card) for a cardiology
appointment here in [**Location (un) 86**].
.
For a primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 86**] through [**Hospital3 **], you can
call [**Telephone/Fax (1) 250**] for an appointment.
.
We would like you to see a doctor to have your blood pressure
and heart rate checked within the next 1-2 weeks (either a
cardiologist or a primary care doctor).
Completed by:[**2170-9-23**]
|
[
"458.29",
"250.00",
"V45.82",
"414.01",
"428.0",
"428.31",
"585.9",
"365.9",
"E879.0",
"410.71",
"403.90",
"799.02",
"414.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"88.56",
"37.23",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
16376, 16382
|
7395, 9884
|
253, 323
|
16631, 16677
|
3861, 3876
|
17806, 18375
|
3323, 3341
|
15394, 16353
|
16403, 16403
|
15055, 15371
|
14448, 15029
|
16701, 17783
|
3356, 3842
|
2709, 3127
|
12270, 14431
|
4126, 7199
|
9917, 12251
|
180, 215
|
351, 2566
|
16570, 16610
|
16422, 16549
|
3890, 4053
|
2610, 2689
|
3143, 3307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,030
| 140,431
|
594
|
Discharge summary
|
report
|
Admission Date: [**2138-10-15**] Discharge Date: [**2138-10-23**]
Date of Birth: [**2065-8-18**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73F with paraplegia, recurrent UTI, chronic sacral decubs,
presenting with fever and altered mental status. She was seen by
her NP yesterday with fever to 102 and positive UA. Her sacral
decub was noted to be improved since last exam. Cipro started
for UTI. Also seen by her visiting nurse today and son reported
that overnight she was confused, talking about getting up to
walk (though paraplegic) and ?visual hallucinations. Per son,
this is similar to when she has had UTIs in the past. She does
admit to sore throat and cough for a few days. Cough
nonproductive though feels she has something to cough up. No
shortness of breath or chest pain. No GI symptoms. No known
sick/flu contacts. [**Name (NI) **] recalls incident in which she told
her son she was going to get up and walk, and thought she was
dreaming. Pt DNR/[**Name6 (MD) 835**] [**Name8 (MD) **] NP.
In the ED, initial vs were: T98.4 77 115/60 18 92% on RA.
Initially tried on 2 L O2 but O2 sats drifted to upper 80s, thus
increased to 4L. Initially normotensive with subsequent BP down
again to upper 80s despite 3 L NS. CXR with ?RLL process but
officially read as no acute process. UA positive. Received vanco
and levofloxacin. Debating MICU vs. floor admission but
ultimately admitted to MICU given borderline BPs and O2 sats.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Denied arthralgias or myalgias.
Past Medical History:
- Paraplegia [**1-6**] Anterior Spinal Infarct ([**2128**]) - patient
reports no sensation or motor function below T8.
- Thoracic Aneurysm Repair ([**2128**])
- COPD (no PFTs in system; has been on home O2 in past though
none recently)
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis
- History of MRSA bacteremia [**11/2137**] thought to be due to sacral
decub abscess and osteomyelitis
Social History:
Lives with son (recently returned home from rehab in late
[**Month (only) 359**]) and has VNA. Smoked 2-3ppd x 40+ years, denies smoking
in last few years. No alcohol or illicit drug use.
Family History:
Son has DM
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL 4->2, MM slightly dry, posterior
oropharynx very difficult to fully visualize.
Neck: supple, JVD to 4 cm ASA, no LAD
Lungs: Few expiratory rhonchi, L>R. No crackles.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: appears grossly distended, though unchanged per
patient. Soft, non-tender, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Suprapubic catheter
site appears benign.
Back: stage IV sacral decub, appears to be down to bone, approx
4x4cm. No drainage or significant surrounding erythema, appears
to have good granulation tissue.
Ext: Slightly cool hands otherwise warm and well perfused, no
clubbing, cyanosis. Trace UE and LE edema, equal bilaterally.
Small pressure ulcers on bilateral heels.
Neuro: Alert and appropriate. CN II-XII intact, UE strength and
sensation preserved. LE sensation and movement absent. No
sensation from abdomen inferiorly.
Pertinent Results:
WBC 6.6
Hct 33.4 MCV 87
Plts 306
Na 140 K 3.3 Cl 107 HCO3 25 BUN 7 Cr 0.4 Gluc 144
Ca 7.4 Mg 2.1 Phos 2.5
ALT 39
AST 34
MB 2
Trop 0.02
BNP 556
Lact 2.3
UCx negative
BCx negative x2
CXR [**2138-10-15**]: The patient is rotated for the examination. The
lungs are clear without consolidation or edema. Again seen is
massive dilation and ectasia of the thoracic aorta with a
particular contour abnormality noted along the course of the
descending thoracic aorta. The cardiac silhouette size is within
normal limits. No definite effusion or pneumothorax is seen.
Chronic bony deformity consistent likely with prior left
thoracotomy is stable. Numerous surgical clips are noted over
the mediastinum. IMPRESSION: No acute pulmonary process.
Markedly dilated and ectatic aorta similar to prior studies but
accentuated by rotation. There is a focal outpouching along the
course of the descending thoracic aorta which may be
superimposition of pulmonary vessels or true contour abnormality
suggesting true or false aneurysm formation.
Addendum: In retrospect, in comparison to multiple prior
radiographs, the contour of the descending thoracic aorta is
stable and is unlikely to represent an acute process.
Additionally, there is subtle silhouetting of the right
hemidiaphragm which may correspond to increased opacity noted on
the lateral view. Atelectasis or an early infiltrate involving
the right lower lobe cannot be entirely excluded.
.
EKG: NSR at 74, normal intervals, borderline LAD, poor RWP, no
ST/T changes, overall minimally changed from prior.
.
[**2138-10-19**] KUB: FINDINGS: Comparison is made to the prior CT scan
and radiographs from [**2138-4-11**].
Similar to the prior studies, there was again seen marked
distention of
several small bowel loops. There is also stool and air is seen
throughout the colon.
No free intraperitoneal air is seen on the decubitus
radiographs. CT scan
will be helpful for further evaluation of the area of
obstruction. There is again noted a fracture deformity involving
the left proximal femur at the intertrochanteric region which is
unchanged since [**2137-10-5**].
Brief Hospital Course:
73F with paraplegia, COPD, recurrent UTI, presenting with UTI,
confusion, mild hypoxia and relative hypotension.
# Hypotension. Pt was mildly low BP's with baseline 100-110's.
Pt responded to IV fluids. Cardaic enzymes were neg. Likely [**1-6**]
to UTI/urosepsis. Pt was given [**Last Name (un) 104**] stim test which responded
appropriately.
# Hypoxia. Pt was on home oxygen in past for COPD, though not
currently. No evidence of PNA. Pt's O2 requirement was weaned,
and pt was also given nebs.
# Fever. Pt has fever to 101 at NP's office but was afebrile
during hospital stay. Likely [**1-6**] to UTI. Sacral decub appears
well. Ortho consulted regarding possibility of osteo, however
rec biopsy at a time when pt is off all antibiotics for at least
5 days. Pt was initially started on Vanc/Zosyn/Cipro for
complicated UTI, then eventually [**Last Name (un) 4662**] down to PO Cefpodoxime
for a total of 14 day course (last dose on [**10-28**]). Blood cx were
neg and flu swab was neg. First urine cx had fecal contamination
but subsequent one was neg.
# UTI. Has had a number of FQ and 2nd-3rd genereation
cephalosporin resistent organisms in the past. Also had history
of enterococcus in the past. On Bactrim prophylaxis at home. Pt
was thus initially started on Vanc/Zosyn/Cipro given
hypotension, then transitioned to PO Cefpodoxime for a total of
14d course (last day [**10-28**]). Pt improved clinically and remained
afebrile.
# Suprapubic catheter. Changed q month and needs to be changed.
# Sacral decub. Stage IV, did not appear overtly infected. Was
followed by wound care during hospital stay.
# Abdominal distension. Patient's abdomen is chronically
distended, but soft, no signs of an acute abdomen. KUB on [**10-19**]
showed marked distention of
several small bowel loops, but similar to the prior studies.
also, no free intraperitoneal air was seen. Patient reports this
distension is no change from baseline. Pt did not have BMs for
several days. Bowel regimen was then escalated, with pt having
soft BMs by the day of discharge. If there is again a concern
regarding distension, a repeat KUB can be performed to reassess.
.
# Paraplegia. Was stable, pt was continued home meds
(tizanidine, baclofen, gabapentin, nortriptyline).
.
Pt was on a regular diet, on SC heparin for DVT ppx. Pt was
DNR/DNI and contact was son [**Male First Name (un) 1704**] [**Telephone/Fax (1) 4655**]. It was
originally though that perhps the pt could be discharged home
with services, however [**Name6 (MD) **] visiting RN emailed with concern
regarding that option- felt the pt needed to be in [**Hospital1 1501**] at least
for some time until she imrpoves further clinically.
Medications on Admission:
Advair 250/50 [**Hospital1 **]
ASA 81 mg daily
Alendronate 70 mg daily
Baclofen 10 mg TID
Bactrim DS [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
gabapentin 900 mg TID
miralax 17grams daily
senna [**Hospital1 **]
nortriptyline 50 mg HS
tizanidine 2 mg TID
wellbutrin 100 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a day.
12. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): last dose on [**2138-10-28**] for total of 14d course of abx.
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H
(every 2 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
UTI
Discharge Condition:
good, satting 96% on 2L
Discharge Instructions:
You were admitted to [**Hospital1 18**] because of fever altered mental
status. You were found to have low BPs and were in the ICU,
where you recovered with IV fluids. You were found to have a
urinary infection, for which you were started on antibiotics.
You were also given an aggressive bowel regimen to help you pass
your bowels. Your belly was distended, however soft, nontender
and stable. You continued to improve clinically and you were
then discharged to a skilled nursing facility where you can
continue to improve under close care.
Please make the following changes to your medications:
1. START Ipratropium Bromide 0.02 % Solution One Inhalation
every 6 hours
2. START Albuterol Sulfate 0.083 % Solution One Inhalation
every 6 hours
3. START Lactulose 10 gram/15 mL Syrup 30 ML PO every 2 hours as
needed for constipation
4. START Bisacodyl 10 mg PO DAILY as needed for constipation
5. START Cefpodoxime 200 mg PO every 12 hours: last dose on
[**2138-10-28**] for a total of 14d course of abx
Please seek immediate medical attention if you start
experiencing confusion, fevers, acute abdominal pain or any
other concerning symptoms.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in Orthopedics on [**11-13**] at 10:30
AM at the [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. Ph # ([**Telephone/Fax (1) 2007**]. A biopsy
to rule out bone infection may be needed, but the biopsy can be
performed only after all all antibiotics have been discontinued
for more than 5 days, which should be the case at this date.
A follow-up appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**] at [**Hospital1 **]
[**Location (un) 538**] will be made for you at the time of discharge from
the skilled nursing facility.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2138-10-23**]
|
[
"909.3",
"401.9",
"272.4",
"787.6",
"599.0",
"038.9",
"707.03",
"785.52",
"344.1",
"596.8",
"311",
"728.89",
"530.81",
"E878.2",
"995.92",
"276.6",
"787.3",
"707.24",
"V46.2",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10542, 10611
|
5995, 8681
|
281, 287
|
10659, 10685
|
3851, 5972
|
11881, 12662
|
2786, 2798
|
9026, 10519
|
10632, 10638
|
8707, 9003
|
10709, 11279
|
2813, 3832
|
11308, 11858
|
1633, 1937
|
236, 243
|
315, 1614
|
1959, 2563
|
2580, 2770
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,135
| 150,402
|
29622+57646
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-12-22**] Discharge Date: [**2154-1-2**]
Date of Birth: [**2091-10-25**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transferred from [**Hospital 108**] Hospital w/ AMI s/p CABG, Resp failure
s/p Trach, CVA
Major Surgical or Invasive Procedure:
bilateral thoracenteses
History of Present Illness:
62 y/o M with PMHx significant for Hyperchol, HTN developed
sudden onset nausea, diaphoresis, presyncope on [**2153-12-7**] while
in [**Last Name (un) 3625**] land. He was then taken to a local hospital in [**State 108**]
where he was found to have acute STEMI. He was then transferred
to [**Hospital 108**] Hospital in [**Location (un) 6185**] where he had a cath which showed
totally occluded left main, dz in R post descending and
stenoisis of proximal LAD. He immediately underwent an emergent
CABG and had 6 grafts placed. On [**2153-12-9**], he was extubated.
Soon after his extubation, he went into PEA. He then had a ?
embolic stroke with right sided hemiplegia with CT brain showing
hypodensity in Left parietal region, L external capsule region.
During his postoperative period, he developed HIT (started on
Bivalirudin) and AFib (started on Amiodarone drip). He was then
trached on [**2153-12-18**] and started on Dialysis on [**2153-12-21**] for
renal failure. During his OSH course, he developed low grade
fevers between 100-101 with all workup being negative including
Blood Cx, Urine Cx, Sputum Cx, CT chest/abd/pelvis although his
chest xray did show LLL consolidation. HE was emperically
started on Meropenem, Linezolid, Diflucan and his white count
started coming down and was afebrile for 24 hrs before transfer
to [**Hospital1 18**]. He was transferred to [**Hospital1 18**] as was wished by his
family with the plan to eventually transition him to a rehab.
Past Medical History:
Hypercholesterolemia
Hypertension
Social History:
no smoking/drinking history
Family History:
Noncontributory
Physical Exam:
100.4, 134/69, 89, 12, 98%
CPAP/PS PS/PEEP of 15/5 TV of 575 w/ RR 15 FiO2 0.4
HEENT: trach, NG tube, Dobhoff
Heart: S1/S2, no mumur
Lungs: coarse crackles
Abd: distended, BS +, non-tender, no rigidity/guarding
Ext: no edema, ulcer on left foot, cellulitis on incision on
left foot
Neuro: PERLA 5 mm, EOMI, right hemiparesis, downgoing plantars
bilaterally
Pertinent Results:
[**2153-12-22**] 10:10PM BLOOD WBC-17.7* RBC-3.17* Hgb-9.8* Hct-29.5*
MCV-93 MCH-31.0 MCHC-33.3 RDW-19.3* Plt Ct-414
[**2154-1-1**] 04:35AM BLOOD WBC-8.5 RBC-2.95* Hgb-9.2* Hct-27.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-17.4* Plt Ct-295
[**2153-12-22**] 10:10PM BLOOD PT-17.2* PTT-53.1* INR(PT)-1.6*
[**2154-1-1**] 04:35AM BLOOD PT-40.9* PTT-77.3* INR(PT)-4.6*
[**2153-12-22**] 10:10PM BLOOD Glucose-124* UreaN-69* Creat-3.0* Na-145
K-5.4* Cl-108 HCO3-23 AnGap-19
[**2154-1-1**] 04:35AM BLOOD Glucose-128* UreaN-63* Creat-1.7* Na-138
K-3.3 Cl-103 HCO3-25 AnGap-13
[**2153-12-22**] 10:10PM BLOOD ALT-50* AST-44* CK(CPK)-930* AlkPhos-150*
Amylase-62 TotBili-1.0
[**2153-12-30**] 03:00AM BLOOD ALT-36 AST-19 AlkPhos-128* TotBili-0.5
[**2153-12-22**] 10:10PM BLOOD Lipase-28
[**2153-12-22**] 10:10PM BLOOD CK-MB-3 cTropnT-6.26*
[**2153-12-23**] 03:00AM BLOOD CK-MB-3
[**2153-12-24**] 03:00AM BLOOD CK-MB-3 cTropnT-4.90*
[**2153-12-26**] 05:26AM BLOOD CK-MB-4 cTropnT-2.30*
[**2153-12-27**] 05:15AM BLOOD CK-MB-4
[**2153-12-22**] 10:10PM BLOOD Albumin-4.1 Calcium-8.8 Phos-7.5* Mg-3.4*
Cholest-109
[**2154-1-1**] 04:35AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.5
[**2153-12-29**] 04:15AM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
[**2153-12-22**] 10:10PM BLOOD Triglyc-162* HDL-21 CHOL/HD-5.2
LDLcalc-56
[**2153-12-25**] 08:03AM BLOOD Type-ART Temp-37.4 Rates-/21 Tidal V-500
FiO2-40 pO2-111* pCO2-34* pH-7.47* calTCO2-25 Base XS-1
Intubat-INTUBATED Vent-SPONTANEOUS
Investigations at OSH
.
LENI: neg
UEUSG: Chr RIJ DVT, superficial left cephalic vein thrombosis
.
R/L Carotid: no evidence of stenosis
.
ECHO [**12-10**]:
-EF of 25%
-trace pericardial effusion
-sev [**Month (only) **] LV EF
-mild MR
[**Name13 (STitle) **] TR
.
CT Chest [**11-21**]:
large bil pleura effusion w/ compression atelectasis in lung
bases w/ diffuse pulmonic infiltrates
.
CT ABD/Pelvis (for FUO) on [**12-20**]
- L inguinal hernia w/o obstruction
- diverticulosis
- fluid collection in the anterior abdomial chest wall
.
CHest [**Last Name (un) **] [**12-19**]
- diff pulm infiltrates
- bil effusions
- dense lLL consolidation
.
CT Brain [**2153-12-11**]
- no ICH/mass effect
- hypodensity in Left parietal region, L external capsule
.
EKG
Afib @ 110/[**Last Name (LF) **], [**First Name3 (LF) **] dep in lateral leads
Brief Hospital Course:
62 M w/ HTN, Hyperchol p/w STEMI s/p CABG, CVA, Resp failure s/p
trach, AFib, HIT, ARF on HD
.
1) Cardiac:
a) Coronaries: Patient is s/p STEMI with emergent CABG performed
at [**Hospital 108**] hospital, 6-vessel bypass.
- BB (will try maximal blockade), ASA
- Started low-dose AceI once Cr =1.5 (in the setting of
resolving ATN)
- Lipitor initially started for modification of hyperlipidemia.
Patient had elevated CPK status-post lipitor. CK trending down
with discontinuation. Statin held for now; will need to be
re-addressed as outpatient.
.
b) Rhythm: h/o Afib during recent hospitalization.
- CHADS2 score undetermined (1 point definitely for HTN only;
unable to determine if patient has long-term CHF as cardiac
remodeling still in progress, no prior h/o DM, and cannot
determine definitively if embolic CVA related to CVA)
- Argatroban for anti-coagulation; have now bridged to coumadin
for goal INR [**2-2**]
- Initially on Amio gtt for rate/rhythm control -> tapered with
Amiodarone HCl 300 mg PO BID Duration x 7 Days (end date [**12-29**]);
then Amiodarone 300 mg daily
.
c) PUMP:
- ECHO: EF of 25% initially s/p MI on [**12-10**] at OSH
- Repeat TTE on [**12-25**] shows depressed LVEF, but unable to
quantify because of limited echo windows
- ACEI, BB
- diuretics PRN
.
2) Resp failure: was intially on IMV, switched to CPAP/PS, now
s/p trach and s/p extubation. Respiratory status was further
compromised by bilateral pleural effusions. Pt currently able to
breath with trach mask for 20-24 hours at a time but becomes
subjectively dyspneic and requests CPAP/PS for 2-4 hours after
that; this should continue to improve.
-PE unlikely, LENI's were negative, although upper ext USG
showed chronic RIJ DVT, superficial left cephalic vein thromosis
- diuresed PRN for pulm edema; however, patient auto-diuresed
with resolving ATN
- thoracenteses performed under ultrasound guidance on [**12-26**] &
[**12-28**] for large pleural effusions
.
3) Fevers: of unknown source, white count trending down
(compared to OSH). Consider nosocomial pneumonia vs. drug fever.
- Patient managed initially on Meropenem and Linezolid but
changed to Cefepime and Linezolid for VAP and good response to
fever; sputum cultures grew [**Last Name (LF) 8974**], [**First Name3 (LF) **] plan for nafcillin through
[**2154-1-6**].
.
4) Stroke: Presumed embolic event, consider in the differential
DVT vs. hypokinetic cardiac thrombus s/p MI vs. PFO. Afib seems
unlikely to be the cause as the temporal relationship does not
correspond, although again this cannot be determined. Patient
with residual right side hemiplegia which correlates with
infarction of left parietal region and left external capsule
region.
- ASA; argatroban transitioning to coumadin
- Per neurology consult: recommended TTE to evaluate for PFO.
Bedside TTE [**12-23**] inadequate secondary to poor patient windows.
No bubble study performed. Patient sent for nuclear right
vetriculogram to eval for EF but again, study inadequate. Per
cardiology - although unable to see PFO - treatment would be
lifelong ASA therapy. Because patient had massive MI, he will
already be on chronic ASA therapy and finding of PFO would not
change treatment.
- bilateral UE ultrasounds: no signs of clot.
.
5) Acute Renal Failure: likely due to ATN in the setting of
hypovolemic shock
- Initially managed at OSH with HD but this measure was
discontinued after arrival to [**Hospital1 18**] with resolution of ARF. HD
catheter pulled [**12-26**], tip sent for culture.
- On arrival to [**Hospital1 18**], patient initially managed with Diuril and
IV Lasix with good response. Afterward, patient autodiuresing
well.
- renally dose meds; now corrected for improving renal function
- ACEI restarted once Cr =1.5.
.
6) Anemia: baseline HCT unknown, HCT stable compared to OSH
- transfuse for HCT <28 in the setting of recent MI and CHF
- EPO
- Hemodynamically stable
.
7) Thrombocytopenia: unclear baseline plt count; however,
downward trending from 400+ on admission to [**Hospital1 18**] to 221.
Consider Linezolid-induced thrombocytopenia.
- h/o HIT per OSH
- Confirmed that patient received no heparin flushes; documented
in allergy list
.
8) Hyperglycemia: patient does not carry a diagnosis of DM, now
with persistent hyperglycemia and requirement of ~60 units/day
of insulin. Initially was managed with insulin gtt; now
transitioned to NPH 25 units qAM, 10 units qHS, plus SSI for
coverage.
.
9) PPX: protonix, HOB elevation, pneumoboots. Regarding need for
anti-coagulation, patient has multiple indications, including
Afib (Chads2 score undeterminable), embolic CVA, deep vein
thrombus, HIT. Duration of anticoagulation therapy for each of
these comorbidities varies; will bridge to coumadin therapy now
with Argatroban, with plan to determine duration of therapy in
discussion with Cardiology as outpatient.
.
10) FEN: Started on tube feeds for nutritional support. S&S
study on [**12-28**] revealed patient able to tolerate pureed solids
and thin liquids. PO intake very slow at first and patient
unable to meet caloric requirements; tube feeds continued while
advancing diet. Replete electrolytes to maintain K>4, Mg>2.
- Aspiration precautions
- If pt able to continue advancing diet over next week or two,
would favor tapering tube feedings and resuming normal diet. If
not able to maintain caloric intake, will need PEG, but pt
appears able to tolerate increasing po diet for now, so
hopefully will avoid PEG with Dobhoff for now.
.
11) Access: PICC (repositioned [**12-26**]), Dialysis catheter
(discontinued [**12-26**]), Aline (discontinued [**12-23**])
.
12) Code Status: Full
.
Contact: Wife - [**Name (NI) **] [**Name (NI) 23203**] (H: [**Telephone/Fax (1) 71005**], C: [**Telephone/Fax (1) 71006**])
Medications on Admission:
Medicatons at home
ASA
MVA
Meds on transfer from OSH
Carvedilol 6.25 mg
Amiodarone gtt
Angiomax
Novolin R ISS
ASA 325
Protonix 40 mg IV
Diflucan 200 MG Q4
Alumin
Linezolid 600 MG Q12
Senna
docusate
Ferric Gluconate
niacin
Lipitor 10
Meropenem 1G Q12
.
PRN meds
Albuterol
Lorazepam
Lopressor
Zofran
Dilaudid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily)
for 7 days.
6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as dir
Subcutaneous twice a day: 25units qam and 10units qpm.
9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
11. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours) for 5 days.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] -[**Location (un) 86**]
Discharge Diagnosis:
coronary artery disease s/p coronary artery bypass grafting
perioperative embolic stroke
heparin induced thrombocytopenia
ventilator associated pneumonia
Discharge Condition:
Fair
Discharge Instructions:
Take all medications as directed.
Followup Instructions:
Call your PCP for an appointment within one week of leaving
rehab.
Name: [**Known lastname 2180**],[**Known firstname **] J Unit No: [**Numeric Identifier 11966**]
Admission Date: [**2153-12-22**] Discharge Date: [**2154-1-2**]
Date of Birth: [**2091-10-25**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 5448**]
Addendum:
Please check vitals every 2-4 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] -[**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**]
Completed by:[**2154-1-2**]
|
[
"410.91",
"V45.81",
"584.5",
"401.9",
"V55.0",
"414.00",
"511.9",
"272.0",
"999.9",
"428.0",
"250.00",
"287.4",
"285.9",
"438.20",
"427.31",
"486",
"E934.2",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"00.11",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12755, 12980
|
4728, 10490
|
366, 391
|
12186, 12193
|
2426, 4705
|
12275, 12732
|
2016, 2033
|
10850, 11896
|
12010, 12165
|
10516, 10827
|
12217, 12252
|
2048, 2407
|
237, 328
|
419, 1898
|
1920, 1955
|
1971, 2000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,490
| 115,121
|
14760
|
Discharge summary
|
report
|
Admission Date: [**2166-12-22**] Discharge Date: [**2167-2-3**]
Date of Birth: [**2088-3-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
[**2166-12-24**] Pericentesis
R IJ CVL placement
PICC line placement
[**2167-1-26**] Bronchoscopy
History of Present Illness:
[**Known firstname **] [**First Name4 (NamePattern1) **] [**Known lastname **] is a 78-year-old G4P30013 Taiwanese female with
history of aortic stenosis and HTN, who initially presented to
[**Hospital1 **] [**Location (un) 620**] on [**2166-12-16**] with complaint of worsening
fatigue, early satiety, increasing abdominal distention and
discomfort, and constipation alternating with diarrhea. The
patient denied any associated fevers, chills, cough, shortness
of breath, dyspnea on exertion or headaches. On [**2166-12-16**], the patient underwent a CT scan of the abdomen and pelvis.
This study revealed moderate diffuse abdominal and pelvic
ascites. In addition, the omentum was noted to be thickened and
somewhat nodular. There was an asymmetric fullness of the left
adnexa.
The patient was admitted to the medical service for further
evaluation. On [**2166-12-17**], the patient underwent a
diagnostic paracentesis. 1.5 liters of cloudy, yellow fluid was
removed and sent for the appropriate studies. Serum CA 125
level was found to be elevated at 746. CEA is 1.8. Cytology
from the peritoneal fluid is pending.
On [**2166-12-19**], the patient underwent a second
paracentesis. She noted a mild improvement of her symptoms
after the paracentesis, however now reports increasing
discomfort due to further abdominal distention.
The patient is transferred to [**Hospital1 18**] for further management.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Mild to moderate aortic stenosis; mild aortic regurgitation;
moderate tricuspid regurg; moderate pulmonary artery
hypertension
(TTE done [**2166-12-19**]).
3. Patient hospitalized twice ([**2162**], [**2165**]) with CP which
resolved
with SL NTG; see most recent stress test below.
4. Osteoporosis.
5. History of tuberculosis.
6. History of Hep B. Cleared infection. HBsAg non-reactive;
HBsAb
<5; HBcAb reactive.
PAST GYN HISTORY:
Denies history of abnormal pap smear. Pap smear negative for
malignancy [**2160-3-7**]. Denies history of sexually
transmitted
infections. Denies postmenopausal vaginal bleeding.
PAST OBSTETRICAL HISTORY:
SVD x 3, TAB x 1
PAST SURGICAL HISTORY:
Right eye surgery
Social History:
The patient lives in [**Location **], [**State 350**], with her son,
[**Name (NI) **] and her daughter-in-law [**Name (NI) 43425**]. The patient has not smoked
cigarettes and denies use of alcohol.
Family History:
Per [**Name (NI) **], the patient's son, the patient's mother had gastric
cancer. The patient's sister also had an unknown type of
malignancy. The patient's daughter had breast cancer.
Physical Exam:
VS: T 98.3 BP 110/60 HR 92 RR 16 O2Sat 97% RA
General: Elderly Asian female, A&O x 3
Cardiac: RRR, no murmurs, rubs, gallops
Lungs: CTAB, no rales, wheezes or crackles
Abdomen: Moderate abdominal distention, shifting dullness c/w
ascites, no tenderness to palpation, no masses, no HSM
Ext: 1+ edema bilaterally, non tender
Pertinent Results:
** LABS ON ADMISSION **
[**2166-12-22**] 08:00PM BLOOD WBC-8.5 RBC-3.32* Hgb-11.3* Hct-32.8*
MCV-99* MCH-33.9* MCHC-34.4 RDW-13.5 Plt Ct-257#
[**2166-12-22**] 08:00PM BLOOD Plt Ct-257#
[**2166-12-22**] 08:00PM BLOOD PT-13.9* PTT-67.6* INR(PT)-1.2*
[**2166-12-22**] 08:00PM BLOOD Glucose-101 UreaN-16 Creat-1.0 Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
[**2166-12-22**] 08:00PM BLOOD ALT-46* AST-130* AlkPhos-41 Amylase-32
TotBili-0.3
[**2166-12-22**] 08:00PM BLOOD Lipase-21
[**2166-12-22**] 08:00PM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.8 Mg-1.9
[**2166-12-22**] 08:00PM BLOOD CA125-696*
LABORATORY DATA:
CA-125: 696
.
[**2166-12-17**] Peritoneal fluid: Albumin was 1.8, LDH was [**Telephone/Fax (1) 43426**]
nucleated cells of which on preliminary analysis many appeared
malignant. Final cytology pending.
.
[**2166-12-19**] Cell block, peritoneal fluid: Mesothelial cells,
lymphocytes, neutrophils, histiocytes and red blood cells.
Cytology pending.
.
[**2166-12-24**] Pathology report from mesenteric biopsy: Burkitt's.
.
[**2166-12-26**] Bone Marrow:
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes demonstrate
anisopoikilocytosis. They appear to have increased central
pallor, with scattered polychromatophils present. Abnormal
forms including target cells, ecchinocytes, and elliptocytes are
also present. The white blood cell count appears normal.
Platelet count appears normal with rare clumping. Large forms
are seen. Differential count shows 69% neutrophils, 5%
monocytes, 2%lymphocytes, 1% basophils, 3% atypical mononuclear
cells with cytoplasmic vacuoles within deep blue cytoplasm.
.
Aspirate Smear:
The aspirate material is adequate for evaluation and shows
several cellular spicules with many stripped nuclei. The M:E
ratio is 0.9:1. Erythroid precursors are present in mildly
megaloblastoid maturation. Myeloid precursors appear normal in
number and show left shifted maturation. Megakaryocytes are
present in decreased numbers. Differential shows: 3% Blasts, 1%
Promyelocytes, 12% Myelocytes, 14% Metamyelocytes, 14%
Bands/Neutrophils, 13% Plasma cells, 16% Lymphocytes, 35%
Erythroid. There are foamy hemosiderin laden macrophages
present in the smear. There are large cells with intensely blue
cytoplasm with vacuoles.
.
Biopsy Slides:
The biopsy material is adequate for evaluation and demonstrates
a fragmented cellular core (overall cellularity of 20-30%).
There are increased plasma cells and mast cells. There is an
eosinophilic background. The M:E ratio estimate is decreased.
Erythroid precursors are increased in number and show
normoblastic maturation. Myeloid elements are relatively
decreased in number and exhibit full spectrum maturation.
Megakaryocytes are present in normal number. There is an
interstitial infiltrate of plasma cells occurring in small
clusters occupying 20% of marrow cellularity. Marrow clot
section is not submitted. Touch prep is not submitted.
.
Special Stains:
Iron stain is adequate for evaluation. Storage iron is
increased. Sideroblasts are present. Ring sideroblasts are
absent.
.
EKG: sinus rhythm, HR 80, normal axis, normal intervals, non
pathologic q-waves in II, III, aVF. [**Street Address(2) 4793**] depression in III.
.
RADIOGRAPHIC DATA:
CXR [**2166-12-22**]: There is some hyperexpansion of the lungs with
coarseness of interstitial markings consistent with chronic
pulmonary disease. Apical pleural thickening bilaterally, more
prominent on the right, consistent with old granulomatous
disease. No evidence of acute focal pneumonia, vascular
congestion, or pleural effusion. Loss of height of a mid dorsal
vertebra, most likely on a postmenopausal basis.
.
CT CHEST [**2166-12-19**]:
1. CALCIFIED SCARRING AT THE LUNG APICES. CALCIFIED MEDIASTINAL
LYMPH NODES. CALCIFICATIONS IN THE LIVER AND SPLEEN. THESE
FINDINGS ARE SUGGESTIVE OF CHRONIC TUBERCULOSIS OR ANOTHER
CHRONIC GRANULOMATOUS INFECTION.
2. BILATERAL CALCIFIED PLEURAL PLAQUES, WHICH ARE MOST LIKELY
ALSO RELATED TO A CHRONIC GRANULOMATOUS INFECTION. HOWEVER,
ASBESTOS EXPOSURE [**Month (only) **] ALSO BE CONSIDERED, AND CLINICAL
CORRELATION IS SUGGESTED.
3. SMALL BILATERAL PLEURAL EFFUSIONS.
4. ABDOMINAL ASCITES, WHICH WAS BETTER ASSESSED ON THE [**2166-12-16**]
ABDOMINAL CT SCAN.
5. 9 MM LUCENT LESION IN THE LEFT GLENOID WITHOUT AGGRESSIVE
FEATURES, WHICH MOST LIKELY REPRESENTS A SUBCHONDRAL CYST.
HOWEVER, A
METASTASIS CANNOT ENTIRELY BE EXCLUDED, AND A BONE SCAN [**Month (only) **] BE
CONSIDERED.
6. MODERATE COMPRESSION DEFORMITIES OF THE VERTEBRAL BODIES OF
T7 AND
T12, OF UNKNOWN CHRONICITY.
.
[**2166-12-16**] CT ABDOMEN ([**Hospital1 **] [**Location (un) 620**]): ASCITES. OMENTAL THICKENING
THAT [**Month (only) **] REFLECT PERITONEAL CARCINOMATOSIS. THERE IS ASYMMETRIC
FULLNESS OF THE LEFT PELVIC ADNEXA BUT NO DEFINITE MASS IS
IDENTIFIED. SMALL PLEURAL EFFUSIONS. OLD GRANULOMATOUS DISEASE.
.
[**2166-12-27**] ECHO: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. The study is inadequate to fully assess
aortic valve, however mild stenosis is suggested based on
two-dimensional images. Mild (1+) aortic regurgitation is seen.
No mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Calcific aortic valve disease with mild regurgitation
and probable mild stenosis. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Compared with the report of the resting portion of the prior
stress study (images unavailable for review) of [**2163-9-9**],
tricuspid regurgitation and pulmonary hypertension are now seen.
Aortic valve is not fully assessed on the current emergency
study. The other findings appear similar.
.
[**2167-1-2**] LE Ultrasound: The examination was negative for DVT in
the lower extremities.
.
[**2167-1-12**] Chest CT:
1. Diffuse ground-glass opacity and more focal left upper lobe
subpleural
opacity. Findings most likely reflect an infectious process or
drug-related alveolitis.
2. Right PICC line lies at the level of the tricuspid valve.
3. Moderately-severe aortic valve calcifications of uncertain
physiologic
significance.
.
[**2167-1-25**] Chest CT:
1. Interval progression of diffuse ground-glass opacity, which
remains most consistent with an infectious process such as a
viral or atypical pneumonia, or drug-reaction.
2. No pleural effusion.
3. Calcified pleural plaques and interstitial lung disease, may
represent
asbestos-related disease.
.
[**2167-1-25**] Shoulder film: Three views of the right shoulder
demonstrate some mild degenerative changes with small
osteophytes but no fracture is identified. As seen in the chest
CT from the prior day there is right apical pleural plaque and
increased interstitial markings on the right.
.
[**2167-1-26**] Bronchoscopy: preliminary negative
.
.
Brief Hospital Course:
[**Known firstname **] [**First Name4 (NamePattern1) **] [**Known lastname **] is a 78-year-old female transferred to [**Hospital1 18**] with CT
findings of ascites, omental thickening, and left adnexal
fullness, as well as an elevated CA-125, concerning for ovarian
cancer versus primary peritoneal cancer, found to have Burkitt's
lymphoma as well as likely peritoneal TB.
.
# Burkitt's Lymphoma: Patient was originally admitted to the
gynecologic service for possible ovarian cancer. Patient
underwent CT guided mesenteric biopsy which demonstrated high
proliferation fraction and lack of Bcl-2 expression consistent
with Burkitt's Lymphoma. The patient was transferred to BMT
service and on [**2166-12-28**] started Day 1 modified CODOXM ([**Last Name (un) 43427**]).
Also started on Prednisone 100 mg for 7 days. Bone marrow
biopsy demonstrated MILDLY HYPOCELLULAR ERYTHROID DOMINANT BONE
MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS AND REACTIVE
(POLYCLONAL) PLAMACYTOSIS, but did not show evidence of
lymphoma. Bone marrow acid-fast stain was negative for
microorganisms. MRI demonstrated no discrete lymphadenopathy and
findings consistent with anasarca. Pt completed part A of
[**Last Name (un) 43427**] but was complicated by sepsis requiring ICU admission.
Pt was then switched to a more easily tolerated regimen called
[**Hospital1 **]. She started [**Hospital1 **] cycle 1 on [**2167-1-15**]. She will need to
continue cycle 2 on [**Last Name (LF) 766**], [**2167-2-9**]. The pt was discharged
with a follow up appointment with hematology/oncology for counts
on [**Last Name (LF) 2974**], [**2167-2-6**].
.
# Volume overload: The patient presented with ascites, lower
extremity edema and pulmonary edema. The patient underwent two
diagnostic and therapeutic paracenteses. The patient was
aggressively diuresed on Lasix 40 mg IV BID with improvement.
Ms. [**Known lastname **] was euvolemic at the time of discharge.
.
# Hypoxia: Initially, on the floor the patient required NRB for
O2 sat 90-94%. Pulmonary and cardiac shunt essentially negative:
LENI negative, ECHO bubble no intra-cardiac shunt, V/Q scan
indeterminate secondary to volume overload (unable to do CTA in
setting of renal failure with lysis). EKG showed no acute
changes. Thought to be secondary to fluid overload and
atelectasis. Hypoxia improved significantly with diuresis.
.
However, hypoxia returned days later without significant
evidence of volume overload and concurrent fevers. CT chest was
performed showing diffuse ground glass opacities. Pt was
started on several antibiotics. Pt became hypotensive, hypoxic,
and febrile. She was sent to the ICU before stabilizing. Sputum
culture grew stenothrophomonas. Pt underwent a broncoscopy on
[**1-26**] for evaluation of persistant ground glass opacities. BAL
preliminary was negative. The pt was also treated with
vancomycin and meropenem which were eventually removed. Pt is
now completing a a course of bactrim to be completed [**2167-2-10**] per
the infectious disease service. On discharge the pt was able to
breathe comfortably on room air.
.
# Peritoneal TB: The patient had a history of active TB
(demonstrated on CT chest) without adequate treatment. She ruled
out for pulmonary TB with > 4 sputum samples negative for AFB.
The infectious disease service was concerned for peritoneal TB
due to + [**Doctor First Name **] peritoneal fluid ([**Doctor First Name **] of 96.7 with a reference
range of <7.6 U/L) despite negative TB PCR. The pt was started
on 4 drug therapy with ethambutol, INH, rifabutin, and
pyrazinamide. The pt was followed by Infectious Disease for the
duration of her admission, and they recommended that the pt
continued the four-medication regimen for two months. The pt
will follow up at the infectious disease clinic in [**Month (only) 404**],
[**2167**].
.
# Risk of Strongyloides: As the patient was from an area where
strongyloides is endemic, she was felt to be at high risk prior
to starting a course of steroids. Per ID recommendations the pt
received two doses of Ivermectin therapy.
.
# Hep B exposure: Patient surface antibody positive, viral load
negative. Patient was started on Lamivudine prophylaxis and was
discharged on lamivudine.
.
# Access: The pt was discharged with PICC in place as she will
return for scheduled admission on [**Last Name (LF) 766**], [**2167-2-9**] for
second cycle of [**Hospital1 **].
Medications on Admission:
Fosamax
Atenolol
Calcium
MVI
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
3. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Isoniazid 300 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK
(TU,TH,SA).
Disp:*270 Tablet(s)* Refills:*2*
5. Rifabutin 150 mg Capsule Sig: Two (2) Capsule PO 3X/WEEK
(TU,TH,SA).
Disp:*180 Capsule(s)* Refills:*2*
6. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK
(TU,TH,SA).
Disp:*270 Tablet(s)* Refills:*2*
7. Pyrazinamide 500 mg Tablet Sig: Six (6) Tablet PO 3X/WEEK
(TU,TH,SA).
Disp:*540 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO Q 8H (Every 8 Hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
15. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection once
a day as needed for line flush.
Disp:*qs * Refills:*0*
16. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*2*
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*6 Tablet(s)* Refills:*0*
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Caregroup Home Care
Discharge Diagnosis:
Burkitt's lymphoma
Pneumonia
Peritoneal tuberculosis
Discharge Condition:
Good, able to climb stairs with assistance, ambulate without the
use of nasal canula oxygen.
Discharge Instructions:
You were admitted to the hospital for increased abdominal girth.
During your hospitalization you were diagnosed with Burkitts
lymphoma. You were started on chemotherapy treatment
immediately. Your hospitalization was complicated by
inflammation of your mouth and throat which limited your ability
to eat and required intravenous nutrition. You also had a
significant infection in your lungs. You were treated with
antibiotics and recovered well. You will need to continue with
further cycles of chemotherapy in the future.
.
The following changes were made to your medications:
- Your atenolol has been changed to metoprolol.
- Many medications have been added to your medication regimen.
The following are new medications:
Omeprazole: for heartburn
Senna: as needed for constipation
Pyridoxine: to take with tuberculosis medications
Isoniazid: tuberculosis medication
Ethambutol: tuberculosis medication
Pyrazinamide: tuberculosis medication
Docusate Sodium: for constipation
Fluconazole: to prevent fungal infection
Rifabutin: tuberculosis medication
Metoprolol Tartrate: for blood pressure
Acetaminophen: for pain
Lamivudine: to prevent infection
Trimethoprim-Sulfamethoxazole: to prevent infection
Acyclovir: to prevent infection
Hydromorphone: as needed for pain
Lorazepam: as needed for nausea
.
Please continue all other home medications as previously
directed.
.
Please follow up with your doctors as detailed below. It is
very important that you follow up with your doctors as listed
below.
.
Please notify your physician or return to the hospital if you
experience fever, chills, abdominal pain, diarrhea, nausea,
vomiting, cough, sore throat, shortness of breath, rash or any
other symptom that is concerning to you.
Followup Instructions:
Hematology/Oncology follow up: [**Last Name (LF) **],[**First Name3 (LF) 674**] H. [**Telephone/Fax (1) 38619**]
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2167-2-6**] 9:00
.
Infectious disease follow up: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2167-2-24**] 9:30
.
Please call to arrange a follow up appointment with you primary
care doctor: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
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30,154
| 188,029
|
3731
|
Discharge summary
|
report
|
Admission Date: [**2181-7-21**] Discharge Date: [**2181-8-2**]
Date of Birth: [**2106-2-21**] Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Angiography with coiling
History of Present Illness:
HPI: 75M w/ prostate cancer s/p XRT two yrs ago, CAD (s/p BMS x3
to ramus [**2178**], DES x2 to RCA in [**11/2180**]) on ASA and Plavix,
chronic systolic CHF (EF 35-50%), p/w BRBPR. Pt was in his usual
state of health until last evening when following dinner he had
loose brown stools covered in bright red blood which turned the
entire toilet bowl red. No dark/tarry stool. The pt denied
lightheadedness, abdominal pain, rectal pain, SOB, palpitations.
No prior episodes and his last normal BM 2 days ago. No f/c, no
N/V, no sick contacts and no mucus in stool. No recent Abx.
Besides ASA and Plavix, no other blood thinners. No NSAID use.
He has no h/o diverticulosis or hemorrhoids or any GI bleed in
the past. Wife says he does strain to have bowel movements but
patient denies. Says he had normal cscope 2 yrs ago at [**Location (un) 16824**].
On arrival to the ED his orthostatics prior to IVF were, Lying
HR 80 BP 120/75, Sitting HR 80 BP 118/70, Standing HR 75 BP
115/75. No abdominal tenderness. No hemorrhoids visible
externally but he has a small 1cm firm growth near his anus
(old/unchanged per Pt). Rectal exam: small amount of gross
blood, no obvious hemorrhoid or fissure, no tenderness. While in
the ED the pt underwent anoscopy that revealed internal
hemorrhoids seen but none that are visibly bleeding; when
inserted can see friable tissue that is bloody with blood clot.
Labs in ED notable for Hct 31.8 (baseline 40 in [**11/2180**]), Cr 1.2
(is at baseline). Later the pt passed a small amount of blood
and blood clot in bed (without having a bowel movement) but BP
still 127/75. Still no abdominal pain. Was unaware he was
bleeding.
.
On further ROS: Denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, melena, dysuria, hematuria.
Past Medical History:
# HTN
# HL
# NSTEMI in [**2178**] (with 3 bare stents to ramus, also with 70-80%
stenosis in RCA, 50% stenosis in LAD)
# EF 35% to 40% ([**11/2180**])
# Tobacco Abuse
# s/p prostate biopsy secondary to abnormal exam
Social History:
Retired bus driver for the [**Company 2318**]. Retired in [**2164**]. He smokes 2
cigarillos/day, but prior to that smoked ~[**1-21**] ppd times "many
years" up until 5 yrs ago. He has 1 drink/month, no illicit drug
use, including cocaine.
Family History:
No family history of CAD, MI, DM, HTN
Physical Exam:
Admission Exam:
VS: 97.7 115/79 79 18 100RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: Sclera without pallor. NC/AT, PERRLA, EOMI, sclerae
anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, JVD flat, no carotid bruits.
HEART: Regular with occasional irregular beats.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Discharge Exam:
VS: AVSS
ABDOMEN: Soft NT ND
Rest of exam as above.
Pertinent Results:
Admission Labs:
WBC 4.3 Hb 10.9 Hct 31.8 Plts 219
141 107 19 99 AGap=15
3.8 23 1.2
PT: 13.0 PTT: 29.3 INR: 1.1
ECG: NSR Rate 74 NANI LVH TWI II,III, AVF V4-V6
Rads:
[**7-25**] GI Bleed study: Active GI Bleed in the right lower quadrant,
likely cecum.
[**7-27**] CTA Abdomen + Pelvis: No source for active bleeding
localized. Embolization coil demonstrated in good position along
the ileocolic distribution. Vessels are demonstrated to be
peripheral to this point, likely related to collateralization.
The patient is status post aortobiiliac stent placement. Pleural
plaques indicative of prior asbestos exposure. Colonic
diverticulosis.
[**2181-8-2**] 04:15AM BLOOD WBC-5.1 RBC-3.26* Hgb-10.3* Hct-30.1*
MCV-92 MCH-31.5 MCHC-34.1 RDW-15.7* Plt Ct-295
Brief Hospital Course:
75M with hx of prostate CA, CAD s/p BMS x3 in [**11-29**], chronic
systolic CHF here with two days of BRBPR that was admitted with
a large acute LGIB thought to be diverticular in etiology.
Hospital course notable for 2 ICU stays.
.
ACUTE ISSUES:
# Diverticular LGIB: Pt was admitted with LGIB. On day 3 while
being prepped for colonoscopy the pt had an acute GIB and was
brought to the unit. The situation was discussed with his
outpatient cardiologist (Dr. [**Last Name (STitle) **], who recommended
discontinuing plavix but continuing aspirin. He was re-started
on aspirin 325 mg/day but this was stopped again when he
re-bled. As above, ultimately, the source was found to be a
solitary cecal bleed found by a tagged RBC scan. He was treated
with blood transfusions, and ultimately IR deployed 2 coils to a
branch of the ileocolic artery. His bleeding stopped after this
procedure, but upon tranfer to the general medicine service on
the evening of [**2181-7-26**] he again began to have hematochezia. He
underwent a CTA on [**2181-7-27**] that showed no evidence of
extravasation. He was transferred back to the ICU, where Hcts
were stable 30-32. Follow-up colonoscopy to assess for source of
persistent bleeding was was planned for [**2181-7-31**]. Colonoscopy did
not show any active bleeding or any source of bleeding but
revealed diffuse diverticulosis L>R. At time of transfer to
floor, the pt had received a total of 23U PRBC (last [**2181-7-28**]), 2U
platelets, and 4 U FFP. He was on a protonix drip which was
transitioned to 40mg IV daily. The patient was discharged on
[**8-2**] on ASA 81mg, plavix was held after discussing this with his
outpatient cardiologist Dr. [**Last Name (STitle) **] via email.
.
# CAD: s/p two DES in [**2180-11-20**]. Plavix was discontinued;
aspirin was continued, then stopped when he re-bled. After IR
embolization procedure, pt was tachycardic and hypertensive for
a brief period of time, EKG was performed with ST-depressions in
V3-4, which was felt to be demand ischemia in the setting of low
HCT (trop 0.03, 0.04, 0.06). He was transfused again to a goal
of 28-30 (in the setting of possible ischemia) with resolution
of his EKG findings. Follow-up EKG showed stable TWI in III,
aVF, V4-V6, no ST segment elevation, cardiac enzymes: CK-MG
negative x2, trop 0.06 x3. Pt denied chest pain on day of
discharge from [**Hospital Unit Name 153**]. His ASA was discontinued in the [**Hospital Unit Name 153**] given
that the patient re-bled. His Plavix continues to be held. His
home statin was resumed on day of discharge from [**Hospital Unit Name 153**]. The pt
did not have CP throughout his admission.
.
# Chronic Systolic CHF: EF 35%. Pt was euvolemic on admission.
His antihypertensives (beta blockers, [**Last Name (un) **]) were both held early
on during his admission given his hypotension in the setting of
bleeding. He was started back on half his home lopressor after
successful IR intervention, and was restarted on his home
carvedilol at half dose upon transfer to the floor. When he
began bleeding again and was transferred back to the ICU, his
Metoprolol was held and his Carvedilol was continued. BPs ran
high in the ICU in the setting of holding metoprolol,
140s-160s/80s-90s, HR 70s. On discharge
# Aortic thrombus: "Small aortic thrombus," noted by radiology
on abdominal CTA, thought to be unlikely to be clinically
significant.
Medications on Admission:
MEDICATIONS: (From pts wife)
ASA 325mg
Plavix 75mg
Carvedilol 25mg [**Hospital1 **]
Metoprolol Succinate 100mg Daily
Diovan 320mg Daily
MVI
Nitrostat 0.3mg PRN
Omega three fatty acids
Vitamin C
Vitamin E
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Nitrostat 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual
once a day as needed for chest pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnsosis
-Acute Blood Loss Anemia Secondary to Diverticular Blled
-Coronary Artery Disease
-Hypertension
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 bloody stools, for which
you were transfused several units of blood and underwent a
procedure where coils were placed in the bleeding vessels to
control the bleeding. It was felt that this was most likely due
to a diverticular bleed.
.
We have made the following changes to your medications:
1) Please decrease the dose of your Aspirin from 325mg daily to
81mg (baby) aspirin
2) Please discontinue use of Plavix 75mg Daily
3) Please discontinue use of Carvedilol (Coreg)
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1216**] E.
Address: [**Location (un) **], [**Hospital Unit Name **], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 16823**]
When: Tuesday, [**8-7**], 1:35PM
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2181-8-20**] at 1 PM
With: [**Male First Name (un) **] CULLEN, MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2181-8-29**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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icd9cm
|
[
[
[]
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[
"49.21",
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[
[
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8498, 8504
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4262, 6534
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285, 312
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8663, 8663
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3472, 3472
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2262, 2481
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,195
| 132,029
|
54600
|
Discharge summary
|
report
|
Admission Date: [**2112-5-20**] Discharge Date: [**2112-6-6**]
Date of Birth: [**2032-10-23**] Sex: F
Service: MEDICINE
Allergies:
Cipro / Cardura / Codeine / Bactrim Ds / Augmentin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of breath, progressive fatigue
Major Surgical or Invasive Procedure:
Intubation
Midline placement
Chemotherapy
History of Present Illness:
79 year old woman with the medical history below presents to the
ED at the recommendation of her PCP [**Name Initial (PRE) **] 1 month of progressive
fatigue and anemia concerning for progression of her known MGUS
to SMM or MM, and for evalution for other etiologies to explain
profound fatigue. On arrival to ED patient complained of
worsening shortness of breath and progessive fatigue.
In ED patient with 84% Sa02 on room air. CXR in ED concering
for infiltration consistent with pnuemonia. Patient started on
Levoquin and O2 therapy and admitted for observation.
Past Medical History:
1. CAD - c. cath in 04 with RCA stent, no other disease, EF 55%
2. hypertension
3. IPF
4. hyperglycemia without NIDDM
5. hypercholesterolemia
6. GERD
7. hypothyroidism
8. SVT
9. adrenal adenoma
10. Meniere's disease
11. Hysterectomy at age 34 for fibroids
12. s/p Cholecystectomy
[**16**]. s/p bilateral broken arms from a fall with residual UE
weakness
14. MGUS
Social History:
Lives with husband and two sons. 13 pack year smoking history,
quit in [**2086**]. No EtOH.
Family History:
Father died at 54 from an MI; mother had a stroke at 65.
Physical Exam:
On arrival to the medical [**Hospital1 **]:
Tmax 100.1 orally
VSS, except, ra O2 saturation 84 percent, up to 94 percent with
6 litres per minute of O2 via nasal cannula
Pale
Fatigued-appearing
Mildly tachypneic and with visible pursed-lip breathing, but not
in overt acute distress
MMM
RRR no MRG
Diffuse rales and RML and RLL ronchorous adventitiae
Abd soft, nt, nd, bs present
No peripheral edema
Alert, oriented
Moving all four ext., facies symmetric, speech fluent
Pertinent Results:
Admission labs:
[**2112-5-20**] 10:35AM NEUTS-88.6* LYMPHS-7.8* MONOS-2.7 EOS-0.8
BASOS-0.2
[**2112-5-20**] 10:35AM WBC-15.1* RBC-2.63* HGB-7.9* HCT-23.3* MCV-89
MCH-30.0
[**2112-5-20**] 10:35AM TSH-2.2
[**2112-5-20**] 10:35AM ALT(SGPT)-8 AST(SGOT)-18 CK(CPK)-23* ALK
PHOS-89 TOT BILI-0.4
[**2112-5-20**] 10:35AM GLUCOSE-127* UREA N-33* CREAT-2.1* SODIUM-140
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14
[**2112-5-20**] 06:41PM TYPE-ART PO2-98 PCO2-28* PH-7.49* TOTAL
CO2-22 BASE XS-0
[**2112-5-20**] 08:50PM HCT-21.7*
[**2112-5-20**] 11:19PM URINE HOURS-RANDOM TOT PROT-462
Discharge labs:
[**2112-6-3**] 06:50AM BLOOD WBC-12.9* RBC-2.95* Hgb-9.1* Hct-27.1*
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.4 Plt Ct-234
[**2112-6-3**] 06:50AM BLOOD Glucose-86 UreaN-58* Creat-1.8* Na-140
K-3.5 Cl-109* HCO3-22 AnGap-13
[**2112-6-1**] 06:10AM BLOOD ALT-33 AST-28 AlkPhos-99 TotBili-0.6
[**2112-6-1**] 06:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.8
Imaging:
CHEST (PORTABLE AP) Study Date of [**2112-5-20**]
RIGHT AP VIEW OF THE CHEST: Compared to the prior study, there
is new diffuse alveolar opacification predominantly in the right
lung. These findings are most concerning for infection.
Hemorrhage, edema or worsening of underlying interstitial lung
disease is unlikely given the asymmetry. Small right pleural
effusion is noted. No pneumothorax is present. The
cardiomediastinal silhouette, hilar contours and pulmonary
vasculature are not significantly changed.
IMPRESSION: Interval development of diffuse alveolar
consolidation in the
right hemithorax concerning for infection. Hemorrhage, edema or
worsening of underlying interstitial lung disease is less likely
given asymmetry.
.
CT CHEST W/O CONTRAST Study Date of [**2112-5-22**]
IMPRESSION:
1. Worsening interstital and air space opacities. Could reflect
exacerbation
of known fibrotic NSIP or in the right clinical setting would
include an
infectious process.
2. Stable mediastinal adenopathy.
3. Stable low-attenuation renal lesions, however, are
incompletely
characterized given non-contrast setting.
4. The previously described suspicious right middle lobe
subpleural nodule is only partially imaged.
5. Smaller LLL subpleural cyst.
.
CT CHEST W/O CONTRAST Study Date of [**2112-5-25**]
IMPRESSION:
Overall improvement in diffuse widespread ground-glass opacities
suggestive of resolving bilateral pulmonary hemorrhage. Multiple
enlarged mediastinal lymph nodes, likely reactive.
Right central venous catheter terminating in the right
brachiocephalic vein.
.
Pathology:
SPECIMEN SUBMITTED: Native renal biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2112-5-26**] [**2112-5-26**] [**2112-5-28**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/ttl
Previous biopsies: [**-7/2632**] GASTRIC BX'S, 2 + RANDOM COLON
BX.
[**Numeric Identifier 111688**] IMMUNOFLORESCENCE SPECIMEN/tj.
[**Numeric Identifier 111689**] RECTUM BIOPSY/hw.
[**Numeric Identifier 111690**] (Not on file)
DIAGNOSIS:
Renal biopsy, needle: Pauci-immune crescentic glomerulonephritis
in the setting of P-ANCA positivity, see note.
Note:
Light Microscopy: The specimen consists of renal cortex and
medulla, containing approximately 10 glomeruli, of which 2 are
globally sclerotic. Of the remainder, 5 show segmental necrosis
and/or cellular/fibrocellular crescents.
There is mild-moderate interstitial fibrosis and tubular
atrophy. Mild chronic inflammation accompanies the scarring.
Intact tubulointerstitium shows mild chronic inflammation. Red
cell casts are noted.
Arteries show moderate intimal fibroplasia.
Arterioles show moderate mural thickening and hyaline change. No
active vasculitis is noted.
Immunofluorescence: The specimen consists of renal cortex,
containing approximately 5 glomeruli, of which 1 is globally
sclerotic. There is no staining for IgG, IgA, C1q. Mesangial
IgM (1+), C3 (trace), and Kappa and Lambda (both 0-trace) are
seen. 3 glomeruli show crescents on fibrin stain.
1+C3 is seen along tubular basement membranes and in vessels.
Albumin is non-contributory.
Electron microscopy: Findings will be issued in an addendum.
Clinical: ? MGUS. SCr was WNL in [**10-20**].0 on [**5-12**], and now
2.4. Pulmonary process, intubated. [**Doctor First Name **] negative, P-ANCA
positive.
Gross: Received are needle core(s) of light brown tissue. The
specimen is viewed in the dissecting microscope, identified as
renal by Dr. [**First Name4 (NamePattern1) 3535**] [**Last Name (NamePattern1) **], and divided into material for light
(formalin fixation) and electron microscopy and
immunofluorescence studies.
PAS and [**Doctor Last Name **] stains were done to evaluate basement membranes -
Masson's trichrome stains were done to evaluate interstitial
fibrosis.
Brief Hospital Course:
79 year old woman with history of IPF and MGUS who presented
with increasing shortness of breath and fatigue. She became in
a stable condition after aggressive treatment in ICU for acute
lung disease and ARF secondary to P-ANCA associated small vessel
vasculitis (Wegener's' granulomatosis versus microscopic
polyangiitis). She has continued improvement on Cytoxan and
prednisone.
She was initially treated for presumed pneumococcal pneumonia
with IV ceftriaxone and azithromycin. Images were consistent
with worsening bilateral airspace disease. Multiple cultures
were taken with no growth to date. The initial clinical
suspicion at that point was multiple myeloma, evolving from her
known monoclonal gammopathy given evidence of renal failure and
profound anemia, complicated by pneumococcal pneumonia in the
setting of deficient humoral immunity. Shortly following
presentation, her oxygen saturation fell to 82 percent. She was
placed on a NRB and was transferred to the ICU for possible need
for mechanical ventilation for acute hypoxemic respiratory
failure. The ABX spectrum was broadened to Vancomycin and
Cefepime. Chest CT on [**2112-5-22**] showed patchy consolidations,
septal thickening, and multiple areas of traction
bronchiectasis. She eventually required intubation for presumed
ARDS. Mini-BAL and multiple cultures were unrevealing for an
infection. Repeat UPEP and free kappa/lambda studies did not
show MM. A skeletal survey was negative for lytic lesions.
Repeat SPEP showed low level M-spike less suggestive of myeloma.
Renal and Rheumatology were consulted and initial autoimmune
work up came back positive for P-ANCA. A follow up renal biopsy
was done with concern for renal pulmonary syndrome showed
progressive cresenteric glomerular nephritis. Patient was
started on Cytoxan and Solu-Medrol for presumed P-ANCA
associated-small vessel vasculitis. Patient extubated on [**5-28**]
and continued to improve with above treatment on Cytoxan and
prednisone. She will need 6 months Cytoxan and 1 month
prednisone 60mg followed by slow taper. Her ARF is likely
secondary to vasculitis. She had nephrotic range proteinuria and
was started on 10mg lisinopril which was titrated to 20 mg. She
was initially on three antihypertensive medications, including
amlodipine, metoprolol, and hydralazine. We added lisinopril
and discontinued hydralazine. We recommend to titrate
lisinopril for goal of SBP <130. On discharge, she was started
on Keflex for UTI, cultures and sensitivities pending. Her
anemia is chronic and likely related to myelosuppression
secondary to inflammation and Cytoxan. No evidence of hemolysis
or acute bleed during course.
Perianal dermatitis is secondary to incontinence was is
improving on clotrimazole cream.
Medications on Admission:
ATENOLOL - 50MG Tablet - ONE TABLET EACH EVENING
CLOTRIMAZOLE - 1 % Cream - twice a day to groin rash
DOXEPIN - 10 mg Capsule - 1 - 2 Capsule(s) PO at bedtime for
itch
HYDROCHLOROTHIAZIDE - 12.5 mg Capsule - 1 Capsule(s) PO qdaily
NIFEDIPINE [NIFEDICAL XL] - 60 mg Tab PO qdaily
NITROGLYCERIN - 0.4 mg Tablet, Sublingual 1Tab prn angina
PANTOPRAZOLE [PROTONIX] - 40 mg 1 Tab [**Hospital1 **]
PRAVASTATIN - 10 mg Tablet - 1 Tab PO qdaily
SYNTHROID - 50 MCG - ONE PER DAY-ONLY SYNTHROID
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 Tab PO BID
. OTC
ACETAMINOPHEN 500 mg Tablet - 1 Tab at bedtime prn pain
ACETYLCYSTEINE [N-ACETYL-L-CYSTEINE] - (OTC) (Not Taking as
Prescribed: on hold until feels better) - Powder - 600 mg
three
times a day
ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day with food - protect heart
CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3] -
(OTC) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a
day
with food
CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - (OTC) - 0.5 %-0.5 % Lotion
-
once a day as needed for itching
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet - 1 Tablet(s) by mouth once a day
PSYLLIUM [METAMUCIL] - (OTC) - 0.52 gram Capsule - 1- 2
Capsule(s)(s) by mouth twice a day to regulate bowels
Discharge Medications:
1. Cyclophosphamide 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Please give at 8AM with 500 cc of po fluids. .
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): This may be adjusted by your rheumatologist.
3. Zofran 8 mg Tablet Sig: 1-2 Tablets PO once a day: To be
taken with Cytoxan. If she cannot tolerate this, may give 24 mg
in IV form.
4. Prochlorperazine Maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H
(every 6 hours) as needed for nausea.
5. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
6. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for Groin rash for 1 weeks.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO
DAILY (Daily) as needed for severe constipation.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
22. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
23. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
24. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at bedtime.
25. Insulin Lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous four times a day: pls see attached insulin sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
P-ANCA associated small vessel vasculitis
Adult respiratory distress syndrome
Acute renal failure
Secondary:
Hypertension
Chronic Anemia
Coronary artery disease
Hypothyroidism
Discharge Condition:
Stable with improving respiratory and renal function. Satting
95% on 4L. Cr 1.8.
Discharge Instructions:
You were admitted for shortness of breath. You required
intubation with a machine to help you breath for a few days in
the intensive care unit. You have been diagnosed with a
vasculitis affecting your lungs and kidneys. Rheumatology and
Nephrology (Kidney doctors) have been helping with the treatment
of your vasculitis. You are now on cytoxan (cyclophosphamide)
and prednisoe to treat your vasculitis.
Your medications have been changed. Your blood pressure
medications have been changed. Please take your medications as
prescribed.
You will be going to a rehabilitation facility to help you get
stronger before you get home.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**2112-7-5**] 02:30p
[**Hospital6 29**], [**Location (un) **]
RENAL DIV-CC7 (SB)
Provider:[**Name10 (NameIs) **],[**Name11 (NameIs) **] (RHEUM LMOB) [**2112-7-4**] 10:30a
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
RHEUMATOLOGY LMOB WEST (SB)
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2112-6-23**] 9:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2112-6-23**] 9:10
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2112-6-13**] 9:15
|
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"446.4",
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"584.9",
"250.00",
"583.9",
"446.0",
"414.01",
"481",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"55.23",
"99.25",
"33.24",
"96.04",
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] |
icd9pcs
|
[
[
[]
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] |
13450, 13550
|
6890, 9652
|
352, 396
|
13780, 13865
|
2075, 2075
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14549, 15316
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2692, 6867
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1585, 2056
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272, 314
|
424, 997
|
2091, 2676
|
1019, 1384
|
1400, 1495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,902
| 187,365
|
13269
|
Discharge summary
|
report
|
Admission Date: [**2185-3-12**] Discharge Date: [**2185-3-23**]
Date of Birth: [**2121-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
OUTPATIENT CARDIOLOGIST: [**Doctor Last Name **]
.
Chief Complaint: Transfer for possible cath
Major Surgical or Invasive Procedure:
Cardiac Cath
Placement then removal of of temporary HD catheter.
Placement of tunnelled HD catheter.
Hemodialysis
History of Present Illness:
The patient describes progressive dyspnea on exertion since
[**2184-10-14**]. On approximately [**2185-3-7**] the patient awoke with
severe respiratory distress. He went to [**Hospital3 3583**] where he
was noted to be diaphoretic, tachypneic to 26 in obvious
distress with audible rales throughout his lung fields. Vitals
at that time were 96.3 120 156/88 26 with ABG 7.29/47/278. EKG
revealed sinus tachycardia with 1-2mm ST elevations in V1-4 new
from prior. CXR revealed pulmonary vascular congestion. The
patient received furosemide (40mg IV), nitropaste (1in) and
morphine (4mg IV) and was rapidly intubated. The patient
subsequently received metoprolol, aspirin and [**Hospital3 4532**] load. He
also received ceftriaxone (1g) and azithromycin (500mg) for a
question of a right sided infiltrate on CXR.
.
The patent was transferred to [**Hospital1 18**] on [**2185-3-8**]. The patient was
continued on aspirin, [**Month/Day/Year 4532**], beta-blocker and was started on
heparin. His cardiac enzymes (by verbal report) were modestly
elevated. The patient was noted to be in acute on chronic renal
failure with Cr 5.5 up from baseline 3.4. The patient underwent
TTE revealing a thin, scarred anterior wall suggestive more of
an old infarct with chronic sequelae. Given the correlation
between this chronic area of change and the geographic
distribution of EKG changes this was felt to potentially
represent an old ischemic change. Given the severity of renal
dysfunction, the decision was made to defer cardiac
catheterization rather than risk the remaining renal function.
The patient was continued on heparin for 48 hours. The patient's
blood pressure and volume status was optimized. Initially that
patient EF was estimated at 20% by echo, though repeat study
prior to transfer revealed improvement to 30%.
.
The patient's respiratory status improved dramatically with
diuresis. He was extubated on [**2185-3-9**] and at the time of
discharge the patient is saturating well on room air. The day
after extubation, the patient developed a fever to 103,
leukocytosis and had persistent CXR findings suggestive of a
right sided consolidation. The Ceftriaxone and Azithromycin
initially started at [**Hospital3 3583**] had been discontinued but
at this time were reinstituted for treatment of presumed
community acquired pneumonia (effectively, day 1 antibiotic
therapy [**2185-3-9**]). The patient was also noted to have bilateral
small, layering effusions on chest x-ray.
.
The patient's renal dysfunction was profound (Cr 5.5 up from
baseline 3.4) and he had hyperkalemia on admission to 6.9. The
renal consult team was involved in the patient's care at [**Hospital1 2177**].
They felt he did not necessitate dialysis. His hyperkalemia
resolved however his Cr is persistently >5 at the time of
transfer. The decision was made to defer cardiac cath or
possible CABG if possible until the patient is dialysis
dependent.
Past Medical History:
DM2 for 22 years from asulfadine
Diabetic nephropathy
Dye-induced nephropathy
Diabetic retinopathy
Hemorrhoids
PVD with claudication
Hypothyroidism
Hypercholesterolemia
Hypertension
PVD s/p bilateral lower extremity revascularization in [**2181**]
Chronic kidney disease (baseline Cr 3.4)
DM I complicated by neuropathy, nephropathy and retinopathy
Hypothyroidism
Social History:
Lives alone at home. Sells carpet.
Smoked 1 ppd x 38 years, quit 10 years ago.
EtOH 2 drinks/day
Family History:
Mother DM, died at age 63 from colon cancer
Brother CAD age 55
Father CAD, died of MI at age 62
Physical Exam:
PHYSICAL EXAMINATION:
VS - 97.0 BP 140/83, HR 55, RR 19, 97RA
Gen:
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: supple jvp 10cm
CV: RRR nl s1/s2, no murmurs, s3/s4
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Trace edema Strong DP/PT bilat.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
[**2185-3-12**] 07:22PM WBC-5.9 RBC-3.94* HGB-11.7* HCT-35.1* MCV-89
MCH-29.6 MCHC-33.2 RDW-13.0
[**2185-3-12**] 07:22PM NEUTS-55.1 LYMPHS-26.5 MONOS-6.0 EOS-11.6*
BASOS-0.8
[**2185-3-12**] 07:22PM PT-11.6 PTT-22.5 INR(PT)-1.0
[**2185-3-12**] 07:22PM GLUCOSE-146* UREA N-56* CREAT-5.2*#
SODIUM-139 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18
[**2185-3-12**] 07:22PM ALT(SGPT)-13 AST(SGOT)-16 LD(LDH)-230
CK(CPK)-94 ALK PHOS-109 TOT BILI-0.1
[**2185-3-12**] 07:22PM CK-MB-NotDone cTropnT-0.16*
[**2185-3-12**] 07:22PM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-6.0*
MAGNESIUM-2.2
[**2185-3-12**] 07:22PM TSH-2.9
ADDITIONAL LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2185-3-23**] 07:00AM 7.3 3.28* 9.7* 29.8* 91 29.6 32.6 13.3
324
[**2185-3-21**] 07:10AM 9.1 3.71* 11.1* 33.5* 90 29.8 33.1 13.0
370
[**2185-3-19**] 06:00AM 10.9 3.29* 10.0* 29.5* 90 30.3 33.8 13.3
298
[**2185-3-18**] 03:14PM 30.6*
[**2185-3-18**] 03:05AM 10.6 3.19* 9.5* 27.3* 86 29.7 34.6 13.2
318
[**2185-3-17**] 07:15AM 8.8 4.04* 11.7* 35.1* 87 28.9 33.3 13.1
420
[**2185-3-16**] 07:05AM 8.4 3.66* 10.8* 32.0* 87 29.5 33.8 12.6
323
[**2185-3-15**] 07:20AM 6.9 3.74* 10.8* 32.3* 86 29.0 33.5 13.0
364
[**2185-3-14**] 06:45AM 6.7 3.76* 11.1* 32.7* 87 29.6 34.0 12.8
322
[**2185-3-13**] 05:45AM 5.2 3.42* 10.2* 30.1* 88 29.9 34.1 13.0
290
[**2185-3-12**] 07:22PM 5.9 3.94* 11.7* 35.1* 89 29.6 33.2 13.0
345
[**2185-3-23**] 07:00AM 597*1 36* 4.5* 130* 4.5 90* 27 18
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2185-3-22**] 07:30AM 106* 25* 4.2* 139 3.8 96 27 20
[**2185-3-21**] 05:21PM 234* 23* 3.5*# 137 4.3 98 27 16
[**2185-3-21**] 10:22AM 431* 50* 6.1* 131* 4.6 88* 25 23*
[**2185-3-21**] 07:10AM 524*1 50* 5.9* 132*2 4.7 88* 19* 30*
[**2185-3-20**] 05:50AM 186* 35* 5.1* 137 4.3 96 22 23*
[**2185-3-19**] 06:00AM 313* 43* 5.1* 136 5.1 95* 22 24*
[**2185-3-18**] 03:05AM 150* 47* 4.3*# 137 4.2 98 28 15
[**2185-3-17**] 04:28PM 213* 74* 5.4* 137 4.1 101 23 17
[**2185-3-17**] 07:15AM 93 66* 5.2* 138 4.4 101 22 19
[**2185-3-16**] 07:05AM 63* 68* 5.4* 142 4.4 103 24 19
[**2185-3-15**] 07:20AM 136* 62* 5.2* 143 4.5 102 26 20
[**2185-3-14**] 06:45AM 124* 61* 5.0* 141 4.2 101 27 17
[**2185-3-13**] 05:45AM 137* 57* 5.1* 141 3.9 102 26 17
[**2185-3-12**] 07:22PM 146* 56* 5.2*# 139 4.4 100 25 18
.
CK
[**2185-3-18**] 03:05AM 193*
[**2185-3-17**] 04:28PM 140
[**2185-3-13**] 05:45AM 64
[**2185-3-12**] 07:22PM 94
CPK ISOENZYMES CK-MB cTropnT
[**2185-3-18**] 03:05AM 6 0.22*1
[**2185-3-17**] 04:28PM 5 0.14*1
[**2185-3-13**] 05:45AM 4 0.14*1
[**2185-3-12**] 07:22PM NotDone1 0.16*2
HEPATITIS HBsAg HBsAb HBcAb
[**2185-3-18**] 10:30AM NEGATIVE NEGATIVE NEGATIVE
HEPATITIS C SEROLOGY HCV Ab
[**2185-3-18**] 10:30AM NEGATIVE
PROTEIN AND IMMUNOELECTROPHORESIS PEP
[**2185-3-14**] 06:45AM NO SPECIFI1
1 NO SPECIFIC ABNORMALITIES SEEN
COMPLEMENT C3 C4
[**2185-3-14**] 06:45AM 151 63*
TTE ([**2185-3-8**]) form [**Hospital1 2177**]: LV mildly dilated and hypertrophied
with severely reduced systolic function. Inferior and
inferolateral walls move normally at the base and are
hypokinetic at mid level. The base of the anterior wall, lateral
wall and anterior septum are akinetic. LVEF 20%. RV is normal in
size with apical hypokinesis and normal overall systolic
function. Mild LA enlargement. Trace MR and trace TR. IVC is
dilated with blunted respirophasic variation. Small pericardial
effusion without hemodynamic significance.
.
TTE ([**2185-3-11**]) from [**Hospital1 2177**]: Severely reduced LVEF 30%. Mid-distal
anterior wall, anteroseptal and apical areas are akinetic. Focal
RV apical hypokinesis. Mild LAE. Trace MR [**First Name (Titles) **] [**Last Name (Titles) **]. IVC dilated.
Small pericardial effusion without tamponade.
.
CXR ([**2185-3-8**]) from [**Hospital1 2177**]: Densities in the lower lobes radiating
from the hila suggesting interstitial and alveolar edema. Small
right effusion.
.
CXR ([**2185-3-11**]) from [**Hospital1 2177**]: Small bilateral layering effusions,
right greater than left. Lungs are clear bilaterally without
opacities.
.
ETT MIBI ([**10-20**]): 6 minutes of a [**Hospital1 **] [**First Name9 (NamePattern2) 40406**] [**Doctor First Name **] protocol and
was stopped for fatigue, Very poor functional capacity. The
patient was asymptomatic throughout. No significant ST segment
changes. Appropriate hemodynamic response to imposed demands in
the setting of beta blockade therapy. The rhythm was sinus with
no ectopy. Normal exercise myocardial perfusion study performed
at slightly submaximal workload on beta-blockers. There is mild
global left ventricular hypokinesis on gated SPECT images with a
slightly low LVEF calculated to be 47%. These findings are not
significantly changed from [**2182-6-7**].
.
Carotid U/S ([**2184-8-3**]): Moderate plaque with right 40%-59% and
left 60%-69% carotid stenosis.
.
Exercise arterial study ([**2185-2-25**]): The patient has a study from
[**7-/2184**], which demonstrated mild tibial disease only. Currently,
again appreciated are noncompressible vessels, triphasic
waveforms through to the popliteal level and volume recordings
demonstrating waveform widening at the ankle and metatarsal
levels bilaterally. Femoral waveforms remain triphasic after
exercise testing. The left lower extremity demonstrating a
normal response to exercise testing. The right lower extremity
could not be evaluated due to noncompressible vessels not
allowing ABI post-exercise to be performed. IMPRESSION: No
change compared to five months earlier, i.e., mild-to-moderate
tibial disease bilaterally.
.
Cardiac cath ([**2182-8-15**]): 1. Access was retrograde via the LCFA.
2. Catheter placement was to the contralateral popliteal. 3. The
RCFA was normal, and there was no proximal SFA disease. The
distal RSFA had a tubular 90% lesion at the adductor canal, with
a normal popliteal. The AT was patent to the foot, and the PT
was occluded, with collaterals from the PA also supplying the
foot. There was a gradient of 13 mmHg from the central aorta to
the LCFA with an eccentric 70% lesion in the CIA. 4. Successful
atherectomy and POBA of the RSFA stenosis. 5. Successful
stenting of the LCIA with a 7.0 x 29 mm Genesis stent,
post-dilated with a 8.0 mm balloon.
Normal sinus rhythm. Left axis deviation. Left atrial
abnormality. Q waves
in leads V1-V2 with prominent T wave inversions in the anterior
precordial
leads suggestive of prior anteroseptal myocardial infarction and
anterior
ischemia. Compared to the previous tracing of [**2183-3-4**] the
anterior ischemic changes are new. Clinical correlation is
suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 172 122 492/500 27 -43 151
.
ECG Study Date of [**2185-3-17**] 11:55:44 AM
Sinus rhythm. Left atrial abnormality. Left axis deviation,
possibly due to left anterior fascicular block. Prior septal
myocardial infarction. Lateral ST segment changes are
non-specific but may be due to ischemia or secondary
repolarization from left ventricular hypertrophy. Compared to
tracing #1 the T waves in leads V1-V4 are now upright and the
ST-T wave changes in leads V5-V6 are not as obvious.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 168 116 362/426 32 -63 93
.
ECG Study Date of [**2185-3-18**] 9:25:16 AM
Sinus rhythm. Left axis deviation with left atrial abnormality.
Probable
left anterior fascicular block. Left ventricular hypertrophy
with lateral
ST-T wave changes which may be due to left ventricular
hypertrophy with
repolarization changes or to lateral ischemia. Compared to
tracing #2
no significant interim change.
TRACING #3
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 158 116 388/437 37 -56 115
.
RENAL U.S. [**2185-3-13**] 10:24 AM
RENAL ULTRASOUND: The right kidney measures 11.7 cm. The left
kidney measures 11.4 cm. There is no evidence of hydronephrosis,
nephrolithiasis, or renal mass. The bladder was not visualized
since the patient had recently voided. IMPRESSION: No
hydronephrosis or nephrolithiasis.
.
[**2185-3-14**] TTE: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the distal half of the anterior
septum and anterior walls and distal inferior wall and apex. The
remaining segments contract normally (LVEF = XX %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). 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 appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD (mid-LAD
distribution).
.
[**2185-3-17**]
PTCA COMMENTS: Initial angiography demonstrated a hazy
lesion in the
proximal left anterior descending artery with flow distal to the
lesion.
The cardiac surgery service was consulted - recommended PCI
given his
high surgical mortality risk. Aspirin, clopidogrel and heparin
were all
started prophylactically. A 6F XB LAD guide provided excellent
support
throuhgout the case. The lesion was crossed with a prowater
guide wire
with minimal difficulty. The lesion was predilated with a
Voyager
(2x15mm) balloon inflated to 12 atm. The lesion was then
treated with
an Endeavor (2.5x18mm) drug eluting stent dilated to 12 atm.
The stent
was then postdilated with a Quantum Maverick (2.75x8mm) balloon
inflated
to twice to 20 and 22 atm. Final angiography demonstrated no
angiographically apparent dissection, no residual stenosis and
TIMI III
flow throughout the vessel.
.
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated an
LMCA without angiographically significant disease. The LAD had a
70-80
hazy proximal lesion thought to be the culprit as well as a 50%
mid-vessel lesion. There was a large ramus intermedius without
angiographically significant disease. The LCX system had a OM1
with 80%
proximal disease. The RCA had a 50% narrowing in its proximal
segment.
2. Limited resting hemodynamics revealed markedly elevated right
atrial
and pulmonary arterial pressures. Cardiac index was preserved.
3. Successful PTCA and stenting of the proximal left anterior
descending artery with an Endeavor (2.5x18mm) drug eluting stent
postdilated with a 2.75mm balloon. Final angiography
demonstrated no
angiographically apparent dissection, no residual stenosis and
TIMI III
flow throughout the vessel (See PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PTCA and stenting of the proximal left anterior
descending
artery with an Endeavor drug eluting stent.
.
CHEST (PA & LAT) [**2185-3-14**] 11:35 AM
FINDINGS: In comparison with study of [**2183-7-8**], there is a patchy
area of increased opacification silhouetting the right
hemidiaphragm with blunting of the costophrenic angle and
meniscus formation. This is consistent with the clinical
impression of pneumonia and pleural effusion at the right base.
At the left base, there is a less prominent area of increased
opacification with meniscus formation at the costophrenic angle,
again consistent with pneumonia and pleural effusion.
The cardiac silhouette is mildly enlarged. Some indistinctness
of pulmonary vessels raises the possibility of increased
pulmonary venous pressure. IMPRESSION: Bibasilar pneumonia,
effusions.
.
CHEST (PORTABLE AP) [**2185-3-17**] 7:39 AM
In comparison with the study of [**3-14**], there is now an
endotracheal tube in place with its tip approximately 5.5 cm
above the carina. Nasogastric tube extends well into the stomach
and right IJ catheter tube has its tip in the mid portion of the
SVC. Prominence of the interstitial markings is consistent with
elevated pulmonary venous pressure in this patient with mild
enlargement of the cardiac silhouette. The blunting of the
costophrenic angle and meniscus formation is not well seen on
the study, presumably because of the semi-upright position.
Haziness in both lungs with preservation of pulmonary markings
is consistent with layering of pleural effusions bilaterally.
.
CHEST (PORTABLE AP) [**2185-3-18**] 7:39 AM
IMPRESSION: Improving pulmonary edema.
.
CHEST (PORTABLE AP) [**2185-3-19**] 7:46 AM
A single AP view of the chest is obtained [**2185-3-19**] at 08:00 hours
and compared with the prior morning's radiograph. Patient has
been extubated. Pulmonary artery catheter has also been removed.
Vascular sheath remains in the right IJ. The mild pulmonary
edema seen on the prior day appears to have improved. There is
persistent small left pleural effusion together with some
increased retrocardiac opacity on the left side which likely
represents a combination of fluid and atelectasis.
.
MICROBIOLOGY:
[**2185-3-22**] CATHETER TIP-IV WOUND CULTURE-PENDING INPATIENT
[**2185-3-20**] URINE URINE CULTURE-FINAL NEGATIVE
[**2185-3-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-3-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-3-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-3-18**] URINE URINE CULTURE-FINAL NEGATIVE
[**2185-3-18**] 12:37 pm SPUTUM Source: Endotracheal. **FINAL
REPORT [**2185-3-20**]**
GRAM STAIN (Final [**2185-3-18**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2185-3-20**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2185-3-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-3-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-3-13**] URINE URINE CULTURE-FINAL NEGATIVE
Brief Hospital Course:
Mr. [**Known lastname 4223**] was transferred to [**Hospital1 18**] for evaluation of coronary
disease by his primary cardiologist after having an ST elevation
MI at OSH one week prior. He had presented initially at OSH w/
dyspnea and respiratory failure, was intubated and treated for
community acquired pnuemonia, developed worsening renal failure
Cr 3.4(baseline)=>5.5, was extubated on [**2185-3-9**], and was kept on
ceftriaxone/azithromycin. His new EF was 20%, then on repeat TTE
was 30%. He was transferred to [**Hospital1 18**] to weigh risks/benefits of
cardiac cath intervention in the setting of CKD stage 5, w/high
risk of becoming HD dependent if to receive dye load. TTE was
done at [**Hospital1 18**] showing EF of 40%.
.
The patient was evaluated by the renal consult service. They
thought there would be benefit to pre-cath mucomyst, precath
hydration, and post-cath prophylactic hemodialysis. Patient had
a temporary HD line placed on [**3-16**]. He received precath hydration
overnight, and IV bicarb the morning prior to cardiac cath. The
patient became hypertensive, hypoxic and dyspneic in the precath
holding area requiring intubation. Please see CCU course below.
.
CCU course:
Respiratory failure:
In the setting of pre-cath hydration and an SBP elevated at
180mmHg, the patient went into pulmonary edema in the holding
area prior to his cardiac catheterization. He was intubated for
hypoxic respiratory failure. Post-cath, PA was line left in and
showed elevated PA diastolic pressure in mid-20s. He received
dialysis to remove fluid allowing for PA diastolic pressure to
fall to 17. Pulmonary edema improved on CXR. He was
successfully extubated on [**2185-3-18**]
.
Pump/Hypotension:
After initial hypertension, patient was hypotensive while
sedated with propofol. He was initially on a dopamine drip but
with further titration of sedation dopamine was weaned off. He
was started on hydralazine and nitrates for afterload reduction
in setting of his systolic heart failure. His blood pressure
was well-controlled on this regimen.
.
CAD
Cardiac surgery was consulted while patient was in cath lab
given finding of 3 vessel disease. Given his comorbidities at
the time (pulm edema, renal disease not yet on dialysis) he was
felt to be a poor operative candidate at present. A stent was
placed in the LAD. If his CAD does not progress further he may
not need bypass surgery.
.
Fever
Patient was on his last day of a 7d course of
ceftriazone/azithromycin for community-acquired pneumonia. He
had a fever to 101 F. He did have some increased sputum
production through his ET tube but once extubated he did not
have significant sputum production. He did not have new
consolidations on preliminary review of his CXR. Ceftriaxone
was continued for an additional day but on further review of
data it did not seem that patient had pneumonia so it was
stopped. Blood cultures did not have growth for 24hrs. U/A
showed few bacteria but did not show significant evidence of
UTI. urine culture was pending. Given that patient had
finished course for CAP, he should be watched clinically for
signs of infection.
.
Patient was transferred out to the general medical floor where
he continued to spike a fever to 101 one hour after his last
prophylactic course of HD (HD x 3times). The patient was
cultured, and started on vancomycin/cefepime for possible
bacteremia. VAP was felt low prob as patient was only intubated
for 24 hours.
.
Problems:
.
#CAD: Time course of ischemic changes at OSH was unclear. This
hospital stay the patient received PTCA and DES to the proximal
LAD. He was continued on regimen of aspirin, hydralazine,
[**Date Range 4532**], beta-blocker, statin. We continued to avoid ACEi and [**Last Name (un) **]
due to renal disease.
.
#Acute on Chronic renal failure: Stage 5 CKD: Cr 5.5 up from
baseline of 3.4. Urine P/Cr: 2.54. RENAL ULTRASOUND: "The right
kidney measures 11.7 cm. The left kidney measures 11.4 cm. There
is no evidence of hydronephrosis, nephrolithiasis, or renal
mass. The bladder was not visualized since the patient had
recently voided." Received regular treatments of prophylactic
HD after cardiac cath and dye load but his Cr continued to
rise.HD temp catheter (RIJ) was removed and he had a tunneled
line placed by IR on [**3-22**]. Outpatient HD was arranged by the
renal team as described in discharge paperwork below.
.
#Fever: Patient developed high grade fevers after extubation,
and post HD. No clear source was identified, CXR not convincing
for pneumonia, urine cultures were negative. There was some
erythema but no pus at the RIJ temporary catheter which
suggested line infection so he was started on vanc/cefepime on
[**3-19**]. All blood cultures were negative, though the patient had
recently completed a course of antibiotics for PNA as below. The
temporary catheter tip was sent for culture and is pending at
the time of discharge. Please follow up on blood/cath tip
culture final results. Surveillance cultures should be drawn at
outpatient HD.
.
#Pump: TTE 20-30% LVEF at OSH records. TTE at [**Hospital1 18**] documented
EF 40%. Now he is status post LAD intervention. He has been
breathing well on room air, with no sign of failure on exam. He
was continued on HD per renal recs. We did no give ACE/[**Last Name (un) **] given
CKD 5. He was continued on metoprolol 50mg TID, imdur,
hydralazine, statin, [**Last Name (LF) 4532**], [**First Name3 (LF) **]
.
#Presumed Community Acquired PNA: Started on Ceftriaxone and
azithromycin at [**Hospital1 2177**] on [**2185-3-9**] continued through [**2185-3-18**].
.
#Respiratory Failure: RESOLVED see CCU course.
.
#DM type 1: Patients sugars were elevated in CCU maintained on
insulin drip. Once extubated patient managed his own blood
sugars with his insulin pump. The patient had nausea and BS in
500s on [**2-18**], had evidence of DKA with AG of 35, ketones in urine
and acetone in blood. This was thought perhaps due to infection
though the etiology was unclear as no organism was identified as
above. He administered an extra 10 of humalog and had HD. Blood
sugars and gap normalized by [**2-19**]. On day of discharge his FS
again were elevated ~600, but he did not have an AG and the
patient was asymptomatic. He gave himself 30 units and monitored
w/q1h FS checks, and the blood glucose trended down. After HD
the FS was ~200. The patient knows to monitor his FS closely and
to arrange f/u with his [**Last Name (un) **] provider in the next 1-2 days to
optimize his regimen.
.
#HTN: He was continued on bb, hydralazine, and imdur.
.
# Hypothyroidism: He was continued on home levothyroxine 200
mcg/day.
#PVD: Patient maintained on [**Last Name (un) 4532**]. Otherwise stable.
.
#Full code.
.
#Follow up as indicated in discharge worksheet.
Medications on Admission:
HOME MEDICATIONS:
At home (per OMR note [**2185-3-1**]):
Aspirin 325 mg daily
Diovan 160 mg daily
Toprol XL 25mg Daily
Nifedipine 90 mg daily
[**Month/Day/Year **] 75 mg daily
Lipitor 40 mg daily
Levoxyl 20 mcg daily
Calcitriol 0.5 mg daily.
.
At time of transfer (from discharge summary [**2185-3-12**]):
Aspirin 325mg Daily
[**Month/Day/Year **] 75mg Daily
Amlodipine 10mg Daily
Isosorbide Dinitrate 10mg Three times Daily
Atorvastatin 80mg Daily
Metoprolol 50mg Three times daily
Clonidine 0.2mg Twice daily
Levothyroxine 175mcg Daily
Insulin pump
Calcitriol 0.5mcg Daily
Ranitidine
Ceftriaxone 1g Daily (Day 1: [**2185-3-9**])
Azithromycin 500mg Daily (Day 1: [**2185-3-9**])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. cardiac rehab
please arrange cardiac rehabilitation services
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
8. Insulin Pump Cartridge Cartridge Sig: self administered
Subcutaneous per regular schedule: please continue administering
insulin based on recommendations by your [**Last Name (un) **] provider.
9. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. 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*
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Outpatient Lab Work
please obtain surveillance blood cultures at HD during the week
of [**3-28**]
Discharge Disposition:
Home
Discharge Diagnosis:
1. 2 vessel coronary artery disease, had LAD drug-eluting stent
placed
2. community acquired pneumonia
3. acute on chronic renal failure requiring hemodialysis
4. diabetic ketoacidosis
5. hypertension
6. hyperlipidemia
7. fever of unknown origin (suspected but not confirmed
temporary catheter line infection)
8. acute systolic congestive heart failure
Secondary
1. diabetes type 1
2. hypothyroidism
Discharge Condition:
Ambulating well without assistance on room air. Afebrile. Chest
pain free.
Discharge Instructions:
Mr. [**Known lastname 4223**] you were transferred to [**Hospital1 18**] from [**Hospital3 9947**] after being treated for fluid in your lungs and after
having a heart attack, for cardiac catheterization. You had
prophylactic hemodialysis before the catheterization and had
pre-cath hydration. Unfortunately you developed further fluid in
your lungs and required intubation. You had your catheterization
which found 2 vessel coronary artery disease and a drug-eluting
stent was placed in your Left Anterior Descending artery. You
were started on [**Hospital3 4532**] which is very important for you to take
in order to prevent further clotting of the stent and vessels.
Your medications were further changed in order to optimize
management for coronary artery disease and heart failure.
.
You also developed a pneumonia for which you were treated with
an 8 day course of ceftriaxone and azithromycin. After
completing this course you developed a fever of unclear origin.
It was felt to possibly be due to an infected catheter line, but
no organism was isolated. You were treated with a brief course
of vancomycin and cefepime.
.
You also had high blood sugars during your stay. Some of this
was likely related to your infections and the stress of
procedures. You developed diabetic ketoacidosis but this
resolved quickly with additional insulin injections. Your sugars
were elevated on the day of discharge. Please arrange to follow
up with your [**Last Name (un) **] diabetes provider [**Name Initial (PRE) 176**] 2 days to review
your blood sugar management.
.
**Please take all medications as prescribed. Please make a
follow up appointment with your PCP and [**Name9 (PRE) **] providers as
instructed below. Please go to your follow up appointment with
Dr. [**First Name (STitle) **].
.
When you go to your PCP, [**Name10 (NameIs) **] bring the script for cardiac
rehabilitation in order to obtain further rehabilitative
services that will assist in regaining your heart function.
.
Please go to your outpatient dialysis sessions as follows:
First session is on [**Last Name (LF) 2974**], [**2185-3-25**] at 3:00pm.
Location: FMC-Cordage
[**Street Address(1) 36198**]
[**Location (un) 3320**] [**Numeric Identifier **]
Phone:[**Telephone/Fax (1) 26577**]
Your confirmed hemodialysis treatment schedule will be every
Monday, Wednesday and [**Telephone/Fax (1) 2974**] at 3:30pm, unless otherwise
instructed.
.
Please have surveillance blood cultures drawn next week at
dialysis.
.
If you develop fever, shortness of breath, palpitations, chest
pain, nausea, change in mental status, or any other concerning
symptoms, please call your doctor or come to the hospital.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 745**]
[**Last Name (NamePattern1) 13248**] ph#[**Telephone/Fax (1) 40407**] with in 2 weeks of your discharge from
the hospital.
.
Please follow up with your cardiologist Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]
pH#[**Telephone/Fax (1) 920**] on [**2185-3-29**] at 2:20pm.
.
Please make an appointment to see your [**Last Name (un) **] diabetes provider
[**Name Initial (PRE) 176**] 2 days.
Completed by:[**2185-3-24**]
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1,794
| 163,615
|
29599
|
Discharge summary
|
report
|
Admission Date: [**2194-2-12**] Discharge Date: [**2194-2-13**]
Date of Birth: [**2156-6-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2194-2-13**]: Cerebral angiogram without emobilization
History of Present Illness:
Pt is a 37 yo female with PMHx significant for anxiety who
p/w SAH. Pt states that she was in her USOH this AM at work
when
she began to have a headache. This was located bifrontally and
described as a throbbing sensation. She left work early and was
pumping gas at ~ 11 AM when she has acute onset severe headache
in the same distribution. She also experienced right sided neck
pain and felt that her legs were numb. She then called 911 and
was brought to an OSH in [**State 1727**]. She was found to have a SAH and
was transferred to [**Hospital1 18**] for further management.
Past Medical History:
anxiety
Social History:
lives with fiance and two children. Non-smoker.
Non-drinker.
Family History:
father - HD, mother DM,HTN
Physical Exam:
T 98; BP 137/68; P 90; RR 17; O2 sat 100% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: + nuchal rigidity
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: A & O x3, tells coherent story. Fluent speech
with no paraphasic or phonemic errors. Adequate comprehension.
Follows simple and multi-step commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. optic discs sharp. VFF.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-10**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
RT: 5 5 5 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: intact to pinprick, light touch, vibration, and
position sense.
Reflexes: Bic T Br Pa Ac
Right 2 2 3 3 2
Left 2 2 2 3 2
Toes downgoing bilaterally.
Coordination: FNF intact.
Pertinent Results:
[**2-12**] MRI/MRA Head/Brain:
INDICATION: Intraventricular and subarachnoid hemorrhage.
COMPARISON: Circle of [**Location (un) 431**] CTA performed earlier on the same
day is
available for correlation.
TECHNIQUE: Multiplanar MR imaging of the brain was performed at
1.5 Tesla
using T1-weighted, T2-weighted, FLAIR, gradient echo,
diffusion-weighted, and gadolinium enhanced T1-weighted images.
Three-dimensional time-of-flight circle of [**Location (un) 431**] MRA was
performed.
BRAIN MRI BEFORE AND AFTER INTRAVENOUS CONTRAST ADMINISTRATION:
Blood
products are present in the fourth, third, and lateral
ventricles. An
intraventricular drain has been placed via the right frontal
approach since the preceding CTA, and previously noted
hydrocephalus has improved.
Subarachnoid blood is again noted in the sulci of both cerebral
hemispheres, most prominent in the frontal lobes. There are no
foci of slow diffusion in the brain parenchyma to suggest an
acute infarction. A 3-mm focus of high T2 signal in the right
frontal periventricular white matter may represent
post-inflammatory demyelination. A lacunar infarction is less
likely, unless the patient has vascular risk factors, which have
not been specified in the history.
CIRCLE OF [**Location (un) **] MRA: Flow is visualized in the major
tributaries of the
circle of [**Location (un) 431**]. There is a 2 mm aneurysm at the origin of the
left
posterior inferior cerebellar artery. Given the pattern of
intraventricular and subarachnoid hemorrhage, this aneurysm
likely represents the source of bleeding. There may be a _____
aneurysm at the junction of the cavernous and supraclinoid
segments of the left internal carotid artery, best demonstrated
on the preceding CTA and the conventional angiogram performed on
[**2194-2-13**]. There are no significant arterial stenoses.
Beaded appearance of the
basilar artery is most likely artifactual, as it appears normal
on the
preceding CTA and on the subsequent conventional angiogram.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who performed the
conventional angiogram in the morning of [**2194-2-13**].
IMPRESSION:
1. Intraventricular and subarachnoid hemorrhage as shown on the
preceding
CTA.
2. 2 mm aneurysm at the origin of the left posterior inferior
cerebellar
artery, which most likely represents the source of hemorrhage.
3. Probable _____ aneurysm at the junction of the cavernous and
supraclinoid segments of the left internal carotid artery.
[**2-12**] CTA Head with and without contrast:
INDICATION: Subarachnoid hemorrhage discovered at an outside
hospital.
COMPARISON: No previous studies at [**Hospital1 18**]. No outside studies
available for
comparison.
TECHNIQUE: Noncontrast head CT was obtained. CT angiogram of
the circle of
[**Location (un) 431**] was performed using 70 cc of intravenous Optiray.
Multiplanar two
dimensional and three dimensional reformatted images were
performed.
NONCONTRAST HEAD CT: There is blood in the fourth ventricle and
the frontal
and occipital horns of the right and left lateral ventricles.
The temporal
horns of the lateral ventricles are abnormally dilated,
indicative of
hydrocephalus. Blood is present in the interpeduncular cistern.
Small amounts
of blood are also noted in the sulci of both cerebral
hemispheres, most
prominent in the frontal lobes. [**Doctor Last Name **]/white matter
differentiation is
preserved. The imaged bone appear unremarkable.
CTA OF THE CIRCLE OF [**Location (un) **]: There is a 2 mm aneurysm at the
origin of the
left posterior inferior cerebellar artery. Given the pattern of
the
intraventricular and subarachnoid hemorrhage, this aneurysm
likely represents
the source of bleeding. There also appears to be a 2.6 mm
sessile aneurysm at
the junction of the cavernous and supraclinoid segments of the
left internal
carotid artery (series 223, image [**Numeric Identifier 70961**], and series 400B, image
82). The major
tributaries of the circle of [**Location (un) 431**] are patent without evidence
of significant
stenoses.
CT RECONSTRUCTIONS: Multiplanar three dimensional and two
dimensional
reformatted images were essential in identifying and evaluating
both of the
above-described aneurysms.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who completed a
conventional
angiogram on this patient in the morning of [**2194-2-13**].
The
conventional angiogram confirmed the CTA findings.
IMPRESSION:
1. Intraventricular and subarachnoid hemorrhage with associated
mild
hydrocephalus.
2. 2 mm aneurysm at the origin of the left posterior inferior
cerebellar
artery, which likely represents the source of hemorrhage.
3. Probable 2.6 mm sessile aneurysm at the junction of the
cavernous and
supraclinoid segments of the left internal carotid artery.
Brief Hospital Course:
HD1: Admitted to surgical ICU. On review of head CT
demonstrating bilateral ventricular hemorrhage and enlarged
ventricles, an external intraventricular drain was placed.
Opening pressures were high but ICP monitoring dmonestrated max
ICP of 17, range 6-17 throughout hospital stay. Neurology
consulted and case was discussed with neurology throughout
hospital course.
HD2: CTA head performed: 1. Intraventricular and subarachnoid
hemorrhage with associated mild hydrocephalus. 2. 2 mm aneurysm
at the origin of the left posterior inferior cerebellar artery,
which likely represents the source of hemorrhage.
3. Probable 2.6 mm sessile aneurysm at the junction of the
cavernous and
supraclinoid segments of the left internal carotid artery.
HD3: MRA head performed: 1. Intraventricular and subarachnoid
hemorrhage as shown on the preceding CTA. 2. 2 mm aneurysm at
the origin of the left posterior inferior cerebellar artery,
which most likely represents the source of hemorrhage.
3. Probable _____ aneurysm at the junction of the cavernous and
supraclinoid
segments of the left internal carotid artery.
Following these findings, angiogram performed but aneurysm was
not succesfully embolized. After discussion with family and
team, decision was made to transfer to [**Hospital6 **] for
further management.
Medications on Admission:
trazadone, zoloft
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
4. HydrALAzine 10 mg IV Q6H:PRN SBP>140
5. CefazoLIN 1 gm IV Q8H while ventriculostomy is in place
6. Famotidine 20 mg IV Q12H
7. Morphine Sulfate 1 mg IV Q2H:PRN
8. Promethazine HCl 25 mg IV Q6H:PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PICA aneurysm
Subarachnoid hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Transferring to [**Hospital6 **] Hospital
Followup Instructions:
Per team at [**Hospital1 112**]
Completed by:[**2194-2-13**]
|
[
"300.00",
"331.4",
"437.3",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
9230, 9245
|
7404, 8723
|
328, 388
|
9327, 9336
|
2483, 5494
|
9426, 9489
|
1130, 1159
|
8792, 9207
|
9266, 9306
|
8749, 8769
|
9360, 9403
|
1174, 1488
|
1507, 1507
|
280, 290
|
416, 1003
|
1690, 2464
|
5504, 7381
|
1522, 1674
|
1025, 1034
|
1050, 1114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,436
| 195,728
|
10975+56197
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-5-29**] Discharge Date: [**2197-6-13**]
Date of Birth: [**2119-11-29**] Sex: F
Service: MICU B
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
female with recently diagnosed renal cell carcinoma status
post left nephrectomy and left adrenalectomy in [**4-1**] with
known metastases to the lungs and liver, who presents to the
Emergency Department on [**5-29**] with hypotension, history of
poor po intake, as well as worsening dyspnea. In the
Emergency Room, the patient had a blood pressure less than
60/palp that responded quickly to normal saline boluses.
Random cortisols at that time showed normal adrenal function
of 45. On x-ray, there was noted bilateral pleural effusions
and a calcium of 15 that corrected to 17.
The patient was admitted to CC7 with the following course:
Was treated with intravenous fluids and loop diuretics for
hypercalcemia. The left effusion was tapped on [**5-31**], which
subsequently was noted to be chylous. Her chylothorax had
triglycerides of 200 mg/dl with approximately 1100 cc
removed.
The patient later developed atrial fibrillation and was
adequately rate controlled with diltiazem and spontaneously
converted to normal sinus rhythm. The following day, [**6-1**],
the patient was started on base beta blocker and subsequently
received 25 mg of IV Lopressor during spontaneous episodes of
supraventricular tachycardia. Echocardiogram was obtained
which was normal, which showed no effusions, normal valves,
and an ejection fraction of 60%. Patient responded well to
IV fluids and loop diuretics, and treated for hypercalcemia
that reverted to normal.
Subsequent days [**6-1**] to [**6-3**], the patient became
increasingly dyspneic. On physical exam, was noted
decreasing breath sounds on the left. X-ray on [**6-3**] showed
complete obstruction of the entire lung field. An arterial
blood gas was obtained at that time of 7.32, 73, and 143.
Repeat thoracentesis on [**5-/2189**] yielded 1 liter of
serosanguinous fluid. Patient became promptly hypotensives
to 80s/palp with a respiratory rate of 6. Her arterial blood
gas at that time was 7.23, 73, 21. She was minimally
responsive and intubated for hypercarbic respiratory failure.
She was transferred to the MICU, and treated with aggressive
IVF and neo and then switched to Levophed for pressure
control. Right IJ was placed for adequate fluid
resuscitation and central venous pressure monitoring.
Preceding chest x-ray showed little evidence of pneumothorax
or fluid accumulation. The patient was weaned successfully
off pressors with aggressive IVF administration. On [**6-7**],
patient was becoming increasingly dyspneic. Chest x-ray was
obtained at that time showing persistent right effusion that
was tapped and showing exudate picture.
Also of course during her MICU time, the patient was notably
hypotensive, responding well with IVF, but necessitated the
addition of Levophed due to mental status change and
decreasing urine output. Urine output was continuously
monitored, and subsequently the diagnosis of acute tubular
necrosis was made, which was treated with pressors and volume
resuscitation.
On [**6-9**], the patient was continuing to show signs of
dyspnea, and failed multiple attempts to be weaned off the
ventilator with hypotension persisting despite resuscitation
with intervascular fluids with the addition of pressors.
Empiric antibiotics were started to rule out sepsis, and the
patient was pancultured, although cultures were no growth to
date.
In assessing the etiology of respiratory failure, patient
obtained second echocardiogram which was again normal showing
normal ejection fraction and normal valve function. A CT
scan on [**6-9**] was obtained of the chest, abdomen, and pelvis
to assess for 1) increase in local recurrence of renal cell
carcinoma, 2) the presence or absence of ascites in her
belly, 3) the presence of mediastinal metastases as a
possible etiology of her hypercarbic respiratory failure and
chylothorax/exudate pleural effusions.
CT scan showed permanent findings of increased number of
metastases in her liver as well as or her lungs bilaterally.
In comparison with previous CT scan, the multitude and size
were profoundly larger.
At that time, [**2197-6-10**], the MICU team and patient's family
were sat down to discuss continuing care in particularly her
code status. At the time of this dictation, the family has
yet to review her full code status, and addendum will be made
to this note as to subsequent decisions made by them.
Ms. [**Name13 (STitle) **] oncologist, Dr. [**Last Name (STitle) **], is acutely aware of guarded
situation in the MICU, and it is optimistic that if the
patient is able to be discharged from the MICU, she would be
able to start interleukin therapy for treatment of her renal
cell carcinoma.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2197-6-11**] 20:47
T: [**2197-6-16**] 10:17
JOB#: [**Job Number 35598**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6343**]
Admission Date: [**2197-5-29**] Discharge Date: [**2197-6-13**]
Date of Birth: [**2119-11-29**] Sex: F
Service:
Not certain of the date of admission, but admission lasted
through Saturday, [**6-11**] and continued.
HOSPITAL COURSE: The patient continued to do poorly and
family was involved in discussions about whether to make
patient comfort measures only. Patient's urine output
decreased, and the patient developed whole body anasarca with
weeping. The patient did require pressors for blood pressure
support, and was placed on Levophed on [**6-11**] and [**6-12**], and the patient continued to be intubated.
In discussions with the family, the family continued to
discuss whether to make the patient comfort measures only.
The patient was able to come off the Levophed drip for some
time, but then was placed back on a phenylephrine drip for
blood pressure support, and continued to be intubated.
On [**6-13**], the decision was made to make the patient
comfort measures only, and that evening the drip was stopped,
and mechanical ventilation was halted. The patient was made
comfortable with Morphine and patient passed away on the
evening of [**6-13**].
DISPOSITION: Death.
DISCHARGE INSTRUCTIONS: None.
MEDICATIONS: None.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 5452**]
Dictated By:[**Last Name (NamePattern1) 2223**]
MEDQUIST36
D: [**2197-6-14**] 11:35
T: [**2197-6-14**] 12:28
JOB#: [**Job Number 6344**]
|
[
"457.8",
"276.5",
"584.9",
"518.81",
"427.31",
"V10.52",
"197.7",
"197.0",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72",
"99.15",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
5501, 6459
|
6484, 6785
|
165, 5483
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,724
| 107,008
|
28209
|
Discharge summary
|
report
|
Admission Date: [**2184-10-10**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2129-2-16**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
SOB, Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 year old male with a PMH of STEMI s/p stent '[**79**] who stopped
his plavix 2 months ago [**2-10**] financial issues, who presents from
[**Hospital3 2737**] with near syncope and SOB.
.
The patient states he was doing yardwork, started walking across
the lawn, felt dizzy and lightheaded for 1 minute and felt like
he was going to pass out. The patient states that this was
nothing like his prior MI. He sat down on his steps where he
"blacked out" for less than 30 seconds and he immediately came
to. FSBG was 168 at that time. His wife called the ambulance
and the patient presented to [**Hospital1 **] where he was worked up for
MI, initial troponin I was .29 and repeat was .6. He was
transfered to [**Hospital1 18**] with concern for ACS on heparin drip.
.
Per patient there has been no recent travel, no smoking, no
prolonged immobilization, though he has been less active at
work.
.
In the ED initial vital signs were 98.5 75 147/86 18 98% 2L NC.
Heparin drip was continued at 1000 unites per hour. CTA
revealed saddle PE, and dopplers revealed a non-obstructive
popliteal clot. No labs were checked and the patient was
admitted directly to the [**Hospital Unit Name 153**]. Vitals at the time of transfer
were 97.8, 70, 151/91, 23, 100 2L
Past Medical History:
Diabtets mellitus, Type II
Hypertension
Hypercholesterolemia
Ruptured Vertebral Disc
Social History:
No alcohol or tobacco use
Family History:
Not relevant
Physical Exam:
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Loud)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, diffuse scarring
Skin: Warm, Tan
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): Person, Place, Time, Movement:
Purposeful, Tone: Normal, CNII-XII intact
Pertinent Results:
[**2184-10-10**] 09:30PM BLOOD WBC-10.3 RBC-5.30 Hgb-15.6 Hct-45.3
MCV-86 MCH-29.4 MCHC-34.3 RDW-13.5 Plt Ct-213
[**2184-10-10**] 09:30PM BLOOD PT-13.2 PTT-37.1* INR(PT)-1.1
[**2184-10-10**] 09:30PM BLOOD Glucose-98 UreaN-44* Creat-1.8* Na-140
K-4.0 Cl-106 HCO3-21* AnGap-17
[**2184-10-10**] 09:30PM BLOOD ALT-15 AST-23 LD(LDH)-271* CK(CPK)-204
AlkPhos-76 TotBili-0.4
[**2184-10-10**] 09:30PM BLOOD CK-MB-6 cTropnT-0.09*
[**2184-10-11**] 03:33AM BLOOD CK-MB-5 cTropnT-0.05*
[**2184-10-11**] 12:06PM BLOOD CK-MB-4 cTropnT-0.03*
[**2184-10-10**] 09:30PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0
Imaging:
[**10-10**] CTA chest:
1. Saddle pulmonary embolus with early evidence of right
ventricular heart
strain. Thrombus burden is very high.
2. Hypoattenuating focus in the left ventricular apex in an area
surrounded
by fibrofatty replaced myocardium is concerning for a left
ventricular apical
thrombus in an area of prior infarct. Further evaluation with
echocardiography is recommended.
[**10-10**] LENI:
Non-occlusive left popliteal vein DVT.
[**10-11**] echo:
Mild focal LV systolic dysfunction consistent with prior mid-LAD
infarction. Early appearance of agitated saline seen in the left
atrium and left ventricle, consistent with a small ASD or PFO.
The right ventricle is probably mildly dilated with borderline
systolic function.
Compared with the prior study (images reviewed) of [**2183-7-19**],
agitated saline was used in the current study and suggests a
small ASD or PFO. The aorta is slightly dilated on the current
study.The right ventricle is mildly dilated/hypokinetic on the
current study. The other findings are similar
Discharge Labs: [**2184-10-18**] 07:30AM
WBC-8.1 RBC-4.85 Hgb-14.1 Hct-41.8 MCV-86 Plt Ct-277
Glucose-160* UreaN-33* Creat-1.7* Na-138 K-4.9 Cl-105 HCO3-21*
AnGap-17
Calcium-9.9 Phos-4.1 Mg-1.9
Brief Hospital Course:
55M presenting with syncope, found to have saddle PE on CTA with
troponin leak.
#Saddle PE, acute: On admission pt was started on weight based
heparin ggt, which was then overlapped with coumadin starting
[**10-11**] with a goal INR [**2-11**]. Patient has remained HD stable
throughout admission, although bradycardic at times, with
excellent oxygenation, no chest pain & no SOB. LENIs show
non-occlusive popliteal vein DVT. TTE suggests small ASD or
PFO, likely visible now given increased right-sided pressures in
the setting of PE. This will need to be adressed in the future
re: potential closing. He will also need age-appropriate cancer
screening in the outpatient setting. an outpt hypercoaguable
workup.
- He will be discharged on Coumadin 5mg, which is the dose he
has been consistently receiving in the hospital. The
[**Hospital3 **] will be in contact with him tomorrow
morning, and will arrange follow-up INR checks. A prescription
for outpatient lab work was given at the time of discharge.
- Of note, CTA, initial echo suggested LV Thrombus. [**10-11**] TTE
shows stable EF at 40-45% (EF at 40-45% in [**July 2183**]). A left
ventricular mass/thrombus cannot be excluded. Cardiology was
consulted who recommed contrast echo for further eval. This did
NOT show any LV thrombus
#Troponin Leak: Most likely right heart strain in the setting
of the PE. Peak trop 0.09 -> 0.05 this AM. EKG unconcerning.
#HTN: Given potential for cardiogenic shock, antihypertensives
were initially held. They were slowly re-introduced with stable
blood pressures. His home medication regimen was resumed prior
to discharge with the exception of Toprol, which was decreased
to 25mg given bradycardia during his hospital stay.
#DM2: Placed on reduced dose 70/30 with HISS coverage. Resumed
to usual dose at discharge.
Medications on Admission:
ASPIRIN - 81 mg po, Delayed Release (E.C.) DAILY
HYDROCHLOROTHIAZIDE - 25 mg po DAILY
LISINOPRIL - 40 mg po DAILY
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Sust. Rel. 24 hr po
DAILY
AMLODIPINE - 5 mg po DAILY
DOXYCYCLINE MONOHYDRATE - 100 mg Capsule, po BID
GEMFIBROZIL - 600 mg po BID
NITROGLYCERIN
ROSUVASTATIN [CRESTOR] - 20 mg po DAILY
SILDENAFIL [VIAGRA] - 100 mg, 0.5-1.0 Tablets PRN
INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL
(70-30)
Suspension - 20 units twice a day or as directed max dose 50 u
per day [**First Name8 (NamePattern2) **] [**Last Name (un) **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 2 days.
Disp:*3 Capsule(s)* Refills:*0*
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Outpatient Lab Work
Please have your PT/INR checked within two days of discharge.
8. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: Twenty (20)
units Subcutaneous twice a day.
9. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Coumadin 2 mg Tablet Sig: 2.5 Tablets PO once a day: Please
take at the same time each day.
Disp:*75 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pulmonary Embolus
Deep Vein Thrombosis
Patent Foramen Ovale
CAD
Hypertension
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for syncope and found to have a blood clot in
your lung (pulmonary embolus) and blood clot in your leg (DVT).
You were started on heparin to thin your blood. You have been
transitioned to Coumadin. Your INR must be monitored to ensure
a level between [**2-11**]. Avoid any activity that would increase the
risk of bleeding/bruising and eat a consistent diet.
Please follow up with your PCP as scheduled, and have your INR
checked within 2 days of discharge. The [**Company 191**] anticoagulation
service will call you on [**2184-10-19**] to enroll you in their clinic.
Please discuss with them which lab you will be having your blood
drawn at so that the results can be forwarded to their office.
They will be helping to manage your Coumadin dosing going
forward.
Ultrasound of your heart also found an incidental PFO, or small
hole. Please discuss this with your PCP.
The dose of your Toprol was decreased during this
hospitalization due to a low heart rate. Please discuss this
with your PCP. [**Name10 (NameIs) **] other changes were made to your home
medications.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2184-10-21**] at 1:10 PM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] [**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.
Department: CARDIAC SERVICES
When: TUESDAY [**2185-1-25**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"403.90",
"585.3",
"278.00",
"453.41",
"250.42",
"415.19",
"745.5",
"V01.79",
"250.52",
"362.01",
"V45.82",
"287.5",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7969, 7975
|
4370, 6195
|
283, 289
|
8126, 8126
|
2516, 4152
|
9393, 10279
|
1748, 1762
|
6827, 7946
|
7996, 8105
|
6221, 6804
|
8276, 9370
|
4168, 4347
|
1777, 2497
|
231, 245
|
317, 1581
|
8141, 8252
|
1603, 1689
|
1705, 1732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,645
| 162,996
|
21748
|
Discharge summary
|
report
|
Admission Date: [**2147-3-6**] Discharge Date: [**2147-3-16**]
Date of Birth: [**2103-9-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chronic back pain.
Major Surgical or Invasive Procedure:
Anterior-posterior lumbar fusion on [**3-6**] and [**3-7**]
History of Present Illness:
43 y/o female admitted on [**3-6**] to the ortho service for a
anterior-posterior lumbar fusion being transferred to the
medicine service for further management of aspiration PNA. Pt
underwent anterior-posterior lumbar fusion at the L4-S1 level
without complication on [**3-6**] and [**3-7**] (staged procedure). She
did have a significant amout of pain following the operation so
a pain service consult was obtained. Per their recs, she is
currently on a scheduled oxycontin and PRN percocets. On [**3-9**],
the pt spiked a temperature to 104 and became hypoxic to 87% on
RA. Her oxygen saturation improved to 97% on 2 L NC. At this
time, the pt was reporting sharp right CP and a cough productive
of greenish/brown sputum. WBC count was elevated at 17.1. CXR
was obtained which showed an illdefined opacity in the right
upper lobe that was concerning for a pneumonia. The pt was
started on levofloxacin at that time. On [**3-10**], a medicine
consult was obtained to further evaulate the pt. Flagyl was
added to the pt's regimen. A CTA was obained to rule out PE. It
was negative for PE but showed an acute pneumonia predominantly
involving the posterior segments of the right upper and lower
lobes. There were also additional patchy opacities within the
posterior aspect of the left upper lobe. On [**3-11**], the pt
continued to be febrile and had an increased oxygen requirement
so the decision was made to transfer her to the medicine
service.
On discussion, pt denies SOB. Continues to have occasional sharp
pains in her right chest. Is bringin up greenish sputum.
Past Medical History:
1. Chronic low back pain
2. H/O nephrolithiasis
3. Carpal tunnel surgery in [**2144**]
Social History:
Pt lives at home with her husband. She has not been able to work
since hurting her back in 03/[**2146**]. No ETOH since that time as
she has been on pain medications. She drank rarely before that
time. Pt quit smoking one month ago. No drugs.
Family History:
NC
Physical Exam:
100.6 Tm- 104.4 110/70 (106-133/65-81) 109 20 89% 2L NC
increased to 95% on 4 L NC
I/O: 1200/675
Gen- Alert and oriented. Resting in chair but appears very
uncomfortable.
Cardiac- Tachycardic. Regular rhythm. No m,r,g.
Pulm- Decreased breath sounds throughout with crackles
throughout the right middle and upper lobes.
Abdomen- Soft. Tenderness along area of incision. Mildly
distended. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- CN II-XII intact.
Pertinent Results:
[**2147-3-11**] 12:32PM BLOOD WBC-23.9* RBC-3.20* Hgb-9.6* Hct-28.4*
MCV-89 MCH-30.0 MCHC-33.8 RDW-12.6 Plt Ct-423
[**2147-3-11**] 12:32PM BLOOD Plt Ct-423
Lumbar pathology ([**3-7**]):
DIAGNOSIS:
Intervertebral disc, L4-L5 and L5-S1:
Cartilage with degenerative changes; small fragments of bone.
Clinical: Lumbar disc degeneration.
Gross: The specimen was received fresh labeled with "[**Known lastname 57153**],
[**Known firstname 717**]" and "disc L4-5, L5-S1" and multiple fragments of white
dense connective tissue measuring 4.2 x 4.1 x 1.9 cm in
aggregate. The specimen is represented in A.
CHEST (PORTABLE AP) ([**2147-3-9**]):
The study is somewhat limited due to overpenetration. The
cardiac and mediastinal contours are within normal limits. Note
is made of illdefined opacity in the right upper lobe, probably
representing pneumonia. No CHF is noted. No pleural effusion
noted. Gas is slightly dilated in the left upper quadrant.
IMPRESSION:
Illdefined right upper lobe opacity, probably representing
pneumonia. Correlate clinically and with follow up study.
CTA CHEST W&W/O C &RECONS ([**2147-3-10**]):
CT OF CHEST WITH IV CONTRAST/CT ANGIOGRAM: There are no
intra-arterial filling defects suggestive of pulmonary emboli.
The heart, pericardium and great vessels are unremarkable. Noted
are scattered prevascular, mediastinal, subcarinal and hilar
lymph nodes, none of which meet the CT criteria for pathologic
enlargement. Lung windows show focal areas of consolidation,
with intervening air bronchograms, predominantly involving the
posterior aspects of the right upper and lower lobes. There are
also scattered ground glass opacities involving both upper lobes
and the posterior aspect of the left lower lobe. Multiple
subpleural blebs are seen within both lung apices, right side
greater than left. The central airways are widely patent. Bone
windows show no suspicious osseous abnormalities.
Within the imaged portion of the lower neck, there is a
partially-visualized enlarged left lobe of the thyroid gland,
with inferior nodularity measuring 2.1 x 1.8 cm. Within the
imaged portion of the upper abdomen, there is diffuse low
attenuation of the liver parenchyma, without evidence of focal
lesions. There is a small calcification within the peripheral
aspect of the right hepatic lobe, likely representing a
calcified granuloma. Noted is a replaced left hepatic artery,
which originates from the left gastric artery. The
partially-visualized adrenal glands, left kidney, pancreas and
spleen are unremarkable.
Multiplanar reformatted images were helpful in confirming the
above findings and in the delineation of the above-described
anatomy.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Findings suggestive of an acute pneumonia predominantly
involving the posterior segments of the right upper and lower
lobes. Additional patchy opacities within the posterior aspect
of the left upper lobe are also suggestive of an acute
infectious process. Correlation with the patient's surgical
history is recommended, as these findings could be found
following an aspiration event. Follow-up imaging to ensure
resolution is recommended.
3. Diffuse fatty infiltration of the imaged portion of the liver
parenchyma.
4. Partially imaged thyroid gland shows an enlarged and nodular
left lobe. Correlation with the patient's clinical exam and a
dedicated thyroid ultrasound, if clinically warranted, may be
helpful.
Brief Hospital Course:
43 y/o female admitted on [**3-6**] to the ortho service for a
anterior-posterior lumbar fusion being transferred to the
medicine service for further management of aspiration PNA.
1. Aspiration PNA- As above, pt became febrile and had a new
oxygen requirement on [**3-9**]. She was found to have an aspiration
PNA and medicine was consulted. On [**3-11**], due to worsening
oxygen requirement, pt was transferred to medicine. At that
time, her antibiotics were changed from levofloxacin and flagyl
to levofloxacin and clindamycin. One difficulty in clearing the
pneumonia was the pt's impaired ability to take deep breaths and
cough secondary to her post op pain. This was very concerning as
pt could develop an abcess or other collection of infection if
she can not mobalize the sputum. She was had a brief MICU stay
for increased monitoring [**3-1**] delirium and hypoxia w/ rapid
improvement. SHe received 1 day of vancomycin, and her final
course of antibiotics was levofloxacin and clindamycin. She was
d/c'ed on a 2 week course.
.
2. S/P L4-S1 anterior-posterior fusion- pain service was
involved for management of post-op pain. She used a dilaudid PCA
and was eventually transitioned to 60mg po bid oxycontin w/
5-10mg po q3-4h prn for breakthrough. SHe also had withdrawal
from her benzos and was eventually restarted on her valium 2mg
po tid and alprazolam 0.5mg po tid.
.
3. FEN- Regular diet. Agressive electrolyte replacement.
.
4. Proph- Pneumoboots; PPI; bowel regimen.
.
5. Dispo- To home pending resolution of aspiration PNA and
stability from surgical standpoint.
Medications on Admission:
1. Alprazolam 0.5 mg TID PRN
2. Compazine 10 mg TID PRN
3. Oxycontin 60 mg [**Hospital1 **]
4. Peri colace 2 tabs daily
5. Percocet [**1-29**] tab Q4-6H PRN
6. Protonix 40 mg daily
7. Diazepam 10 mg QHS PRN
8. Diazepam 2 mg TID PRN
9. Welbutrin SR 150 mg [**Hospital1 **]
10. Nicotine patch 21 mgs daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a
day.
Disp:*240 Tablet(s)* Refills:*2*
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
8. Diazepam 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
9. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: 1.5
Tablet Sustained Release 12HRs PO Q12H (every 12 hours).
Disp:*90 Tablet Sustained Release 12HR(s)* Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Tolterodine Tartrate 1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*0*
12. Clindamycin HCl 300 mg Capsule Sig: Three (3) Capsule PO
every eight (8) hours for 2 weeks.
Disp:*42 Capsule(s)* Refills:*0*
13. Alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
14. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary diagnosis:
Anterior-posterior lumbar fusion
Secondary diagnosis:
Aspiration pneumonia
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow up appointments.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, pain at the incision site, or other
concerns.
Followup Instructions:
Primary care: Please follow up with Dr. [**Last Name (STitle) 57154**],TZVETAN
[**Telephone/Fax (1) 57155**] in 1 week.
Ortho: please follow up with Dr. [**Last Name (STitle) 28003**] as scheduled.
Completed by:[**2147-3-16**]
|
[
"424.0",
"997.3",
"507.0",
"722.10",
"721.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.90",
"84.51",
"81.62",
"84.52",
"77.79",
"81.08",
"81.06"
] |
icd9pcs
|
[
[
[]
]
] |
10104, 10187
|
6346, 7929
|
332, 394
|
10326, 10334
|
2884, 6323
|
10598, 10828
|
2382, 2386
|
8283, 10081
|
10208, 10208
|
7955, 8260
|
10358, 10575
|
2401, 2865
|
274, 294
|
422, 1996
|
10282, 10305
|
10227, 10261
|
2018, 2106
|
2122, 2366
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,884
| 157,976
|
31738
|
Discharge summary
|
report
|
Admission Date: [**2140-10-7**] Discharge Date: [**2140-10-13**]
Service: MEDICINE
Allergies:
Diovan
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
85yo F who is now transferred from [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 18896**] after she
presented there with flash pulmonary edema. On presentation to
the OSH she had an initial O2 sat 60% with respiratory distress
and a CXR consistent with pulmonary edema. She was intubated and
received NTG SL, morphine, lasix 100mg. She was transfered to
[**Hospital1 18**] for further management as there were no ICU beds at the
OSH.
.
On arrival to the ED here, the patient was found to be
intubated, with a HR 84, BP of 160/80, T 98.8 and O2 Sat of 100%
on AC with FIO2 of 100%. A murmur was noticed on exam.
Cardiology was consulted and an ECHO showed severe AS with a
valave area of 0.5cm and a peak gradient of 65mmHg, also with
2+MR and 2+TR, moderate pulmonary artery systolic hypertension.
EF 50%.
.
On arrival to the floor the patient was alert and intubated. She
was answering yes and no questions appropriately, however
history was limited due to intubation.
.
Pt reports shortness of breath, which worsened over several days
and made her go to the OSH on the day of admission. She denied
any chest pain, syncope or presyncope and alse denies any
dietary indiscretion or any other pain, nausea, vomiting. She
also denies [**First Name8 (NamePattern2) 691**] [**Location (un) **]. ? Orthopnea, PND hard to elucidate from
intubated patient, but present per PCP [**Name Initial (PRE) 626**]. The family is not
able to contribute to her recent history.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, black stools or red stools. He denies
recent fevers, chills or rigors, no cough. All of the other
review of systems were negative.
.
Her family reports that at baseline she is very active and
independent in all her ADL. She has a history of CHF and has DOE
but is able to ambulate a flight of stairs without problems and
is babys[**Name (NI) 12854**] her grandchildren on her own.
Past Medical History:
Osteoporosis
HTN
Hypercholesterolemia
DM 2
Paget's disease
H/o of mild AS: Aortic valve area is estimated to be 1.5 cm sq.
Mean pressure gradient is 20 mmHg and maximum pressure gradient
is 28 mmHg on ECHO in [**2136**]. ECHO from [**6-/2140**] AS with 0.7cm2,
peak gradient 76 and mean 49 mmHg.
S/p PCM, DDD, for bradycardia
Anemia, unclear baseline, Vit B12 def
Breast cancer, s/p L mastectomy and chest radiation
S/p R hip fracture and L knee fracture in the 60s and 70s
Social History:
Social history is significant for the absence of current or
prior tobacco use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had angina in her 60s and a stroke in
her 70s. Son with DM2.
Physical Exam:
VS: T 99.8, BP 126/52 , HR 69 , RR 20, O2 100% on AC 500
Gen: NAD, intubated. Pleasant.
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with JVP at earlobe.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2 not audible. Harsh late systolic murmur
loudest over RUSB. No S4, positive S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
unlabored, no accessory muscle use. No wheeze, rhonchi. Postive
crackles throughout b/l.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. Bowing of the tibia and fibula b/l anteriorly. No
femoral bruits.
Skin: Stasis dermatitis b/l.
Pulses:
Right: Carotid 2+ with bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ with bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2140-10-7**] EHCo
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). 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 are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: severe calcific aortic stenosis with moderate
concentric left ventricular hypertrophy and low normal ejection
fraction
.
CXR:
Extensive pulmonary fibrosis with most marked abnormalities at
left apex.
Suspect chronic lung disease such as idiopathic pulmonary
fibrosis with superimposed scarring from prior granulomatous
disease at left apex.
.
CT Chest:
IMPRESSION:
1. Pulmonary fibrosis is severe in the left apex and compatible
with known prior chest radiation, and mild-to-moderate in the
remainder of the lung parenchyma.
2. Mild dependent ground-glass opacity is compatible with
pulmonary edema.
3. Scattered mild relative lucency in both lungs may be
secondary to a perfusion abnormality such as pulmonary
hypertension or air trapping.
4. Severe aortic valvular calcification with associated left
ventricular chamber enlargement.
5. Multiple calcified and noncalcified pulmonary nodules
measuring up to 4 mm in diameter. If the patient has no known
malignancy or risk factors for lung cancer, no additional
followup is required.
6. Extensive left anterior descending coronary artery
calcifications.
Brief Hospital Course:
85 year old with severe AS and acute pulmonary edema.
.
CHF(Acute, diastolic): Likely acute decompensation in the
context of severe AS and difficult fluid balance. Patient
diuresed gingerly in light of preload dependent AS. Volume
overload resolved with PRN lasix. ECho [**Last Name (un) **] preserved EF and
severe EF. Patient was started on 12.5 metoprolol [**Hospital1 **]. Patient
had left and right heart caths showing branch vessel disease
only, no needed for stent. Patient also started on daily ASA.
.
Aortic stenosis: Patient with known AS, but this is first
incident of acute pulmonary edema. Aortic valve area <.8cm2
here. Patient very hesitant to go for surgery, and after much
discussion, conclution reached that she be discharged home, and
is scheduled for AVR on [**10-25**].
.
Pulmonary fibrosis: Patient has history of breast Ca, with
radiation. PFT's in house demonstarted mild restrictive disease
with normal DLCO. She is cleared for surgery from a pulmonary
perspective, and can f/u as outpatient.
.
# HTN: Amlodipine dc/ed and toprol XL continued.
.
# ARF: pt without evidence of chronic failure on records from
PCP, [**Name10 (NameIs) 8856**] have to presume this is ARF. Likely due to poor
forward flow in the context of CHF and severe AS. Patient was
diuresed with stabilization of creatinine to 1.1.
.
# Rhythm: ventricularly paced at heart rate of 80
.
# DM2: Glyburide held on floor, on ISS. discharged on glyburide.
Medications on Admission:
Amlodipine 5mg Qdaily
Atenolol 25mg Qdaily
Levothyroxine 150mcg Qdaily
Glyburide 10mg [**Hospital1 **]
KCl 10meq Qdaily
Imdur 60mg Qdaily
Aspirin 81mg
Folic acid
Vit B12
risedronate 35mg 1/qweekly
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Aortic valve stenosis
Acute diastolic CHF
.
Secondary
Hyperlipidemia
Hypothyroidism
Discharge Condition:
stable, euvolemic
Discharge Instructions:
You were admitted to the hospital with heart failure secondary
to your aortic valve stenosis. You were initially intubated with
for respiratory distress, but this was removed the day after you
were admitted.
.
You are to have Aortic Valve replacement by Cardiac surgery on
[**2140-10-25**] for definitive treatment of the aortic stenosis.
.
You also had a CT scan of your lungs for further workup up the
pulmonary fibrosis. Dr [**Last Name (STitle) **] will follow up with you in that
regard.
.
Please return to the hospital or call your cardiologist if you
have shortness of breath, chest pain, lightheadedness or any
other concerning symptoms.
Followup Instructions:
You are scheduled for aortic valve replacement on Tuesday
[**2140-10-25**] by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please call ([**Telephone/Fax (1) 1504**] with
questions.
.
Please also call Dr. [**Last Name (STitle) 2168**] for follow up for your pulmonary
fibrosis. His number is ([**Telephone/Fax (1) 513**] to schedule an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2140-10-16**]
|
[
"428.0",
"585.9",
"250.00",
"584.9",
"733.00",
"272.0",
"403.90",
"428.31",
"518.4",
"424.1",
"V45.01",
"V10.3",
"244.9",
"731.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8312, 8370
|
6102, 7549
|
235, 261
|
8507, 8527
|
3969, 6079
|
9221, 9752
|
2952, 3103
|
7796, 8289
|
8391, 8486
|
7575, 7773
|
8551, 9198
|
3118, 3950
|
176, 197
|
289, 2304
|
2326, 2801
|
2817, 2935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,141
| 197,949
|
49429
|
Discharge summary
|
report
|
Admission Date: [**2101-8-3**] Discharge Date: [**2101-8-10**]
Date of Birth: [**2028-2-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin / Morphine Sulfate
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
positive exercise stress test, admission for elective cardiac
catheterization
Major Surgical or Invasive Procedure:
Cardiac catherization [**2101-8-3**]
Coronary artery bypass graft x4 (left internal mammary > left
anterior descending, saphenous vein graft > obtuse marginal,
saphenous vein graft > right coronary artery, saphenous vein
graft > PLV)
History of Present Illness:
This is a 73 year old female with a history of HTN, HC,
hyperthyroidism who presented to the ED following a positive
exercise stress test. The patient reports that she has had teeth
pain especially with exertion for several months, but she did
not attribute this to a cardiac issues. She describes over past
2-3 weeks 3 episodes of chest heaviness with pain radiating to
her jaw/teeth. The first episode occured while pushing her
grandchildren uphill in a stroller. She also reports mild
dyspnea with this episode. Her pain was relieved by rest. A
second episode occurred post-prandial with similar
characteristics lasting about 1 hour while the patient was
cleaning dishes and relieved by falling asleep. The patient's
husband was very concerned by these episodes and encouraged his
wife to seek care. An ECG last week prompted an admission to the
[**Hospital3 2358**]. Serum CKs were negative and the highest troponin
was 0.42 (lab normal
0.40). Work-up including dobutamine echo stress test on [**2101-7-14**]
indicated old, but no new defects. The patient increased her
atenolol to 75 mg daily. The patient was referred for ETT, but
put it off by one week, during which time she had an additional
episode of exertional angina relieved with rest without jaw
pain. This additional episode of pain prompted the patient to
have her ETT done today which was grossly abnormal and highly
suggestive for ischemia. Patient has had no nausea, diaphoresis,
PND, orthopnea, presyncope, syncope, or palpitations.
Past Medical History:
Dyslipidemia
Hypertension
Hyperthyroidism
Osteoarthritis
s/p femur fracture
s/p hysterectomy
s/p bladder suspension
s/p tonsillectomy
Social History:
Her social history is significant for the absence of current
tobacco use, remote 15 pack yr smoking history. There is no
history of alcohol abuse.
Lives with spouse
Family History:
Father sudden death at 51
Physical Exam:
VS - 97.9, bp 134/71, hr 56, rr 18, o2sat: 100% 2LNC
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2101-8-8**] 11:15AM BLOOD WBC-8.5 RBC-3.15* Hgb-9.6* Hct-27.7*
MCV-88 MCH-30.6 MCHC-34.8 RDW-13.3 Plt Ct-250#
[**2101-8-3**] 11:30AM BLOOD WBC-7.4 RBC-4.63 Hgb-13.4 Hct-40.1 MCV-87
MCH-29.0 MCHC-33.5 RDW-13.7 Plt Ct-282
[**2101-8-8**] 11:15AM BLOOD Glucose-132* UreaN-16 Creat-0.6 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
[**2101-8-3**] 11:30AM BLOOD Glucose-111* UreaN-24* Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-27 AnGap-13
[**2101-8-10**] 05:45AM BLOOD WBC-11.0 RBC-3.10* Hgb-9.4* Hct-27.2*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.9 Plt Ct-299
[**2101-8-10**] 05:45AM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-140
K-3.7 Cl-106 HCO3-26 AnGap-12
Brief Hospital Course:
Admitted for cardiac catherization that revealed coronary artery
disease and she was referred to cardiac surgery for surgical
evaluation. She underwent preoperative workup and was brought
to the operating [****]. She underwent coronary artery
bypass graft surgery, see operative report for further details.
She received vancomycin for perioperative antibiotic due to
augmentin allergy and in hospitalization. She was transferred
to the intensive care unit for hemodynamic monitoring. She was
weaned from sedation, awoke neurologically intact, and was
extubated without complications. She continued to progress and
was transferred to the floor POD 1. Physical therapy worked
with her for strength and mobility. POD#3 following chest tubes
removal, cxr revealed a right pneumothorax. A CT was reinserted
and the right lung fully reexpanded. After 24 hours on suction,
the CT was placed on water seal, the lung remained fully
expanded, and the CT was dc'd. A follow up CXR revealed a
lessening of both the right and left pneumothoraces. She was
asymptomatic on room air, saturating 97% on room air. She was
discharged to home with instructions to return on the following
Tuesday to clinic with a chest X-ray.
Medications on Admission:
ATENOLOL 75 mg daily
ATORVASTATIN 40 mg daily
ASA 81 mg daily
MULTIVITAMIN daily
Discharge Medications:
1. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
Disp:*30 Tablet(s)* Refills:*0*
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 5
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Osteoarthritis
Hyperthyroidism
Elevated lipids
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 call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) 914**] for next Tuesday with CXR in am (CXR already ordered)
[**Telephone/Fax (1) 170**]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for 1 week [**Telephone/Fax (1) 67509**]
Dr [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 103470**] for 2-3 weeks
Completed by:[**2101-8-10**]
|
[
"715.90",
"401.9",
"272.4",
"E878.2",
"414.01",
"411.1",
"242.90",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.53",
"37.22",
"88.56",
"39.61",
"36.15",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6637, 6686
|
4007, 5224
|
370, 606
|
6823, 6830
|
3350, 3984
|
7341, 7729
|
2496, 2523
|
5355, 6614
|
6707, 6802
|
5250, 5332
|
6854, 7318
|
2538, 3331
|
253, 332
|
634, 2141
|
2163, 2298
|
2314, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,417
| 170,165
|
7773
|
Discharge summary
|
report
|
Admission Date: [**2152-1-11**] Discharge Date: [**2152-1-26**]
Date of Birth: [**2071-7-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] porcine )& coronary
artery bypass grafts x 4(LIMA-LAD, SVG-Dg, SVG-OM, SVG-RCA) [**1-17**]
History of Present Illness:
The patient is an 80 year old male who, while ascending a [**Doctor Last Name **],
suddenly felt shortness of breath, diaphoresis and palpitations.
He presented to the ED at an outside hospital, was admitted and
ruled out for MI. He was transferred to [**Hospital1 18**] where cardiac
catheterization and coronary angiography revealed three vessel
coronary artery disease. Echo revealed aortic stenosis. The
patient did receive Plavix on [**2152-1-11**]. He was admitted for
plavix washout prior to surgical revascularization and aortic
valve replacement.
Past Medical History:
CAD
hypertension
History of lacunar infarction with mild residual right
hemiparesis [**2131**]
History of prostate cancer [**2133**]
Urinary incontinence
Intention tremor of the right hand
Hypercholesterolemia
Knee replacement on left
gastroesophageal reflux disease
hiatal hernia
TIA, CVA [**2133**]
Acute systolic heart failure
PAST SURGICAL HISTORY: Radical prostatectomy [**2136**]. Left total
knee replacement approximately 30 years ago.
Social History:
tobacco: 40 pack year hx, quit [**2123**]
alcohol: 1 beer/month
lives alone
retired curtain store owner
Family History:
Mother died at 79 of MI, father died 80 renal disease.
Physical Exam:
VS: 97.6, 104/60, 18
Gen: NAD
Skin: unremarkable
HEENT: pupils- R 3mm, L 4mm round and reactive to light
Neck: supple with FROM, no LAD
Chest: lungs CTAB
Heart: RRR, 2/6 systolic murmur
Abd: soft, non-tender, non-distended, +bowel sounds
Extremities: warm, no edema
Neuro: A+O x 3, strength 5/5 throughout x [**5-15**] Rhand
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 28162**], [**Known firstname 870**] [**Hospital1 18**] [**Numeric Identifier 28163**]
(Complete) Done [**2152-1-17**] at 11:41:50 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2071-7-8**]
Age (years): 80 M Hgt (in): 69
BP (mm Hg): 146/53 Wgt (lb): 185
HR (bpm): 67 BSA (m2): 2.00 m2
Indication: intraop CABG AVR. Evaluate wall motion, valves,
aortic contours
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2152-1-17**] at 11:41 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: ie33 new
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.2 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 40% to 50% >= 55%
Left Ventricle - Stroke Volume: 81 ml/beat
Left Ventricle - Cardiac Output: 5.46 L/min
Left Ventricle - Cardiac Index: 2.73 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.02 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *45 < 15
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *20 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg
Aortic Valve - LVOT pk vel: 0.60 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.4 cm
Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.9 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 99 ms
Mitral Valve - MVA (P [**2-10**] T): 2.1 cm2
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.50
Mitral Valve - E Wave deceleration time: *296 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement. Elongated LA. No mass/thrombus
in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous
hypertrophy of the interatrial septum. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Moderate AS (AoVA 1.0-1.2cm2) AR vena
contracta is <0.3cm. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild to moderate ([**2-10**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Mild PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
Pre Bypass: The left atrium is mildly dilated. The left atrium
is elongated. No mass/thrombus is seen in the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%). 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. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**2-10**]+) mitral regurgitation is seen.
Post Bypass: Patient is A paced, on phyenylepherine and
epinepherine infusions (.02 mcg/kg/min). Global biventricular
function is unchanged. Septum appears mild- moderately
hypokinetic initally, improving over time to mild septal
hypokinesis. Other wall motion appears slightly improved. Mitral
regurg begins as 2+, then becomes trace. A bioprosthetic aortic
valve #21 is insitu wihtout perivalvular leaks or AI. Peak
gradient 19, mean 7 mm hg. Aortic contours intact. Remaing exam
is unchanged. All findings discussed with surgeons at the time
of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2152-1-17**] 15:31
Brief Hospital Course:
The patient was admitted for plavix washout and surgical
management of his coronary artery disease and aortic stenosis.
He was cleared for surgery from a dental standpoint. Due to the
patient's history of prostate cancer, foley catheter was unable
to be placed. The urology team was consulted and foley was
placed under cystoscopy, pre-operatively. The patient underwent
CABG x 4 and AVR on [**2152-1-17**]. Please see operative report for
further details. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU for
further invasive monitoring. By POD 1 the patient was
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. The patient developed atrial
fibrillation and was started on amiodarone and diltiazem. The
patient became hypotensive requiring neosynephrine. Cardizem
was discontinued and verapamil started. The patient converted
to sinus rhythm and neo was weaned. Chest tubes and pacing
wires were discontinued without complication. He was eventually
transferred to the telemetry floor on POD 7. The patient made
excellent progress with physical therapy. He was gently
diuresed toward his preoperative weight. His foley was
discontinued and the patient was able to void without
difficulty. On POD 9 he was placed on Keflex for a left hand
phlebitis. He was discharged to rehab on the same day.
Medications on Admission:
asa 81'
metoprolol 50''
simvastatin 20'
prilosec 20'
detrol LA 4'
plavix 75'
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days: L hand phlebitis.
Disp:*28 Capsule(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg 2x/day for 1 week, then 200mg daily until further
instructed.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once):
titrate for an INR goal of [**3-14**] for atrial fibrillation.
Disp:*30 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
9. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
coronary artery disease
CHF (probable chronic, systolic)
aortic stenosis
Aortic Valve Replacement
coronary artery bypass grafts x 4
prostatic carcinoma and hypertrophy
h/o stroke
hypercholesterolemia
s/p Left total knee replacement
peripheral vascular disesase
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr.[**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks ([**Telephone/Fax (1) 28164**])
Dr.[**Last Name (STitle) 28165**] in 2 weeks
wound clinic in 2 weeks
please call for appointments
follow up with your dentist regarding tooth #14
Completed by:[**2152-1-26**]
|
[
"443.9",
"333.1",
"428.0",
"V70.7",
"413.9",
"790.29",
"V10.46",
"451.82",
"424.1",
"272.0",
"530.81",
"553.3",
"788.30",
"428.23",
"E878.2",
"438.20",
"458.29",
"V43.65",
"427.31",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.64",
"35.21",
"36.15",
"59.8",
"57.32",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
10877, 10943
|
8031, 9497
|
340, 499
|
11248, 11255
|
2114, 8008
|
11660, 12020
|
1694, 1750
|
9624, 10854
|
10964, 11227
|
9523, 9601
|
11279, 11637
|
1465, 1557
|
1765, 2093
|
281, 302
|
527, 1089
|
1111, 1442
|
1573, 1678
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,823
| 103,724
|
54891
|
Discharge summary
|
report
|
Admission Date: [**2183-5-28**] Discharge Date: [**2183-6-4**]
Date of Birth: [**2103-6-1**] Sex: F
Service: MEDICINE
Allergies:
ceftriaxone
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Saddle pulmonary embolus
Major Surgical or Invasive Procedure:
IVC filter placement by interventional radiology [**2183-5-30**]
History of Present Illness:
Pt is a 79 y/o F with unknown PMHx, who presented to the ED with
generalized weakness and DOE for the past week. She presented
earlier this week to her PCP, [**Name10 (NameIs) 1023**] was planning ot see her in
follow-up on Friday. However, her symptoms progressed, and she
ultimately presented to an OSH ED today, where she was found to
have a large saddle pulmonary embolus. While at the OSH, she
received 100 mg tpa. She was hypoxic to the 80's on NC and was
placed on NRB.
On arrival to the [**Hospital1 18**] ED, she was started on a heparin gtt
after her tpa was completed. Labs were significant for troponin
0.11, BNP 3456, lactate 4.8. Per report, K was low at OSH;
repeat here was 5.2 but was hemolyzed. WBC 18.7. CXR was
unremarkable. Bedside ultrasound was performed and "generous" RV
with some septal bowing during systole. ECG showed TWI in V1-V4.
BP's were borderline in the ED; she received a total of 1 L NS.
VS prior to transfer BP 98/50, HR 75, 100% on NC.
On arrival to the MICU, the patient endorsed some mild SSCP that
was non-radiating. She reports chronic BLE swelling and
tightness, which has been worse recently (R>L). No other
complaints.
Past Medical History:
- lower extremity edema
- HTN
- "phlebitis" vs. DVT during her pregnancies
- GERD
- insomnia
Social History:
Tobacco: Denies. Alcohol: Denies. Illicits: Denies. Lives alone
in a senior complex. Son recently died [**1-23**] EtOH; daughter
attempted suicide as a result.
Family History:
Many family members with depression. Mother with ovarian cancer
(at 35) and colon cancer (at 75). Father with throat cancer,
Alzheimer's. 2 brothers with skin cancer, one with ?lymphoma.
Physical Exam:
Admission:
Vitals: T: 99.1 BP: 136/68 P: 74 R: 16 O2: 995 NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, BLE edema, increased warmth erythema
of medial distal RLE
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
DISCHARGE:
VS: 98.4 116/57 79 18 99% RA
Skin: back, buttocks and thighs with pruritic maculopapular
rashes. no ulcerations or skin openings.
otherwise essentially unchanged.
Pertinent Results:
ADMISSION LABS:
[**2183-5-28**] 05:30PM cTropnT-0.11*
[**2183-5-28**] 05:30PM proBNP-3456*
[**2183-5-28**] 05:33PM LACTATE-4.8*
[**2183-5-28**] 05:30PM GLUCOSE-132* UREA N-32* CREAT-1.2* SODIUM-137
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-20* ANION GAP-18
[**2183-5-28**] 05:30PM WBC-18.7* RBC-4.26 HGB-12.9 HCT-38.2 MCV-90
MCH-30.3 MCHC-33.8 RDW-13.6
DISCHARGE LABS:
[**2183-6-2**] 06:10AM BLOOD WBC-7.6 RBC-3.87* Hgb-11.6* Hct-34.9*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.2 Plt Ct-222
[**2183-6-2**] 06:10AM BLOOD PT-18.7* PTT-110.4* INR(PT)-1.8*
[**2183-6-2**] 06:10AM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-143
K-4.5 Cl-108 HCO3-29 AnGap-11
[**2183-6-2**] 06:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.3
CHEST X-RAY ([**2183-5-28**]): Single AP portable chest radiograph was
provided. Subtle hazy opacity at the right base which may
represent atelectasis; however, early infection cannot be
excluded. The lungs are otherwise clear. There is no pleural
effusion or pneumothorax. Heart size is top normal; however,
this may be due to AP projection. There are no acute skeletal
abnormalities. IMPRESSION: Subtle hazy opacity right base is
most likely atelectasis but cannot exclude early infectious
process.
LOWER EXTREMITY DOPPLER [**2183-5-29**]:
IMPRESSION:
1. Deep venous thrombosis involving the right mid femoral vein
extending into the popliteal vein. No evidence of below-knee
DVT on the right side.
2. On the left side there is non-occlusive thrombus in the
popliteal vein
extending into the left peroneal vein.
ECHOCARDIOGRAM [**2183-5-30**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 65%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is mildly dilated with depressed
free wall contractility. 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 appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. There
is no pericardial effusion.
IVC FILTER PLACEMENT [**2183-5-30**]:
IMPRESSION:
1. Placement of a Bard Eclipse IVC filter into the infrarenal
inferior vena cava via a femoral approach.
2. No evidence of IVC thrombus or IVC duplication anomalies on
IVC venogram which preceded IVC filter placement.
MICROBIOLOGY:
UCx [**2183-5-31**]:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
2ND MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
TRANSITIONAL ISSUES:
[ ] Restarting home antihypertensives as patient's clinical
status stabilizes. Pt was restarted on 5 mg of lisinopril (20 mg
daily at home). Her metoprolol was held as we did not want to
interfere with compensatory tachycardia if pt needed it (home
dose 50 mg metoprolol succinate daily). She had recently been
started on diltiazem, which was stopped.
[ ] Lasix was also held as we did not want to decrease her
preload, and the recently increased swelling were thought to be
due to DVT. It can be restarted in the future if lower extremity
swelling does not improve with treatment of DVT.
[ ] Patient will need to make sure that her cancer screening is
up to date as an outpatient to rule out hypercoagulable state.
Hypercoagulable work up is not recommended during this acute
episode of clot, but can be considered in the future.
[ ] Patient will also need an appointment with interventional
radiology to remove the retrievable IVC filter in about [**3-28**]
weeks. IR is aware and will be contacting the patient to make
the appointment.
============================
79 yo F with PMH of chronic lower extremity swelling and HTN who
presented to the ED with generalized weakness and DOE for the
past week, found to have saddle PE and bilateral DVT, now s/p
TPA and on heparin gtt/coumadin. Pt also had troponin leak to
0.11 and evidence of right heart strain on bedside
echocardiogram so underwent IVC filter placement to prevent
further clot burden. She was continued on heparin gtt/coumadin
until her INR was therapeutic.
# PE/bilateral DVT: Pt is now s/p TPA and on heparin
gtt/coumadin. Given a bedside echo with reported evidence of
right heart strain and troponin leak to 0.11, underwent
placement of IVC filter. Patient Stable in terms of respiratory
status. Unclear etiology for pt's PE, ?history of "phlebitis"
with her 9 pregnancies, but no obvious clotting history. Patient
also reports normal mammogram 1 year ago, and had colonoscopy 5
years ago but does not know the result, as she did not follow
up.
Patient received 100 mg TPA at OSH prior to admission to the
[**Hospital1 18**] MICU. Bedside ultrasound showed large RV with some septal
bowing during systole. ECG showed TWI in V1-V4. The patient's
respiratory status improved and the patient was weaned from NRB
to NC. She was put on a heparin gtt and LENIs showed bilateral
DVTs (RLE femoral to popliteal occlusive thrombus, LLE popliteal
nonocclusive thrombus).
She had IVC filter placed given the extent of her saddle emboli
and bilateral DVT. It was thought that risk of further clot
burden would be of significance. After the IVC filter was
placed, she was started on coumadin with goal INR of [**1-24**].
Echocardiogram was also obtained to evaluate for evidence of
right heart strain, given the report of septal bowing seen on
bedside echocardiogram in the ICU. The formal echocardiogram
showed mild RV dilation but no bowing or other evidence of
strain/failure. Patient was seen by PT and was recommended
discharge to rehab for conditioning/strengthening.
# Hypertension: Patient's antihypertensives were held initially
given that her BP was borderline low on admission. As her
treatment for PE continued, her blood pressure improved, likely
due to decreased strain on RV. As we did not want to beta-block
the patient to allow her compensatory tachycardia if needed, she
was started on low dose lisinopril only and her blood pressure
remained within normotensive range. Her metoprolol was not
restarted on discharge, but can be restarted as an outpatient if
needed.
# Insomnia/anxiety: patient with anxiety over her PE/DVT and IVC
filter placement. She also has had recent loss of her son,
suicide of her son's GF and overdose of her daughter. Social
work and pastoral care were consulted and patient appreciated
their care.
# [**Last Name (un) **]: Unclear baseline. With treatment of her PE, her
creatinine improved.
# UTI: patient had fevers, found to have urinary tract
infection. She was treated with IV ceftriaxone for 3 days.
Patient developed rash that was thought to be due to allergic
reaction to ceftriaxone, so it was stopped.
Medications on Admission:
Lisinopril 20 mg 1 tab QD
Toprol XL 50 mg 24 hr, 1 tab QD
Lasix 20 mg 1 tab QD
Zolpidem 10 mg 1 tab QD
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
5. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for itching for 5 days.
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Itching.
8. diphenhydramine HCl 12.5 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q6H (every 6 hours) as needed for
itching/pruritus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing and Rehab Centre
Discharge Diagnosis:
Primary Diagnosis: Saddle pulmonary embolus, deep vein
thrombosis
Secondary Diagnosis: Hypertension, lower extremity swelling,
drug rash
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 28331**],
Thank you for allowing us to participate in your care at [**Hospital1 1535**]. You were admitted because you
had large blood clots in your lungs (saddle pulmonary embolus).
We also found that you had blood clots in your legs, and we
treated the blood clots in your lungs and legs with a blood
thinner called heparin. You will also have placement of a filter
(IVC filter) in one of your blood vessels to help prevent future
clots in your lungs.
These CHANGES were made to your medications:
STOP diltiazem
STOP lasix for now, this can be restarted in the future if you
have worsening lower extremity swelling
DECREASE lisinopril to 5 mg daily
DECREASE ambien to 5 mg at bedtime as needed for sleep. Given
your age, it is recommended that you take the smaller dose.
START warfarin 2 mg daily (please follow directions from your
facility and from your PCP to change the warfarin doses)
START colace/senna twice daily for constipation
START acetaminophen (tylenol) 325-650 mg every 6 hours as needed
for pain/fever. Do not take more than 3000 mg daily.
START hydrocortisone 0.5 % Cream. apply to skin twice a day as
needed for itching/rashes for up to 5 days. Please avoid
face/armpit/groin areas.
START camphor-menthol (sarna) lotion. apply to skin up to 4
times a day as needed for itching/rashes.
START diphenhydramine (benadryl) 12.5 mg every 6 hours as needed
for itching/pruritus.
Followup Instructions:
Please call and make an appointment with your primary care
physician once you are discharged from the long term acute care
facility. Please follow up with your doctor regarding your
cancer screening.
Interventional radiologists will be calling you to schedule a
removal of your IVC filter. Please make this appointment in
about 4-6 weeks from [**2183-5-30**].
|
[
"V16.41",
"593.9",
"300.00",
"041.3",
"693.0",
"599.0",
"530.81",
"453.41",
"415.13",
"429.9",
"E930.5",
"780.52",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
11690, 11757
|
6590, 6590
|
295, 361
|
11938, 11938
|
2823, 2823
|
13570, 13934
|
1866, 2054
|
10887, 11667
|
11778, 11778
|
10760, 10864
|
12121, 13547
|
3199, 6567
|
2069, 2804
|
6611, 10734
|
231, 257
|
389, 1557
|
11865, 11917
|
2839, 3183
|
11797, 11844
|
11953, 12097
|
1579, 1673
|
1689, 1850
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,219
| 127,319
|
34088
|
Discharge summary
|
report
|
Admission Date: [**2181-6-5**] Discharge Date: [**2181-6-7**]
Date of Birth: [**2103-10-24**] Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
referred for left carotid angiography and intervention
Major Surgical or Invasive Procedure:
[**2181-6-5**] Stent to LCA
History of Present Illness:
Ms. [**Known lastname 12303**] is a 77 year old woman with history of TIA in [**5-/2181**],
stroke in [**2175**], hypertension, dyslipidemia, CAD s/p CABG in
[**2-/2179**], referred for left carotid stenting. In [**5-/2181**], she
developed a left facial droop and slurred speech. MRI showed an
old right parietal infarct with no evidence of acute infarct.
Subsequent MRA showed greater than 70% stenosis of the left
internal carotid artery and occluded right ICA. Antegrade flow
was demonstrated in both vertebral arteries. An ultrasound was
also done, demonstrating a peak velocity across the [**Doctor First Name 3098**] of
458cm/sec and an ICA/CCA ratio of 5.8. She refused carotid
endarterectomy, and was referred to [**Hospital1 18**]/Dr. [**First Name (STitle) **] for carotid
angiography and intervention.
.
During the procedure, she developed hypotension when the balloon
was inflated and was started on a neosynephrine drip with good
response in her blood pressure. There were no neurologic
sequela, and a final angiogram demonstrated good flow without
dissection and intact intracerebral circulation.
.
She reports prior history of stroke and TIA as above. She denies
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain, or
lightheadedness. 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, palpitations, syncope or presyncope.
Past Medical History:
- CAD s/p CABG in [**2179**] at [**Hospital1 2177**]
- ? prior IMI by EKG
- COPD
- CVA in [**2175**] (found to have totally occluded [**Country **]), mild
residual memory deficits
- Hypertension
- Glaucoma
- Dyslipidemia
- s/p CCY
- C. difficile infection in [**2179**]
.
Cardiac History:
CABG, in [**2179**] (at [**Hospital1 2177**]), anatomy unknown
Social History:
Lives alone but has several children involved in her care.
Denies current alcohol. Heavy smoker until [**2174**]. She worked for
35 years as a therapy assistant in a nursing home. She is
independent in self-care, home making activities, is able to
climb stairs and do most housekeeping. No routine exercise
program. Some deficits with short term and medium term memory
loss.
Family History:
There is a strong family history of atherosclerotic disease.
Both her parents died at 62 of myocardial infarctions. She has
no siblings.
Physical Exam:
VS: T98.4F, BP 137/70, HR 57, RR 12, O2 95%2L
Gen: WDWN elderly woman in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, could not assess JVP as patient required to remain
supine.
CV: PMI located in 5th intercostal space, midclavicular line.
Atrial fibrillation, rate 57. normal S1, S2. No S3. II/VI
systolic murmur at apex.
Chest: Exam limited by supine position. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No clubbing or cyanosis. Evidence of skin darkening c/w
chronic venous stasis, some hair loss R>L. Trace edema
bilaterally. DP and PT pulses 1+ BL. No bruit or hematoma at
catheter insertion site.
Skin: + stasis dermatitis, left leg scar c/w SVG. No ulcers or
xanthomas.
Pulses: Palpation of carotid and femoral arteries deferred in
light of recent procedure. No carotid or femoral bruits.
Neuro: A&O x 3. CN II-XII intact. Full strength exam deferred
given patient required to remain supine.
Pertinent Results:
EKG: Normal sinus rhythm at 67bpm. Q waves in III and aVF. Poor
R wave progression. Normal axis, normal intervals. TWF in III,
aVF, V3. No ST segment elevations or depressions.
.
Echo [**2181-5-23**]: 1+ mitral regurgitation. Hyperdynamic left
ventricle, LVEF 70%.
.
CAROTID ANGIOGRAM/CATHETERIZATION ([**2181-6-5**]): Patent bilateral
vertebrals. There is occlusion of the right ICA. The left ICA
and ECA were visualized and patent. The left ICA had a high
grade occlusive lesion of approximately 90% with some
calcification. Just distal to the stenosis there was a moderate
angulation with the remainder of the cervical ICA without
tortuosity or angulations. The left MCA and ACA were patent
without aneurysm or lesions. A 6.0 Spider distal protection was
delivered. There was hypotension responsive to Neo drip. A
8/6x40 Protege was delivered and post dilated with 4.5 mm
balloon at 8atm. There were no neurologic sequela and stable
hemodynamics on a Neo drip. final angiogram demonstrated good
flow no dissection with intact intracerebral circulation.
.
ADMISSION LABORATORY DATA:
Na 143 K 4.6 Cl 104 HCO3 24 BUN 25 Creat 0.9 Gluc 82
.
WBC 8.2
N:64.4 L:25.7 M:6.4 E:3.0 Bas:0.6
Hgb 13.9
Hct 41.8
Plt 266
MCV 91
.
PT: 12.8 INR: 1.1
.
Brief Hospital Course:
77yF with history of CVA in [**2175**] and recent TIA, 70-90%
stenosis of [**Doctor First Name 3098**], presented for elective angiography and
stenting of the left internal carotid artery. SHe underwent
PCI of her L. ICA. Post procedure she was placed on a
neosynephrine drop for hypotension. SHe was monitored in the
ICU. Her neo gtt was weaned off. She had no complications.
her home anti-HTN medications were held on dishcarge and she had
scheduled follow up with her cardiologist on discharge to
discuss resuming her medications.
.
.
.
Medications on Admission:
Toprol XL 200mg daily
Norvasc 10mg daily
Zestril 40mg daily
Protonix 40mg daily
Plavix 75mg daily
ASA 325 mg daily
Zoloft 50mg daily
Zocor 80mg QHS
Folic acid 1mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid stenosis
Discharge Condition:
good
Discharge Instructions:
You were admitted for an elective carotid stent. You tolerated
the procedure without significant complications. You were
admitted to the CCU for monitoring of your blood pressure after
the procedure. You were briefly on medications to increase your
blood pressure.
.
Please take all of your medications as prescribed. Please note
that you were taken off your Toprol XL, Norvasc, and Zestril.
Please do *NOT* restart these medications unless instructed by
your cardiologist or Dr. [**First Name (STitle) **].
.
If you experience lightheadedness, weakness or numbness of your
arms or legs, neck pain, fever, or other concerning symptoms,
please call your doctor or go to the ER.
Followup Instructions:
Please follow up with:
Dr. [**First Name4 (NamePattern1) 30564**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 14967**], [**2181-6-22**], 2:15pm
Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 32467**] [**Telephone/Fax (1) 17663**], [**2181-6-11**], 4:00pm
|
[
"V15.82",
"433.10",
"458.8",
"424.0",
"365.9",
"V12.79",
"496",
"272.4",
"414.00",
"401.9",
"427.89",
"V12.54",
"V45.81",
"433.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.61",
"00.63",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
6754, 6760
|
5462, 6012
|
321, 350
|
6821, 6828
|
4199, 5438
|
7557, 7873
|
2820, 2958
|
6232, 6731
|
6781, 6800
|
6038, 6209
|
6852, 7534
|
2973, 4180
|
227, 283
|
378, 2036
|
2058, 2412
|
2428, 2804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,928
| 108,955
|
15538
|
Discharge summary
|
report
|
Admission Date: [**2114-12-19**] Discharge Date: [**2115-1-1**]
Date of Birth: [**2043-12-9**] Sex: F
Service: GEN SURGERY
HISTORY OF PRESENT ILLNESS: Patient is presenting with a
sternal wound infection. She had been slowly improving from
a coronary artery bypass graft on [**2114-10-25**] and was
being seen on a routine postoperative wound checks with no
symptomatology. She had no fever, no chills and no redness.
This morning, when she awoke on [**12-19**], she noticed a
large amount of drainage, which increased from the upper part
of her incision on her sternum, and on exam it was open half
a cm draining a copious amount of purulent pus.
PAST MEDICAL HISTORY:
1. Significant for a coronary artery bypass graft times two
on [**2114-10-25**], was off pump.
2. Right carotid endarterectomy on [**2114-10-22**] with Dr.
[**Last Name (STitle) 1391**]. Atrial fibrillation, postoperative delirium.
3. Chronic back pain.
4. Non Q wave myocardial infarction.
5. Hypercholesterolemia.
6. Migraines headaches.
7. PVT.
8. Hypertension.
9. Previous left carotid endarterectomy.
MEDICATIONS: She takes Lopressor 100 mg t.i.d. at home,
Plavix 75 mg once a day, Lisinopril 20 b.i.d. and amiodarone
200 mg once a day, Zosyn 75 once a day, Devoprolax 125
b.i.d., aspirin 81 once a day, Norvasc 10 once a day, Colace
100 b.i.d., Dolculax as needed, oxycodone as needed, Percocet
as needed and Tylenol as needed.
HOSPITAL COURSE: She was started on wide spectrum
antibiotics and sent to the Operating Room the following day
where she underwent a sternal debridement and was transferred
to the Intensive Care Unit with an open chest and was
paralyzed and sedated, where she remained thus until [**10-23**] when Plastic Surgery took her to the Operating Room where
she had a right pectoral muscle/rectus flap procedure done.
Postoperatively, she was then transferred to the Intensive
Care Unit where she was slowly weaned off her sedation and
weaned off of paralytics, weaned off vent requirements and
was eventually extubated without incident. At this point,
she was transferred to the floor.
The patient had been started on oxacillin, which the
Operating Room cultures grew back positive for methicillin
sensitive Staphylococcus aureus. She was transferred to the
floor where she continued to receive Physical Therapy and
Plastic Surgery was constantly evaluating her wound.
For her cardiac, however, she had hypotension and her
medications were titrated upwards in regard to this. A PICC
line was then placed on her on [**2114-12-31**] for
long-term antibiotics.
Patient, on physical examination, this morning has clear
heart and lungs. The incision looks clean and dry with
minimal exudate. No evidence of cellulitis, some baseline
redness. VNA and an Infusion Therapy has been set up for her
to receive oxacillin 2 grams intravenous q. 6h for the next
six weeks postoperatively, to end on [**2115-1-31**].
DISCHARGE MEDICATIONS:
1. Colace 100 mg po b.i.d.
2. Iron gluconate 300 mg po q.d.
3. Oxycodone SR 10 mg po q. 12 h.
4. Lopressor 50 mg po t.i.d.
5. Norvasc 10 mg po q.d.
6. Amiodarone 400 mg po q.d.
7. Aspirin 325 mg po q.d.
8. Protonix 40 mg po q.d.
9. Dilaudid 2-4 mg as needed for pain.
DISCHARGE PLAN: The patient understands the discharge plan.
She will go home to follow-up with Dr. [**Last Name (STitle) 5385**], who was the
Plastic Surgeon who did the surgery, in one week. Plastic
Surgery has been made aware of this plan and discharge. She
will also follow-up with Dr. [**Last Name (STitle) 1537**], as well as the nurse
practitioning staff on Cardiac Surgery. The patient, upon
discharge, has been afebrile with a white blood cell count of
less than 5, doing well, with a stable hematocrit.
She still has ongoing active issues and will follow-up with
her primary care physician as well for optimization of her
cardiac medications.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D.
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2115-1-1**] 12:04
T: [**2115-1-1**] 14:54
JOB#: [**Job Number 34718**]
|
[
"412",
"272.0",
"790.7",
"998.32",
"998.59",
"427.31",
"414.01",
"041.11",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.72",
"38.93",
"96.04",
"77.11",
"89.68",
"96.72",
"86.22",
"99.61",
"77.61",
"93.59",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
2974, 3252
|
1461, 2951
|
172, 672
|
3269, 4154
|
694, 1443
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,385
| 123,776
|
39459
|
Discharge summary
|
report
|
Admission Date: [**2199-11-20**] Discharge Date: [**2199-12-8**]
Date of Birth: [**2126-1-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Type B aortic dissection
Major Surgical or Invasive Procedure:
[**2199-11-20**] Replacement of descending thoracic aortic aneurysm
using a 32-mm Vascutek Dacron tube graft and deep hypothermic
circulatory arrest. Catalog #[**Numeric Identifier 87179**], lot #[**Serial Number 87180**], serial
#[**Serial Number 87181**].
Clipping of thoracic duct and placement of fibrin glue.
right video assisted thoracoscopy and thoracic duct ligation
[**2199-12-4**]
History of Present Illness:
This 73 year old gentleman developed left upper extremity
swelling 3 months ago. An ultrasound was performed which
revealed thrombus in his left subclavian vein and jugular vein.
He was placed on Coumadin and underwent a hematologic work-up
which revealed Factor V Leiden. He was subsequently referred for
a CT which revealed an old Type B dissection with an aneurysmal
component of the descending thoracic aorta measuring 6cm. He was
subsequently referred to Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**] for
surgical evaluation.
Past Medical History:
Type B dissection
Left subclavian deep vein thrombosis extending into internal
jugular
Factor V Leiden
Hypertension
s/p Cholecystectomy Laparoscopic [**2196**]
s/p Left wrist surgery for fracture2001
s/p Umbilical hernia repair [**2188**]
Social History:
Last Dental Exam:edentulous
Lives with:wife
Occupation:retired electrician
Tobacco:17 PY Hx, quit 41 yrs ago
ETOH: 2 drinks/month
Family History:
Brother with MI at 43 and other brother with CABG at 68.
Diebetes in parents and siblings.
Physical Exam:
Pulse: 54 Resp: 16 O2 sat: 97%-RA
B/P Right: 120/80 Left:
Height: 66" Weight: 185
General:
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x] MMM, normal oropharynx
Neck: Supple [x] Full ROM [x] no JVD or lymphadenopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- no MRG
Abdomen: Soft[x] non-distended [x] non-tender[x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact- non focal exam
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 none
Pertinent Results:
PREBYPASS
The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the body of
the right atrium. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal with normal free wall
contractility. The descending thoracic aorta is markedly dilated
with an intimal flap extending distally from the distal aortic
arch. The false lumen (without evidence of flow on color
doppler) contains a large thrombus. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
POSTBYPASS
The patient is on a phenylephrine infusion and is V-paced. There
is a new descending aortic graft extending from the distal arch
to the distal thoracic descending aorta. Below the graft there
is the native aorta which continues to have a false and true
lumen. Biventricular systolic function continues to be normal.
The tricuspid regurgitation is now mild. Mitral regurgitation
continues to be trivial and there continues to be no aortic
regurgitation. The ascending aorta is intact.
Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2199-11-26**] 16:27
[**2199-12-6**] 04:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.3* Hct-25.5*
MCV-89 MCH-32.5* MCHC-36.4* RDW-15.4 Plt Ct-290
[**2199-11-20**] 06:50PM BLOOD WBC-11.5*# RBC-3.50*# Hgb-10.8*#
Hct-30.7* MCV-88 MCH-30.9 MCHC-35.2* RDW-14.7 Plt Ct-103*
[**2199-12-6**] 04:58AM BLOOD Glucose-158* UreaN-33* Creat-1.2 Na-135
K-3.9 Cl-106 HCO3-21* AnGap-12
[**2199-11-29**] 04:49AM BLOOD Glucose-158* UreaN-26* Creat-0.9 Na-135
K-4.5 Cl-108 HCO3-22 AnGap-10
[**2199-11-20**] 06:50PM BLOOD UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-109*
HCO3-24 AnGap-11
[**2199-12-8**] 06:30AM BLOOD PT-15.1* PTT-45.4* INR(PT)-1.3*
Brief Hospital Course:
He was admitted on [**11-20**] and underwent surgery with Drs. [**Last Name (STitle) 914**]
and [**Name5 (PTitle) **]. See operative note for details of the procedure.
there was an injury to the Tthoracic duct noted at surgery and
fibrin tissue glue was utilized in an attempt to seal it. Dr.
[**First Name (STitle) **] was asked to see the patient in the Operating Room for this
as well. there remained an obvious ooze of chyle at the end of
the case and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed neat this. He was
transferred to the CVICU in stable condition, extubated on POD
#1 and was neurologically intact. He was transferred to the
floor to begin increasing his activity level.
Heparin was started and Coumadin held pending evaluation of
further chyle leak. Octreotide was given but the chylous
drainage persisted from the [**Doctor Last Name 406**] drain after CTs were removed.
After several days his low fat diet was changed to NPO and TPN
was begun. drainage persisted, however. He continued to be
followed by Dr. [**First Name (STitle) **] from Thoracic Surgery.
An attempt was made by Interventional radiology to embolize the
leak but they could not gain access for this. On [**12-4**] he was
returned to the Operating Room with Thoracic Surgery for repair.
A right video assisted thoracoscopy was performed with duct
ligation. He tolerated this well, the right chest tuybe was
subsequently removed and he was fed. There seemed to be no
further chyle leakage and TPN was tapered and dicontinued
toatally on [**12-8**].
The left [**Doctor Last Name 406**] drain was removed on [**12-7**] and a CXR was okay. He
was begun on Coumadin after the second surgery and Heparin
continued. At discharge the INR was subtherapeutic and Lovenox
was utilized (he was injecting himself previously).
Arrangements were made for follow up with all concerned parties
and for Coumadin management by [**Hospital 5700**] [**Hospital 197**] Clinic as
preoperatively.
Medications on Admission:
***COUMADIN 5 mg daily
labetalol 100 mg [**Hospital1 **]
vit. d 1000 units daily
vit. B12 500 mg daily
Discharge Medications:
1. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose) for 1 doses.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
3. ibuprofen 200 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for fever or pain.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/temp.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days: Until INR is >2.0.
Disp:*14 * Refills:*0*
9. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 2 tablets(400mg) [**Hospital1 **] for 2 weeks, then one tablet
(200mg) [**Hospital1 **] for 2 weeks, then 1 tablet (200mg) daily
.
Disp:*100 Tablet(s)* Refills:*2*
10. Coumadin 5 mg Tablet Sig: as directed Tablet PO once a day:
INR goal 2-2.5
one daily unless otherwise instructed.
11. Outpatient Lab Work
INR [**2199-12-10**] then prn. Phone results to:[**Doctor First Name **] at
[**Telephone/Fax (1) 87182**].
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
Type B aortic dissection
s/p graft repair of Type B dissection,left subclavian to
internal jugular artery graft
Factor V Leiden deficiency
h/o deep vein thrombosis of left internal jugular & subclavian
veins
thoracic duct injury
hypertension
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
edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]on [**2199-12-17**] at 2pm
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) 71878**] in [**5-6**] weeks ([**Telephone/Fax (1) 71880**])
Thoracic surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-4**] weeks [**Telephone/Fax (1) 3020**]
**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 UE- DVTs
Goal INR 2-2.5 First draw [**2199-12-10**]
Results to phone: [**Hospital 5700**] [**Hospital 197**] Clinic [**Telephone/Fax (1) 87182**] (att:
[**Doctor First Name **])
Completed by:[**2199-12-8**]
|
[
"458.29",
"457.8",
"E870.0",
"289.81",
"998.2",
"441.01",
"401.9",
"511.9",
"790.7",
"784.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91",
"40.64",
"34.21",
"99.15",
"87.34",
"31.42",
"38.45",
"39.62",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8319, 8364
|
4705, 6718
|
346, 741
|
8650, 8828
|
2555, 4682
|
9752, 10596
|
1742, 1835
|
6873, 8296
|
8385, 8629
|
6744, 6850
|
8852, 9729
|
1850, 2536
|
282, 308
|
769, 1315
|
1337, 1578
|
1594, 1726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,507
| 118,789
|
12578
|
Discharge summary
|
report
|
Admission Date: [**2187-5-15**] Discharge Date: [**2187-5-18**]
Date of Birth: [**2118-10-20**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname **] is a
68-year-old woman with multiple medical problems who
underwent a coronary artery bypass graft x3 on [**2187-3-26**]
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her postoperative course was delayed
due to pulmonary problems requiring reintubation for
increased amount of secretions and also atrial fibrillation.
She was transferred out of the Intensive Care Unit on
postoperative day 9 and finally discharged to rehabilitation
on postoperative day 11 in a stable condition on po Kefzol.
She was seen by Dr. [**Last Name (STitle) **] on [**2187-4-25**] for
postoperative checkup where she was noted to have a small
amount of purulent drainage from her sternal wound. As
stated above, she had been on Keflex which was changed to
clindamycin at that time.
Mrs. [**Known lastname **] returned for a wound check on [**2187-5-9**] from
rehabilitation where she had an open area approximately 1 cm
long and 1.5 cm deep at the distal aspect of her incision
with eschar and minimal erythema surrounding the open area.
She had been otherwise progressing well and remained
afebrile. The wound was debrided locally and she was placed
on levofloxacin 500 mg and at that time was instructed to
keep for 14 days. A follow up appointment was scheduled for
[**2187-5-18**]. On [**2187-5-13**], she was admitted to [**Hospital3 38921**] Hospital in [**Location (un) 8973**] with an episode of
hypertension, increased white blood cell count to 25,000.
She was found to be in atrial fibrillation, hyperkalemia up
to 9 as per outside report and found to be in renal
insufficiency. She was intubated at that time for question
of respiratory failure, placed on intravenous Diltiazem to
control her heart rate and a dopamine drip for her
hypertension. She was admitted to the Intensive Care Unit
for further management.
A chest CT at that time revealed a small substernal
collection. Since she developed these findings and she was
better known to the [**Hospital6 256**], she
was transferred to this institution for further and
definitive treatment, as well as assessment of that sternal
wound.
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft x3 on [**2187-3-26**].
2. Asthma with occasional steroid use.
3. Chronic obstructive pulmonary disease
4. Gastroesophageal reflux disease
5. Transient ischemic attacks. The patient had a carotid
ultrasound on [**2190-3-22**] that showed 40% to 59% bilateral
ICA stenosis with right subclavian steel.
6. Status post lacunar stroke in [**2178**]
7. Insulin dependent diabetes
8. Hypertension
9. Episode of anaphylaxis due to ACE inhibitors and aspirin
in the past.
10. Status post THR in [**2182**]
ALLERGIES: THE PATIENT HAS ANAPHYLACTIC REACTION TO ACE
INHIBITORS AND ASPIRIN.
ADMISSION MEDICATIONS:
1. Dilantin 100 mg po tid
2. Trazodone 100 mg po q hs
3. Bumex 6 mg q a.m. and 2 mg q p.m.
4. Procardia XL 120 mg po q day
5. Hydrocortisone and acetaminophen prn
6. Prevacid 30 mg po bid
7. Ativan 1 mg po tid
8. Hydralazine 25 mg po tid
9. Reglan 10 mg po q hs
10. Xanax 2.5 mg prn
11. Insulin 75/25 50 units q a.m. and 60 units q p.m.
12. Nitro-Dur patch at 7 a.m. and 10 p.m.
13. Catapres 0.3 mg transdermal patch once a week
ADMISSION PHYSICAL EXAMINATION:
GENERAL: The patient was in atrial fibrillation with a rate
of 60s, intubated on assist control ventilation, but patient
was awake and alert, moving all extremities well. Nodded her
head appropriately to questions.
LUNGS: Clear to auscultation bilaterally anteriorly.
HEART: Irregularly irregular and no murmurs, thrills or
rubs.
ABDOMEN: Obese, nontender.
STERNUM: Stable, small opening in the area at the distal
aspect of the incision with no erythema and very small amount
of scant yellow drainage.
EXTREMITIES: Warm and well perfuse, no peripheral edema.
LABS: A white blood cell count aspirate at the outside
hospital was 24,000 with a hematocrit of 43.5. She had a
neutrophil count of 85, sodium of 140, potassium of 3.0,
chloride of 103, CO2 of 26, BUN of 21 with a creatinine of
1.3. The glucose level was 215, bilirubin 1.9, AST of 48,
ALT of 49, alkaline phosphatase of 113, protein of 6.8.
HOSPITAL COURSE: As stated above, the patient was admitted
to the Intensive Care Unit and her Diltiazem drip was weaned
to off. She required multiple fluid boluses to improve her
blood pressure, but in spite of that the patient was kept on
the dopamine drip overnight. Her antibiotics upon transfer
was levofloxacin and vancomycin that were kept on her
admission in the Intensive Care Unit. By hospital day #2,
[**2187-5-16**], she was awake, alert and oriented. She had no
complaints, except for some mild tenderness on her left
flank. Her white count was 25,000 with a hematocrit of 35
and a platelet count of 144. Her Chem-7 was sodium 139,
potassium 3.8, chloride 103, CO2 26, BUN 21 and her
creatinine came down to 0.9 with a glucose level of 117.
Once again, several exams documented that there was not a lot
of purulent drainage coming out of her sternal wound. She
had an abdominal CT done that morning that was negative for
intraabdominal collections, diverticulitis or any other
abnormality. She was found to have a heterogeneously
enhancing solid left renal mass that measured approximately
2.5 cm. The patient required dopamine to be given through
the entire day to keep adequate blood pressures.
On [**2187-5-17**], SICU day 3, Mrs.[**Doctor Last Name 38922**] [**Name (STitle) **] count was
down to 14.6. She remained afebrile and her dopamine was
weaned to off, keeping good blood pressures. Sternal wound
had dressing changes wet to dry [**Hospital1 **] and there was no
increasing erythema observed. On the afternoon of that day,
she was evaluated by the urology service for that incidental
left renal mass. The consultation stated that it was unclear
whether the lesion was a renal CA primary versus an upper
tract urothelial renal pelvis malignancy. They were
suggesting that this might be a renal cell carcinoma and
suggested that the patient would require an MRI with
gadolinium that could be obtained as an outpatient. The
patient should make follow up arrangements with Dr.[**Name (NI) 13919**]
office in the urology clinic to further work up this renal
mass.
By hospital day #4, Mrs. [**Known lastname **] was off pressors, remained
afebrile, was started on a diabetic diet tolerating well
po's. Her white count was 13.7 and her creatinine was 0.6.
She was asymptomatic. The sternum remained stable. No
drainage was evident. She was offered a bed at
rehabilitation where she is being discharged under stable
conditions.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg po tid
2. Prednisone 5 mg po qd
3. Accolate 20 mg po q day
4. Digoxin 0.25 mg po q day
5. Aldactone 75 mg po q 12 hours
6. KCL 20 milliequivalents po q 12 hours
7. Heparin subcutaneous 5000 units tid
8. Colace 100 mg po bid
9. Plavix 75 mg po q day
10. Albuterol/Atrovent metered dose inhaler 2 to 5 puffs q4h
and prn
11. Nystatin powder to groin area tid
12. Protonix 40 mg po q day
13. Amiodarone 20 mg po q day
14. Imdur 90 mg po q day
15. Regular insulin sliding scale
16. Percocet 5/325 mg 1 to 2 tablets po q 4 to 6 hours prn
17. Roxicet elixir 5 to 10 cc po q 4 to 6 hours prn
DIET: American Diabetic Association diet
DISCHARGE INSTRUCTIONS: The patient is to have sternal wound
dressing changes wet to dry [**Hospital1 **]. She will have to call Dr.[**Name (NI) 22446**] office and make a follow up appointment. She is
also instructed to call Dr.[**Name (NI) 13919**] office, telephone
([**Telephone/Fax (1) 38923**], to make a follow up appointment with the
urology service.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2187-5-18**] 11:42
T: [**2187-5-18**] 12:18
JOB#: [**Job Number 38924**]
|
[
"780.39",
"V45.81",
"493.20",
"038.9",
"998.59",
"250.00",
"276.7",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6892, 7548
|
4420, 6869
|
7573, 8191
|
3018, 3467
|
3489, 4402
|
185, 2351
|
2373, 2995
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,641
| 193,376
|
19863
|
Discharge summary
|
report
|
Admission Date: [**2169-10-26**] Discharge Date: [**2169-11-14**]
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
female patient who was reporting about a six month history of
progressive fatigue and exercise intolerance. She now
reports at least a single walk dyspnea on exertion and
exertional angina after climbing 22 stairs to her house. Her
symptoms are easily resolved with sublingual Nitroglycerin.
On [**2169-10-20**], angiogram revealed three vessel coronary artery
disease and diastolic ventricular dysfunction, ejection
fraction was approximately 49%. The patient denies
claudication, orthopnea, paroxysmal nocturnal dyspnea or any
light-headedness. She does report some occasional ankle
edema.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoarthritis.
3. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Left knee surgery [**2169-6-13**].
2. Appendectomy.
3. Tonsillectomy.
4. Hysterectomy.
5. Bilateral cataract surgery.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 mg once daily.
2. Atenolol 50 mg once daily.
3. ************** once daily
4. ************** q.h.s.
5. Lasix 20 mg once daily.
6. Pepcid 20 mg once daily.
SOCIAL HISTORY: She is married. She lives in [**Hospital1 3494**].
LABORATORY DATA: Preoperative laboratory values were
unremarkable and within normal limits.
HOSPITAL COURSE: On [**2169-10-26**], the patient was admitted for
an elective coronary artery bypass graft. After consent was
confirmed, the patient was taken to the operating room for a
coronary artery bypass graft. Please refer to the previously
dictated operative note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**2169-10-26**],
for full details of the surgery. In brief, a four vessel
coronary artery bypass graft was performed which the patient
tolerated well. Of note, the patient did receive several
units of packed red blood cells during the procedure. She
was transferred to the CSRU in stable condition and
intubated. On postoperative day two, the patient's Intensive
Care Unit course was remarkable for hemodynamic monitoring
and attempted extubation. On postoperative day two, the
patient was extubated, however, because of respiratory
insufficiency, she had to be reintubated and she remained
intubated until postoperative day five on [**2169-10-31**]. She
stayed in the Intensive Care Unit until postoperative day
seven during which time she was evaluated by the swallow
team, nutrition team, the physical therapy team. It was
determined that she was able to tolerate a p.o. diet and that
she would eventually need to be discharged to rehabilitation.
On [**2169-11-3**], the patient was transferred to the floor where
she was tolerating an oral diet. Her main issue on the floor
was her fluid status. The patient was markedly fluid
overloaded following the week in the Intensive Care Unit and
she was gently diuresed for her week on the floor. Despite
this, she had consistent bilateral pleural effusions and
congestive symptoms including bilateral 2+ pedal edema.
She was followed with serial chest x-rays which showed slowly
resolving bilateral pleural effusions and eventually
interventional pulmonology was consulted on postoperative day
fourteen, [**2169-11-9**], but the effusions were not able to be
tapped due to scant layering while the patient was supine.
In addition, [**Last Name (un) **] team was consulted to assist with the
patient's diabetic status prior to discharge.
On discharge, neurologically, she is being treated with
Klonopin and Benadryl to help her sleep. Cardiovascularly,
she is on Amiodarone. To help with her atrial fibrillation,
she is also being anticoagulated with subcutaneous Heparin
twice a day, Plavix and Aspirin. Pulmonary wise, the patient
does receive nebulizer treatment every four hours with some
relief. She still has bilateral pleural effusions.
Gastrointestinal, the patient is tolerating [**Doctor First Name **] diet without
nausea, vomiting or abdominal pain. She is on sliding scale
insulin and she also receives Protonix and laxatives.
Hematologically, the patient's hematocrit is stable at 33.0
prior to discharge. FEN - she is a markedly fluid
overloader, however, she is diuresing well on 40 mg of Lasix
once a day and receiving Potassium supplementation with her
Lasix dose. Also, prior to discharge, the patient's latest
creatinine was 1.4 which has been treading downward over the
past week. Infectious disease - The patient will go home on
a ten day course of Levaquin.
DISPOSITION: The patient will be sent to [**Hospital **]
Rehabilitation facility on [**2169-11-14**], in good condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Congestive heart failure.
3. Chronic blood loss anemia requiring packed red blood cell
transfusion.
4. Hypertension.
5. Hypercholesterolemia.
6. Osteoarthritis.
7. Pulmonary hypertension.
8. Intra-aortic balloon pump.
9. Platelet transfusion.
10. Postoperative atrial fibrillation.
11. Postoperative atelectasis.
12. Wound infection.
13. Hypokalemia.
14. Hypomagnesemia.
15. Fluid overload status.
16. Bilateral pleural effusions.
MEDICATIONS ON DISCHARGE: Klonopin, Benadryl, Amiodarone,
Heparin, Plavix, Aspirin, Atrovent, Albuterol, Protonix,
sliding scale insulin, Colace, Lasix, Potassium, Levaquin.
Please refer to the discharge instructions for the exact
dosages on these medications or the addendum to this
dictation summary. The patient is recommended to have
follow-up appointments with Dr. [**Last Name (STitle) **] and her primary
cardiologist. Recommended follow-up appointments are with
Dr. [**Last Name (STitle) 36795**] in one to two weeks, with cardiologist in two to
three weeks, and Dr. [**Last Name (STitle) **] in four weeks.
DISCHARGE INSTRUCTIONS: She is to keep her wound clean, dry
and intact. No driving for six weeks. No heavy lifting. Do
not apply lotions, creams or ointment to her wound, and to
continue her incentive spirometry and ambulation.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2169-11-13**] 17:52
T: [**2169-11-13**] 18:16
JOB#: [**Job Number 53675**]
|
[
"996.72",
"414.01",
"458.29",
"428.0",
"280.0",
"518.5",
"998.59",
"427.31",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"34.03",
"36.14",
"96.6",
"99.04",
"36.15",
"39.61",
"96.04",
"96.71",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
4763, 5277
|
5304, 5898
|
1063, 1252
|
1434, 4742
|
5923, 6412
|
864, 1037
|
127, 754
|
776, 841
|
1269, 1416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,417
| 105,034
|
52053
|
Discharge summary
|
report
|
Admission Date: [**2129-6-17**] Discharge Date: [**2129-6-21**]
Date of Birth: [**2082-10-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Anterior STEMI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46yo M with hyperlipidemia, no known CAD, and +FHx who was
transferred from [**Hospital **] Hospital with an acute MI. Developed
[**10-3**] CP at 4pm while playing tennis. Taken to [**Location (un) **] where
EKG showed STE in anterolateral leads. Started on ASA, BB,
Plavix, and Integrilin, and Benadryl. Developed rapid AF just
before cath. Cath at [**Location (un) **]-occluded mid-LAD, 2 stents placed,
and 40% OM1. SBP dropped to 80-90 in cath lab, started on
dopamine gtt. Converted to NSR upon revasc. No further CP
post-cath. Required 100% NRB, rapid desat on RA. Cr 1.5,
baseline 0.9-1.1. En route, developed 20-30 beat run of VT, for
which he was started on a lidocaine gtt. Upon arrival,
lidocaine gtt stopped, DA gtt at 8 to maintain BP in 90s.
Bedside TTE: EF 35%, severe apical akinesis, no regurg.
Intermittent runs of VT.
Past Medical History:
hyperlipidemia
no known CAD, nl EKG stress test in [**2121**]
nephrolithiasis (ureate stone), s/p lithotripsy ([**2123**])
Social History:
dentist
married, 3 children
nonsmoker
Family History:
mother- MI/CABG @65yo
Physical Exam:
general: ill-appearing man, lying in bed, somnolent but easily
arousable to name
HEENT: small scleral hemorrhage medial L eye, PERRL
Neck: supple, no JVD
Pulm: bibasilar crackles
CV: irregular rhythm--frequent PVCs, nl S1/S2, no murmur, +S3
Abd: soft, NT, ND, +BS throughout
R groin: arterial sheath in place, some oozing
Ext: warm, no edema, DP pulses palpable b/l
Pertinent Results:
EKG (6:50pm,pre-cath)- AF @ 115bpm, nl axis, STE V2-V6, I, aVL
(11pm, post-cath)- NSR@80bpm, nl axis, poor R wave
progression, resolution of STE
Cardiac cath- 30% proxLAD, TO midLAD (2 zeta stents), 80% OM1,
RCA
nl; PCWP 19
TTE- EF 30-35%, severe apical hypokinesia, no valvular regurg
CXR- pulmonary edema
[**2129-6-17**] 10:53PM BLOOD WBC-20.1*# RBC-4.58* Hgb-14.0 Hct-39.5*
MCV-86 MCH-30.5 MCHC-35.4* RDW-12.7 Plt Ct-288
[**2129-6-17**] 10:53PM BLOOD Glucose-169* UreaN-16 Creat-1.0 Na-139
K-4.8 Cl-108 HCO3-21* AnGap-15
[**2129-6-18**] 05:40AM BLOOD CK-MB-291* MB Indx-15.9* cTropnT-1.24*
[**2129-6-17**] 11:10PM BLOOD Type-MIX pO2-148* pCO2-40 pH-7.29*
calHCO3-20* Base XS--6
Brief Hospital Course:
1) STEMI: Mr. [**Known lastname **] suffered a large anterior STEMI. He is s/p
cardiac cath at the OSH with 2 stents placed to his STEMI, and
resolution of ST elevation and chest pain upon
revascularization. He experienced intermittent runs of VT en
route to [**Hospital1 18**] and had evidence of cardiogenic shock upon
arrival. TTE revealed depressed EF and apical akinesis. He was
continued on ASA, Integrilin, and Plavix, and started on
high-dose statin. He was initially diuresed with Lasix for his
pulmonary edema. He was weaned from dopamine the next day with
the help of IV fluids to replete his volume. He was started on
heparin gtt for the indication of apical akinesis and low EF.
His cardiac enzymes continued to trend down. He was chest
pain-free throughout his admission. He was also started on a
beta blocker and ACE inhibitor during this admission. TTE on
[**6-20**] showed improved EF of 45% and residual apical akinesis.
Heparin gtt was discontinued. The patient's follow-up plan
includes cardiology f/u in 2 weeks and cardiac rehabilitation
program in [**3-30**] weeks. He was also instructed to follow up with
his PCP.
.
2) VT: The patient had frequent, intermittent, non-sustained
runs of VT. The decision was made to monitor the patient
without treatment as he was hemodynamically stable and VT can be
expected within 48 hours of MI--AIVR vs. NSVT. His electrolytes
were repleted as necessary. The VT resolved within 48 hours.
The patient remained hemodynamically stable throughout his
admission.
.
3) ARF: On admission, the patient had an elevated creatinine of
1.5, likely secondary to hypoperfusion, with possible
contribution from the dye load received in cardiac
catheterization. It had returned to [**Location 213**] by the time of
discharge.
.
4) Dispo: The patient was discharged to home with a plan to
follow up with his PCP and Dr. [**Last Name (STitle) **] for Cardiology within the
next 2 weeks.
Medications on Admission:
ASA 325mg po qd
Plavix 75mg po qd
Integrilin gtt
Lidocaine gtt
Dopamine gtt
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Anterior ST elevation myocardial infarction
Discharge Condition:
good
Followup Instructions:
Cardiology
PCP
Completed by:[**2129-8-3**]
|
[
"285.9",
"785.51",
"599.7",
"410.71",
"428.0",
"V45.82",
"427.89",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
5180, 5238
|
2606, 4553
|
330, 336
|
5326, 5332
|
1854, 2583
|
5355, 5400
|
1430, 1453
|
4679, 5157
|
5259, 5305
|
4579, 4656
|
1468, 1835
|
276, 292
|
364, 1213
|
1235, 1359
|
1375, 1414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,332
| 134,935
|
18042
|
Discharge summary
|
report
|
Admission Date: [**2151-4-11**] Discharge Date: [**2151-4-17**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female transferred from an outside hospital ([**Hospital6 3426**]) with symptoms of malaise and fever.
The patient had symptoms of endocarditis and petechiae noted
bilaterally on the hands as well as ecchymoses over the left
back. The patient's white blood cell count at the outside
hospital was 16. Initially treated with Zithromax and
ceftriaxone. Blood cultures returned gram-positive cocci in
clusters and was switched to vancomycin and gentamicin.
The patient was transferred to [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY: (Past Medical History consists of)
1. Hypertension.
2. History of pneumonia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
SOCIAL HISTORY: The patient lives alone. She is independent
and was working in a nursing home. No smoking and no
alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's
initially temperature was 100.4, blood pressure was 96/48,
heart rate was 110, and respiratory rate was 12. In general,
the patient was lethargic and somnolent. Pupils were equal,
round, and reactive to light. Sclerae were anicteric. No
carotid bruits. Mucous membranes were dry. The lungs were
clear to auscultation. Heart was tachycardic but regular.
The abdomen was mildly distended with mild tenderness to
palpation. No rigidity and no rebound. Guaiac-negative.
Extremities had some positive [**Last Name (un) 1003**] lesions. Dorsalis
pedis pulses were present.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial white
blood cell count was 16.6 and platelets were 150 (then repeat
was 105). Urinalysis showed greater than 100,000 Escherichia
coli. White blood cell count was 15 to 19.
PERTINENT RADIOLOGY/IMAGING: Initial chest x-ray showed a
possible left lower lobe infiltrate.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: The patient had gram-positive
cocci in clusters that grew out Staphylococcus.
Transthoracic echocardiogram confirmed a vegetation in one of
her valves. She was switched oxacillin when her
sensitivities came back. She was treated with gentamicin for
the Escherichia coli.
2. CREATININE ISSUES: In terms of her creatinine of 1.2,
likely prerenal, the patient was given lots of fluids.
3. MENTAL STATUS CHANGES ISSUES: In terms of her change in
mental status, a computed tomography of the head was
negative.
4. HYPOTENSION ISSUES: She initially required pressors for
her sepsis and dehydration. Cortisol levels were checked,
and electrocardiograms were checked as well.
5. RESPIRATORY ISSUES: On [**4-12**], the patient's
respiratory status worsened. The patient was intubated using
a blade and a 7.5 endotracheal tube. No paralytics were
used. The patient was placed on AC ventilation, and chest
x-ray confirmed proper placement of the intubation tube.
6. HEMATOLOGIC ISSUES: A Hematology consultation was
obtained, as the patient's heparin-induced thrombocytopenia
antibodies were positive. It was likely type I, and heparin
products were withheld.
Supportive care was provided, and platelet levels were
followed.
On [**4-17**], a resident was called to the room for decreased
breathing. Per family, the patient was placed on comfort
measures only. The patient was extubated and expired shortly
thereafter on [**4-17**] at 12:15 a.m.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 48388**]
MEDQUIST36
D: [**2151-7-5**] 14:55
T: [**2151-7-12**] 07:17
JOB#: [**Job Number 49930**]
|
[
"276.2",
"424.1",
"427.31",
"599.0",
"584.9",
"518.81",
"287.5",
"038.11",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.04",
"89.64",
"00.11"
] |
icd9pcs
|
[
[
[]
]
] |
848, 848
|
1965, 3684
|
117, 680
|
703, 821
|
865, 1931
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,238
| 169,939
|
45625
|
Discharge summary
|
report
|
Admission Date: [**2112-10-3**] Discharge Date: [**2112-10-11**]
Date of Birth: [**2044-3-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
DOE x 6 weeks
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year-old F with multiple myeloma, on Thalidomide and Decadron
who presents with progressive DOE x 6 weeks. She used to be
able to walk up one flight of stairs without SOB and today she
was unable to walk to her bathroom. On the morning of
admission, she also reported left-sided chest pain that radiated
to her back. She had accompanying dizziness and
nausea/vomiting. No pleuritic or positional components to the
pain. She denies SOB at rest, orthopnea, or PND. No change in
her chronic LE edema. Of note she was taken off her diuretics
(for mild renal failure) 6 weeks ago, but had to restart them 3
weeks ago due to worsened LE edema. She also recently traveled
in a car to VA for the Labor Day weekend.
.
In the ED she was hypoxic to the low 90's on 100% NRB. Her
lactate was elevated at 3.4, SBP 95, and out of concern for
sepsis, she received 1.2 L of IVF. Once her BNP returned at
4948, her IVF was stopped and she put out 1200cc to 80 IV lasix.
She also received a dose of levoflox and was placed on BIPAP.
ABG on 60% FiO2: 7.42/47/72. Her EKG was unchanged, cardiac
enzymes were negative.
Past Medical History:
Multiple Myeloma - Dx in [**2108**] with IgA Kappa monoclonal protein,
followed without treatment. In [**2112-3-30**], she was noted to have
an IgA level of 2300, with increased fatigue. Bone Marrow Bx
revealed > 50% plasma cells qualifying her for the Vaccine
Study, for which she is enrolled. She received 3 cycles of
velcade. She has been receiving Zometa and started on
Thalidomide and Decadron ([**2112-5-30**]).
2. Hypertension.
3. Hypercholesterolemia.
4. Hyperglycemia on Decadron
5. Restrictive lung dz: by PFTs in [**4-4**]
6. Chronic back pain (s/p MVA)
7. Duodenal ulcer 11 years ago.
8. History of Lichen simplex chronicus.
9. Right knee pain: s/p cortisone injections
Social History:
She is married and lives with her husband. She has three
children. She works as a high school librarian. Denies tobacco
use; drinks EtOH socially.
Family History:
One daughter has sarcoidosis. No FH of MI or CVA
Physical Exam:
Vitals: T: 96.7 P: 92 BP: 107/30 RR: 21 SaO2: 96% on
BiPAP: 12/5/0.60
General: Awake, alert, NAD on BiPAP mask.
HEENT: PERRL, EOMI, sclera anicteric.
Neck: thick, JVD to clavicle. no carotid bruits appreciated, 2+
carotid pulses.
Pulm: Lungs clear bilaterally, occ crackles to b/t bases
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no hepatomegaly noted.
Rectal (in ED): guaiac negative brown stool
Ext: 1+ edema b/t, 2+ radial, DP pulses b/l.
Neurologic: Alert & Oriented x 3. Able to relate history without
difficulty.
Pertinent Results:
[**2112-10-3**] 01:45PM PT-12.7 PTT-24.8 INR(PT)-1.1
[**2112-10-3**] 01:45PM PLT COUNT-265
[**2112-10-3**] 01:45PM ANISOCYT-1+
[**2112-10-3**] 01:45PM NEUTS-88.3* LYMPHS-8.4* MONOS-2.9 EOS-0.3
BASOS-0.1
[**2112-10-3**] 01:45PM WBC-14.8*# RBC-3.51* HGB-10.8* HCT-31.6*
MCV-90 MCH-30.9 MCHC-34.4 RDW-16.9*
[**2112-10-3**] 01:45PM CRP-167.3*
[**2112-10-3**] 01:45PM CORTISOL-50.7*
[**2112-10-3**] 01:45PM CALCIUM-9.0 PHOSPHATE-4.4# MAGNESIUM-1.9
[**2112-10-3**] 01:45PM CK-MB-NotDone proBNP-4948*
[**2112-10-3**] 01:45PM cTropnT-0.07*
[**2112-10-3**] 01:45PM LIPASE-53
[**2112-10-3**] 01:45PM ALT(SGPT)-16 AST(SGOT)-16 CK(CPK)-89 ALK
PHOS-57 AMYLASE-152* TOT BILI-0.3
[**2112-10-3**] 01:45PM GLUCOSE-227* UREA N-42* CREAT-3.4*#
SODIUM-137 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-28 ANION GAP-20
[**2112-10-3**] 01:55PM LACTATE-3.8* K+-4.1
[**2112-10-3**] 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2112-10-3**] 04:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2112-10-3**] 05:38PM PO2-72* PCO2-47* PH-7.42 TOTAL CO2-32* BASE
XS-4 INTUBATED-NOT INTUBA
[**2112-10-3**] 10:41PM %HbA1c-9.2* [Hgb]-DONE [A1c]-DONE
[**2112-10-3**] 10:41PM ALBUMIN-3.3*
[**2112-10-3**] 10:41PM CK-MB-4 cTropnT-0.06*
[**2112-10-3**] 10:41PM CK(CPK)-74
[**2112-10-3**] 11:04PM LACTATE-1.1
[**2112-10-3**] 11:04PM TYPE-ART PO2-56* PCO2-48* PH-7.44 TOTAL
CO2-34* BASE XS-6 INTUBATED-NOT INTUBA
[**2112-10-3**] 11:29PM TYPE-ART PO2-95 PCO2-44 PH-7.45 TOTAL CO2-32*
BASE XS-5
EKG:
NSR @ 85, nl axis/intervals, no ST or T wave changes.
.
<b>Radiologic Data:
CXR [**10-3**]: Mild cardiomegaly, low lung volumes, but no evidence
for
pneumonia.
.
PFTs [**4-/2112**]: Reduced FVC (72%) and Dsb (63%) with low-normal TLC
suggests a restrictive process.
.
Echo [**3-/2112**]:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The LV cavity
size is normal. Regional LV wall motion is normal. Overall left
ventricular systolic function is normal (LVEF> 55%). Tissue
velocity imaging demonstrates an E/e' <8 suggesting a normal LV
filling pressure.
3. Right ventricular chamber size is normal. RV systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic gradient is
likely related to high cardiac output. No aortic regurgitation
is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure could not be
estimated because of the lack of a tricusped regurgitation jet.
7.There is no pericardial effusion.
Brief Hospital Course:
68 yo F with multiple myeloma on Thalidomide and Decadron who
presents with progressive DOE x 6 weeks, hypoxia, hypotension,
and ARF. The following issues were investigated during her
hospitalization:
1) Resp Distress: On presentation to the CCU, the patient still
was still hypoxic to 80s on room air, requiring 60% face mask.
Her physical exam was unremarkable for CHF - she had no
peripheral edema, no JVD and her lungs were clear bilaterally.
Given her hypoxia, elevated A-a gradient (297), history of
multiple myeloma and her treatment with Thalidomide and Decadron
(known to be thrombogenic and pt. was not on outpatient
anticoagulation), there was significant concern for a PE. Her
Thalidomide was discontinued and she was started on a Heparin
drip. Her elevated creatinine did not allow for a CTA so a VQ
scan was performed and was highly suspcious for a PE with
multiple perfusion deficits. Additionally, an echo showed
depressed RV function and evidence of RV hypertrophy and LE
dopplers showed a DVT in her right popliteal artery. The
evidence of RV hypertrophy and multiple VQ mismatches suggested
an acute and chronic thromboembolic disease. The Heparin drip
was continued and she was started on Coumadin. As she rapidly
improved she was not thought to be a candidate for
thrombolytics. Her aPTT goal was 60-80 while she was
transitioned to Coumadin. Upon arrival to the BMT service, her
hypoxia continued to improve. By time of discharge, she
maintained normal oxygen saturation on room air. As the patient
had transient risk factors for DVT/PE (i.e. recent long car ride
and thalidomide), will anticipate ~6 months of anticoagulation
with INR [**3-4**].
.
2.) CARDIAC:
* Ischemia: On admission to the ED, the patient had CE drawn to
r/o an MI. CK = 89 and Trop = 0.07. There is no reported history
of CAD and no EKG changes, but the patient has hyperlipidemia,
HTN, and hyperglycemia. She was continued on ASA 81 mg.
Metoprolol 12.5 was added once her BP could tolerate it. A
statin should perhaps be considered given an LDL in [**March 2112**] of
131; this can be revisited as an outpatient.
.
* Pump: Pt's pro-BNP on admission was 4948. She also has a
history of chronic LE edema for which she takes Lasix and
Triamterine as an outpatient. However, on exam her lung exam was
unremarkable and she had no peripheral edema. Her CXR was also
unremarkable. Given her ARF, her diuretics were held. On
transfer to BMT, she was restarted on her outpatient dose of
Lasix since she had some trace LE edema and b/l pulmonary
crackles. Her Ace-inhibitor was still held because of her
resolving ARF. By time of discharge, her renal impairment had
resolved to baseline and she will resume her home dose of ACEi.
* Hypotension: Likely due to PEs. She was initially treated
empirically with Vancomycin and Zosyn for concern of sepsis
given the high lactate. Her lactate decreased to 1.1 on repeat
ABG. She was never febrile and her vitals stabilized so the
antibiotics were d/c'd on day 2 of hospitalization. Blood and
urine cultures are still pending, but show no growth. Her BP
meds (Diltiazem and Lisinopril) were held, but a Metoprolol 12.5
was started on [**10-5**] because her blood pressure had improved and
because of her cardiac risk factors.
.
3 Leukocytosis: Pt's WBC trended down. There was no bandemia and
no signs of infection. Etiology is unclear, but patient did
recently complete a recurring treatment of Decadron.
.
4 Acute Renal Failure: Admission Cr was 3.4 and her baseline Cr
is 1.1. All diuretics were held as was Metformin for concern of
lactic acidosis in the setting of ARF. Her creatinine trended
downward for the remainder of her hospitalization. By time of
discharge, her Cr resolved to normal.
5 Hyperglycemia: Secondary to decadron. Outpatient Metformin was
held because of ARF. FS were done QID with humalog/SSI until all
blood sugars were normal. She did not require insulin while on
the medical floor.
.
6 Multiple Myeloma: Hem/Onc fellow was notified that the patient
had been admitted and the decision was made to hold Thalidomide
for now. Pt. was transferred to BMT service on [**10-5**]. She will
follow-up with her primary hematologist after discharge.
.
7 Anemia: Baseline Hct is in the 30s, on iron as an outpatient.
Pt. received 1 [**Location **] on [**10-4**] for Hct of 28.5 which
appropriately responded to 30.1.
.
8 Prophylaxis: PPI (on steroids), heparin gtt, bowel regimen.
.
9 FEN: low Na diabetic renal diet. check albumin
.
10 Access: PIVs x 2
.
11 Code Status: Full, discussed with pt and family
Medications on Admission:
Triamterene/HCTZ 37.5/25 mg po daily
Aspirin 81 mg PO daily
Lasix 40 mg PO
Lisinopril 20 mg PO daily
Diltiazem XR 480 mg PO
Metformin 850 mg PO BID
Prilosec 40 QD
Thalidomide 100 mg PO QHS
Dexamethasone pulse Q2 weeks
Epogen 40,000 units
zometa Qmonth
T#3 1-2 tabs prn TID
Diprosone 0.05% cream
Discharge Medications:
1. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Outpatient Lab Work
Please get the following blood tests checked 2 days after being
discharged: PT, PTT, INR.
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Warfarin 5 mg Tablet Sig: asdir Tablet PO at bedtime:
alternated taking 1 tablet and 1 1/2 tablets at night. start 1
tablet on [**2112-10-11**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pulmonary Embolism
Deep Venous Thrombosis
Acute Renal Failure
.
Secondary:
Multiple Myeloma
Discharge Condition:
good. normal oxygenation on room air. renal function resolved
to baseline. tolerating oral nutrition and medication.
ambulating unassisted.
Discharge Instructions:
If you develop any concerning symptoms particularly shortness of
breath, chest pain, worsening leg swelling, or signs of severe
bleeding, seek medical care.
.
You need to have your blood checked twice a week to make sure
the coumadin dose is the right one for you. You have an
appointment in Dr.[**Name (NI) 6168**] clinic on Thursday to get your blood
drawn.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction to less than 2 liters per day.
Followup Instructions:
1) Cardiology Clinic with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] on [**2112-11-15**] at
3:40pm. Please call [**Telephone/Fax (1) 920**] to confirm.
2) [**Hospital **] Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] on [**2112-10-13**] at 12pm.
3) Please call Dr.[**Name (NI) 25189**] office at [**Telephone/Fax (1) 3581**] to schedule
an appointment within the next 2 weeks.
|
[
"203.00",
"453.41",
"584.9",
"276.2",
"428.0",
"415.19",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11155, 11161
|
5759, 10321
|
330, 337
|
11306, 11450
|
3016, 5736
|
12009, 12460
|
2369, 2420
|
10667, 11132
|
11182, 11285
|
10347, 10644
|
11474, 11986
|
2435, 2997
|
276, 292
|
365, 1478
|
1500, 2186
|
2202, 2353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,535
| 171,776
|
32740
|
Discharge summary
|
report
|
Admission Date: [**2198-1-6**] Discharge Date: [**2198-1-18**]
Date of Birth: [**2143-7-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hypotension, anorexia
Major Surgical or Invasive Procedure:
Paracentesis.
Blood transfusion
History of Present Illness:
54 y/o female with HTN who was persuaded to go to [**Hospital 16843**]
Hospital by her son after one month of nausea and vomiting after
eating, leading to about two weeks of very poor po intake, along
with new jaundice and several days of diarrhea. She denies
weight loss, lymphadenopathy, URI symptomes, fevers, chills,
headache, dyspnea, chest pain, abd pain, pale stools, dysuria,
edema, or rash. She admits to dark urine over the last month and
her family noted yellowing of her skin over the last week.
.
At [**Hospital 16843**] Hospital, T 97.3 BP 100/63 HR 80 RR 16. Her sodium
was 119, T bili 8.5, Direct Bili 4.5, AP 125, AST 98, hct 24
(baseline 40), Alb 2.1, BUN 20/Cr 2.5, WBC 12.6, HCT 24, PLT
122. She had a distended abdomen. CXR was reportedly normal. She
had hypotension to 66/40 which wwas somewhat responsive to
fluids. She received 1.5 L of IV fluids without any urine
output.
.
In the ED, she was afebrile at 98.6, with blood pressures in the
80's to 100's systolic, RR 22, SAT 96%RA. RUQ U/S showed
moderate ascites, and CT showed ascites and small bilateral
pleural effusions. Her hct was 22, transfused 2 units PRBC, and
given 3.5 L NS. Guaiac neg. Treated empirically with
levofloxacin and flagyl for intrabdominal infection. Given
decadron for stress dose steroids because of hypotension.
Past Medical History:
Hypertension since [**2194**]
EtOH abuse
Social History:
Cleans houses for a living. Lives with husband and dog in
[**Name (NI) 13056**]. Mother lives nearby. Has 2 sons. Very concerned
about the welfare of her husband and dog while she is
hospitalized as she is main caretaker of the family. She is
post-menopausal since age 40. Patient does not smoke, admits to
[**1-28**] drinks a day, more on weekends, and denies IV drug use.
Family History:
Mother is living and has alcohol abuse problem, father smoked
and died of emphysema. She is an only child. No family hx of
liver disease.
Physical Exam:
GEN: Tired, but appropritate female in no distress.
VITALS: T 96.7 HR 97 BP 105/64 RR 19 SAT 99% on 4 L NC
HEENT: Sclera mildly icteric, mouth dry, dentition poor, pupils
equal, no nystagmus.
NECK: Supple, no JVP, no bruits, no thyroid masses, no cervical
LAD.
CHEST: Left axilllary freely mobile, non tender Lymph node
palpable. Lungs clear but with somewhat diminished bases.
HEART: Regular with systolic flow murmur.
ABD: Distended, dull to percussion, caput over upper abdomen,
positive fluid wave, non tender.
EXT: Trace pedal edema, good pulses.
SKIN: Facial lesions and one right sided back lesion. No palmar
erythmea. No spider angiomata.
NEURO: A&O x3. CN intact. Strength 5/5 throughout. Toes
downgoing. No asterixis.
Pertinent Results:
LABS AT ADMISSION:
[**2198-1-5**] 06:25PM BLOOD WBC-10.9 RBC-1.66* Hgb-8.0* Hct-22.3*
MCV-135* MCH-48.0* MCHC-35.7* RDW-15.5 Plt Ct-132*
[**2198-1-5**] 06:25PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL How-Jol-OCCASIONAL
Pappenh-1+
[**2198-1-7**] 05:29AM BLOOD PT-22.6* PTT-40.6* INR(PT)-2.2*
[**2198-1-5**] 06:25PM BLOOD Plt Smr-LOW Plt Ct-132*
[**2198-1-5**] 06:25PM BLOOD Glucose-103 UreaN-19 Creat-2.1* Na-123*
K-3.5 Cl-86* HCO3-24 AnGap-17
[**2198-1-5**] 06:25PM BLOOD ALT-21 AST-72* CK(CPK)-62 AlkPhos-100
TotBili-9.1*
[**2198-1-6**] 02:58AM BLOOD Albumin-2.5* Calcium-6.8* Phos-2.5*
Mg-1.3* Iron-89
.
LABS AT DISCHARGE:
[**2198-1-11**] 06:25AM BLOOD Glucose-103 UreaN-6 Creat-1.3* Na-138
K-4.6 Cl-105 HCO3-24 AnGap-14
[**2198-1-11**] 11:35AM BLOOD WBC-12.9*# RBC-2.36* Hgb-9.6* Hct-28.3*
MCV-120* MCH-40.5* MCHC-33.8 RDW-22.8* Plt Ct-124*
[**2198-1-11**] 11:35AM BLOOD Plt Ct-124*
[**2198-1-11**] 06:25AM BLOOD PT-22.8* PTT-40.2* INR(PT)-2.2*
.
[**2198-1-7**] 05:12PM ASCITES WBC-55* RBC-40* Polys-3* Lymphs-3*
Monos-82* Mesothe-7* Other-5*
[**2198-1-7**] 05:12PM ASCITES TotPro-0.9 Glucose-143 LD(LDH)-58
Albumin-LESS THAN 1.0.
.
[**2198-1-6**] 02:58AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2198-1-11**] 06:25AM BLOOD HAV Ab-PND
[**2198-1-6**] 02:58AM BLOOD CEA-3.3 AFP-3.9
.
IMAGING:
[**2198-1-6**] Liver U/S: 1. Very limited study given large amount of
intra-abdominal ascites. Coarsened echogenic liver, which may be
compatible with cirrhosis. 2. Tiny 6-mm structure adherent to
the posterior gallbladder wall which may be compatible with a
small polyp.
[**2198-1-6**] Abd CT: 1. Suboptimal study given lack of IV contrast
administration and moderate-to- severe intra-abdominal ascites.
Diffusely heterogeneous appearance of the liver with with the
suggestion of a mass lesion in the right lobe and nonspecific
cyst vs hemangioma in the caudate lobe. MRI is recommended for
evaluation of the liver and pancreas.
2. Pericardial effusion and small right greater than left
pleural effusions. 3. Cholelithiasis.
[**2198-1-6**] CXR: Cardiac size is enlarged. Some upper zone
redistribution is present and a degree of failure is probably
present. Some air bronchograms are seen behind the left heart
and I suspect some consolidation in this area.
.
Peritoneal [**Last Name (un) 3041**] [**2198-1-7**]: NEGATIVE FOR MALIGNANT CELLS.
.
CXR [**2198-1-12**]: Compared to previous examination, the retrocardiac
volume loss has completely resolved. In a persistent manner,
however, the right lung base shows subtle opacities with air
bronchograms, that could correspond to pneumonia. Additionally,
a bilaterally present mild-to-moderate pleural effusion can be
seen. The size of the cardiac silhouette is slightly enlarged.
As compared to [**2198-1-6**], suspicion of right-sided basal
pneumonia and bilateral mild-to-moderate pleural effusions.
Brief Hospital Course:
Patient is a 54 y/o female with newly diagnosed alcoholic
hepatits/cirrhosis and possible hepatorenal syndrome. She was
admitted for hypotension and renal failure, which have improved
significantly over her stay. However, she has a high risk of
significant morbidity over the next 30 to 90 days given her DF
(48 pts) and MELD score (24 pts). Patient has been insistent
over last couple of days that she wants to sign out AMA despite
the risks which she understands. She seems to be in denial about
the severity of her disease. She completed her hospitalization,
and she was discharged when stable with the agreement that she
would have close follow up with her PCP, [**Name10 (NameIs) **] that then can
arrange for her to be followed by a hepatologist closer to
[**Location (un) 16843**] if she does not want to be followed here at [**Hospital1 18**].
Details by problem:
Hypotension: Fluid responsive. Never needed pressors. Likely [**1-27**]
hypovolemia with superimposed liver disease, though differential
also included sepsis. Initially treated with [**Last Name (un) **]/flagyl for
possible SBP, but Paracentesis without evidence of SBP so
levo/flagyl D/Ced. CXR showed LLL [**Last Name (LF) 76283**], [**First Name3 (LF) **] treated
with Azithromycin for 4 day course which she finished on her
last day in the [**Hospital Unit Name 153**].
#. Cirrhosis: Likely [**1-27**] ETOH. Causing her transaminitis,
hyperbilirubinemia. Likely also contributing to her
thrombocytopenia due to splenic sequestration. Pt also had
ascites on presentation, and ascitic fluid analysis shows no
evidence of SBP. Presented with elevated creatinine likley [**1-27**]
splanchinc vasoconstriction of cirrhosis. She was given over 10
L of IVF, albumin after paracentesis, and midodrine/octreotide
and UOP improved with decrease in creatinine. Discriminant
function calculated, and was elevated at ~60 and pt started on
pentoxyfiline. After call out to floor, patient's LFTs continued
to improve, with coags, transaminases and Tbili generally
trending downwards and a corresponding upward trend in Hct and
plts. By the time of discharge she had an elevated AST and a
TBili consistently elevated at 7.0. She was not
encephalopathic. She had only superficial understanding of the
severity of her disease, and her family seemed to have better
understanding. She was discharged with pentoxyfylline for an
additional 3 weeks for the alcoholic hepatitis. She was also
given plenty of vitamin supplements, and a prescription for
lactulose. She is to follow up with a hepatologist, either here
at [**Hospital1 18**] or at [**Hospital1 498**], closer to home.
# LLL consolidation: A retrocardiac opacity seen on CXR in the
[**Hospital Unit Name 153**]. Treated with 4 day course of azithromycin, completed in
the ICU. She had periodic low grade temps and a cough while on
the medical floor. The decision was made to initiate a 10 day
course of levofloxacin for pneumonia.
# ARF: Pt had elevated creat on admission, which trended down
and then stabilized around 1.6. Most likely due to splanchnic
vasocontriction seen in cirrhosis. Has recieved roughly 10 L
IVF during her stay, albumin after paracentesis, and
midodrine/octreotide. UOP picked up particularly after starting
midodrine/octreotide. It was not clearly hepatorenal syndrome,
though this was treated.
# Macrocytic Anemia: Pt had iron studies that were c/w anemia of
chronic dz, however this would be expected to cause microcytic
rather that macrocytic anemia. B12 and Folate levels are normal
so nutritional causes of macrocytic anemia are less likely.
Most likely that the direct toxic effect of ETOH is to blame for
her macrocytic anemia. Treated with thiamine, folate, and MVI.
Given the anemia and cirrhosis, she was offered and encouraged
to have endoscopic evaluations for varicies and gastropathy, but
she declined repeatedly.
# ETOH withdrawal: Treated with Ativan on CIWA while in the ICU,
and this was not an issue on the medical floor.
# Coagulopathy: Pt recieved vit K x3, so nutritional causes are
less likely. Most likely etiology is depressed synthetic
function of the liver in cirrhosis. Did not have any bleeding
and did not require FFP.
# Thrombocytopenia: Likely [**1-27**] splenic sequestion. Montiored
plts throughout stay and no acute drop.
# Anorexia: This was felt to be due to her severe medical
illness (cirrhosis) and alcoholism. She claimed that she just
did not like the food here, and would periodically consume
supplements.
She was a full code during the admission.
Medications on Admission:
Lopressor 50 mg [**Hospital1 **] since [**2194**]
Discharge Medications:
1. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
Disp:*30 Tablet Sustained Release(s)* Refills:*3*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
7. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) injection
Injection Q8H (every 8 hours).
Disp:*90 injection* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol hepatitis and cirrhosis with possible hepatorenal
syndrome.
Anemia
Thrombocytopenia
Anorexia
Discharge Condition:
Stable, adequate renal function, ambulating without assistance.
Discharge Instructions:
You were admitted for anorexia and hypotension. While you were
hospitalized, tests showed that you have liver disease due to
alcohol, called alcoholic hepatitis and cirrhosis. This is a
very serious condition with a considerable likelihood of severe
illness or even death over the next several weeks. Tests also
showed that you have a moderate amount of fluid in your abdomen,
as well as a mass in your liver. You were also found to have
anemia related to alcohol, and there are also problems with your
blood clotting due to your liver disease. You were also found to
have poor kidney function related to your liver disease.
Your hypotension required a blood transfusion, and a procedure
was performed to withdraw fluid from your abdomen. You were also
started on a medication for your alcoholic hepatitis called
Trental, and another medication for your alcoholic cirrhosis
called Orvaten. You were also prescribed vitamin supplements to
correct any nutritional deficiencies which might have
contributed to your anemia.
.
You should continue to take these new medications as prescribed.
You should also stop taking your previously prescibed
medication, Lopressor, as it can cause problems with your blood
pressure in your current condition.
It is extremely important that you abstain from drinking any
kind of alcohol. It is also very important that you increase
your nutritional status by eating full meals at breakfast, lunch
and dinner, with Ensure supplements whenever possible.
.
You should seek immediate medical attention if you experience
any of the following symptoms: fevers, chills, nausea, vomiting,
shortness of breath, dizziness, lightheadedness, fainting
spells, or find blood in your stools, urine or vomit.
Followup Instructions:
You should follow up with your primary care physician within one
week.
You have an appointment at Dr.[**Name (NI) 76284**] office on Thursday,
[**2198-1-25**], at 1pm. Her phone is [**Telephone/Fax (1) 75498**].
.
It is very important that you have a liver doctor follow up as
well. If you cannot get a liver doctor near your home through
your PCP, [**Name10 (NameIs) **] call the [**Hospital1 18**] Liver Center at ([**Telephone/Fax (1) 1582**]
to schedule a follow-up visit in one to two weeks.
|
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1,695
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22828+22829
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Discharge summary
|
report+report
|
Unit No: [**Unit Number 59010**]
Admission Date: [**2139-1-31**]
Discharge Date: [**2139-2-14**]
Date of Birth: [**2060-11-11**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
gentleman with a past medical history significant for
cerebrovascular accident, mechanical valve replacement and
coronary artery bypass graft who was admitted to [**Hospital1 346**] status post a subarachnoid
hemorrhage. The patient developed headache two days prior to
admission with worsening confusion, presented to an outside
hospital where a head CT showed a subarachnoid hemorrhage
centered around the left sylvian fissure. There was a
question of a ruptured aneurysm. The patient was transferred
to [**Hospital3 **] for further management. Patient had a
cerebrovascular accident in [**2138**] with aphasia and word
finding difficulties as his only baseline residual.
PAST MEDICAL HISTORY: Also includes rheumatic heart disease,
coronary artery bypass graft.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: His blood pressure was 101/39, heart
rate was 58, respiratory rate 15, saturations 98 percent. In
general he was in no acute distress, calm. Head, eyes, ears,
nose and throat: His pupils are equal, round and reactive to
light. Neck was supple. Cardiovascular: Regular rate and
rhythm. Lungs clear to auscultation. Abdomen soft,
nontender, nondistended, positive bowel sounds. Extremities:
No clubbing, cyanosis or edema. Neurologic: Awake, alert
and oriented times three with word finding difficulties,
fluent aphasia. Cranial nerves grossly intact. Strength
was 5 out 5 in all muscle groups.
He was admitted to the Intensive Care Unit for close
neurologic observation. He was on Coumadin for his
mechanical valve on admission and his INR was 2.8 on
admission. Anticoagulation was stopped and reversed on
admission. Cardiology was consulted to assess the risk of
leaving off anticoagulation versus mechanical valve
thrombosis. It was felt the patient could be off
anticoagulation for a week safely. The patient was taken to
angio to rule out aneurysm which was negative. Post angio he
was awake, alert and oriented. His groin site was clean, dry
and intact with no hematoma. He continued to be monitored in
the Intensive Care Unit. He did have a new onset of atrial
fibrillation on [**1-30**] with left bundle branch block.
Neurology was also consulted regarding when it was safe to
restart Coumadin. They felt the patient could be safely off
for one to two weeks. The patient continued to be monitored
in the Intensive Care Unit and remained neurologically
stable. Patient had repeat head CT on [**2139-2-1**]. This
showed increase in the left temporal lobe hemorrhage.
Therefore, all anticoagulation was held and the patient's INR
was corrected to normal. The patient had a transesophageal
echocardiography. Transesophageal echocardiography was
negative for any clots around his valves. Neurology
continued to follow the patient. On [**2139-2-5**] the patient was
taken back for repeat angio to assess for possible aneurysm
or vasospasm. The patient did have some left middle cerebral
artery vasospasm which was treated with papaverine intra-
arterially. There was no evidence of aneurysm. The patient
continued to be intubated but opening his eyes, attending to
examiner, squeezing well on the left, moving all extremities.
He continued to have plegia in the right upper extremity,
moving the left upper extremity spontaneously. His left side
moved spontaneously. His right side at times moves to
command and at other times does not. The patient had bedside
swallowing evaluation which he failed and a PEG was placed on
[**2139-2-13**]. He has remained neurologically stable. He will
follow up with Dr. [**Last Name (STitle) 739**] in two weeks with a repeat
head CT.
His medications at the time of discharge include Dilantin 200
mg per PEG B.I.D., famotidine 20 mg per PEG B.I.D.,
metoprolol 50 per PEG t.i.d., Lasix 20 mg per PEG daily,
hydralazine 10 mg per PEG q 6 hours, amlodipine 60 mg P.O. q
4 hours, Pravastatin 20 mg per PEG daily, levofloxacin 500 mg
per PEG q 24 hours, digoxin 0.125 mg daily, may be switched
to P.O. daily.
CONDITION ON DISCHARGE: Stable at the time of discharge.
FOLLOW UP: With Dr. [**Last Name (STitle) 739**] in two weeks with a repeat
head CT.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2139-2-13**] 16:24:37
T: [**2139-2-13**] 17:18:10
Job#: [**Job Number 59011**]
Admission Date: [**2139-1-30**] Discharge Date: [**2139-2-15**]
Date of Birth: [**2060-11-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 59012**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Angiogram
History of Present Illness:
78 yo M with history of CVA, mechanical valve replacement, CABG
developed headache 2 days prior to admission. Evaluated at
outside hospital with CT that showed subarachnoid hemorrhage and
was transferred to [**Hospital1 18**].
Past Medical History:
CVA one month prior to admission
CVA 2 yrs ago
Rhuematic heart disease
CABG
Bilat hearing deficit
Social History:
lives at home with wife, no tobacco, no EtOH
Family History:
No stroke or neurologic disease
Physical Exam:
WDWN,[**Last Name (un) 12718**] supple,heart: audible mechanical valve clicks,lungs
clear, abdomen benign,extremities no cyanosis,clubbing or
edema,Neuro:Awake, alert, comprehension intact. problems with
[**Name2 (NI) 59013**], [**Name (NI) 22031**], [**Name (NI) 3899**],decreased hearing bilat, tongue
midline,full strength upper and lower extremities, no pronator
drift, light touch intact throughout.
Pertinent Results:
[**2139-1-30**] 11:10PM GLUCOSE-107* UREA N-18 CREAT-0.9 SODIUM-134
POTASSIUM-6.4* CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
[**2139-1-30**] 11:10PM WBC-6.6 RBC-4.09* HGB-12.8* HCT-35.5* MCV-87
MCH-31.4 MCHC-36.2* RDW-14.1
[**2139-1-30**] 11:10PM NEUTS-73.2* LYMPHS-21.3 MONOS-3.6 EOS-1.6
BASOS-0.3 [**2139-1-30**] 11:10PM PLT COUNT-163 [**2139-1-30**] 11:10PM
PT-21.2* PTT-42.1* INR(PT)-2.8
Brief Hospital Course:
Admitted to ICU for close neurological monitoring. SBP kept less
than 140 with nipride drip. Coags were reversed with FFP. Loaded
with Dilantin. New onset afib. Cardiology also saw pt and agreed
with total reversal of anticoag secondary to SAH risk for
24-48hr then to start with heparin and then to coumadin.Angigram
done [**2139-1-25**] was negative for aneurysm.Neurology consult advised
continued CT to follow hemorrhage. Ct [**2-1**] of head showed
worsening of hemorrhage and old stroke left occiput and left
corona radiata. Started on nimodipine for spasm
prophylaxis.Needed intubation for airway protection [**2139-2-4**] for
copiuos secretions. Had TEE [**2-4**] which showed no thrombus.MRI [**2-5**]
showed stroke in left MCA territory, started on ASA
daily.Angigram [**2-5**] showed spasm in L MCA and recieved injection
of papverin. Exam slowly improved allowing extubation and
transfer to floor. Coumadin was started [**2139-2-6**]. Started on
levofloxicin for pneumonia [**2-7**]. Secretions slowly resolved. PEG
was placed [**2-13**]. PT/OT worked with pt and recommended rehab
placement.
Medications on Admission:
coumadin
aggvenox
atenolol
lanoxin
pravachol
altase
Discharge Medications:
Discharge Worksheet-Discharge
Medicatons-Finalized:[**Last Name (LF) **],[**First Name3 (LF) **], PA on [**2-15**] @ 1009
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q3-4H () as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) tsp PO BID (2
times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Digoxin 250 mcg/mL Solution Sig: 0.5 Injection DAILY
(Daily).
13. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime) for 1 doses: titrate for goal INR = 2
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
neurologically stable
Discharge Instructions:
Call if develop severe headache, fever, change in mental status
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 739**] in two weeks with Head CT. Call
[**Telephone/Fax (1) 3571**] for appt.
Completed by:[**2139-2-15**]
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|
4242, 4277
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,050
| 154,984
|
700
|
Discharge summary
|
report
|
Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"070.70",
"431",
"342.92",
"285.9",
"V11.3",
"V15.82",
"287.5",
"784.51",
"V49.86",
"348.5",
"711.06",
"V08"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10087, 10096
|
8184, 9679
|
330, 336
|
10185, 10195
|
5055, 8161
|
10906, 11028
|
2485, 2514
|
10058, 10064
|
10117, 10164
|
9705, 10035
|
10219, 10883
|
2529, 2543
|
5027, 5036
|
266, 292
|
364, 1851
|
3612, 4999
|
2557, 2945
|
2984, 3596
|
2969, 2969
|
1873, 2336
|
2352, 2469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,103
| 177,111
|
43507
|
Discharge summary
|
report
|
Admission Date: [**2157-2-27**] Discharge Date: [**2157-3-4**]
Date of Birth: [**2087-8-27**] Sex: M
Service: Medicine
ADDENDUM: The patient was discharged on [**2157-3-4**]. He
was kept overnight since he continued to ooze some bright red
blood per rectum, and his hematocrit drifted down to 38.7. He
was transfused one more unit, and his repeat hematocrit was 31.6.
The patient was stable. His right internal jugular line was
sacral decubitus ulcer changes is to continue dressing changes
b.i.d. with Duoderm as well as placing a rectal bag that does not
involve the area of ulcer to prevent skin breakdown. In
addition, to his medication regimen we have added Canasa
suppositories q.d.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2157-3-4**] 15:28
T: [**2157-3-5**] 04:00
JOB#: [**Job Number 93643**]
|
[
"401.9",
"569.41",
"250.60",
"707.0",
"357.2",
"578.9",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,179
| 199,545
|
37137
|
Discharge summary
|
report
|
Admission Date: [**2123-8-12**] Discharge Date: [**2123-8-15**]
Date of Birth: [**2061-9-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 33434**] is a 61 year old female with history of severe
COPD, diastolic dysfunction who presents with one day of
confusion. Patient notes increasing confusion starting earlier
today. Daughter was concerned for increasing confusion, and
also reported recent URI-like symptoms, with cough productive of
green sputum. Daughter was concerned, and urged patient to seek
evaluation at [**Hospital1 18**]. Patient denies f/c, no headache/neck
stiffness. No pre-syncope/syncope. No recent falls. She also
denies any chest pain/pressure, and denies any worsening DOE.
Per report, patient recently finished a prednisone taper and
antibiotic course last week for presumed COPD exacerbation.
.
In ED, initial vitals were 98F, 123/61 HR 88, 98% 3 liters n/c.
Patient was somnolent on arrival, oriented to self, and pCO2
was 73. Patient was then started on non-invasive ventilation.
She also received albuterol and ipratropium nebs, prednisone 60
mg x 1, and levoflox 750 mg PO x 1. Vitals at time of transfer
were 84/54 t 98 76 18 99%. with repeat SBP in the 90s.
repeat pCO2 was essentially unchanged.
.
Upon arrival to the unit , patient reported diffuse pain c/w her
h/o fibromyalgia. She denied feeling confused. She also denies
f/c, chest pain, and dyspnea. Upon further questioning, she did
endorse cough productive of green sputum. Remainder of ROS as
noted below.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.
MICU Green Course.
Patient was put on prednisone taper and did not require any type
of oxygen support other than NC 3L for her COPD, and albuterol
and ipratropium nebs . Patient was not felt to have active
infection and her mental status was felt to be due to possible
excess pain medications making her more drowsy and decreasing
her respiratory rate. She has no clincal signs of active
infection and remained afebrile. Her mental status has remained
stable since her first day of admission and she is currently at
her baseline.
_
_
_
_
_
________________________________________________________________
Past Medical History:
1. Severe COPD (FEV1/FVC 33 FEV1 41%predicted; 3L N/C home O2)
2. LUL mass with negative neoplastic eval, plan for Q3-4 mo
serial CTs
3. Probable Chronic diastolic CHF, EF 60% Diagnosed: [**12-2**]
4. Fibromylagia
Status post electromagnetic navigational bronchoscopy with
radial endobronchial ultrasound, transbronchial biopsy,
bronchoalveolar lavage, and brushing of the left upper lobe mass
as well as placement of fiducials x4 into the left upper lobe
lung mass.
Social History:
Lives at home alone, has two daughters, widowed. Quit smoking
[**11/2122**] when diagnosed with new lung mass, but previously smoked
for 2 ppd for 50 years. Retired. No ETOH in 17 years, denies
IVDU.
Family History:
Father: MI at age 55, died at age 63. Mother died of 63 of MI,
Paternal Great Uncle died of MI at age 41. Brother has lung CA
Physical Exam:
VS: 105/42 HR 76 93% 3 liters n/c RR 16
GA: AOx3, NAD, no increased work of breathing
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, although quiet heart sounds
Pulm: CTAB no crackles or wheezes. very quiet breath sounds,
with prolonged expiratory phase
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, trace LE edema. DPs, PTs 2+.
Skin:
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 deferred. mild asterixis
Pertinent Results:
Admission Labs
[**2123-8-12**] 09:51PM TYPE-ART PO2-137* PCO2-71* PH-7.37 TOTAL
CO2-43* BASE XS-12
[**2123-8-12**] 07:00PM TYPE-ART PO2-167* PCO2-73* PH-7.39 TOTAL
CO2-46* BASE XS-15
[**2123-8-12**] 05:20PM GLUCOSE-100 UREA N-12 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-40* ANION GAP-10
[**2123-8-12**] 05:20PM estGFR-Using this
[**2123-8-12**] 05:20PM ALT(SGPT)-15 AST(SGOT)-18 CK(CPK)-79 ALK
PHOS-99 TOT BILI-0.2
[**2123-8-12**] 05:20PM cTropnT-<0.01
[**2123-8-12**] 05:20PM CK-MB-5 proBNP-92
[**2123-8-12**] 05:20PM URINE HOURS-RANDOM
[**2123-8-12**] 05:20PM URINE GR HOLD-HOLD
[**2123-8-12**] 05:20PM WBC-8.1 RBC-4.04* HGB-11.5* HCT-34.8* MCV-86
MCH-28.5 MCHC-33.1 RDW-14.5
[**2123-8-12**] 05:20PM NEUTS-68.0 LYMPHS-23.0 MONOS-4.3 EOS-4.2*
BASOS-0.5
[**2123-8-12**] 05:20PM PLT COUNT-226
[**2123-8-12**] 05:20PM PT-12.6 PTT-23.3 INR(PT)-1.1
[**2123-8-12**] 05:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2123-8-12**] 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2123-8-12**] 05:20PM URINE RBC-0 WBC-[**11-13**]* BACTERIA-MOD YEAST-NONE
EPI-0-2
.
Discharge Labs
[**2123-8-15**] 06:35AM BLOOD WBC-7.2 RBC-3.72* Hgb-10.4* Hct-32.2*
MCV-87 MCH-27.9 MCHC-32.2 RDW-14.9 Plt Ct-237
[**2123-8-14**] 06:15AM BLOOD WBC-7.3# RBC-3.59* Hgb-10.4* Hct-31.0*
MCV-86 MCH-29.0 MCHC-33.6 RDW-14.8 Plt Ct-226
[**2123-8-13**] 05:18AM BLOOD WBC-4.3 RBC-3.87* Hgb-11.0* Hct-33.1*
MCV-86 MCH-28.4 MCHC-33.2 RDW-14.4 Plt Ct-229
[**2123-8-12**] 05:20PM BLOOD Neuts-68.0 Lymphs-23.0 Monos-4.3 Eos-4.2*
Baso-0.5
[**2123-8-15**] 06:35AM BLOOD Plt Ct-237
[**2123-8-14**] 06:15AM BLOOD Plt Ct-226
[**2123-8-14**] 06:15AM BLOOD PT-11.7 PTT-21.9* INR(PT)-1.0
[**2123-8-15**] 06:35AM BLOOD Glucose-82 UreaN-12 Creat-0.5 Na-143
K-3.5 Cl-98 HCO3-38* AnGap-11
[**2123-8-14**] 06:15AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-139
K-3.8 Cl-97 HCO3-37* AnGap-9
[**2123-8-13**] 05:18AM BLOOD Glucose-121* UreaN-10 Creat-0.4 Na-137
K-3.8 Cl-96 HCO3-32 AnGap-13
[**2123-8-12**] 05:20PM BLOOD ALT-15 AST-18 CK(CPK)-79 AlkPhos-99
TotBili-0.2
[**2123-8-12**] 05:20PM BLOOD cTropnT-<0.01
[**2123-8-12**] 05:20PM BLOOD CK-MB-5 proBNP-92
[**2123-8-15**] 06:35AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
[**2123-8-14**] 06:15AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0
[**2123-8-13**] 05:18AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9
[**2123-8-13**] 02:00AM BLOOD Type-ART pO2-79* pCO2-62* pH-7.40
calTCO2-40* Base XS-10
[**2123-8-12**] 09:51PM BLOOD Type-ART pO2-137* pCO2-71* pH-7.37
calTCO2-43* Base XS-12
[**2123-8-13**] 02:00AM BLOOD Lactate-0.6
.
Micro: Legionella urine anigen-neg, MRSA-neg, Urine cx.-negative
Brief Hospital Course:
Upon arrival to the MICU, patient reported diffuse pain c/w her
h/o fibromyalgia. She denied feeling confused. She also denies
f/c, chest pain, and dyspnea. Upon further questioning, she did
endorse cough productive of green sputum. Remainder of ROS as
noted below.
.
_
_
_
_
_
_
________________________________________________________________
MICU Green Course.
Patient was put on prednisone taper and did not require any type
of oxygen support other than NC 3L for her COPD, and albuterol
and ipratropium nebs . Patient was not felt to have active
infection and her mental status was felt to be due to possible
excess pain medications making her more drowsy and decreasing
her respiratory rate. She has no clincal signs of active
infection and remained afebrile. Her mental status has remained
stable since her first day of admission and she is currently at
her baseline.
# Confusion- [**1-26**] acute on chronic respiratory acidosis. Severe
COPD with FEV 1 0.71, 41% predicted, last year. Suspected
patient had recent URI illness which led to COPD exacerbation.
Patient currently a and o x 3, not somnolent. Only sign of
hypercarbia is mild asterixis on exam on admission which later
went away. Was managed as mild COPD exacerbation, although
suspect [**1-26**] fibromyalgia regimen and possible overmedication.
Continued prednisone 60 mg daily x 5 days with taper according
to the following: Day 1 [**8-15**] -40 mg Day 2-8/23-40 mg Day
3-8/24-20mg Day 4 8/25-20mg Day 5 8/26-20mg . Given levoflox
which was d/c'd given on signs of infection'Continued nebs Q6H.
Avoided oversedation with pain meds.Will need to optimize
outpatient regimen with inhaled corticosteroid, long-acting
beta-agonist
.
# Fibromyalgia- continued fentanyl, TCA, and Soma
.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
LUL mass with negative neoplastic eval, plan for Q3-4 mo serial
CTs
.
-She requested information for referral to a different hospital
as she had difficulty getting to [**Hospital3 **].Referrals to
urogynecologists at [**Hospital3 **] and [**Hospital1 112**] given for uterine
prolapse
-Will need to optimize outpatient regimen with inhaled
corticosteroid, long-acting beta-agonist for her COPD
Medications on Admission:
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS
Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Furosemide 40 mg Tablet Sig: 2.5 Tablets PO once a day.
Multivitamin Tablet Sig: One (1) Tablet PO DAILY
Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H PRN
Omega-3 Fatty Acids [**Hospital1 **]
Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H
Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY
Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q12H
Carisoprodol 350 mg Tablet TID
Ipratropium-Albuterol 0.5 mg-2.5 mg base(3 mg)/3 mL Q6H
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Q4H PRN
Potassium 99 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-26**] Inhalation Q4H PRN as needed for
shortness of breath or wheezing.
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: [**12-26**] Inhalation Q6H PRN as needed for
shortness of breath or wheezing.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO once a day.
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO tid ().
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H PRN as
needed for pain.
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days: Please taper according to the following:
Day 1 [**8-15**] -40 mg
Day 2-8/23-40 mg
Day 3-8/24-20mg
Day 4 8/25-20mg
Day 5 8/26-20mg .
Disp:*7 Tablet(s)* Refills:*0*
13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Potassium 99 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
COPD
Possible overmedication of pain medications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to care for you as your doctor.
You were brought to the hospital because of mild confusion. You
were found to have high carbon dioxide levels in your blood. You
were treated with your home nasal canal oxygen and steroids and
improved to your baseline function.
We made the following changes to your home medication list:
1. We added steriods which you must taper off in the next 5
days as directed. Please taper according to the following: Day
1 [**8-15**] -40 mg (2pills) Day 2-8/23-40 mg (2 pills) Day
3-8/24-20mg (1 pill) Day 4 8/25-20mg (1 pill) Day 5 8/26-20mg (1
pill) .
2. Hold Valium 5 mg q8 hours until you have your follow-up
appointment.
Please follow up with the following outpatient [**Month/Year (2) 4314**]
below:
Followup Instructions:
Please make a appointment with your primary care physician as
soon as possible. You mentioned that it may be difficult for you
to travel to [**Location (un) 24356**] for doctors [**Name5 (PTitle) 4314**]. You may call
([**Telephone/Fax (1) 29108**] to make an appointment with a primary doctor near
the hospital if that is more convenient for you.
Name: [**Last Name (LF) **],[**First Name3 (LF) 1112**] J.
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 17002**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 26190**]
Fax: [**Telephone/Fax (1) 81080**]
Department: RADIOLOGY
When: TUESDAY [**2123-10-12**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2123-10-12**] at 11:00 AM
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2123-10-12**] at 11:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
|
[
"428.32",
"780.97",
"E935.2",
"E938.0",
"491.21",
"276.2",
"428.0",
"292.81",
"518.89",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11521, 11527
|
7110, 9367
|
326, 332
|
11620, 11620
|
4387, 7087
|
12547, 13899
|
3503, 3632
|
10131, 11498
|
11548, 11599
|
9393, 10108
|
11771, 12524
|
3647, 4368
|
1804, 2778
|
276, 288
|
360, 1785
|
11635, 11747
|
2800, 3269
|
3285, 3487
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,197
| 194,561
|
35662
|
Discharge summary
|
report
|
Admission Date: [**2156-1-12**] Discharge Date: [**2156-1-23**]
Date of Birth: [**2076-11-4**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Status epilepticus.
Major Surgical or Invasive Procedure:
Central line placement.
Intubation.
History of Present Illness:
[**Known firstname 487**] [**Known lastname 12303**] is a 79-year-old left handed man with a history
of right fronto-temporal anaplastic astrocytoma, atrial
fibrillation, s/p ablation, DVT/PE on Lovenox, and asbetosis who
presented with 30 minutes of seizure. Patient history began on
[**2155-9-28**] when he developed a generalized tonic-clonic seizure
and MRI revealed a large mass in the right frontal and temporal
lobes. He was transferred to [**Hospital6 **] and was
hospitalized there for 3 weeks, but he developed complications
of pneumonia, urinary tract infection, deep vein thrombosis, and
pulmonary embolism. He underwent a underwent an elective
stereotaxic brain biopsy on [**2155-12-9**]
that showed gliosis. Patient had been on Dilantin (stopped on
[**2155-12-29**]), recently was switched to Keppra 1000 mg [**Hospital1 **]. The
patient was seen by Dr. [**Last Name (STitle) 724**] and Dr. [**Last Name (STitle) **] on [**2156-1-8**], and Dr.
[**Last Name (STitle) **] discussed the options of a repeat biopsy. However, the
slides from [**Hospital3 **] were reviewed in pathology and
showed anaplastic astrocytoma WHO Grade III. On the afternoon
of admission (unknown exact time) at nursing home, patient was
found to have generalized-tonic clonic seizure and was
transferred to OSH. The seizure lasted for 30 minutes. There he
was loaded with phosphenytoin 2400 mg and found to have
pneumonia; started on vancomycin 1 gram IV and ceftriaxone and
patient was transferred to [**Hospital1 18**].
On arrival, his BP was 83/44 and oxygen saturation was at 95%.
He required intubation for airway protection and BP dropped to
39/14, requiring levophed.
Past Medical History:
-anaplastic astrocytoma (WHO Grade III), right fronto-temporal
s/p stereotactic biopsy [**11-28**]
-atrial fibrillation s/p ablation
-DVT/PE during recent hospitalization at [**Hospital3 **], on Lovenox
-recent retroperitoneal hemorrhage
-asbestosis
-hepatitis C
-shingles
Social History:
He was in the Air Force. He was smoking 1-2 packs of cigarettes
per day for 15 years; but he stopped in [**2132**]. He had 12 to 14
alcoholic drinks per week previously. He did not use any illcit
drugs.
Family History:
His mother died of dementia. His father died of a bee sting.
He had a sister who died of pneumonia while another has bladder
cancer. One brother died of lymphoma while another has skin
cancer. He has 2 sons, one has hypertension while another has
Sapo syndrome.
Physical Exam:
VITAL SIGNS: Temperature 99.7 F, blood pressure 83/44, pulse
60, and oxygen saturation 95%, on arrival
GENERAL: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
NECK: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
BACK: No point tenderness or erythema
CARDIOVASCULAR: RRR, Nl S1 and S2, no murmurs/gallops/rubs
LUNGS: Clear to auscultation bilaterally
ABDOMEN: +BS soft, nontender
EXTREMITIES: no edema
NEUROLOGICAL EXAMINATION:
Mental status: intubated, does not follow commands; grimaces on
sternal rub
Cranial Nerves: Pupils equally round and reactive to light, 4 to
3 mm
bilaterally. Corneals + BL; gag +.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor.
He retracts all extremities to noxious stimuli. He moves left
lower extremety less than right
Sensation: Reflexes:
+1 and symmetric throughout.
Toes downgoing bilaterally
Pertinent Results:
ADMISSION LABS:
CBC:
[**2156-1-12**] 04:45AM BLOOD WBC-12.0* RBC-3.44* Hgb-11.9* Hct-34.4*
MCV-100* MCH-34.6* MCHC-34.5 RDW-14.6 Plt Ct-267
[**2156-1-12**] 04:45AM BLOOD Neuts-78.6* Lymphs-14.8* Monos-6.2
Eos-0.3 Baso-0.1
COAGS:
[**2156-1-12**] 04:45AM BLOOD PT-13.7* PTT-59.8* INR(PT)-1.2*
CHEMISTRIES:
[**2156-1-12**] 04:45AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-134
K-3.3 Cl-98 HCO3-25 AnGap-14
CARDIAC ENZYMES:
[**2156-1-12**] 09:02PM BLOOD CK-MB-3 cTropnT-<0.01
[**2156-1-13**] 02:49AM BLOOD CK-MB-NotDone cTropnT-<0.01
PHENYTOIN LEVELS:
[**2156-1-12**] 04:45AM BLOOD Phenyto-20.7*
[**2156-1-12**] 10:53AM BLOOD Phenyto-21.3*
[**2156-1-13**] 02:49AM BLOOD Phenyto-20.1*
[**2156-1-14**] 01:59AM BLOOD Phenyto-19.4
[**2156-1-17**] 07:20AM BLOOD Phenyto-14.3
[**2156-1-18**] 07:55AM BLOOD Phenyto-11.9
[**2156-1-19**] 06:15AM BLOOD Phenyto-10.8
CBC:
[**2156-1-23**] 05:30AM BLOOD WBC-7.3 RBC-3.42* Hgb-11.9* Hct-35.2*
MCV-103* MCH-34.8* MCHC-33.9 RDW-14.0 Plt Ct-335
CHEMISTRIES:
[**2156-1-23**] 05:30AM BLOOD Glucose-91 UreaN-24* Creat-0.6 Na-137
K-3.9 Cl-103 HCO3-26 AnGap-12
IRON STUDIES:
[**2156-1-21**] 05:30AM BLOOD calTIBC-183* VitB12-528 Folate-4.6
Ferritn-1175* TRF-141*
EGD [**2156-1-12**]:
This is an abnormal portable EEG recording due to the right
PLEDs and slower and lower voltage background on the right. The
first
abnormality suggests an acute significant abnormality in the
right
hemisphere predominantly frontal and probably cortical
irritability in
this region. The other abnormality suggests subcortical
dysfunction of
the right hemisphere. The excessive background activity is
probably a
medication affect.
MRA [**2156-1-12**]:
IMPRESSION: Subacute hematoma with edema around the hematoma in
the right
temporal lobe probably related to biopsy. Diffuse T2
hyperintensity in the
right frontal and temporal lobes does not enhance after contrast
administration and is similar in appearance to prior study.
Findings may
represent a glioma.
CT Pelvis [**2156-1-15**]:
1. No evidence of retroperitoneal hematoma. Stranding and tiny
hematoma
surrounding the right common femoral vein.
2. Bilateral pleural effusions and mild pulmonary edema
superimposed on
moderate emphysema.
3. Unusual tapering of the mid gallbladder with calcification of
the
gallbladder fundus - a right upper quadrant ultrasound is
recommended when the patient's clinical condition improves to
further evaluate the gallbladder.
Brief Hospital Course:
The patient is a 79-year-old left handed man with a history of
right fronto-temporal anaplastic astrocytoma, atrial
fibrillation s/p ablation, DVT/PE on Lovenox, and asbetosis who
presents with a 30 minute GTC on Keppra 1000 mg [**Hospital1 **]. At the OSH
he was loaded with phosphenytoin 2400 mg. He was found to have
pneumonia, and was started on vancomycin 1 gram IV. On arrival
to [**Hospital1 18**], BP was 83/44, SaO2 95%. He required intubation for
airway protection, and his BP dropped to 39/14, requiring
levophed. Repeat CXR on admission showed diffuse prominent
interstitial markings but no pneumonia, so the antibiotics were
discontinued.
He was initially admitted to the NeuroICU. MRI/MRA Brain showed
subacute hematoma with edema around the hematoma in the right
temporal lobe probably related to biopsy, and the previously
seen diffuse T2 hyperintensity in the right frontal and temporal
lobes. EEG showed right PLEDs and slower and lower voltage
background on the right. He was initially on Dilantin 100 mg
tid, and his Keppra was increased to 1500 [**Hospital1 **]. He was also
started on oxcarbazepine, with the goal of titrating off the
Dilantin and up on the oxcarbazepine (given that Dilantin can
interact with the chemotherapeutic agents). He was to also
remain on the Keppra 1500 mg [**Hospital1 **].
He was briefly called out to floor on [**1-15**]; however, he was
found to be somnolent with SBP 83. For this he received 500 cc
NS with improvement in his blood pressure. On examination, he
was found to have right IP and quadriceps weakness consistent
with femoral neuropathy, and there was palpated a 2 cm hematoma
in right groin. There was concern for an retroperitoneal bleed
versus hematoma around lumbar plexus, especially given recent
catheterization for atrial fibrillation ablation, as the cause
of his hypotension. CT abdomen/pelvis showed no evidence of
retroperitoneal hematoma, but there was stranding and a tiny
hematoma surrounding the right common femoral vein. A repeat
EEG in the NeuroICU showed right hemisphere and right frontal
slowing, and an occasional isolated sharp and slow wave
discharges in the right frontal region.
Dr. [**Last Name (STitle) 724**] and Dr. [**Last Name (STitle) 3929**] were consulted for field radiation
therapy with concurrent chemotherapy (Temodar). He was
transferred to OMED for further treatment. On the oncology
service patient received combination temozolomide (started
[**2156-1-20**]) and radiation therapy (started on [**2156-1-19**]) which will
continue for a total 6 week course at [**Hospital1 18**]. Patient has
experienced nausea with these treatments which has responded
well to compazine and low dose Zyprexa. He was also tapered
down on his Dilantin. He is currently taking Dilantin 100mg
daily.
Of note, patient noted to have loose stool prior to discharge.
We were unable to send a stool culture for Clostridium difficile
toxin and would recommend that this is done at rehabilitation.
Medications on Admission:
-Keppra 100o mg [**Hospital1 **] (dilantin D/ced [**12-29**])
-Atrovent
-Tylenol
-Lovenox 100 mg [**Hospital1 **]
-Multivatimin
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe [**Hospital1 **]: One (1) Subcutaneous [**Hospital1 **]
(2 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: 0.5 Tablet, Rapid
Dissolve PO TID (3 times a day) as needed for nausea.
5. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2
times a day).
6. Oxcarbazepine 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once
a day (in the morning)).
7. Oxcarbazepine 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once
a day (at bedtime)).
8. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule
PO DAILY (Daily).
9. Compazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6)
hours as needed for nausea.
10. Atrovent HFA 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: One (1)
Inhalation as needed as needed for shortness of breath or
wheezing.
11. Temodar 140 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day:
Patient takes a total of 165mg daily (last dose [**2156-3-4**]).
12. Temodar 20 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO once a day:
Patient takes total dose of 165mg daily until [**2156-3-4**].
13. Temodar 5 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO once a day:
Patient takes total dose of 165mg daily until [**2156-3-4**].
14. Multivitamin Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary: Generalized tonic clonic seizure, anaplastic
Astrocytoma
Secondary: History of deep venous thrombosis and pulmonary
embolism, history of atrial fibrillation now status post
ablation, history of asbestosis, and history of Hepatitis C.
Discharge Condition:
Stable.
Discharge Instructions:
You were transferred to this hospital for further management of
seizures and your brain cancer. We have altered your seizure
medication and this problem has stabilized. You were started on
whole brain radiation and chemotherapy during this admission and
will require a total of 6 weeks of treatment. At time of
discharge you were feeling well other than some transient
nausea.
If you experience fevers, chills, shortness of breath, or chest
pain please contact your oncologist or primary care physician or
go to the emergency department for further evaluation.
Followup Instructions:
You will have radiation therapy for the next 6 weeks Monday
through Friday (start date [**2156-1-19**] - [**2156-2-27**]) at 2:15 pm in
Radiation Oncology, [**Hospital Ward Name 332**] Basement, [**Hospital Ward Name 516**] [**Hospital1 18**]. The
phone number is [**Telephone/Fax (1) 9710**].
Completed by:[**2156-1-24**]
|
[
"501",
"427.31",
"E879.2",
"348.5",
"486",
"787.01",
"V58.61",
"191.8",
"V12.51",
"998.12",
"V02.62",
"E879.8",
"345.3",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"92.29",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
11207, 11284
|
6236, 9234
|
313, 350
|
11572, 11581
|
3779, 3779
|
12195, 12519
|
2583, 2849
|
9412, 11184
|
11305, 11551
|
9260, 9389
|
11605, 12172
|
2864, 3327
|
4201, 6213
|
254, 275
|
378, 2048
|
3419, 3760
|
3795, 4184
|
3342, 3403
|
2070, 2344
|
2360, 2567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,951
| 151,685
|
13947+56498
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-1-2**] Discharge Date: [**2195-1-12**]
Date of Birth: [**2118-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
low grade fever and bacteremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo Male with sCHF (EF 20-25% on TTE on [**11-28**]), CAD s/p CABG
(3 vs 4? vessel), HTN, NIDDM, A-fib on coagulation, s/p PPM, s/p
recent CCU stay for VF arrest requiring pressor support, h.o.
Pseudomonas + bld cultures admitted from cardiac rehab for
fevers, +GPC x 2 bottles 2 days ago.
Per [**Hospital **] rehab records and pt noticed started feeling weak 2
days PTA, noted to have a low grade fever yesterday of 100.4.
Bld cultures and labs were drawn which grew GPC x1 bottle within
24hours and showed a leukocytosis of 15.0 (increased from 6.1 3
days prior). In the ED was noted to have SBP in the 90s-100s, pt
also noted to have a new holosystolic murmur. Pt received 4l
IVF, Vancomycin, Zosyn. R IJ was placed, CXR showed no
pneumonia, urine cultures and bld cultures were drawn from
central line.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
CHF (EF 15-20% on ECHO in [**11/2194**])
CABG ([**2182**])
PPM ([**2189**]) s/p syncopal event
A-fib on Coumadin
h.o. VF Arrest [**11/2194**]
Left foot drop and weakness s/p gunshot wound in Korean War
s/p recent admission for sepsis ?[**1-19**] VAP vs line infection
requiring intubation/vasopressors
h.o.+ Pseudomonas on line cx
HL
HTN
Social History:
Pt denies any tobacco, Etoh or drug use. Pt usually lives at
home with his wife.
Family History:
NC
Physical Exam:
Vitals: T: BP:109/50 HR:75 RR:12 O2Sat:100%
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2195-1-2**] 11:50AM GLUCOSE-157* UREA N-24* CREAT-1.3*
SODIUM-128* POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-24 ANION GAP-16
[**2195-1-2**] 11:50AM WBC-11.2* RBC-3.02*# HGB-11.1*# HCT-31.3*#
MCV-104* MCH-36.9* MCHC-35.6* RDW-20.9*
[**2195-1-2**] 11:50AM NEUTS-82.7* LYMPHS-14.0* MONOS-2.7 EOS-0.4
BASOS-0.3
[**2195-1-2**] 11:50AM PLT COUNT-106*#
[**2195-1-2**] 12:08PM LACTATE-1.7
[**2195-1-2**] 07:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-1-2**] 11:27PM ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-128 ALK
PHOS-53 TOT BILI-1.1
[**2195-1-2**] 11:27PM ALBUMIN-2.9* CALCIUM-7.3* PHOSPHATE-1.8*
MAGNESIUM-1.9
[**2195-1-2**] 11:59PM LACTATE-1.5
ECG: Ventricular paced at 75 bpm.
CXR ([**1-2**]): No acute intrathoracic process.
[**2195-1-8**] 06:13AM BLOOD WBC-4.7 RBC-2.18* Hgb-8.1* Hct-22.4*
MCV-103* MCH-37.2* MCHC-36.2* RDW-20.3* Plt Ct-152
[**2195-1-7**] 06:37AM BLOOD Neuts-62.9 Lymphs-27.0 Monos-4.0 Eos-5.9*
Baso-0.2
[**2195-1-8**] 09:29AM BLOOD PT-19.5* PTT-29.1 INR(PT)-1.8*
[**2195-1-7**] 06:37AM BLOOD ESR-69*
[**2195-1-7**] 06:37AM BLOOD Ret Aut-2.3
[**2195-1-8**] 06:13AM BLOOD Glucose-69* UreaN-12 Creat-1.3* Na-138
K-3.3 Cl-104 HCO3-26 AnGap-11
[**2195-1-7**] 06:37AM BLOOD ALT-30 AST-29 LD(LDH)-134 AlkPhos-51
TotBili-0.7
[**2195-1-6**] 06:15AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0
[**2195-1-6**] 06:15AM BLOOD CRP-25.0*
[**2195-1-4**] 02:25AM BLOOD Lactate-1.0
[**2195-1-2**] 07:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Blood cultures
1/16
4/4 bottles positive for Enterococcus Faecalis
[**2195-1-2**] 11:50 am BLOOD CULTURE SET # 1.
**FINAL REPORT [**2195-1-6**]**
Blood Culture, Routine (Final [**2195-1-6**]):
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2195-1-3**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 41713**], R.N. ON [**2195-1-3**] AT 0320.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2195-1-3**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Blood cultures
[**1-4**] x2 NGTD, [**1-5**] x2 NGTD, [**1-6**] NGTD
[**1-2**] Urine culture negative
Echo [**1-6**]
No atrial septal defect is seen by 2D or color Doppler. Left and
right ventricular systolic function appears depressed. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened with fusion of the right and left coronary
cusps. No masses or vegetations are seen on the aortic valve.
The study is inadequate to exclude significant aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
Impression: Thickened aortic valve with fusion of left and right
cusps. No evidence of vegetation or mass to suggest
endocarditis. The pacing wire is without evidence of
vegetations. Biventricular systolic dysfunction.
[**1-6**] RUQ US
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for acute cholecystitis.
2. Likely gallbladder polyp; recommend son[**Name (NI) 493**] followup in
[**5-29**] months.
[**1-7**] US of pacemaker site
IMPRESSION: No fluid collection or hyperemia involving the
pacemaker pocket.
Brief Hospital Course:
76 yo Male with sCHF (EF 20-25%), CAD s/p CABG, HTN, NIDDM,
A-fib on anticoagulation, s/p PPM, s/p recent CCU stay for VF
arrest requiring pressor support, admitted from cardiac rehab
with fevers and bacteremia.
1. Bacteremia/Hypotension: The patient was admitted with 2/2
Blood cultures from Cardiac rehab growing enterococcus on [**1-1**].
In the ED he had hypotension responsive to IVF. After admission
to the ICU his SBPs dropped briefly, but were responsive to more
IVF fluids. He was initally treated with ceftriaxone and
vancomycin empirically. [**3-21**] sets of BCx sent from the ED on [**1-2**]
grew GPCs within less then 24 hours and speciated to
enterococcus sensitive to vancomycin and ampicillin.
Antibiotics were narrowed to ampicillin 2 gm IV q4h when
sensitivities returned. A TTE was ordered to evaluate for
endocarditis and showed no evidence of vegatations. Patient had
no stigmata of endocarditis on physical exam. Surveillance
cultures on [**1-5**], 20th, and 21st were all NGTD on
discharge. The patient had a work up to evaluate for source of
enterococcus bacteremia. Infectious disease was consulted. Urine
culture was negative. Prostate exam negative for tenderness. RUQ
US negative. CT abdomen negative for intraabdominal process. The
patient has no decubitus ulcers. The patient received a 1 week
course of Ampicillin. VNA refused to administer Ampicillin q4
hours at home. Patient refused rehab. Though Vancomycin is
second line therapy, patient opted for 3 week course of
Vancomycin, so that he could go home. He understood the risks
of Vancomycin over Ampicillin, and decided to proceed with this
course of therapy.
-Please follow up on final read of Blood cultures
-Please follow up on final read of CT scan
-follow up Vanc trough prior to 3rd dose of Vancomycin. Please
check weekly CBC, CRP, ESR, Chem 7. Fax results to [**Hospital **] clinic [**Telephone/Fax (1) 18871**]. Call [**Hospital **] clinic at [**Telephone/Fax (1) 11581**] with questions
regarding Vancomycin.
# CHF: The patient has an EF of 20-25% on Echo in [**2194-11-17**].
Outpatient regimen of Metoprolol 25mg daily and Spironolactone
25mg daily were held on admission secondary to hypotension.
These were restarted on discharge.
# A. Fib: Patient has history of A. fib on Coumadin and
Amiodarone for rhythm control. EKG showed a paced rhythm on
admission. He was continued on amiodarone. Coumadin was
continued with goal INR 2.0-3.0.
-INR will need to be checked 2 days after discharge.
# CRI: The patient's Creatinine on admission noted to be
elevated at 1.3, on review of [**Hospital 228**] rehab records show his
lowest Creatinine to be 1.2 from several days prior to
admission. Patient's Creatinine yesterday in rehab noted to be
1.6. Most likely [**1-19**] hypovolemia. On discharge Creatinine was
1.3.
# NIDDM: The patient was continued on Glargine, SSI and
underwent qid fingersticks for monitoring.
# h.o. V. fib: The patient was recently admitted to CCU
following a 6 minute episode of V. fib arrest. He currently has
a PPM, and was scheduled to have an ICD upgrade and possible LV
lead on [**1-9**] with Dr. [**Last Name (STitle) **]. The eletrophysiology service
postponed this procedure given bacteremia. They will follow up
with him in [**Month (only) 956**]. In the meantime, the patient was fitted
for a LifeVest.
# Macrocytic Anemia: HCT 22.4 on discharge. 31.3 on admission.
However looking at previous hospitalization, baseline HCT about
23-25. No active signs of bleeding. Acute renal failure
resolved. No evidence of thrombocytopenia. Patient had elevated
B12 in [**2194-11-17**], elevated ferritin, and normal folate.
Stools were guaiac negative. No evidence of hemolysis.
-Please follow HCT as an outpatient
-consider outpatient Hematology follow up
# Gall bladder polyp incidentally seen on RUQ US: Recommend
son[**Name (NI) 493**] followup in [**5-29**] months.
Medications on Admission:
Amiodarone 400mg daily
ASA 81 mg daily
Coumadin 2mg qhs
Metoprolol 25mg daily
Spironolactone 25mg daily
Simvastatin 10mg qhs
Pantoprazole 40mg daily
Ascrobic Acid 500mg [**Hospital1 **]
Ferrous Sulfate 325mg daily
Folic Acid 1mg daily
ISS
Glargine 18u qhs
Metronidazole 500mg x 10 days (started [**2195-1-1**])
Polyetheline glycol daily
Pyridoxine 50mg daily
Vitamins/minerals 1 tab daily
Ambien 10mg qhs
Acetaminophen 650mg q6hr PRN
Biasacodyl 10mg PR PRN
miconazole PRN to groin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed units Subcutaneous qachs: Please follow sliding scale
as you were prior to admission.
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Outpatient Lab Work
Please have INR checked 2 days after discharge and faxed to your
primary care doctor's office
11. BP cuff
Patient requires a blood pressure cuff
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
once a day for 21 days.
Disp:*21 recon solns* Refills:*0*
14. Outpatient Lab Work
Please have Vancomycin trough drawn prior to 3rd dose of
Vancomycin. Fax results to Infectious disease clinic at [**Telephone/Fax (1) 18871**].
15. Outpatient Lab Work
Weekly CBC, CRP, ESR, Chem 7. Please have results faxed to
Infectious disease clinic at [**Telephone/Fax (1) 6313**].
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **]
Discharge Diagnosis:
Primary diagnosis:
1. Enterococcus bacteremia
2. Hypotension secondary to bacteremia
Secondary diagnosis:
1. Chronic systolic congestive heart failure
2. Atrial fibrillation
3. Hypertension
4. history of Ventricular fibrillation cardiac arrest
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
You were admitted with an infection in your blood. You were
treated with your antibiotics and your blood was closely
monitored. You were monitored in the ICU because your blood
pressure was running low. We looked for a source of infection,
but you CT scan of your abdomen, Ultrasound, and echo of your
heart showed no sources of infection. Your pacemaker is not
infected either. We are started you on Ampicillin for this
infection. However, you refused to complete the 4 week course of
Ampicillin because you would need to be in rehab for this. You
agreed to 2nd line treatment with Vancomycin for the remaining 3
weeks of antibiotics.
Thereafter, cardiology will consider placing a defibrillator. In
the meantime, you will have a Lifevest fitted for your heart.
If you have chest pain, palpitations, shortness of breath,
fevers, chills, or any other symptoms that concern you please
see your primary doctor or go to the emergency room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please call Infectious disease clinic if you have questions
about Vancomycin at [**Telephone/Fax (1) 11581**]. Please fax lab results to them
at [**Telephone/Fax (1) 23413**].
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] in Infectious disease
on [**2-3**] at 10am. The clinic phone number is [**Telephone/Fax (1) 10**].
You have an appointment with Dr. [**Last Name (STitle) **] in Cardiology on
[**2-4**] at 1pm. The clinic phone number is [**Telephone/Fax (1) 2037**].
Completed by:[**2195-1-9**] Name: [**Known lastname 7542**],[**Known firstname **] Unit No: [**Numeric Identifier 7543**]
Admission Date: [**2195-1-2**] Discharge Date: [**2195-1-12**]
Date of Birth: [**2118-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7544**]
Addendum:
Correction: After much discussion with the patient, family, and
consulting teams, patient agreed to go to rehab to complete the
recommended 4 week course of Ampicillin. He was discharged on
[**1-12**] to rehab, and will require Ampicilin until [**1-30**].
Thus, he was not started on Vancomycin.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 7545**] Green Nursing & Rehab Center - [**Hospital1 1947**]
Discharge Diagnosis:
Primary diagnosis:
1. Enterococcus bacteremia
2. Hypotension secondary to bacteremia
Secondary diagnosis:
1. Chronic systolic congestive heart failure
2. Atrial fibrillation
3. Hypertension
4. history of Ventricular fibrillation cardiac arrest
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
You were admitted with an infection in your blood. You were
treated with your antibiotics and your blood was closely
monitored. You were monitored in the ICU because your blood
pressure was running low. We looked for a source of infection,
but you CT scan of your abdomen, Ultrasound, and echo of your
heart showed no sources of infection. Your pacemaker is not
infected either. We are started you on Ampicillin for this
infection. You will be kept on a 4 week course of Ampicillin to
treat this infection. Thereafter, cardiology will consider
placing a defibrillator. In the meantime, you will have a
Lifevest fitted for your heart.
If you have chest pain, palpitations, shortness of breath,
fevers, chills, or any other symptoms that concern you please
see your primary doctor or go to the emergency room.
Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please call Infectious disease clinic if you have questions
about Vancomycin at [**Telephone/Fax (1) 7546**]. Please fax lab results to them
at [**Telephone/Fax (1) 7547**].
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 3682**] in Infectious disease
on [**2-3**] at 10am. The clinic phone number is [**Telephone/Fax (1) 7548**].
You have an appointment with Dr. [**Last Name (STitle) **] in Cardiology on
[**2-4**] at 1pm. The clinic phone number is [**Telephone/Fax (1) 7549**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7550**] MD [**MD Number(2) 7551**]
Completed by:[**2195-1-12**]
|
[
"287.5",
"V45.01",
"250.00",
"428.0",
"585.9",
"V45.81",
"414.8",
"790.7",
"424.1",
"041.04",
"427.31",
"403.90",
"428.22",
"276.1",
"V58.61",
"584.9",
"354.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15858, 15964
|
7065, 10975
|
345, 351
|
16253, 16289
|
2801, 7042
|
17422, 17897
|
2025, 2030
|
11506, 13100
|
15985, 15985
|
11001, 11483
|
16313, 17399
|
2045, 2782
|
275, 307
|
379, 1548
|
16091, 16231
|
16004, 16070
|
1570, 1910
|
1926, 2009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,279
| 119,998
|
53258
|
Discharge summary
|
report
|
Admission Date: [**2159-4-14**] Discharge Date: [**2159-4-19**]
Service: NEUROLOGY
Allergies:
Codeine / Morphine / Ace Inhibitors
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
new onset LEFT-sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 yo RH woman with a PMH significant for multiple strokes,
HTN,DM II p/w with new onset LEFT-sided weakness.
This HPI is obtained through the patient's daugther ([**First Name5 (NamePattern1) 8665**]
[**Known lastname 8666**]).
Code status: DNR/DNI HCP: [**Name (NI) **] [**Name (NI) 8666**]: Cell: [**Telephone/Fax (1) 109615**]
ED: FSG 336.
She was last seen at her baseline at midnight (0:30 am). Today
in
the early am, her daughter heard her walking in her bedroom and
started fixing her breakfast. After a while she heard her
"trying
to open the dresser". After a few minutes she heard the same
sound. Finally for a third time she heard the same noise after a
total of approximately 5 to 10 minutes.
She was found on the floor trying to stand up while reaching for
the bed with her RIGHT arm. She was mute. She did not follow any
commands. Her LEFT side of the body was limp. She did not vomit.
One eye was closed, the other gazing to the RIGHT (per
daughter).
There was some urine in the floor (she had partially removed her
diaper). Not witnessed seizure - like activity. No PMH of
seizure
events.
After her last admission in [**2155**] at [**Hospital1 18**], she has not been
admitted to any hospitals. Her daughter explains that she "feels
weird" around once per month for the past few months. Then she
checks her SBP (> 200). During those episodes she has trouble
swallowing both solids and fluids and her LEFT arm feels
heavier.
There may be a LEFT facial droop. There are no visual or sensory
complaints. Her daughter says her tongue "[**Last Name (un) 109616**] up" while
talking. However, she is able to produce speech (not slurred)
and
to understand people. These events happened once q 4 months,
but
have become more frequent lately.
At baseline, she has been incontinent for years and wears a
diaper.
Refuses to use her walker. Refuses to take her glyburide unless
FSG > 200. Able to have a normal conversation. Able to eat on
her
own. Bathes on her own (requires help to sit down in the tub).
Does not handle money or buy groceries. She has remained at home
for two years.
Last documented stroke clinic Neurological Exam in [**2156**] (Dr.
[**Last Name (STitle) **]: Remarkable for a slight right facial droop. Strength
5-
in R IP and KF. No pronator drift.
Last MRI/A: [**2156-1-2**]:
There are two foci of restricted diffusion in the posterior left
corona radiata/internal capsule, consistent with an acute
infarct. Again, there are multiple T2 and FLAIR hyperintensities
in the cerebral white matter bilaterally, consistent with
chronic
microvascular ischemia.
The previously noted area of restricted diffusion in the region
of the left corona radiata has resolved.
There are also T2 and FLAIR hyperintensities within the
cerebellar infarcts bilaterally.
Acute infarcts in the left corona radiata/internal capsule.
There is no area of hemodynamically significant
stenosis or
ulceration within the vertebral artery or common or internal
carotid arteries. Normal MRA of the neck.
Past Medical History:
1. Multiple prior strokes - 1st right internal capsule lacunar
infarct in [**2148**] with left hemiparesis; 2nd [**6-/2153**] post-surgical
from mitral valve replacement with R arm weakness and multiple
bilateral cerebellar infarcts; 3rd [**2153-12-20**] with right sided
weakness and a posterior left coronal radiata infarct, 4th [**1-8**]
with left corona radiata/internal capsule
2. HTN
3. DM, diet-controlled
4. hypothyroid
5. asthma
6. DJD
7. renal insufficiency
Social History:
Social History: h/o smoking until [**2137**], beer on occasion, lives
with daughter and granddaughter
Family History:
Family History: mother died of stroke, brother died of stroke
age
[**Age over 90 **], aunt with multiple strokes
Physical Exam:
Physical Exam: with a FSG 330
On NC 2 L breathing at 20 RR
Off sedation. 220/ 112. Started on nicardipine drip at 1 mcg/
kg/
min. 100 bpm.
Afebrile.
Gen: Lying in bed, responsive to verbal commands (axial and
appendicular). Head turned to her RIGHT, gaze to her RIGHT.
Does not cross midline
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or megalies.
Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Neurologic examination:
MS:
She gives me a thumb or two fingers with her RIGHT hand.At
command wiggles her right toes and flexes her RIGHT knee.
Mute, comprehension is intact.
CN: Brain stem reflexes : preserved:
Corneals + bl. Pupils 2.5 to 1.5 bl and symmetrically. RIGHT
gaze deviation. Head turned to her RIGHT, gaze to her RIGHT.
Does
not cross midline. Does not blink to threat on the LEFT. No
bobbing or Robbing. No nystagmus. Mild LEFT facial droop.
Gag +.
Withdraws from noxious stimuli with LEFT arm and LEFT leg
vigorously.
DTR: 2+. First toes: upgoing at rest (Cavus deformity in bl
feet)
Pertinent Results:
[**2159-4-14**]: Head CT
1. Severe chronic small vessel ischemic disease, with areas of
probable old
infarction in bilateral cerebral hemispheres, basal ganglia.
Detection of
superimposed small areas of infarction is limited.
2. No intracranial hemorrhage.
[**2159-4-14**]:MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK
W&W/O CONTRAST
Interval development of large acute infarct within the right
middle cerebral artery territory, with reduced flow within the
right middle
cerebral artery that would correlate with the presence of this
infarct, and
potentially represent an occlusive process. Multiple areas of
susceptibility
in the brain, which could reflect amyloid angiopathy, prior
small vessel
hemorrhagic infarctions, or both diagnoses. Chronic small vessel
ischemic
infarcts.
Brief Hospital Course:
ASSESSMENT AND PLAN AT TIME OF ADMISSION: 86 yo RH woman with a
PMH significant for multiple strokes, HTN, DM II p/w with new
onset LEFT-sided neglect and mute. Her exam localizes to the
RIGHT hemisphere. Given her neglect a right MCA territory stroke
could account for this presentation. Subcortical structures such
as the pulvinar could invoke similar symptoms too. She is RH and
mute, but follows commands properly. Aphemia may localize in
some cases to the insular cortex, however i would
expect her left side to be involved if she trylu is
right-handed.Another possible diagnosis is seizure. She has
never has any events in the past, but has extensive vascular
disaese and prior strokes. Finally, she could have PRES.
MRI/A CNS and neck with DWI. as soon as possible
EEG
Admit to Neurology-ICU: Dr. [**Last Name (STitle) **].
SBP> 180 hydral 10 mg iv (unlikely current occlusion or severe
carotid disease)
Zocor 40 qhs. Insulin ss, Tylenol prn.
Off AC, off antiplatelets. Off hep sc.
f/u HbA1C, Lps, LFTs (started zocor), f/u trop, UTox, serum tox.
For MRI/ MRA of head and neck.
For Echo.
Pneumoboots.
Head of the bed flat.
Hydration: NS 70 cc/hr.
Hospital course:
#Neurology
Head CT on admission showed severe chronic small vessel ischemic
disease, with areas of probable old infarction in bilateral
cerebral hemispheres, basal ganglia.
Subsequently, MRI/A head and neck showed interval development of
large acute infarct within the right middle cerebral artery
territory, with reduced flow within the right middle cerebral
artery that would correlate with the presence of this infarct,
and potentially represent an occlusive process. Multiple areas
of susceptibility in the brain, which could reflect amyloid
angiopathy, prior small vessel hemorrhagic infarctions, or both
diagnoses. Chronic small vessel ischemic infarcts.
Due to this devastating stroke, her health care proxy made her
[**Name (NI) 3225**] (comfort measures only).
#Cariology
Patient admited to ICU with new onset of afib. She was placed
on diltiazem drip and returned to sinus rhythm. PO diltaizem
was started. On metoprolol for her HTN. On Zocor 40 mg QHS.
Medications were discontinued once patient made [**Name (NI) 3225**].
#Pulmonary:
--Satted well on 2 L NC. Once [**Name (NI) 3225**] on room air.
#Gastrointestinal / Abdomen:
--No issue
#Hematology:
--Hct stable
#Endocrine:
--RISS
#ID:
--Afebrile
Medications on Admission:
Toprol XL 25 mg po qHS
[**Name (NI) **] 25/200, [**Name (NI) **] 81mg po QD
Levoxyl 50 mcg po QD
Glyburide refuses to take it on daily basis. Only takes it if
FSG
> 200. Usually 140.
Zoloft 25 mg po BID
Calcium, vitamin D.
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO Q
1hour as needed for pain, discomfort: Please give sublingually.
Disp:*60 ml* Refills:*0*
2. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**2-3**]
Tablet, Sublinguals Sublingual Q4H (every 4 hours) as needed for
excessive secretions.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
Disp:*2 Patch 72 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Good [**Last Name (un) 3952**]
Discharge Diagnosis:
stroke (right MCA infarct)
Discharge Condition:
Eyes open, does not track, does not respond to voice.
Discharge Instructions:
You were admitted with stroke. Specifically you had a right MCA
infarct. Due to this devastating stroke, your health care proxy
has made you [**Name (NI) 3225**] (comfort measures only).
Followup Instructions:
none
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2159-4-18**]
|
[
"V12.54",
"V43.3",
"250.00",
"427.32",
"244.9",
"788.30",
"434.11",
"342.90",
"403.10",
"784.3",
"585.9",
"427.31",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9351, 9412
|
6173, 7331
|
274, 280
|
9483, 9539
|
5357, 6150
|
9776, 9927
|
3970, 4069
|
8843, 9328
|
9433, 9462
|
8592, 8820
|
7348, 8566
|
9563, 9753
|
4099, 4729
|
205, 236
|
308, 3325
|
4754, 5338
|
3347, 3817
|
3849, 3938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,715
| 189,583
|
8522
|
Discharge summary
|
report
|
Admission Date: [**2187-7-19**] Discharge Date: [**2187-8-6**]
Date of Birth: [**2146-12-2**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
History of Present Illness:
Mr. [**Known lastname 30003**] is a 40 male with HIV and PML who presents after being
found down in his apartment. One week ago his [**Location (un) **] care proxy
visited and noted that he was becoming progressively fatigued
and lethargic. On Monday he was found in his bed incontinent of
stool and urine by cleaning staff, but refused admission to the
hospital. On Tuesday his health care proxy received a phone call
that Mr. [**Known lastname 30003**] was in distress, and he was found down by staff
at his apartment building. At that time he was brought to the
[**Hospital1 18**] ED where he was found to be febrile and pancytopenic with
epigastric pain, jaundice, and altered mental status.
ROS: Per his healthcare proxy notable for lethargy x 1 week, no
cough, rhinorrhea, pain, nausea, vomiting, urinary symptoms, or
rash.
Past Medical History:
HIV per report undetectable viral load, CD4 379 in [**4-9**]
PML [**2174**] - not currently undergoing therapy
Expressive aphasia
R hemiparesis
EtOH abuse
Chronic R foot 5th digit infection s/p course of
TMP-SMX/cephalexin on [**2187-7-5**]
Social History:
Lives in group home but has a home nursing aide. His HCP who is
very involved in his care. Has two cats. Per his HCP he has has
a steady decline in function over several years but is able to
transfer independently and get around on power wheelchair
himself. His medications are delivered to his home and
organized by nursing aid. He purchases his own food, but his
nutritional intake has declined. He is a former smoker, no IVDU.
Per his HCP he has current alcohol abuse, drinking large
amounts of liquor. He frequently is found intoxicated by his
HCP. His date of last drink is unclear, but he last visited
liquor store [**2187-7-10**].
Family History:
Unknown
Physical Exam:
Exam:
VITALS: 98.2, 112/60, 94, 18, 96% on 2L
GEN: Male in bed in NAD, interactive answering yes and no
questions
HEENT: PERRL, EOMI, MMM. Neck supple, no lymphadenopathy. No
JVD.
COR: Regular rate and rhythm. Normal S1 and S2. No murmur.
PULM: Clear to auscultation anteriorally. No wheeze or
crackles.
ABD: Abdomen soft, non-tender and non-distended. + BS
EXT: Feet edematous, right greater than left, pitting to shin.
Abrasion on right 5th toe.
NEURO: Alert, not oriented to place or date. CNII-XII grossly
intact. Face symmetric. Follows commands to move left arm. Left
arm and leg strength 4+/5 with good effort. Right arm and leg
hemiparetic with 1+/5 strength. Sensation grossly intact.
Pertinent Results:
[**2187-8-6**] 07:30AM BLOOD WBC-10.4 RBC-3.36* Hgb-10.4* Hct-31.9*
MCV-95 MCH-31.0 MCHC-32.7 RDW-21.9* Plt Ct-308
[**2187-8-5**] 05:00AM BLOOD PT-12.6 PTT-21.5* INR(PT)-1.1
[**2187-7-29**] 07:39AM BLOOD Gran Ct-[**Numeric Identifier 30004**]*
[**2187-7-28**] 06:50AM BLOOD Gran Ct-[**Numeric Identifier 30005**]*
[**2187-7-19**] 09:40PM BLOOD WBC-0.5* Lymph-71* Abs [**Last Name (un) **]-355 CD3%-95
Abs CD3-339* CD4%-33 Abs CD4-116* CD8%-64 Abs CD8-228
CD4/CD8-0.5*
[**2187-7-30**] 07:55AM BLOOD Ret Man-6.9*
[**2187-7-22**] 07:10AM BLOOD Ret Man-.4*
[**2187-7-19**] 12:25AM BLOOD Ret Aut-0.4*
[**2187-8-6**] 07:30AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139
K-4.7 Cl-103 HCO3-27 AnGap-14
[**2187-8-4**] 07:36AM BLOOD ALT-46* AST-24 AlkPhos-119* TotBili-0.9
[**2187-8-2**] 07:50AM BLOOD Lipase-157*
[**2187-7-19**] 12:25AM BLOOD Lipase-747*
[**2187-8-6**] 07:30AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.4
[**2187-7-30**] 07:55AM BLOOD calTIBC-204* VitB12-1746* Folate-10.6
Hapto-41 Ferritn-GREATER TH TRF-157*
Brief Hospital Course:
40yo HIV+ male with PML presents with mental status change,
fever, and pancytopenia.
# Acute delirium ?????? At time of presentation was lethargic and
confused, but he returned to his baseline awarenes early in the
course of hospitalization. PML at baseline with stable
expressive aphasia and right hemiplegia. Potential etiologies
considered included CNS infectious process, progression of PML,
medication effect, metabolic abnormalities, or delrium in the
setting of systemic infection. LP negative. MRI showed no new
infarct or enhancing lesion. Infectious workup negative
including cryptococcal antigen, CSF HSV, [**Male First Name (un) 2326**] virus PCR,
parvovirus DNA, bacterial/viral/fungal cultures.
# Pancytopenia ?????? Labs notable for depressed haptoglobin,
supporting component of hemolysis, but no evidence of DIC.
Original stool guaiac positive, but subesquently negative. His
presenting anemia improved with 3x pRBCs and remained stable
untill he developed RP bleed as noted below. On presentation he
was neutropenic with WBC less than 1 and ANC as low as 0.
Neutropenia resolved after [**Male First Name (un) 30006**] x 3 days, etiology unclear
but potentially secondary to combination of multiple bone marrow
suppressive agents including AZT, bactrim, keflex, dapsone. Bone
marrow biopsy initially consistent with toxic insult, perhaps
bactrim and or HAART (combivir/viramune) related. Also the
marrow had the appearance expected to see in a viral process,
specifically parvovirus, but infectious workup negative.
Investigation included blood/sputum/urine cultures which
remained negative as well as testing for adenovirus,
parvovirus, HSV, EBV, CMV, lyme, bartonella, mycoplasma,
erlichia, babesia, campylobacter and PCP. [**Name10 (NameIs) **] was
administred for three doses and this restored a normal
neutrophil count. He retained normal WBC count for the remainder
of presentation. While neutropenic he was febrile and was
initially on empiric vanc/cefepime/azithro/acyclovir, but all
antimicrobials were discontinued once he was no longer
neutropenic. His bactrim and combivir/viramune were held. On
discharge his HAART was modified as indicated below.
# Pulmonary embolism: He was noted to have PE on CTA chest. He
initially was treated with heparin ggt with plan to transition
to warfarin. However, he developed an acute anemia after
starting heparin and CT abdomen confirmed a stable
retroperitoneal hematoma. Anticoagulation was discontinued and
an IVC filter was placed.
# Retroperitoneal hemorrhage: As noted his HCT decreased from 28
to 20 after onset of heparin and CT showed hematoma in psoas and
kidneys both of which were stable. He received 4x pRBC (for a
total of 7 units during this hospitalization) and heparin was
d/c'd. His HCT remained stable untill discharge (>72 hrs).
# C. Diff colitis - Clinically abdomen mildly tender in
bilateral lower quadrants, CT abdomen shows no colitis or bowel
wall thickening. Diarrhea stable with three loose BMs daily. He
was treated with po vancomycin.
# Abdominal pain, elevated LFTs, elevated lipase- RUQ US showed
dilated CBD at 9mm with focal gallbladder wall thickening and
gallstones. Surgery and ERCP were consulted with inital plan for
ERCP. Because the patient developed RP bleed as noted above, the
ERCP was delayed and in the meanwhile the patients symptoms
improved and so did his laboratory values. He was initially NPO
but his diet was advenced and he tolerated it well. Per
discussion with the consulting teams the ERCP was defered and
plan was to follow up with [**Doctor First Name **] as outpt.
#HIV ?????? At home he was on combivir and viramune, with bactrim for
PCP [**Name Initial (PRE) **]. Per OSH records at [**Hospital1 **], patients CD4 in [**4-9**] was
379 and viral load <75. Here CD4 116 and HIV VL undetectable.
Originally ARVs held for concern of marrow suppression. He was
subsequently restarted on viramune and truvada, as AZT thought
to be contributor to pancytopenia. Also bactrim was discontinued
for concern of contributing to marrow toxicity. He will need ID
follow up and determination of alternative PCP [**Name9 (PRE) **] method.
#EtOH ?????? History of EtOH abuse, date of last drink unclear. [**Name2 (NI) **]
signs of withdrawal or DT's. Continued MVI, folate, thiamine
Medications on Admission:
dapasone 100mg daily
trazadone 100mg qhs
combivir 1 tab [**Hospital1 **]
viramune 1 tab [**Hospital1 **]
zoloft 150mg daily
seroquel 50mg [**Hospital1 **]
MVI
KCl 10meq daily
neurontin 900mg tid
hctz 25mg daily
klonipin 2mg TID
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Sertraline 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
10. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 11 days.
Disp:*44 Capsule(s)* Refills:*0*
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1o
mental status changes
Pancytopenia
Macrocytic anemia
Febrile neurtopenia
C. difficil infection
Pancreatitis
Cholelithiasis
Pulmonary embolism
2o
retroperitoneal bleed
HIV
progressive multifocal leukoencephalopathy
hemiparesis
expressive aphasia
Discharge Condition:
Good. Vital signs stable; hematocrit stable.
Discharge Instructions:
You were admitted for fever, belly pain, diarrhea, and changes
in mentation. While in the hospital you were found to have low
blood counts which was treated with blood transfusion and
medications to stimulate the production of blood cells
([**Hospital1 30006**]). You also were noted to have pulmonary emboli which
was intially treated with blood thinning medication but this was
complicated by an internal bleed into your abdomen. Because of
this, the blood thining medications were discontinued and a
filter was placed to decrease the risk of further emboli to your
lungs. In addition, you were treated for an bowel infection,
which was the likely cause of your diarrhea. During your
admission you were also found to have gallstones and
pancreatitis for which you received supportive care.
You should follow up with general surgery to have further
evaluation of your gall stones.
You should follow up with infectious disease (HIV doctor) to
discuss your medication changes.
The following changes were made to your medications:
1. added vancomycin
2. added truvada
3. added nevirapine
4. added famotidine
5. added thiamine
6. added folate
7. discontinued dapsone, combivir and viraimmune.
Please be sure to follow-up with your primary care physician and
keep all follow-up appointments after discharge from the
hopsital. If you develop fever, diarrhea, abdominal pain,
dizziness, shortness of breath, chest pain or other worrisome
symptoms please call your doctor and/or go to the emergency room
immediately.
Followup Instructions:
Please follow-up with PCP ([**Last Name (LF) 30007**],[**First Name3 (LF) 30008**] G. [**Telephone/Fax (1) 14771**])
within 7 days.
Please follow-up with your HIV docotor within two weeks. If you
prefer to have follow up at [**Hospital1 18**] you may call ([**Telephone/Fax (1) 4170**] to
make an appointment with dr [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD, or another doctor
if Dr [**Last Name (STitle) 12838**] is not available.
Please follow up with general surgery in two weeks: Pelase call
([**Telephone/Fax (1) 30009**] to make an appointment with Dr [**Last Name (STitle) **] or another
doctor if Dr [**Last Name (STitle) 468**] is not available.
Completed by:[**2187-8-8**]
|
[
"008.45",
"568.81",
"281.9",
"780.61",
"438.20",
"577.0",
"042",
"574.20",
"415.19",
"046.3",
"438.11",
"305.01",
"288.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"03.31",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
10013, 10028
|
3874, 8180
|
278, 298
|
10321, 10368
|
2842, 3851
|
11930, 12635
|
2100, 2109
|
8459, 9990
|
10049, 10300
|
8206, 8436
|
10392, 11907
|
2124, 2823
|
228, 240
|
326, 1159
|
1181, 1424
|
1440, 2084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,859
| 118,646
|
35499
|
Discharge summary
|
report
|
Admission Date: [**2114-4-15**] Discharge Date: [**2114-4-20**]
Date of Birth: [**2056-11-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Acalculous Cholecystitis and Decubitus Ulcer
Major Surgical or Invasive Procedure:
Open cholecystectomy.
Debridement of sacral decubitus ulcer.
History of Present Illness:
57y M w/ protracted hospital course, initiated with an
admission for pneumonia complicated by respiratory failure
leading to intubation and eventaul tracheostomy in late
[**Month (only) **].
The patient also developed an acalculous cholecystitis, and was
treated with a percutaneous cholecystosomy on [**2114-2-21**] tube given
his debilatated state. In mid/late [**Month (only) **] pt was rehospitalized
for fevers, and elevated WBC. An U/S on [**3-10**] demonstrated a
thickened galbladder wall without ductal dilatation or
obstruction. On [**3-12**] his percutaneous cholecystosomy tube was
noted to be dislodged and was replaced. Pt was d/c'd to rehab
facility at this time. On [**4-7**] Pt was transfered from [**Hospital1 **] to
[**Hospital1 **] for fevers of 101 and a WBC of 31. At [**Hospital1 **] a ERCP
w/ sphincterotomy w/stent placement was performed on [**4-9**]. a
tube cholesytogram demonstrated stones in the gallbladder, and
free filling into the duodenum. At this time it was decided the
pt was to be transferred to [**Hospital1 18**] fro further management.
Past Medical History:
PMH:
DM on insulin
Afib
Decubitus ulcers (stage 4)
Pneumonia requiring intubation s/p trach ([**1-22**])
Acalculous cholecystitis ([**1-22**])
CHF (unknown EF)
? CRI
.
PSH:
trach/EG
cholecystostomy tube on [**2-21**], Tube replaced on [**3-12**]
Social History:
Rehab since admission in [**Month (only) 1096**]. Used to live
with his children, Taxi driver, Divorced, 2 children.
Family History:
NC
Physical Exam:
General: NAD, +trached, awake, nods to questions
HEENT: PEERl, dry mm
Neck: supple
+trach
Lungs: Crakels at te base belateral, tolerating PMV very well
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft, obese,
+PEG, Incision clean dry and intact, staples in place, flexseal
in place to protect sacral decubitus clean
Extrem: +1 edema
GU: + foley with clear fluid
Neuro: MAE, PERRL
Skin: no rash
Lymph: no cervical, axillary or inguinal LAD
+rectal tube
Back: sacral decub clean and intact, needs dressing change wet
to dry [**Hospital1 **]
Pertinent Results:
[**2114-4-19**] 04:50AM BLOOD WBC-17.0* RBC-3.33* Hgb-10.0* Hct-30.0*
MCV-90 MCH-29.9 MCHC-33.2 RDW-15.4 Plt Ct-92*
[**2114-4-19**] 04:50AM BLOOD Neuts-84.2* Lymphs-8.7* Monos-4.7 Eos-2.0
Baso-0.4
[**2114-4-17**] 02:11AM BLOOD PT-15.4* PTT-34.9 INR(PT)-1.4*
[**2114-4-19**] 04:50AM BLOOD Glucose-89 UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-97 HCO3-35* AnGap-8
MICRO:
[**4-15**] BCx pending, UCx no growth(final)
[**4-15**] C diff negative
[**4-16**] Sputum cx - PSEUDOMONAS AERUGINOSA, sparse, sensitive to
cefepime/gent/zosyn/tobra, intermediate: ceftazidine, [**Last Name (un) 2830**],
cipro.
3/2 blood cx P
[**4-17**] peritoneal swab - negative
[**4-17**] gallbladder lumen - 1+ POLYMORPHONUCLEAR LEUKOCYTES. sparse
pseudomonas, staph aureus 2+.
[**4-17**] sacral decub swab - rare GNR, no growth
.
Imaging/Diagnostics:
[**4-15**] CXR: Moderate cardiomegaly with signs of moderate
overhydration. Small lung volumes, no evidence of focal
parenchymal
opacities. No right-sided pleural effusion.
[**4-17**] CXR: LEFT atelectasis and pleural effusion
.
Video swallow study: Pending
Brief Hospital Course:
[**4-15**]: admitted SICU
[**4-16**]: TF restarted. trach mask most of day
[**4-17**]: OR for cholecystectomy/sacral debridement
[**4-18**]: NG tube d/ced, started on TFs, PMV eval started by
speech/swallow, reglan started.
[**4-19**]: PT eval for rehab screening/discharge planning, video
swallow needed by S/S/PMV, decub ulcer dressings changed by
plastics team. Abx d/c'ed.
Hospital course:
The patient was admitted to the SICU [**2114-4-15**]. He was taken to
the OR [**2114-4-17**], he underwent open cholecyctectomy with [**First Name8 (NamePattern2) **]
[**Doctor Last Name 468**] and Sacral decubitus debridment with [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **].
tolerated both procedure without event.
Neuro: The patient received Morphine PRN iv with good effect and
adequate pain control. He also recieved intermettent dose of
versed for anxiety
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,The
patient was switched to trach mask 24 hours after the procedure,
the patient upon discharge had passery muir valve in place
conversing appropriately.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF. The
patient's TF was advanced to goal when appropriate, which was
tolerated well Replete with fiber at 90cc/h. and IVF were
adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary. He was evaluated by Speach and swallow
therapoist, today he passed vedio swallow
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. On addmission he was
evaluated by ID and he was started on Meropenem by ID for
presumed Psedomonas in sputum and Gallblader lumen. The
meropenem was stopped by ID on postop day 3.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
OT and PT: Evaluated by OT and PT, the paient deemed to go to
extended facility.
TLD: The jp was removed on postop day 2, discharged to rehab
with Foley, Peg,Flexseal to protecte the dicub wound, and 2
peripheral IV,
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating TF well,
pain was well controlled.
[**4-20**]: Patient discharged to rehabiliation facility in stable
condition.
Medications on Admission:
HISS, Lantus 16u QAM, Imipenem 250'QAM, Ativan 1 Q4P, Zofran 4
Q6P, Morphine 3 Q4P, Florastor 250'', Betapace 40'', Fluconazole
200', Linezolid 600'', Ceftaz 2''', Albuterol, protonix 40',
SQH, MVI, Vit C, Zinc sulfate 220', Bumex 1'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5,000
unit/mL Solution Injection TID (3 times a day).
2. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Inhalation Q6H (every 6 hours) as needed for
wheezing.
4. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) 50 mg/5 mL
Liquid PO BID (2 times a day).
6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day) as needed.
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Famotidine 20 mg IV Q12H
12. Morphine Sulfate 2-4 mg IV Q2H:PRN
13. Ondansetron 4 mg IV Q8H:PRN
14. Lantus 100 unit/mL Solution Sig: Sixteen (16) units sq
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Open cholecystectomy.
Debridement of sacral decubitus ulcer.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
.
Humalog Insulin Sliding Scale:
Humalog Insulin SC Sliding Scale Q4H
Glucose Insulin Dose
0-60mg/dL [**2-16**] amp D50
61-120mg/dL 0 Units
121-140mg/dL 3 Units
141-160mg/dL 5 Units
161-180mg/dL 7 Units
181-200mg/dL 9 Units
201-220mg/dL 11 Units
221-240mg/dL 13 Units
241-260mg/dL 15 Units
261-280mg/dL 17 Units
281-300mg/dL 19 Units
301-320mg/dL 21 Units
> 320 mg/dL Notify M.D.
Instructons for NPO Patients: hold glargine
.
Site: R+L gluteus
Description: Pt has old decubitus ulcers stage 3, debrided in OR
[**4-17**], some fibrinous tissue building up.
Care: Moist to Dry gauze, covered with an abdominal pad, changed
[**Hospital1 **], last changed am [**4-20**].
.
Tracheostomy Care per Facility protocol
Followup Instructions:
Please call ([**Telephone/Fax (1) 471**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 468**] (Surgery) in 3 weeks.
Please call ([**Telephone/Fax (1) 77878**] to schedule follow-up with Dr. [**First Name (STitle) **]
(Plastics) in 2 weeks
Completed by:[**2114-4-20**]
|
[
"995.91",
"V09.81",
"518.83",
"574.10",
"V44.0",
"707.03",
"427.31",
"250.00",
"285.29",
"707.24",
"041.12",
"V58.67",
"038.9",
"428.0",
"V44.1",
"276.1",
"576.1",
"V12.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"96.71",
"86.22",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7861, 7935
|
3631, 4008
|
358, 421
|
8040, 8049
|
2531, 3608
|
10466, 10758
|
1954, 1959
|
6738, 7838
|
7956, 8019
|
6479, 6715
|
4026, 6453
|
8073, 10443
|
1974, 2512
|
274, 320
|
449, 1532
|
1554, 1802
|
1818, 1938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,577
| 132,059
|
18945
|
Discharge summary
|
report
|
Admission Date: [**2145-9-13**] Discharge Date: [**2145-9-20**]
Date of Birth: [**2092-8-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zestril / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2145-9-15**] - Off pump CABGx3 (Left internal mammary artery->Left
anterior descending artery, Saphenous vein graft->First diagonal
artery, Saphenous vein graft->Second obtuse marginal artery)
History of Present Illness:
53 year old Male with known coronary artery disease, s/p stent,
and a complicated medical history, consisting of pre [**Month/Day/Year **]
kidney evaluation requiring elective cardiac cath.Cath revealed
3 vessel coronary artery disease.He was transferred to [**Hospital1 18**]
from OSH for consult with Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] for coronary
revascularization.
Past Medical History:
1) Motorcycle trauma ([**2144-11-8**]) with BL open Monteggia
fractures, R knee degloving injury, hypotension, facial
laceration s/p ex-lap, ORIF R and L elbows, trach and peg
2) Chronic renal failure (baseline creatinine 1.8-2.1)
3) Anemia of chronic renal disease
4) Morbid obesity s/p lap gastric band ([**Doctor Last Name **]) [**12-25**], now
removed
5) Diabetes [**Month/Year (2) **] type 2
6) CAD s/p stenting ([**12-19**] at [**Hospital1 1774**]), no MI or stenting since
7) s/p Cardiac arrest in setting of CHF exacerbation in [**12-26**]
8) Hypertension
9) Hypercholesterolemia
10) CHF, diastolic
11) OSA, has not used CPAP/BIPAP for years but does use 2L NC at
night
12) Back Pain
13) Psoriatic Arthritis
14) L shoulder pain
15) h/o Hypernatremia
Social History:
Lives with wife, 3 children. On disability, former truck driver.
Tobacco: Former smoker, quit [**9-/2143**] after 80 pack-year history.
ETOH: Former heavy drinker, currently only has one drink on
occasion.
Illicits: does endorse very remote history of cocaine use, no
history of any drug use in many years
Family History:
Father - Leukemia, [**Name2 (NI) 32071**] heart disease
Mother - Diabetes [**Name2 (NI) **] type 2
Sister - Diabetes [**Name2 (NI) **] type 2
Physical Exam:
Pulse: 69 SR Resp: 18 O2 sat: 96%RA
B/P Right:171/83 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x] psoriatic changes of nails
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] trach scar
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds
+
[x] firm, obese, healed mid-abd incision, psoriatic lesions, 2
ventral hernias
Extremities: Warm [x], well-perfused [x] Edema 2+ bilateral
ankles to 1+ bilateral lower legs, Varicosities: None [x] early
venous stasis changes bilaterally
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 1+
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: Left: not palpable [**3-22**] edema
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits appreciated
Pertinent Results:
[**2145-9-15**] - ECHO
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately 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. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
POST Grafting
Biventricular systoliuc function remains normal. The study is
otherwise unchanged from pregrafting. LVEF > 55%
[**2145-9-19**] 07:15AM BLOOD WBC-9.3 RBC-2.71* Hgb-8.3* Hct-24.7*
MCV-91 MCH-30.4 MCHC-33.5 RDW-15.0 Plt Ct-157
[**2145-9-18**] 04:15AM BLOOD WBC-13.6* RBC-2.74* Hgb-8.3* Hct-24.8*
MCV-90 MCH-30.3 MCHC-33.5 RDW-15.2 Plt Ct-112*
[**2145-9-17**] 03:00AM BLOOD WBC-9.1 RBC-2.80* Hgb-8.4* Hct-24.6*
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.9* Plt Ct-104*
[**2145-9-19**] 07:15AM BLOOD Glucose-149* UreaN-113* Creat-3.9* Na-137
K-4.4 Cl-99 HCO3-22 AnGap-20
[**2145-9-18**] 04:15AM BLOOD UreaN-112* Creat-4.7* Na-139 Cl-100
HCO3-25
[**2145-9-17**] 03:00AM BLOOD Glucose-168* UreaN-111* Creat-5.4* Na-139
K-4.1 Cl-101 HCO3-23 AnGap-19
[**2145-9-19**] 07:15AM BLOOD Mg-3.0*
[**2145-9-20**] 04:55AM BLOOD WBC-8.3 RBC-2.67* Hgb-7.9* Hct-24.0*
MCV-90 MCH-29.6 MCHC-32.8 RDW-14.6 Plt Ct-194
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2145-9-13**] for surgical
management of his coronary artery disease. He was worked-up in
the usual preoperative manner. The renal, orthopedic and [**Last Name (un) **]
diabetes services were consulted for assistance in his care as
they had been following him previously. On [**2145-9-15**], Mr. [**Known lastname **]
was taken to the operating room where he underwent off-pump
coronary artery bypass grafting to three vessels(Left internal
mammary artery grafted to Left anterior descending
artery/Saphenous vein grafted to Diag 1/Diag 2). Please see
Dr[**Doctor Last Name 14333**] operative note for further details. He
tolerated the procedure well and was transferred to the CVICU in
stable but critical condition. He awoke neurologically intact
but remained intubated due to hypoxia and acidosis. POD#2 his
pulmonary issues had improved, with continued aggressive
pulmonary hygiene and he was ready to extubate without
difficulty. All lines and drains were discontinued in a timely
fashion. Beta-Blocker, statin, and aspirin initiated. All
preoperative consulting groups resumed following postop.
Mr.[**Known lastname **] continued to progress. POD#3 he was transferred to
the step down unit for further monitoring. Physical therapy was
consulted and evaluated his strength and mobility progression.
The remainder of his postoperative course was essentially
uneventful. He continued to progress and Physical therapy
cleared him for discharge to home, with recommendations to
continue use of his oxygen as needed with ambulating. Mr.[**Known lastname **]
has oxygen already set up at home, due to his continued use at
night for obstructive sleep apnea, in which he does not use
CPAP. Dr.[**Last Name (STitle) **] cleared Mr.[**Name14 (STitle) 51788**] for discharge to home
today, with VNA. All follow up appointments were advised.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1Tablet(s) by mouth DAILY (Daily)
ATORVASTATIN [LIPITOR] - 80 mgTablet - 1 Tablet(s) by mouth
once
a day
CALCITRIOL - 0.25 mcg Capsule 1 Capsule(s) by mouth once a day
CITALOPRAM - 20 mg Tablet - 1Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mgTablet - 1 Tablet(s) by mouth once a
day
DILTIAZEM HCL - 360 mg Capsule Sustained Release - 1 Capsule(s)
by mouth at bedtime
DOXAZOSIN - 4 mg Tablet - 1 Tablet(s) by mouth
EPOETIN ALFA [EPOGEN] - 40,000unit/mL Solution - 1 shot per
week if needed prn
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth once aweek
ETANERCEPT [ENBREL] - 50 mg/mL(0.98 mL) Syringe - 1 shot q week
weekly
EZETIMIBE [ZETIA] - 10 mgTablet - 1 Tablet(s) by mouth once a
day
FAMOTIDINE - 20 mg Tablet - 1Tablet(s) by mouth twice a day
FUROSEMIDE - 80 mg Tablet - 1Tablet(s) by mouth twice a day
GEMFIBROZIL - 600 mg Tablet - 1Tablet(s) by mouth twice a day
GLIMEPIRIDE - 4 mg Tablet - 1/2Tablet(s) by mouth twice a day
HYDRALAZINE - 25 mg Tablet -TWO Tablet(s) by mouth three times
a day
ISOSORBIDE MONONITRATE - 60 mgTablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
L-THYROXINE - - 0.05 once [**Last Name (un) 5490**]
LOSARTAN [COZAAR] - 25mgTablet - 2 Tablet(s) by mouth ONCE a
day
METOLAZONE - 2.5 mg Tablet - 1Tablet(s) by mouth q12
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - 1
Tablet(s) by mouth every six (6) hours as needed for pain
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - - 81 mg Tablet, Delayed
Release (E.C.) - oneTablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] -
(Prescribed by Other Provider) - 600 mg (1,500 mg)-400 unit
Tablet - 1 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D3) [VITAMIN D] - 400 unit Capsule - 1
Capsule(s) by mouth once a day
FERROUS SULFATE - 325 mg (65 mgIron) Tablet - 1 Tablet(s) by
mouth twice a day
INSULIN NPH HUMAN RECOMB [NOVOLIN N] - 100 unit/mL Suspension -
per sliding scale
INSULIN REGULAR HUMAN [NOVOLIN R INNOLET] - 300 unit/3 mL
Insulin
Pen - as directed Insulin(s)
four times a day Sliding Scale: 61-120 mg/dL 0 Units
121-140
mg/dL 4 Units 141-160 mg/dL 6 Units 161-180 mg/dL 8
Units 181-200 mg/dL 10 Units 201-220 mg/dL 12 Units
mg/dL 18 Units 281-300 mg/dL 20 Units 301-320 mg/dL 22
Units 321-340 mg/dL 24 Units 341-360 mg/dL 26 Units
361-380 mg/dL 28 Units 381-400 mg/dL 30 Units > 400
mg/dL 32 Units
MULTIVITAMINS WITH MINERALS - (OTC) - Tablet - 1 Tablet(s) by
mouth twice a day Recommended once per day for Lap Band
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
21. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
22. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
23. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
24. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) units
Subcutaneous once a day: 16 units in AM/20 units in PM.
Disp:*30 units* Refills:*2*
25. Humalog 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous
ACHS: per sliding scale.
Disp:*qs * Refills:*2*
26. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
CAD s/p Off-pump CABGx3
coronary stent and ongoing angina,Hypertensive
Urgency,respiratory arrest in [**February 2145**] with rescusitation,chronic
diastolic heart failure, Acute on chronic renal failure, Angina
pectoris,diabetes and ATN lead to chronic kidney disease. Last
creatinine is 3.9-[**Year (2 digits) 1326**] Center following for his
pretransplant kidney evaluation. hypertension,obesity, status
post laparoscopic banding and subsequently removing the
laparoscopic band due to prolonged hospitalization in [**Month (only) **]
[**2144**] from a motor vehicle accident, history of rheumatoid
arthritis, high cholesterol, hypertension
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**First Name (STitle) 437**] in [**3-23**] weeks
Please follow-up with Dr. [**Last Name (STitle) 51789**] in 2 weeks.
Please call all providers for appointments
Scheduled Appointments:
1) Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-10-21**] 8:00
2) Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-10-21**] 8:30
3) Provider: [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 24317**], MD Phone:[**Telephone/Fax (1) 6429**]
Date/Time:[**2145-12-7**] 1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2145-9-20**]
|
[
"411.1",
"272.0",
"278.01",
"696.0",
"584.9",
"285.21",
"276.2",
"414.01",
"V49.83",
"428.32",
"428.0",
"V45.86",
"327.23",
"585.4",
"E947.8",
"250.40",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
11740, 11805
|
4624, 6530
|
311, 509
|
12493, 12500
|
3096, 4601
|
13298, 14255
|
2056, 2199
|
9318, 11717
|
11826, 12472
|
6556, 9295
|
12524, 13275
|
2214, 3077
|
261, 273
|
537, 932
|
954, 1714
|
1730, 2040
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,710
| 106,877
|
14215
|
Discharge summary
|
report
|
Admission Date: [**2135-7-11**] Discharge Date: [**2135-7-16**]
Date of Birth: [**2060-4-27**] Sex: M
Service: CCU
REASON FOR ADMISSION: Status post left carotid stent on
Neo-Synephrine.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman
(with past medical history of coronary artery disease, CABG
(5 years ago), atrial fibrillation, ejection fraction of 30%,
peripheral vascular disease) status post left internal
carotid artery stent on Neo-Synephrine for systolic blood
pressure goal of 120-160 mm Hg. The patient has a history of
visual blurring with standing. No vertigo or dizziness.
Patient had 2-3 episodes of hemiparesis (face, arm, and leg),
and left sided numbness 2-3x. It was decided to place a
stent in the ICA because of a progressive left sided lesion
to 95% with symptoms.
In the Catheterization Laboratory on [**2135-7-11**], the patient
underwent left ICA stent. The findings intraoperatively were
a 95% [**Doctor First Name 3098**] lesion, 40% [**Country **] lesion. After the stent, there
was a 10% residual stenosis on the left with ipsilateral
filling of the [**Doctor First Name 3098**]. Secondary to intractable hypotension,
the patient was placed on a Neo-Synephrine drip with a goal
systolic blood pressure of 120-160.
REVIEW OF SYSTEMS: Negative for chest pressure, discomfort,
shortness of breath, or dizziness.
SOCIAL HISTORY: The patient is married, lives in [**Location **],
[**State 350**]. Is a machinist. Does not smoke. Has not had
a drink of alcohol since [**2116**].
FAMILY HISTORY: Father died in [**2131**] of a CCY complication.
Mother died at 62 years of age, cause unknown.
PAST MEDICAL HISTORY:
1. Coronary artery disease four vessel disease.
2. Chronic atrial fibrillation on Coumadin.
3. Diabetes mellitus x20 years (hemoglobin A1C 7.0).
4. Congestive heart failure with an ejection fraction of 30%.
5. Mitral regurgitation.
6. Hypertension.
7. Osteoarthritis.
8. Hyperlipidemia.
9. Peripheral vascular disease.
10. Bilateral carotid disease as described above.
11. Alcohol abuse.
12. Gastric ulcer.
13. Panic attacks.
14. Tonsillectomy.
15. Cataract surgery.
16. CABG with a LIMA to LAD graft and saphenous vein graft to
OM-1, D1, D2 graft.
ALLERGIES: No known drug allergies. Potential allergy to
dye.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg po q day.
2. Metformin 850 tid.
3. Lisinopril 20 q day.
4. Isordil 20 [**Hospital1 **].
5. Lipitor 10 q day.
6. lanoxin 0.125 q day.
7. Toprol 50 [**Hospital1 **].
8. Persantine 75 tid.
9. Plavix 75 q day.
10. Norvasc 5 q day.
11. Coumadin 6/6/7.
12. Avandia 4 q day.
13. Amaryl 4 [**Hospital1 **].
14. Tranxene 7.5 tid.
PHYSICAL EXAM ON ADMISSION: Temperature 97.4. Blood
pressure on Neo-Synephrine 155/56. Heart rate 56.
Respiratory rate 20. Oxygenation 99% on 2 liters nasal
cannula. General: Patient appears younger than stated age
in no apparent distress, lying on back. Alert and oriented
times three with prompting. HEENT: Mucous membranes dry.
Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Neck is
supple. Neck veins are flat. Cardiovascular: Regular rate,
S1 greater than S2 at the apex, 2/6 systolic murmur at the
right base, 1+ carotid bruit on the right, nondisplaced point
of maximal impulse. Pulmonary: Clear to auscultation
bilaterally. Abdomen is nontender and nondistended,
normoactive bowel sounds, soft. Extremities: Right femoral
sheath clean, dry, and intact, 2+ dorsalis pedis, posterior
tibialis, and radial pulses bilaterally. No clubbing,
cyanosis, or edema. Neurologic: Cranial nerves II through
XII are grossly intact. Motor is [**5-9**] bilaterally. Sensation
is grossly intact.
LABORATORY STUDIES: Electrocardiogram showed normal sinus
rhythm at 75 beats per minute, left anterior fascicular
block, poor R-wave progression.
INR of 1.5. Sodium 140, potassium 4.7, chloride 106, bicarb
25, BUN 28, creatinine 1.4, glucose 84, hemoglobin A1C of
7.0.
Catheterization on [**2135-7-11**]: A stent was placed in the left
internal carotid artery, the dimensions of which were 8.0 x40
mm. The final residual is 10% with normal flow and no
dissections. Occlusion time seven minutes 0 seconds. The
patient remained neurologically intact throughout the
procedure.
BRIEF HOSPITAL COURSE: The patient was transferred to the
CCU from the Catheterization Laboratory, as he was on a
Neo-Synephrine drip.
ISSUES:
1. Intractable hypotension: The patient's Neo-Synephrine
drip was at 0.67 mcg/kg/minute on [**2135-7-12**]. Multiple
attempts at weaning with the systolic blood pressure goal of
120-160 were unsuccessful. The patient remained on
Neo-Synephrine until [**2135-7-16**], and maintained a systolic
blood pressure in the 120s-130s. Of note, all of his blood
pressure medications had been held.
2. Bradycardia: The patient's bradycardia was thought to be
secondary to heightened vagal tone. His heart rate remained
in the 40s throughout the majority of his inpatient stay. On
the day of discharge, his heart rate was normal sinus rhythm
in the 60s.
3. Anemia: The patient's nadir of his hematocrit was 27.6.
He was transfused 1 unit of packed red blood cells on
[**2135-7-12**]. It was presumed that the blood loss was secondary
to his catheterization. The patient received an additional
unit of packed red blood cells on [**2135-7-13**] to bring him to a
hematocrit of 33.3. The patient tolerated the transfusions
without difficulty.
4. Transient ischemic attack ?: The patient had an episode
of visual disturbance on [**2135-7-12**]. He described it as a
bilateral blurring/amaurosis fugax. The patient was also
transiently unresponsive. This episode lasted approximately
10-15 seconds. A neurological examination showed no motor or
sensory deficiency, no cranial nerve.
A STAT noncontrast head CT scan within one hour of symptom
onset demonstrated extensive evidence of chronic white
matter, small vessel ischemia with no other findings to
suggest acute or subacute infarction or hemorrhage.
The cause of the patient's transient vision changes and
unresponsiveness were not fully elucidated. A Neurological
consult was obtained with no additional recommendations.
5. Diabetes: The patient was placed on insulin-sliding scale
with qid fingersticks.
6. Agitation: The patient became increasingly agitated
throughout his hospital course. He was quite frustrated with
his clinical course. He was noted surreptitiously be taken
clorazepate from home and was continued on his clorazepate
7.5 tid po regimen with good effect. The patient was helped
markedly with frequent reorientation to person, place, and
time and reassurance and explanation regarding his clinical
course. It was recommended that BuSpar be tried as an
outpatient for the patient's anxiety disorder as Tranxene is
a long-acting benzodiazepine, which the patient was taking on
a prn basis.
7. Activity: The patient had a Physical Therapy evaluation
on [**2135-7-14**], which determined that he was stable to be
discharged home.
CONDITION ON DISCHARGE: On the date of discharge, the
patient's vital signs were as follows: Temperature 98.0,
blood pressure 156/60, respirations 14-19, heart rate in the
60s, and 98% on room air. Patient had been completely weaned
off Neo-Synephrine and was asymptomatic and hemodynamically
stable.
DISCHARGE STATUS: Good.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg one po q day.
2. Coumadin 1 po q day, adjusted to INR.
3. Aspirin 81 mg tablet one po q day.
4. Atorvastatin 10 mg one po q day.
5. Clorazepate 3.75 tablets two tablets po tid.
6. Metformin 850 mg tablet one po tid.
7. Avandia 4 mg tablet one po q day.
8. Amaryl 4 mg tablet one po bid.
RECOMMENDED FOLLOWUP: The patient was to go to [**Hospital Ward Name **] Four on
Monday, [**7-18**] for blood pressure check at 10 am. The patient
was to followup for a vascular study on [**2135-9-13**] at 2:30 pm,
and follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] on [**2135-9-13**] at 3 pm,
[**Telephone/Fax (1) 2207**]. The patient was advised to return to the
Emergency Room or call 911 with any new symptoms (eg,
lightheadedness, chest pressure, chest discomfort, shortness
of breath, dizziness, palpitations, vision or hearing
changes, weakness, or sensory loss).
PRIMARY DIAGNOSIS: Transient ischemic attack unspecified.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2135-8-21**] 16:49
T: [**2135-8-23**] 10:26
JOB#: [**Job Number 42269**]
|
[
"401.9",
"428.0",
"427.31",
"V45.81",
"433.10",
"414.00",
"250.00",
"272.0",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"88.41",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
4337, 7076
|
1566, 1663
|
7430, 8350
|
2326, 2679
|
1303, 1380
|
235, 1283
|
8370, 8687
|
2694, 4313
|
1685, 2300
|
1397, 1549
|
7101, 7407
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,723
| 126,274
|
6896
|
Discharge summary
|
report
|
Admission Date: [**2201-1-8**] Discharge Date: [**2201-2-6**]
Date of Birth: [**2146-1-30**] Sex: M
Service: MICU/[**Company 191**]
CHIEF COMPLAINT: Diarrhea, lightheadedness.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old
Chinese speaking man who presents with a seven day history of
chills, sweats and a three day history of diarrhea. The
patient was in his usual state of health until seven days ago
when he had experience dry mouth, urinary frequency, chills
and sweats. The patient denies fever, burning on urination,
vision changes, diarrhea, abdominal or flank pian. The
patient does not check his finger sticks despite being a
diabetic. The patient noted three days prior to admission
onset of nonbloody diarrhea, perfuse at times, progressive
shortness of breath. Today [**1-8**] the patient felt to be ill
for his usual phototherapy session that he has for his
nodularis pruritus. Primary care physician noted he was
orthostatic and was sent to the Emergency Department. In the
Emergency Department he was given intravenous fluids. His
temperature was noted to be 103 with rigors. He was cultured
and given antibiotics, Levo and Flagyl with a finger stick
noted to be at 500. The patient was admitted to the
Intensive Care Unit for insulin drip for diabetic
ketoacidosis, acute renal failure, diarrhea, fever, chills,
dehydration, rehydration. Of note, the patient on
antibiotics for skin lesions for about two to four weeks.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes type 2.
3. Nocturia.
4. Prurigo.
5. Medullarly sponge kidney.
MEDICATIONS:
1. Phototherapy.
2. Bactrim steroid creme.
3. Atarax prn.
4. Atenolol.
5. Oral hypoglycemic type unknown at present.
ALLERGIES: Aspirin gives him hives.
FAMILY HISTORY: Mother died of uterine cancer. Father died
of lung cancer, diabetes and eczema.
SOCIAL HISTORY: No tobacco, rare ETOH use. He was a chef in
restaurant. Divorced with two children. His sister's name
is [**Name (NI) **] at cell phone [**Telephone/Fax (1) 25998**].
PHYSICAL EXAMINATION: Vital signs temperature 99,
temperature max of 103. Blood pressure 106/62. Heart rate
96. Respiratory rate 36. 97% on room air. General, he is a
middle aged man in no acute distress resting comfortably.
HEENT pupils are equal, round and reactive to light.
Extraocular movements intact. Oropharynx moist with white
plaque on tongue. Cardiovascular regular rate and rhythm.
Normal S1 and S2 with a systolic ejection murmur at the left
upper sternal border. Cardiovascular bilaterally clear to
auscultation with decreased lung sounds at the bases.
Abdomen distended, tympanic, soft, nontender, increased bowel
sounds. Guaiac negative in the Emergency Department.
Extremities no clubbing, cyanosis or edema. Pulses intact
bilaterally. Skin with diffuse nodules over entire body,
many with excoriating lesions, face spared. Neurological
alert and oriented times three. Cranial nerves II through
XII intact, nonfocal examination.
LABORATORY: White blood cell count with 19.3, hematocrit
37.8, platelets 182, 91 NOB, 5 L, 3 M, .1 E, .2 B, INR 1.3,
CK 83, alkaline phosphatase 125, tox negative. ALT 29,
amylase 124, lipase 79, AST 34, TB .8. Urinalysis 1.020,
large blood, greater then 300 protein, trace glucose, trace
ketones, negative nitrates, bilirubin moderate LE, 3 to 5 red
blood cells, greater then 50 white blood cells, many
bacteria, no squamous epithelial. Electrolyte panel on 10:20
p.m., sodium 128, K 3.3, chloride of 96, bicarb 11, BUN 110,
creatinine 6.1, glucose 194, calcium 6.2, phos 4.8, mag 1.7.
Urine electrolytes creatinine 52, sodium 65, K 12, chloride
50, FENA 6%. Blood cultures and urine cultures were taken.
Electrocardiogram normal sinus rhythm at 94, axis normal, QRS
borderline, Q and 3, T wave inversion in 3, V3, V1. No ST
changes, acute line, borderline QRS with T wave inversion in
V3. Chest x-ray showed no acute process. Renal ultrasound
showed no hydro, large left kidney stone, multiple small
echogenic shadows on right, few simple cysts, largely
unchanged with prior study.
HOSPITAL COURSE: 1. Kidney: The patient presents with
fever, hypotension, elevated white blood cell count, elevated
white blood cells in urine, urine culture grew final staph
aureus coagulase positive. MRI was performed, which
demonstrated significant left pyelonephritis, specifically
the impression from the MR on [**2201-1-14**] was an enlarged
inflamed left kidney with very heterogenous striated contrast
enhancement consistent with infection and areas of
nonenhancement that likely represent infarction. The
differential included fulminant pyelonephritis, superimposed
on underlying sponge kidney, as well as
xanthogranulomatosis, pyelonephritis. The patient was
initially treated with Vancomycin and Ox and then Oxacillin.
The antibiotic was switched to Cefazolin in the setting or
rising liver function tests, amylase and lipase. Those
values trended down on Cefazolin. The patient was discharged
on a six to eight week course of intravenous antibiotics for
pyelonephritis.
2. Infectious disease: Blood cultures were obtained on
arrival. Blood cultures showed MSSA. As a result the
patient was maintained on intravenous antibiotics as noted
above. It was felt the likely source of the MSSA was from
the ulcerated skin lesions of the patient. The patient with
fever, high white blood cell count, hypotension and
bacteremia and the patient was felt to be septic. TTE and
then a transesophageal echocardiogram was performed to rule
out endocarditis, both were negative. Several screening
urine and blood cultures were performed, which were negative.
The patient's white blood cell count went down. The patient
was afebrile for the majority of his hospitalization. Of
note, the MR demonstrated multiple cystic lesions in the
kidney, however, it was concluded by the many specialists
that drainage of the cyst in the setting of the patient's
clinical improvement as well as improvement of the patient's
BUN and creatinine made that procedure not indicated during
his hospitalization. The patient will need screening
cultures at the conclusion of his antibiotic course. At that
time it will be decided whether the patient should have
either a biopsy and/or removal of the patient's kidney.
3. Diabetes: Patient with a history of type 2 diabetes
likely not well controlled at home. The patient not liking
to use insulin. The patient maintained on insulin throughout
his hospitalization and discharged with nursing staff and
nursing education regarding insulin.
4. Skin: Patient with a history of nodularis prurigo. The
patient was provided steroid cream in house. The patient
continued to be hypotensive and tachycardic in house during
hospital hospitalization. Endocrine was consulted to further
assess. A cortisol showed likely adrenal insufficiency
secondary to steroid cream and patient initiated on steroid
supplementation. The patient's hypotension and tachycardia
improved. The patient was seen by dermatology in house and
will be followed. The patient was initially given Flagyl in
house, however, given multiple negative C-difficile panels
the patient's Flagyl was discontinued. MR of the abdomen was
notable only for the kidney problems as the patient's
diarrhea improved.
5. Pulmonary: The patient of note had a chest x-ray on
admission, which was negative for infection, however, during
the hospitalization given the patient's continued tachycardia
and hypotension a VQ scan was performed to evaluate for
possible PE. The preliminary chest x-ray demonstrated a
pneumonia. The patient was started on Levaquin.
6. Endocrine: Patient with a history of anemia. The
patient provided with iron and Epogen in house.
Care of this patient was transferred on [**2-2**]. Dictation will
be continued.
DISCHARGE DIAGNOSES:
1. Sepsis.
2. Pyelonephritis.
3. Bacteremia.
4. Nodularis prurigo.
5. Pneumonia.
6. Diabetic ketoacidosis.
Of note, transferred to [**Company 191**] on [**2201-1-12**].
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2201-2-22**] 04:09
T: [**2201-2-23**] 13:12
JOB#: [**Job Number 25999**]
|
[
"560.1",
"255.4",
"577.0",
"785.59",
"584.9",
"590.11",
"276.1",
"038.11",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
1788, 1870
|
7883, 8295
|
4129, 7862
|
2081, 4111
|
167, 195
|
224, 1478
|
1500, 1771
|
1887, 2058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,213
| 156,407
|
52440
|
Discharge summary
|
report
|
Admission Date: [**2203-1-29**] Discharge Date: [**2203-2-1**]
Date of Birth: [**2168-10-6**] Sex: F
Service: MEDICINE
Allergies:
Insulin Pork Purified / Insulin Beef / Erythromycin Base /
Codeine / Aspirin / Compazine / Peanut
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] Bedside partial thickness debridement
History of Present Illness:
34 yo TI DM, triopathy, gastroparesis, long history of
medication non-complicance, foot ulcers, multiple admissions for
DKA presents with HA, nausea, AMS. In [**Name (NI) **], pt extremely
nauseous, rocking back and forth in bed and unable to answer
questions. She received phenergan, ativan, protonix, lopressor,
hydral and RIJ placed. Glucose 448 with AG 12 therefore patient
given insulin SQ and admitted to the floor.
Past Medical History:
1. Diabetes mellitus type 1, diagnosed at age 7. The patient
has had multiple episodes of diabetic ketoacidosis in the past.
Her DM is complicated by neuropathy, nephropathy, and
retinopathy.
2. Chronic renal insufficiency, now failure with creatinine
around 7, starting peritoneal dialysis
3. History of gastroparesis, with episodes of nausea and
vomiting.
4. Atypical chest pain.
5. Hypertension.
6. Asthma.
7. Chronic right foot ulcer being followed by Dr. [**Last Name (STitle) 108352**] of
[**Last Name (STitle) **].
8. Chronic diarrhea- incontinant of stool since abcess removed
([**2194**]).
9. Recurrent pyelonephritis.
10. ECHO [**3-6**]: <b>EF 75%</b>. No WMA/valvular abnormalities.
11. Chronic diarrhea since [**2194**] when she had an abcess removed
from her anus. Since then she has been on chronic loperimide.
12. history of hematemesis and EGD on [**9-22**] revealed Grade IV
esophagitis with contact bleeding was seen in the distal
esophagus, Erythema in the stomach body and fundus compatible
with gastritis.
Social History:
The patient lives in [**Location 686**]. Her PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
She notes that she smokes 2 packs of cigarettes every 5 days.
She has smoked for the past 7 years. She denies use of alcohol
or illicit drugs.
Had been in abusive home relationship. Has close support with
multiple family members nearby.
Worked as nurse's aide in [**Hospital1 2025**] psych [**Hospital1 **] but taking leave due to
her medical problems. Currently going to nursing classes part
time.
Family History:
Father with type 2 DM, CHF, CVA
Physical Exam:
VS 100.7, 200/137, 95, 19, 100%RA
Gen - uncomfortable, chronically ill appearing
HEENT - PERRL, EOMI, opens eyes to commands, poorly dentition
Neck - supple, no JVD, No LAD
Cor - RRR, [**1-7**] diastolic murmur
Chest - CTAB
Abd - S/NT/ND +BS, slightly distended
Ext - no edema, 2+DP pulses, skin with numerous hyperpigmented
lesions over LEs, no purulent drainage
Neuro- lying in bed, does not answer questions, moves all 4
extremeties
Rectal - guaiac neg brown stool (per ED)
Pertinent Results:
[**2203-1-29**] 04:00PM GLUCOSE-242* UREA N-33* CREAT-2.9* SODIUM-144
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-20* ANION GAP-18
[**2203-1-29**] 04:00PM PHOSPHATE-3.6 MAGNESIUM-2.0
[**2203-1-29**] 12:00PM GLUCOSE-153* UREA N-31* CREAT-2.5* SODIUM-145
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-22 ANION GAP-17
[**2203-1-29**] 12:00PM CK(CPK)-352*
[**2203-1-29**] 12:00PM CK-MB-1 cTropnT-<0.01
[**2203-1-29**] 12:00PM ACETONE-LARGE
[**2203-1-29**] 12:00PM WBC-19.5* RBC-3.01* HGB-9.3* HCT-28.7* MCV-95
MCH-30.8 MCHC-32.3 RDW-14.1
[**2203-1-29**] 12:00PM PLT COUNT-562*
[**2203-1-29**] 11:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2203-1-29**] 11:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
admit EKG: Sinus rhythm. Baseline artifact. Normal ECG. Compared
to the previous tracing
of [**2203-1-25**] no diagnostic interim change.
KUB: Distribution of bowel gas is unremarkable and there is no
evidence for gastric dilatation or intestinal obstruction.
Plain film R foot: No evidence of osteomyelitis. A three phase
bone scan may be helpful in further evaluation.
Brief Hospital Course:
Impression: 34 yo with Type I DM, triopathy, gastroparesis,
multiple admissions for DKA presents with AMS, emesis and
evidence of DKA.
Hospital Course:
[the following hospital course is compiled solely by med record
review]
1. DKA - patient intially managed on the floor with SQ insulin,
however, this was found to be ineffective glycemic control. In
combination with her continued somnolence/AMS, she was
transferred to the MICU for insulin gtt and monitoring. Her
glucose normalized over the next 3 days and her urinary ketones
resolved. Her insulin gtt was then stopped.
Before her insulin gtt was stopped, [**Known firstname 3608**] was noted to be
eating non-diabetic food brought in from outside the hospital.
Once the insulin gtt was stopped and she had been given adequate
SQ insulin, arrangements were made for floor transfer. The
patient physically was transferred to the medicine [**Hospital1 **],
however, she decided to sign out AMA. This is very similar to
behaviour on prior admissions. She demonstrated understanding
of the risks of leaving AMA.
2. UTI - pan sensitive ecoli treated with levaquin -> cipro
3. ?UGIB - was thought to have coffee ground emesis in ED x1.
transfused 1 u prbcs with stablization of hct. Was guaiac
negative. No further work up was performed.
4. Anemia - combination of anemia of chronic dz and blood loss
anemia. at baseline by discharge.
5. Osteomyelitis - per [**Hospital1 **], right foot ulcer probed to
bone. in association with elevated ESR, she was started on
zosyn and vanc with plans to complete 6 weeks course. due to
her non-compliance, [**Hospital1 **] did not think OR debridement was
indicated. Additionally, she left AMA before plans for long
term abx could be made. she was discharged with augmentin and
cipro.
Medications on Admission:
protonix 40
mvi
reglan
lipitor
lantus 22 hs
HISS
lopressor 25 [**Hospital1 **]
lisinopril 5
albuterol
phenergan
sl ntg
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO three times a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual every four (4) hours as needed for chest pain:
contact MD if more than 3 tabs in 15 mins.
8. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
9. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**12-3**] puff
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
11. Phenergan 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*1*
12. Neurontin 100 mg Capsule Sig: Two (2) Capsule PO once a day.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation. Tablet(s)
14. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: HISS Subcutaneous four
times a day: humalog insulin sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]
recommendations.
16. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day for 4
weeks.
Disp:*56 Tablet(s)* Refills:*0*
17. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 4 weeks.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Osteomyelitis
Type I DM
DKA
Medication Non-compliance
Gastroparesis
Nausea and Vomiting
Discharge Condition:
unstable, but patient wishes to Leave AMA and refuses further
medical work-up. patient understands risks of leaving AMA
including recurrence of DKA leading to coma or even death.
Discharge Instructions:
D/C to Home AMA
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 722**] [**Hospital 1947**] CLINIC Where: CC-2
[**Hospital 1947**] UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2203-2-4**] 11:10
2. Provider: [**First Name8 (NamePattern2) 1775**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2203-2-9**] 2:30
|
[
"730.27",
"401.9",
"593.9",
"707.14",
"250.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7876, 7895
|
4233, 4370
|
361, 425
|
8027, 8208
|
3035, 4210
|
8272, 8703
|
2490, 2523
|
6194, 7853
|
7916, 8006
|
6051, 6171
|
4387, 6025
|
8232, 8249
|
2538, 3016
|
318, 323
|
453, 879
|
901, 1938
|
1954, 2474
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,919
| 126,015
|
39875
|
Discharge summary
|
report
|
Admission Date: [**2141-8-16**] Discharge Date: [**2141-8-30**]
Date of Birth: [**2100-11-24**] Sex: M
Service: MEDICINE
Allergies:
Propoxyphene / Methadone / pseudoephedrine / Peanut / Adhesive
Bandage / Banana
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fever, chest pain, hypotension
Major Surgical or Invasive Procedure:
Temporary L femoral line placement [**2141-8-16**]
Temporary L femoral line removal [**2141-8-18**]
Incision and drainage of L axillary fluctulant mass [**2141-8-18**]
Removal of RLE femoral HD catheter [**2141-8-21**]
Placement of LLE femoral HD catheter [**2141-8-24**]
Placement of LUE brachial midline venous line (unsuccessful
attempted PICC line placement) [**2141-8-25**]
History of Present Illness:
40yoM with HIV on HAART (CD4 411 on [**4-17**]), ESRD on HD with
multiple graft complications s/p R forearm amputation and
infections (including h/o ESBL sepsis) presented with fever
noted at dialysis center.
Pt was recently hospitalized ([**7-18**]) for pain at R groin tunnel
cath and (as per pt) fever. Pt was empirically rx'd with vanc.
Pt was in USOH until Thursday [**8-10**], when he noted throbbing pain
(radiating to L chest wall) after L axillary LN biopsy. Since
then, he reports progressive pain at site.
On AM of admission, pt reported noting a fever of 103.4 and at
dialysis center, fever of 102.1 was noted. Pt reports feeling
chills and vomited x 1 (non-bloody, non-bilious). Pt also had 1
episode of non-bloody diarrhea (no abd pain).
At dialysis center, pt received Received 1g vanc, 125 gent
ED vitals: 103.4, 110, 116/49, 16, 97%ra
VS 99.5, 113/55, 97, 15, 96%ra
Patient was hypotensive to 80's/60's and received 1.5L iv NS and
meropenem 1g on transfer to MICU. Pt remained stable in MICU.
On transfer to floor, pt complains of L chest pain (EKG shows no
changes).
Past Medical History:
-- ESRD on HD since 4 years due to HTN/DM
-- R tunneled groin cath placed [**6-17**]
-- AV graft failure SP R forearm amputation for recurrent infxn
-- HIV (CD4 411 in [**4-17**], VL undetectable)
-- H/O ESBL sepsis last year
-- C diff colitis [**5-18**]
-- HTN
-- DMII
-- Asthma
-- GERD
-- Chronic phantom limb pain
-- Retinal detachment
Social History:
- Incarcerated
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Endorses marijuana approximately 7 years ago
Family History:
Hypertension, CAD, COPD, bone cancer
Physical Exam:
Physical exam on admission:
Vitals: T98.2 BP: 123/49 P:85 R: 12 O2: 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, R submandibular LAD, rubbery, nontender
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, RUQ tenderness, no rebound, non-distended, bowel
sounds present, no organomegaly
GU: no foley
Ext: warm, peripheral edema bilat R>L, fluctuant mass on R
antecub, nontender, non erythematous, dystrophic nails with
crusting, 4 toes on L foot, no ulcers
ACCESS: R groin line- no erythema, purulent discharge,
induration; L femoral line in place
Neuro: CNII-XII grossly intact, 5/5 strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred
Physical Exam on Discharge
VS: 98.7, BP 134/79, P 85, RR 21, O2 Sat 100% on RA
General: Pt appears intermittently uncomfortable but mostly
laying calmly in bed
HEENT: +L prosis (baseline), sclera anicteric, MMM, Ulcerative
oral lesions (clean base) on palate; PERRL
Neck: Supple, submandibular R posterior neck LAD palpable
(rubbery, nontender)
CV: Regular rate and rhythm, normal S1 + S2, +systolic murmur
([**3-13**])
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +RUQ tender hepatomegaly (slight), no rebound,
non-distended
Ext:
L wound sp I+D, clean edges, packed with dressing, draining
serous discharge. Peripheral LE non-pitting edema R>L. R
antecubital fluctulant mass (non-tender, non erythematous), 4
toes on L foot.
Lines:
L groin HD catheter in place: bloody discharge, tender to
palpation, no erythema, no induration
LUE Midline catheter (tender to palpation, with significant
fluctulance in area of line entry, no erythema or warmth).
Neuro: CNII-XII grossly intact, 5/5 strength upper/lower
extremities, grossly normal sensation.
Pertinent Results:
Admission Labs:
[**2141-8-16**] 07:35PM BLOOD WBC-14.8*# RBC-4.55* Hgb-10.5* Hct-31.7*
MCV-70* MCH-23.0* MCHC-33.0 RDW-19.6* Plt Ct-291#
[**2141-8-17**] 03:53AM BLOOD WBC-14.0* RBC-4.47* Hgb-10.3* Hct-31.6*
MCV-71* MCH-23.1* MCHC-32.7 RDW-19.6* Plt Ct-292
[**2141-8-16**] 07:35PM BLOOD Neuts-88.4* Lymphs-7.1* Monos-3.5 Eos-0.7
Baso-0.4
[**2141-8-16**] 07:35PM BLOOD Plt Ct-291#
[**2141-8-17**] 03:53AM BLOOD PT-13.2* PTT-34.3 INR(PT)-1.2*
[**2141-8-16**] 07:35PM BLOOD Glucose-103* UreaN-35* Creat-6.8*# Na-141
K-4.3 Cl-95* HCO3-34* AnGap-16
[**2141-8-17**] 03:53AM BLOOD Glucose-121* UreaN-39* Creat-7.6* Na-138
K-4.6 Cl-94* HCO3-33* AnGap-16
[**2141-8-16**] 07:35PM BLOOD ALT-68* AST-112* AlkPhos-269* TotBili-0.5
[**2141-8-17**] 03:53AM BLOOD ALT-87* AST-131* AlkPhos-261* TotBili-0.5
[**2141-8-16**] 07:35PM BLOOD cTropnT-0.16*
[**2141-8-17**] 03:53AM BLOOD cTropnT-0.18*
[**2141-8-17**] 03:53AM BLOOD Albumin-4.3 Calcium-9.4 Phos-4.7*# Mg-2.2
Pertinent Labs:
[**2141-8-16**] 07:35PM BLOOD Neuts-88.4* Lymphs-7.1* Monos-3.5 Eos-0.7
Baso-0.4
[**2141-8-18**] 06:10AM BLOOD Neuts-72.9* Lymphs-15.6* Monos-7.5
Eos-2.9 Baso-1.1
[**2141-8-16**] 07:35PM BLOOD ALT-68* AST-112* AlkPhos-269* TotBili-0.5
[**2141-8-17**] 03:53AM BLOOD ALT-87* AST-131* AlkPhos-261* TotBili-0.5
[**2141-8-18**] 06:10AM BLOOD ALT-59* AST-57* LD(LDH)-162 CK(CPK)-83
AlkPhos-267* TotBili-0.3
[**2141-8-19**] 06:10AM BLOOD ALT-49* AST-47* LD(LDH)-164 CK(CPK)-51
AlkPhos-295* TotBili-0.4
[**2141-8-20**] 08:05AM BLOOD ALT-38 AST-32 LD(LDH)-176 CK(CPK)-55
AlkPhos-281* TotBili-0.4
[**2141-8-16**] 07:35PM BLOOD cTropnT-0.16*
[**2141-8-17**] 03:53AM BLOOD cTropnT-0.18*
[**2141-8-18**] 06:10AM BLOOD CK-MB-2 cTropnT-0.15*
[**2141-8-19**] 06:10AM BLOOD CK-MB-1 cTropnT-0.17*
[**2141-8-20**] 08:05AM BLOOD CK-MB-2 cTropnT-0.16*
[**2141-8-21**] 07:30AM BLOOD CK-MB-1 cTropnT-0.16*
[**2141-8-18**] 10:20AM BLOOD PTH-307*
[**2141-8-21**] 06:15AM BLOOD PTH-291*
[**2141-8-25**] 07:18AM BLOOD PTH-309*
[**2141-8-17**] 03:53AM BLOOD HCV Ab-NEGATIVE
[**2141-8-16**] 07:35PM BLOOD Lactate-2.0
Microbiology:
Blood cultures from [**Hospital 77720**] [**Hospital 87724**] Clinic: VRE
Blood cultures [**2141-8-16**]: negative
Catheter tip Cx [**2141-8-21**]: negative
BCx [**2141-8-21**]: PND
BCx [**2141-8-23**]: PND
Throat viral Cx [**2141-8-22**]: prelim negative
C diff assay [**2141-8-19**]: negative
Wound Cx from L axillary wound [**2141-8-18**]:
GRAM STAIN: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO
MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2141-8-20**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE. RARE GROWTH OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2141-8-22**]): NO ANAEROBES ISOLATED.
Discharge Labs:
[**2141-8-30**] 07:57AM BLOOD WBC-5.0 RBC-4.47* Hgb-10.1* Hct-31.7*
MCV-71* MCH-22.7* MCHC-31.9 RDW-20.1* Plt Ct-236
[**2141-8-30**] 07:57AM BLOOD Glucose-119* UreaN-60* Creat-8.6* Na-143
K-5.6* Cl-99 HCO3-30 AnGap-20
[**2141-8-30**] 07:57AM BLOOD ALT-16 AST-19 LD(LDH)-147 AlkPhos-182*
TotBili-0.3
[**2141-8-30**] 07:57AM BLOOD Calcium-10.1 Phos-8.0* Mg-2.5
Radiology:
LUE US [**2141-8-26**] (preliminary): 1. No son[**Name (NI) 493**] evidence for
left upper extremity DVT with PICC in one of four left brachial
veins. 2. Left upper extremity graft, incompletely evaluated,
likely thrombosed.
RLE US [**2141-8-26**]: IMPRESSION: No son[**Name (NI) 493**] evidence for right
lower extremity deep vein thrombosis. Enlarged right inguinal
lymph node as seen on previous CT.
CT Abd/Pelvis [**2141-8-25**] (to assess for hematoma in LLE):
IMPRESSION: No acute hematoma. A left femoral approach central
venous catheter terminates at lower cavoatrial junction.
R neck US [**2141-8-22**]: Single non-specific non-pathologically
enlarged lymph node in the right side of the neck. No fluid
collection or soft tissue mass is identified.
Echo [**2141-8-22**]: IMPRESSION: No valvular vegetations seen
(good-quality study). Symmetric LVH with normal global and
regional biventricular systolic function. Mild mitral
regurgitation. Moderate pulmonary hypertension.
LUE US [**2141-8-17**]: Mixed echogenic left axillary mass,
predominantly hypoechoic, could represent phlegmon versus
hematoma. Tiny ring-down artifacts may represent foci of gas or
surgical packing material.
RUQ US [**2141-8-16**]: IMPRESSION: Mild intrahepatic bile duct
dilation within the left lobe. Normal CBD. No ultrasound
evidence for acute cholecystitis.
CT Abd/Pelvis [**2141-8-16**]: Limited evaluation due to lack of IV
contrast and paucity of intra-abdominal Preliminary Reportfat.
Within these limitations, no acute intra-abdominal process is
noted. No acute intra-abdominal process is noted on this limited
exam.
CXR [**2141-8-16**]: no acute process
Brief Hospital Course:
Mr. [**Known lastname 15532**] was admitted for treatment of sepsis. He was treated
for the following acute conditions:
Active Issues:
# Pain at midline catheter site
On [**2141-8-26**], pt was noted to have LUE Pain at midline catheter
site. There was no warmth, erythema or evidence of
extravasation. LUE ultrasound showed no son[**Name (NI) 493**] evidence for
left upper extremity deep vein thrombosis, a left upper
extremity graft not well evaluated but likely thrombosed, and a
mid-line catheter in one of 4 left brachial veins.
# VRE Sepsis:
As per records from [**Last Name (un) 77720**] prison, paitnet had VRE bacteremia
based on blood cultures drawn at that time. The source was most
likely the R femoral HD catheter (although tip culture
negative). Blood cx from [**2141-8-16**], [**2141-8-21**], and [**2141-8-23**] were
negative. Pt had originally been treated with vancomycin but
this was discontinued on [**2141-8-21**] and Linexolid was started on
[**2141-8-21**]. Linezolid was later changed to Ampicillin IV q12h on
[**2141-8-22**], on recommendation of the infectious disease consulting
team. Pt underwent removal of the R HD femoral line [**2141-8-21**]. R
femoral site was tender to palpation but nothing was draining
and pain resolved prior to discharge. To facilitate
hemodialysis, a L femoral HD tunnel catheter placed on [**2141-8-24**]
succesfully with no evidence of infection. Pt is also sp midline
catheter ([**2141-8-25**]) on LUE (IR team unable to place PICC) for
administration of ampicillin in his prison facility.
- Continue Ampicillin 2g IV q12h (2 week course intended;
[**2141-8-21**] - [**2141-9-3**])
#ESRD: Pt was on HD three times/wk (MWF). Last succesful
dialysis [**2141-8-24**] (dialysis on [**2141-8-25**] was unsuccesful [**3-9**]
patient inability to tolerate it). HD tunnel catheter (L
femoral) placement in succesful on [**2141-8-24**] as per I/R team.
- Please check Ca x Phosphate product, if >55, hold activated
Vit D supplementation to prevent calcium phosphate crystal
deposition
#Left Axillary lymphadenopathy
s/p LN bx on [**8-10**] and developed swelling and pain thereafter.
Acute care surgery was consulted and did I/D ([**2141-8-18**]) and pt
feeling better. Culture growing coag-negative staph (likely s.
epidermitis). Later, wound noted to be draining serous material
and surgery was re-consulted to evaluate sufficiency of packing
and possibility of closure by secondary intention/further I+D.
Surgery recommended continued wound packing with dry gauze.
#Ulcerative oral lesions/R neck pain
On [**2141-8-21**], lesions were noted on upper gums, raised,
hypopigmented and reported tender. Likely HSV. Pt continued to
have mouth pain [**3-9**] lesions, which have expanded to L side of
mouth and are stable now. Pt reporting jaw and neck pain (neck
pain likely [**3-9**] reactive LN from oral infxn), which is now
improving. Prelim HSV culture negative.
- Lidocaine mouth wash
- FU Final HSV Culture
- Pt completed 7d coutse of acyclovir 200mg po q8h ([**2141-8-21**] -
[**2141-8-27**])
Inactive Issues:
# HD Reaction/Chest Pain
On [**2141-8-25**], pt reported myalgias, chest pain and began to shake
while undergoing dialysis. He reported a "tingling" feeling in
his extremities. There was no evident explanation for this
reaction. [**Month (only) 116**] be [**3-9**] pt's electrolyte changes (pt hyperkalemic
in recent past). Pt not febrile and CP reproducible on
palpation/no EKG changes. Pain resolved spontaneously.
# L groin pain
On [**2141-8-25**], pt noted pain in the L femoral region, around site
of tunnel catheter placement. Pain was radiating to back as per
pt. There was concern for retroperitoneal hematoma given pt's
complicated vascular anatomy. Non-contrast CT of pelvis was
negative for hematoma and back pain resolved.
# Discomfort while receiving IV antibiotics
On [**2141-8-26**], pt reported a "funny" sensation associated with abx.
It was described as a chill on his L chest wall. This was likely
feeling of abx entering through catheter. RRR on heart exam and
no EKG changes. Pt received amp IV x 5d so allergic reaction
unlikely. No pruritis, urticaria, SOB, laryngeal sx to suggest
allergic rxn. Ampicillin infusion was completed succesfully at a
slower rate.
# Hyperkalemia
When not on dialysis, pt had episodes of hyperkalemia (i.e. on
[**2141-8-23**], pt persisted with elevated K despite metolazone, lasix
and kayexelate) above what renal team would expect given pt's
diet. Although no EKG changes, review of pt's meds revealed that
pt was on Lisinopril during this admission. It was previously
DC'd by renal [**3-9**] causing pt to have hyperkalemia. Lisinopril
was DC'd but pt remained hyperkalemic. Pt was placed on a low K
diet.
- Please continue low K diet.
# LE edema R>L
- No evidence of DVT on US
#Transaminitis (resolved)
Hep B negative and Hep C negative. Unlikely direct infectin of
hepatobilliary tract given mostly negative US/CT findings. Now
at baseline. The elevation was likely [**3-9**] sepsis.
#HIV: Last CD4 411 ([**2141-4-10**])
- On HAART: emtricitabine, abacavir, efavirenz
#Anemia:
Most likely [**3-9**] renal failure hx.
- On EPO with HD and Ferrous gluconate and folic acid
supplements
#DM:
FSG well-contolled. Will continue humalog ISS. On Diabetic diet
and ISS during current admission.
#HTN: Home meds: labetalol 800 three times daily, amlodipine 10
mg daily, minoxidil 10 mg daily. Held during admission due to
sepsis/hypotensive episode. Home meds restarted slowly. DC'd
Lisinopril due to hyperkalemia. On amlodipine, minoxidil, and
labetalol per home bp regimen. Dialysis as scheduled will help
in management of HTN episodes. Please consider titrating up BP
meds as necessary or restarting lisinopril with careful
potassium monitoring.
#GERD:
Hx of omeprazole use for GERD put was not on active medication
list from prison.
- Please re-assess for need to continue Omeprazole
#Seizure disorder
On Keppra
Transitional issues:
- Please follow up HSV viral culture for oral lesions
- Please follow-up LFTs, may need to review medications
including HAART medications if transaminitis recurs
- Please provide regular lower extremity monitoring for
worsening of swelling and/or diabetic ulcers.
- Please follow-up on pathology from L LN biopsy
- Please monitor progression or improvement of L axillary wound
and continue thorough dry packing at least two times per day
- Please arrange to follow-up with nephrology and transplant to
plan for graft/fistula establishment in proximal RUE,
tentatively set for [**Month (only) 216**].
- Please note, pt complains of a throbbing, reproducible pain at
the anterior chest wall, if this pain recurs, please compare his
EKG at time of pain with a baseline EKG (no EKG changes have
been noted during this admission).
- Please note, pt had elevated troponin levels on admission
(0.16 - 0.18, stable on several repeat draws). Given pt's renal
failure and low CK-MB fraction, this was not thought to be due
to cardiac ischemia.
- Please note lymphadenopathy noted in R neck, RUE, LUE and L
axilla (sp biopsy and I+D) - please monitor lymphadenopathy to
resolution after completion of treatment for VRE sepsis.
- Please check Ca x Phosphate product, if >55, hold activated
Vit D supplementation to prevent calcium phosphate crystal
deposition
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. LeVETiracetam 1000 mg PO BID
2. sevelamer CARBONATE 4000 mg PO TID W/MEALS
3. Doxercalciferol 2.5 mcg PO MWF
With HD
4. HydrOXYzine 50 mg PO MWF
HD Protocol
5. Labetalol 800 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. Senna 2 TAB PO HS
8. Aspirin 81 mg PO DAILY
9. Amlodipine 10 mg PO DAILY
10. Minoxidil 10 mg PO BID
11. DiphenhydrAMINE 25 mg PO TID
12. Epoetin Alfa 20,000 unit SC MWF Start: HS
with HD
13. Emtricitabine 200 mg PO MF
14. FoLIC Acid 1 mg PO DAILY
15. Abacavir Sulfate 300 mg PO BID
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
17. Efavirenz 600 mg PO QHS
18. Ferrous Gluconate 325 mg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 300 mg PO BID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. Efavirenz 600 mg PO QHS
8. Emtricitabine 200 mg PO MF
9. Ferrous Gluconate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Labetalol 800 mg PO TID
12. LeVETiracetam 1000 mg PO BID
13. Minoxidil 10 mg PO BID
14. Senna 2 TAB PO HS
15. sevelamer CARBONATE 4000 mg PO TID W/MEALS
16. Ampicillin 2 g IV Q12H
On HD days, please dose after HD
RX *ampicillin sodium 1 gram IV every 12 hours Disp #*16 Bag
Refills:*0
17. Lidocaine Viscous 2% 20 mL PO TID:PRN mouth pain.
RX *lidocaine HCl 20 mg/mL Oral Three times per day Disp #*1
Container Refills:*0
18. Epoetin Alfa 20,000 unit SC MWF
with HD
19. HydrOXYzine 50 mg PO MWF
HD Protocol
Discharge Disposition:
Extended Care
Facility:
[**Location **]
Discharge Diagnosis:
Primary diagnosis: Sepsis
Secondary diagnosis: Left axillary abscess, end stage renal
disease, hypertension, Diabetes type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 15532**],
You were admitted with fever from your dialysis center. Your
blood pressure dropped and you were transferred to the intensive
care unit. You were found to have an infection of the blood
(your outside hospital records showed that you had bacteria in
your blood during the dialysis). We think that the infection
most likely came from your right groin dialysis catheter.
Unfortunately, this catheter is very important for you to
continue to undergo dialysis. It was removed and another
hemodialysis catheter was placed in your left groin. You were
treated with antibiotics for your blood infection and a midline
venous line was placed in your left arm to allow you to receive
these antibiotics.
You also underwent incision and drainage of the left underarm
lymph node (which was previously biopsied). The wound is now
healing. Finally, you were found to have oral lesions, which are
likely caused by a virus (HSV), which we have treated with
antibiotics.
Again, it was a pleasure to take care of you at [**Hospital1 18**].
We made the following changes to your medications:
- Please START taking ampicillin IV until [**9-3**]
- Pleast STOP taking vitamin D.
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2141-9-14**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2141-8-31**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
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"86.04",
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icd9pcs
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[
[
[]
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18093, 18135
|
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371, 752
|
18306, 18306
|
4386, 4386
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|
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2455, 4367
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|
5354, 7059
|
1892, 2232
|
2248, 2358
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,268
| 143,700
|
6893
|
Discharge summary
|
report
|
Admission Date: [**2102-2-4**] Discharge Date: [**2102-2-9**]
Date of Birth: [**2022-8-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
fever, rash
Major Surgical or Invasive Procedure:
Skin Biopsy
History of Present Illness:
Pt is a 79 yo female with history of hyperlipidemia, depression,
who is also on anti-psychotics for psychiatric/behavior issues
who presents with one week of rash and oral mucosal lesions. The
rash was accompanied by fevers to 102 one day after the rash and
flu-like illness inlcuding cough non-productive of sputum, nasal
drainage, nausea, chills and rigors, headache. Patient reports
onset of rash approximately one week ago on Sunday, when she
noted an erythematous, maculopapular rash on her palms that
eventually spread towards her trunk, arms, legs and back and
soles. Rash also appeared targetoid in nature mostly on her
abdomen. She was also have great difficulty swallowing due to
the oral lesions in her mouth. Denies any issues with eye or
vaginal lesions. Patient denies any sick contacts. The patient
eventually became dehydrated and weak to the point that she was
unable to rise from bed, so she presented to [**Hospital1 18**] [**Location (un) 620**] ED on
[**2102-2-2**] evaluation and was started on Ciprofloxacin (after the
rash started) for presumed UTI. She denied any other new
medications including allopurinol, other antibiotics, or new
anti-epileptics. She was taking NSAIDs (ibuprofen) for her
fever. She is on anti-psychotics chronically including She
followed up with her PCP [**Last Name (NamePattern4) **] [**2102-2-3**] who stopped the antibiotic.
She was referred to the ED today by her PCP due to concern for
progressing [**Doctor Last Name **]-[**Location (un) **]-Syndrome.
.
In the emergency department, VS were 98.4 125 123/86 16 97% RA.
Pt received viscous lidocaine, Vancomycin 1 gram IV x1, Cefepime
IV x1. Labs were significant for lactate of 3.6, ALT 132, AST
119, WBC 6.6, Hct of 30.9, Trop-T of 0.17. Lactate initially
3.6->2.4 with 1.5 L of IVFs. Dermatology was consulted in the
ED, and thought rash was due to erythema multiforme , and
recommended admission for supportive care, prednisone, and
performed a punch biopsy of the skin lesions and DFA/culture of
an oral mouth lesion.
.
Also in the ED, patient was initially in sinus tachycardia to
120s but would intermittently burst into paroxysms of atrial
fibrillation with RVR into the 170s and would become tachypneic
and short of breath, concerning for flash pulmonary edema.
Cardiology was consulted for possible cardioversion, but pt
converted spontaneously. Cards performed a bedside TTE which per
ED report showed normal EF and no depressed global ventricular
function. Cardiology recommended starting metoprolol or
amiodarone for the atrial fibrillation.
Past Medical History:
Psychiatric/Behavioral Issues
Dyskinesia (from psych meds)
Hyperlipidemia
Lumbar Spine DJD
Osteoporosis
Fatigue/Depression
Lower Back Pain
Social History:
Lives with her husband in [**Name (NI) 620**], who has myasthenia [**Last Name (un) 2902**].
Denies illicits including tobacco, EtOH, or IVDU. No recent
travel. No tick bites.
Family History:
father with stroke. Mother healthy. [**Name2 (NI) **] history of SJS or EN in
family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 125 123/86 16 97% RA
GEN: elderly F no acute distress
HEENT: PERRLA. MMM. small pearly oral lesions noted on roof of
mouth.
NECK: no LAD. neck supple
PULM: CTAB no crackles or wheezes
CARD: S1/S2 present, no m/g/r.
ABD: soft NT +BS no g/rt.
EXT: wwp no edema
SKIN: maculopapular erythematous rash scattered on palms, soles,
arms, legs, trunk, and back. targetoid lesions noted mostly on
trunk. no nailbed lesions noted.
NEURO: cns II-XII intact. 5/5 strength in upper and lower
extremities. sensation grossly intact. reflexes [**1-29**]+ bilaterally
biceps, achilles.
DISCHARGE PHYSICAL EXAM:
VS: T: 99.8 P:76 (24 hr avg 101) BP:124/67 R:20 O2:92RA%
GEN: elderly F in no acute distress, conversational
HEENT: PERRLA. MMM. No oral lesions visible on mucosa
NECK: no LAD. neck supple
PULM: CTAB, no wheezes, LLL mild rhonchi
CARD: S1/S2 present, no m/g/r, irregularly irregular
ABD: soft NT +BS no g/r/t.
EXT: wwp no edema
SKIN: rash largely resolved on arms and legs, hands
Pertinent Results:
Admission Labs
Chemistries:
7.46/30/58/22 (VBG)
.
Lactate:3.6 ->2.4
.
Trop-T: 0.17
.
135 102 32 155 AGap=16
4.3 21 0.9
.
estGFR: 60/73
.
Ca: 9.0 Mg: 2.3 P: 1.3
ALT: 132 AP: 98 Tbili: 0.6
AST: 119 Lip: 21
.
CBC and Coags:
MCV = 85
6.6 >11.0< 165
------------
30.6
.
N:84 Band:3 L:8 M:4 E:0 Bas:0 Atyps: 1
.
STUDIES:
CXR: [**2102-2-4**] #1 Bilateral small pleural effusions, with
associated basal opacities, which likely represent atelectasis.
More confluent right base opacity, can not exclude early/mild
consolidation.
.
CXR: [**2102-2-4**] #2 Bilateral pleural effusions, with mild pulmonary
edema. Bibasilar opacities likely representing atelectasis.
.
CXR: [**2102-2-5**] There is interval improvement in pulmonary edema,
currently almost completely resolved. Bibasilar opacities
accompanied by bilateral pleural effusions are still present and
might represent multifocal infection versus residue of pulmonary
edema. Given the accumulation of pleural effusion since
yesterday, they are potentially reactive to the pulmonary
process, thus multifocal infection would be a consideration.
Cardiomediastinal silhouette is stable and grossly unremarkable.
.
ECHO: [**2102-2-4**] The left atrium is elongated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thicknesses and cavity
size are normal. There is mild to moderate global left
ventricular hypokinesis (LVEF = 40 %). The estimated cardiac
index is normal (>=2.5L/min/m2). 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) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. Suboptimal image quality. Normal
biventricular cavity sizes with mild-moderate global
biventricular hypokinesis c/w diffuse process (tachycardia,
toxin, metabolic, etc.). Mild mitral regurgitation. Mild
pulmonary artery systolic hypertension.
.
MICRO:
- DFA of oral mucosal lesion for HSV-1 and 2 could not be
performed secondary to inadequate sample.
- mycoplasma negative
.
PATH: Skin biopsy of lesion on R abdomen performed by
dermatology: Sparse superficial dermal mast cell and lymphocytic
infiltrate with rare eosinophils and edema.
.
Other Relevant Lab Results:
[**2102-2-4**] 11:35PM BLOOD ESR-95*
[**2102-2-4**] 05:28PM BLOOD TSH-2.2
[**2102-2-4**] 11:35PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2102-2-4**] 11:35PM BLOOD CRP-198.0*
[**2102-2-4**] 05:28PM BLOOD calTIBC-177 VitB12-1442* Folate-18.1
Ferritn-[**2108**]* TRF-136*
.
URINE:
[**2102-2-4**] 05:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2102-2-4**] 05:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2102-2-4**] 05:24PM URINE RBC-0-2 WBC-[**4-1**] BACTERIA-MOD YEAST-NONE
EPI-[**4-1**] TRANS EPI-0-2
Brief Hospital Course:
79 yo F with HLD, depression/psychiatric issues on
anti-psychotics who presents with fever, skin rash with oral
mucosal lesions concerning for [**Doctor Last Name **]-[**Location (un) **] syndrome, also
incidentally noted to have paroxysmal atrial fibrillation with
rapid ventricular rate. She was originially admitted to the
Medical ICU due to concern for SJS/TEN in concert with her Afib,
however she was moved to floor after one day in the MICU as she
was stable. Her brief hospital course, by problem is as follows:
.
#. Rash: Targetoid lesions were most consistent with erythema
mulitforme versus SJS given involvment of both skin and oral
lesions, especially in setting of possible viral infection given
slight lymphocytosis noted on differential and flu-like
symptoms. Skin biopsy of abdominal lesion confirmed erythema
multiforme major.
Most common infectious etiologies of EM are HSV infection and
Mycoplasma infection (CXR without evidence of PNA). Mycoplasma
testing was negative, HSV testing unfortunately not performed
due to inadequacy of sample, however she did have a lesion on
her lower lip which appeared consistent with HSV. She did not
take any ne new medications that could also precipitate EM/SJS
such as anti-epiletics, allopurinol, or antibiotics (other than
Ciprofloxacin which was started after the onset of the rash).
Patient was using NSAIDs, but she did not begin these until
after the rash began. Pt is on anti-psychotics which can also
precipipate EM/SJS, but no changes in any medications per
patient and none of her current anti-psychotics are well known
offenders for SJS. She never had any evidence of hypotension or
hemodynamic instability. RPR titers were also negative. [**Doctor First Name **] was
negative. CRP (198) and ESR (95)were both elevated, in keeping
with an inflammatory process. She was treated with a 60/40/20
prednisone burst 3 day titer per dermatology, as well as topical
emollients, topical anesthesics for her oral cavity. She will
follow-up with dermatology.
.
#Multifocal pneumonia: Initially treated with cefepime and
levofloxacin, which was narrowed to levofloxacin for a 7 day
course. She will follow up with her PCP and needs [**Name Initial (PRE) **] repeat
chest xray in [**5-3**] weeks to ensure complete resolution.
.
#. Atrial fibrillation: Upon presentation she had a tacchycardic
heart rate with episodes of paroxysmal AF with RVR up to the
190s. She does not have a history of AF, so this may be
precipated by current illness/rash. She had episodes of
tachynpea with her AF indicating possible flash pulmonary edema
in setting of AF, with troponin leaks. Troponin leak likely due
to demand ischemia in setting of pt's rapid AF. EKG
demonstrated sinus tachycardia with one episode of AF in the
160s in the ED. TSH was tested and was normal. She had a echo,
which showed mild global hypokenesis. She had similar episodes
over the course of her hospital stay, and she was treated with
metoprolol and diltiazem. She was ultimately seen by cardiology,
and is being discharged on diltiazem 360mg. She never
experienced hemodynamic instability. Her CHADS2 score is 1, so
no anticoagulation was started, however she was placed on a low
dose aspirin. She will follow-up with cardiology for afib
management, repeat echo, and possible initiation of Pradaxa
therapy.
.
#. Elevated LFTs: She had mild elevations of her LFTs, which can
be seen in in EM/SJS/TEN patients. She is also on a statin. She
had no abdominal symptoms or significant myalgias. Her LFTs were
trended down. She will follow-up with her primary care provider
for repeat LFT testing.
.
# Anemia: She was found to have iron deficiency anemia and iron
supplements were started. She did have a guaic + brown stool
while in the hospital. It is recommended that she follow-up with
her primary care provider for further management and work-up of
her anemia, likley to include a colonoscopy.
.
# Malnutrition: Her albumin was found to be 2.6 upon admission.
She was started on Boost low sodium supplements three times a
day. She was seen by nutrition, who recommended continuing that
as well as fasting blood sugar check as an outpatient after this
acute episode has resolved. She will follow-up with her primary
care provider.
.
#. Hyperlipidemia: Her statins were initially held because she
was having difficulty swallowing secondary to her oral lesions.
She was also having elevated LFTS. Her statin was restarted when
she was tolerating POs. She will follow-up with her primary care
provider.
.
#. Psychiatric issues: Her home antipsychotics were initially
held due to her difficulty with swallowing, however they were
restarted the next day without incident.
.
During the course of her stay her vital signs were closely
monitored, her pain was controlled with PRN morphine, tylenol
and topical anesthetics. She was given gentle IV fluids until
she could tolerate POs on hopital day two, then she resumed a
heart healty, low sodium diet with Boost supplmentation. She
also worked with physical therapy to improve her strength and
balance following this hospitalization. She will be discharged
[**Last Name (un) **] with home PT, a walker and increased home elder care and
nursing aide services as set-up by social work.
Medications on Admission:
Perphenazine 6 mg PO daily
Seroquel 25 mg PO QHS
Risperdone 3 mg PO daily
Simvastatin 20 mg PO daily
Eye Drops
Discharge Medications:
1. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. risperidone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. perphenazine 2 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed) as needed for eye dryness.
6. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
7. diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
*Erythema Multiforme Major
*Atrial Fibrillation
Secondary
*Anemia
*Malnutrition
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 Mrs. [**Known lastname 25989**],
You were admitted to the medical service at [**Hospital1 18**] on [**2102-2-4**] with
a fever, rash, and systemic symptoms (cough, aches, nausea). You
were also found to have episodes of irregular heart rate, which
is called atrial fibrillation. You were found to have a
pneumonia, which was likely the cause of the rash (the rash is
called Erythema Multiforme major). You were treated with a
course of antibiotics for the pneumonia, and steroids for the
rash. You will need to follow-up with dermatology, there is an
appointment being scheduled for you. Please call the number
below if you have not heard from them.
Your irregular heart rate was likely also a result of your
infection. You were started on a new medication for your heart
rate called diltiazem, and an aspirin. You will need to take
these medicines once a day, and you will need to follow-up with
Cardiology (the heart doctor, Dr. [**Last Name (STitle) **]. Please call the number
below if you have not heard from them about an appointment. It
is very important that you follow-up.
1. Diltiazem 360mg one time a day
2. Aspirin 81mg one time a day (this can be bought over the
counter).
You were also found to have a low red blood cell count,
otherwise called anemia. This is likely a result of not getting
enough iron in your diet. You were started on a daily iron
supplement. You are being given a prescription for this
medication in case you can not find it as an over the counter
medication. This can cause constipation, so you may want to buy
an over the counter stool softener to take daily as well (e.g.
docusate, miralax). Your primary care doctor should also set you
up to have a colonoscopy as an outpatient.
No other changes were made to your medications.
Followup Instructions:
1. Name: [**Doctor Last Name **] [**Last Name (LF) **],[**First Name3 (LF) 20**] H.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3070**]
Appointment: Wednesday [**2-15**] at 12:20PM
2. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: DERMATOLOGY
Address: [**Street Address(2) **], [**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 3965**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 1 week . You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.
3. Name: Fish, [**Doctor First Name **] E. MD
Specialty: Cardiology
Location: [**Hospital1 **] Cardiology
Address: [**First Name8 (NamePattern2) **] [**Location (un) 620**], [**Numeric Identifier 3002**]
Phone:[**Telephone/Fax (1) 4105**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within
1-2 weeks . You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.
4. Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 25990**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3070**]
Date/Time: [**2102-3-6**] 3:00
|
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"280.9",
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icd9cm
|
[
[
[]
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] |
[
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
13922, 13980
|
7571, 12818
|
281, 295
|
14113, 14113
|
4393, 7548
|
16095, 17599
|
3256, 3343
|
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|
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12844, 12957
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|
3383, 3965
|
230, 243
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323, 2884
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14128, 14272
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2906, 3047
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|
3990, 4374
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,498
| 128,507
|
10352
|
Discharge summary
|
report
|
Admission Date: [**2105-12-23**] Discharge Date: [**2106-1-3**]
Date of Birth: [**2041-8-2**] Sex: F
Service: OMED
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 34355**] is a 64 year old
female with a history of adenocarcinoma with unknown primary
with bone marrow involvement and metastases to spine, ribs
and hips as well as a history of thrombocytopenia likely
immune mediated, who presented to [**Hospital1 190**] in [**2105-8-29**], with headache, lethargy,
ataxia and blurry vision in the setting of platelet counts of
23,000. An MRI at that time revealed a subdural hematoma on
the left side with mass affect and midline shift. She was
seen by Neurosurgery at that time and treated with platelet
transfusions and high-dose steroids. The hematoma was stable
in follow-up imaging and the patient was discharged home with
close monitoring.
The patient was recently admitted to [**Hospital1 190**] from [**12-17**] until [**2105-12-19**], for increasing
left lower extremity pain and weakness. The plan was to
treat this pain with outpatient XRT to the SI joint. During
this admission, the patient received multiple platelet
transfusions and was given intravenous IG for two days.
On [**2105-12-23**], the patient presented to the Radiation
[**Hospital **] Clinic for XRT planning. At that time she was
complaining of headache and she was noted to be increasingly
somnolent and have some gait instability. Her platelet count
was found to be 16,000, therefore, she was admitted and a
STAT head CT scan was done due the suspicion of worsening
subdural bleed. The head CT scan showed an increase in the
left subdural hematoma with sub-falcine herniation. The
patient was transferred directly to the Medical Intensive
Care Unit and was supported with platelet transfusions and
intravenous Decadron.
PAST MEDICAL HISTORY:
1. Metastatic adenocarcinoma of unknown primary, thought to
be breast cancer versus gastric cancer. Metastases to
spine and ribs noted in [**2104-12-29**].
2. Peptic ulcer disease.
3. Endometriosis.
4. Osteopenia.
5. History of positive PPD as a child.
6. Thrombocytopenia and anemia thought to be immune
mediated.
7. Subdural hematoma first noted in [**2105-8-29**].
PHYSICAL EXAMINATION: At admission, temperature of 99.1 F.;
respiratory rate 16; pulse of 88; blood pressure 120/72. In
general, she was somnolent but arousable to voice and in no
acute distress. HEENT: Normocephalic, atraumatic.
Anicteric sclerae. Pupils equally round and reactive to
light, 4 to 2 mm. Mucous membranes are moist. No facial
droop. Neck supple. There was left conjunctival ecchymosis.
Cardiovascular examination: Regular rate and rhythm without
murmurs. No carotid bruits. Chest clear to auscultation
anteriorly. Abdomen soft, nontender, nondistended. Positive
bowel sounds. No hepatosplenomegaly. Extremities: No
cyanosis, clubbing or edema. Neurologic examination:
Oriented to person and date. Was oriented to situation and
place, only with prompting. Cranial nerves intact. Normal
finger-to-nose and heel-to-shin. Light touch sensation
grossly intact in all four extremities. Motor strength five
out of five in bilateral upper extremities, four out of five
in dorsi- and plantar flexion in left lower extremity. Four
out of five hip flexors bilaterally. The left patellar
reflex was one plus. All other reflexes were two plus.
LABORATORY: Labs on admission showed a white count of 7,000,
with 77 neutrophils, 8 bands, 3 monocytes, and 4 nucleated
red blood cells. Hematocrit of 22 and platelets of 14.
Chem-7 showed a sodium of 129, potassium 4.1, chloride 96,
bicarbonate 24, BUN 17, creatinine 0.4, glucose 153. Calcium
8.5, magnesium 1.9, phosphorus 3.0, ALT 22, AST 75, alkaline
phosphatase 687, total bilirubin 1.7, albumin 3.4.
HOSPITAL COURSE: The patient was cared for in the Medical
Intensive Care Unit and was supported with platelets and red
blood cells transfusions as well as Decadron. A
neurosurgical evaluation was done on [**12-23**]. It was felt that
no immediate neurosurgical intervention was indicated and
that the patient should be closely monitored.
The patient had multiple head CT scans monitoring the
subdural hematoma during this time. On [**2105-12-27**], due to
the head CT scan findings and the patient's decreasing mental
status, it was determined to place a subdural drain. The
patient was also loaded with Dilantin procedure prophylaxis
at this time. In the following day, there was minimal change
in mental status and a repeat head CT scan showed no change
in the subdural hematoma, the midline shift or herniation.
On [**12-29**], the patient was noted to have worsened mental
status and also abnormal respirations and periods of apnea.
Therefore, a craniotomy was done on [**12-29**], with
replacement of the subdural drain. At this time, the patient
was transferred to the Neurological Intensive Care Unit for
further care. A repeat head CT scan after this procedure
showed a decrease in the subdural hematoma. It also noted a
new posterior limb of the internal capsule infarction.
On the following day, the patient had a mild improvement in
her mental status. She was awake and following simple
commands. The patient underwent a carotid Doppler and an
echocardiogram to evaluate for embolic sources to explain the
new stroke. Both of these studies were negative. The
patient continued to be supported with blood and platelet
transfusions.
However, at this time, it was noted that there was increasing
difficulty in controlling this patient's hypertension. She
was requiring Nipride, Hydralazine and Lopressor and still
maintaining high blood pressures. On [**2105-12-31**], the
patient was transferred back to the Medical Intensive Care
Unit. She was extubated at this time (the patient had been
intubated on [**12-29**], for the craniotomy. During the day
of [**12-31**], the patient's mental status was noted to be
waxing and [**Doctor Last Name 688**]. The patient's subdural drain had minimal
output and was discontinued.
On [**1-1**], the patient was noted to have worsening mental
status. A family meeting was held at this time and it was
determined not to pursue any further surgical interventions
and therefore to not have any further head imaging as well.
The caregivers and the family discussed the patient's grim
prognosis at this time. It was determined to transfer the
patient to the OMED Service with the expectation that the
emphasis of care would be transition to comfort measures
during the following day.
The patient was completely unresponsive during the day of
[**1-2**]. She continued to have low platelet counts and
labile blood pressures. She had fast labored breathing
patterns which were treated with intravenous morphine
titrated to apparent respiratory comfort.
At approximately 01:00 a.m. on [**1-3**], the patient's
husband acting as health care proxy and in agreement with the
patient's children, changed the patient's status to comfort
measures only. All blood pressure medications and
non-comfort oriented medications were discontinued at that
time. The patient was maintained on an intravenous morphine
drip titrated for comfort.
Approximately five hours later, the patient was pronounced
dead at 05:20 a.m. on [**2106-1-3**]. The patient's
husband was present at the time.
An autopsy was declined by the family.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 25086**], M.D. [**MD Number(1) 34356**]
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D:
T: [**2106-1-6**] 10:11
JOB#: [**Job Number 34358**]
|
[
"253.6",
"199.1",
"198.5",
"432.1",
"372.73",
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"263.9",
"348.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"02.42",
"38.93",
"99.04",
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
3847, 7667
|
2267, 2922
|
161, 1833
|
2946, 3829
|
1855, 2244
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,714
| 146,311
|
30605
|
Discharge summary
|
report
|
Admission Date: [**2177-6-26**] Discharge Date: [**2177-7-2**]
Date of Birth: [**2127-11-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2177-6-27**] Five Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to first diagonal, vein grafts to left
anterior descending, second diagonal, obtuse marginal and
posterior descending artery)
History of Present Illness:
Mr. [**Known lastname 72596**] is a 49 year old male who presented to outside
hospital with chest pain and ruled in for an acute myocardial
infarction. Cardiac catheterization was significant for severe
three vessel disease. He underwent primary angioplasty and
stenting of the right coronary artery with a bare metal stent.
Left ventriculogram revealed extensive inferior wall akinesis
with an estimated LVEF of 35%. He tolerated the procedure well
and was transferred to the [**Hospital1 18**] for surgical revascularization.
Past Medical History:
Coronary artery disease
Acute Myocardial Infarction
Recent Right coronary artery bare metal stent on [**2177-6-25**]
Hypertension
Vasectomy
Social History:
Current smoker, admits to [**2-11**] pack per day for approximately 32
years. Admits to occasional ETOH. He is married with children.
Employed as a house cleaner.
Family History:
No premature coronary disease
Physical Exam:
Vitals: T 99.2, BP 112/64, HR 74, RR 18, SAT 96 on room air
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, carotids 2+ without bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2177-6-26**] Chest x-ray: There is no acute cardiopulmonary process.
The lungs are clear and pleural surfaces are smooth with no
effusion or pneumothorax. Heart size is top normal. The aorta is
mildly unfolded.
[**2177-6-26**] 05:21PM BLOOD WBC-12.8* RBC-4.42* Hgb-14.9 Hct-43.0
MCV-97 MCH-33.8* MCHC-34.7 RDW-13.0 Plt Ct-201
[**2177-6-26**] 05:21PM BLOOD PT-12.6 PTT-25.9 INR(PT)-1.1
[**2177-6-26**] 05:21PM BLOOD Glucose-102 UreaN-12 Creat-1.0 Na-142
K-4.0 Cl-109* HCO3-24 AnGap-13
[**2177-6-26**] 05:21PM BLOOD ALT-38 AST-95* LD(LDH)-532* CK(CPK)-688*
AlkPhos-88 Amylase-78 TotBili-0.3
[**2177-6-26**] 05:21PM BLOOD CK-MB-54* MB Indx-7.8 cTropnT-1.65*
[**2177-6-26**] 05:21PM BLOOD %HbA1c-5.8
Brief Hospital Course:
Mr. [**Known lastname 72596**] was admitted and underwent preoperative evaluation.
Workup was unremarkable and he was cleared for surgery. On [**6-27**], Dr. [**First Name (STitle) **] performed coronary artery bypass grafting. For
surgical details, please see seperate dictated operative note.
Following the operation, he was brought to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. He weaned from pressor support and tolerated low
dose beta blockade. Diuretic therapy was initiated. He made
steady progress and was transferred to the SDU on postoperative
day three. He progressed well on the step down floor. His
epicardial wires were removed and he was seen in consultation by
the physical therapy service. By post-operative day five he was
ready for discharge to home in good condition.
Medications on Admission:
Transfer Medications:
Aspirin 325 qd
Plavix 75 qd
Lipitor 10 qd
Lisinopril 5 qd
Metoprolol 12.5 [**Hospital1 **]
Protonix 40 qd
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:*100 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Acute Myocardial Infarction
Recent Right coronary artery stent on [**2177-6-25**]
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Dr. [**First Name (STitle) **] in [**5-15**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 1295**] in [**3-15**] weeks, call for appt [**Telephone/Fax (1) 6256**]
Local PCP [**Last Name (NamePattern4) **] [**3-15**] weeks, call for appt
[**7-10**] at 9:45 am wound check with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] heart
center [**Telephone/Fax (2) 6256**] please call if you need to reschedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2177-7-2**]
|
[
"410.41",
"401.9",
"414.01",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
4766, 4772
|
2640, 3489
|
330, 547
|
4946, 4953
|
1916, 2617
|
5336, 5929
|
1464, 1495
|
3667, 4743
|
4793, 4925
|
3515, 3515
|
4977, 5313
|
1510, 1897
|
280, 292
|
3537, 3644
|
575, 1104
|
1126, 1268
|
1284, 1448
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,792
| 125,747
|
46465
|
Discharge summary
|
report
|
Admission Date: [**2170-11-30**] Discharge Date: [**2170-12-10**]
Date of Birth: [**2096-5-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Percocet / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
fatigue and mild DOE for approx. one year
Major Surgical or Invasive Procedure:
s/p MVR(31mm Perimount
bioprosthesis)/CABGx1(SVG->LAD)/MAZE/Ligation of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**]
[**2170-11-30**]
History of Present Illness:
74 yo male with known MR who has been managed medically in the
past. He is now referred for surgical repair of his mitral valve
by Dr. [**Last Name (STitle) 1290**]. He was admitted earlier this week for heparin
bridge while off coumadin prior to operation. Cardiac cath in
[**Month (only) **]. revealed 20% LM, 60% LAD, 50% CX, 60% RCA, and EF of 72%,
with a regurgitant fraction of 33%. Prior echo showed moderate
to severe MR, EF 60-70%, and elevated PA pressures.
Past Medical History:
AFib
elev. chol.
remote renal calculus
HTN
MR
Social History:
electrical contractor, lives with wife
quit smoking 35 years ago ( was smoking up to 3 ppd);
has one drink per day
Family History:
non-contributory
Physical Exam:
HR 74 RR 18 114/60
5'[**75**]" 192 #
Pertinent Results:
[**2170-11-30**] 06:43AM BLOOD WBC-13.5* RBC-5.17 Hgb-17.1 Hct-50.1
MCV-97 MCH-33.0* MCHC-34.1 RDW-13.7 Plt Ct-229
[**2170-12-9**] 05:05AM BLOOD WBC-15.3* RBC-3.41* Hgb-11.0* Hct-33.0*
MCV-97 MCH-32.3* MCHC-33.3 RDW-15.1 Plt Ct-390
[**2170-12-9**] 05:05AM BLOOD PT-19.2* INR(PT)-2.6
[**2170-12-9**] 05:05AM BLOOD Plt Ct-390
[**2170-11-30**] 06:43AM BLOOD PT-14.1* PTT-23.7 INR(PT)-1.4
[**2170-12-8**] 05:20AM BLOOD Glucose-89 UreaN-22* Creat-1.0 Na-138
K-3.6 Cl-95* HCO3-33* AnGap-14
[**2170-11-30**] 01:30PM BLOOD UreaN-18 Creat-0.9 Cl-108 HCO3-23
[**2170-12-6**] 12:10PM BLOOD ALT-55* AST-30 LD(LDH)-422* AlkPhos-82
Amylase-279* TotBili-1.5
[**2170-12-6**] 12:10PM BLOOD Lipase-88*
[**2170-12-6**] 12:10PM BLOOD Albumin-3.2*
Brief Hospital Course:
Admitted [**11-30**] and had MVR/CABG x1 /Maze and ligation of [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1916**].Transferred to CSRU in stable condition on titrated
neo and propofol drips. He was extubated later that evening and
was alert and oriented, and neo was weaned off. Echo postop
showed no tamponade and EF intact per report. Chest tubes were
removed on POD #2 and he was A- paced. He went into AFib and
amiodarone was started. BS were diminished on POD #3, and
aggressive pulm toilet was encouraged. Transferred to the floor
on POD #4, and foley, pacing wires and CVL were removed.
diuresis continued and coumadin was restarted on POD #4. Patient
continued to increase his activity level slowly. On POD #6, his
INR bumped to 7.0, and then 7.5. He had some arm heaviness at
that time, so neuro consult was done (negative), including CT
scan ( also negative). Carotid US also showed no significant
disease. Repeat INR later that day was 2.3. He was
hemodynamically stable and was 94% on RA sat. UA sent and CXR
done for elevated WBC. INR on day of discharge 3.4
Blood draw on [**12-11**] (Tues, [**Last Name (un) **], Sat draws) with VNA, and
coumadin dosing with Dr. [**Last Name (STitle) 98715**] [**Name (STitle) **] as done pre-op.
Medications on Admission:
tegretol 200 mg [**Hospital1 **]
atacand 4 mg daily
digoxin 0.125 mg Tue, [**Last Name (un) **], Sat, Sun
synthroid 125 mcg Tues, Thurs, Sat, Sun; and 188 mcg Mon, Wed,
Friday
atenolol 50 mg daily
protonix 40 mg daily
ASA 81 mg daily
HCTZ 25 mg Tues, Thurs, Sat, Sun, and 12.5 mg on Mon, Wed,
Friday
Lasix 20 mg M-W-F
Coumadin 2 mg M-W-F, and 2.5 mg Tue, [**Last Name (un) **], Sat, Sun
lipitor 80 mg daily
trusopt one drop each eye [**Hospital1 **]
nasonex 50 mcg 2 sprays each side daily
Discharge Medications:
1. 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*
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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 bottle* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 1
days: Take as directed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] INR goal 2-2.5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral regurgitation
Afib
elev. chol.
remote renal calculus
s/p MVR/CABG/Maze/ ligation of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**]
Discharge Condition:
Good.
Discharge Instructions:
Shower, wash incision with soap and water and pat dry. No
lotions, creams or powders or baths.
Call with redness or drainage from incision, fever, or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting greater than 10 pounds for 10 weeks.
NO driving until follow up with surgeon.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 410**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Blood draw tomorrow with VNA, results to be sent to Dr.[**First Name8 (NamePattern2) **]
[**Name (STitle) **], and coumadin dosing per Dr. [**Last Name (STitle) **].
Completed by:[**2170-12-10**]
|
[
"401.9",
"244.9",
"782.0",
"V15.82",
"424.0",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.72",
"39.61",
"99.05",
"37.33",
"35.23",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5503, 5561
|
2067, 3326
|
356, 509
|
5758, 5766
|
1316, 2044
|
6123, 6466
|
1224, 1242
|
3867, 5480
|
5582, 5737
|
3352, 3844
|
5790, 6100
|
1257, 1297
|
275, 318
|
537, 1006
|
1028, 1075
|
1091, 1208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,430
| 169,641
|
15689
|
Discharge summary
|
report
|
Admission Date: [**2104-7-30**] Discharge Date: [**2104-8-7**]
Date of Birth: [**2054-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
"High sugars"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo Spanish speaking M with h/o ETOH abuse, cognitive delay
thought to be due secondary to his past ETOH abuse, IDDM with
past hospitalizations both for DKA and for hypoglycemia,
presented to his PCP today after he ran out of insulin 2 days
ago. His sister called the pharmacy for the insulin, but there
was some confusion and no one picked it up. His PCP immediately
sent patient to the ED for further treatment. Found to have FS
> 500 in ED and increased anion gap 45 suggestive of DKA. Pt was
given Insulin 10 U and started on Insulin drip. Also started on
normal saline, given aspirin, nitroglycerin and anzemet.
.
ROS: Pt complained of dry, nonproductive cough x 3 days, also
diarrhea 2-3 times per day for past 3-4 days. He also notes
vomiting since yesterday. States he vomited 3 times today.
Complained of right sided, non pleuritic chest pain in ED with
vomiting that has now gone away. The pain did not radiate. No
shortness of breath. No HA, visual changes. No blood in stool or
black stools. No dysuria. + Frequency.
Past Medical History:
1. DM type 2 - insulin dependent diagnosed [**2097**] followed by Dr.
[**Last Name (STitle) **] at [**Last Name (un) **]. Multiple admissions for hypoglycemia and DKA
in past.
2. h/o EtOH abuse
3. h/o chronic pancreatitis
4. Hypertension
5. Hyperlipidemia
6. Hep B and Hep C by [**Last Name (un) **] report, with hx of periportal
fibrosis - no serologies in system, no record of dx from PCP
7. Tobaccos use
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] (APG)
Social History:
Originally from [**Male First Name (un) 1056**]. Spanish speaking. Lives in an
apartment [**Location (un) 6409**] with a niece. Denies EtOH x 1 year, but
has a history of excessive EtOH use in past. + Tobacco use. Does
not work, is disabled. Sister lives nearby and is involved in
his care. PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**].
Family History:
Not available.
Physical Exam:
VS: T 97.0 HR 100 BP 122/72 RR 18 O2 100% RA
Gen: thin middle aged male alert and oriented to [**Last Name (LF) 205**], [**First Name3 (LF) **],
not year NAD.
HEENT:PERL. EOMI. no scleral icterus. MMM. no sublingual
icterus. no posterior pharynx erythema
Neck: No LAD.
CV: tachy. nl S1, S2. no m/r/g.
Lungs: CTAB
Abd: active BS. soft. NT. ND. no HSM.
Back: no CVA tenderness. no pain over spinous processes.
Extr: no c/c/e. DP 2+ B/l.
Neuro: MAE. CN II-XII intact. unable to get pt to cooperate with
reflexes. Strength intact. Toes downgoing.
Pertinent Results:
Labs: (on admission)
ABG: 7.08/10/157
AG 45
hct 52
WBC 14.4, 10% bands
serum tox neg. no urine for u tox.
U/A trace protein, 1000 glu, 150 ketones, neg for leuk
est/nitrites
.
Labs: ([**2104-8-1**])
WBC 6.9, bandemia resolved
hct 39.7
plt 165
Na 140, K 4.0, Cl 108, HCO3 21, BUN 5, Cr 0.9 Glu 121
AG 11
ALT 26, AST 29, Alk Phos 74, Tbili 0.6
Ph 2.0
Cardiac enzymes negative x3
HIV Ab negative
.
CXR: flattened diaphragms suggestive of hyperexpansion. clear
diaphragms/ heart borders. no infiltrates or edema.
.
EKG: Sinus tach 110. nl intervals. no Q waves. TWI II,III, avF.
J point elevation V1-V4, old.
Brief Hospital Course:
50 y/o Spanish speaking male w/ PMH of type II DM, hep B and hep
C who presented with DKA. A brief problem based hospital course
is outlined below.
1. DKA: Patient presented to the ED in DKA ABG of 7.08/10/157, a
glu of 418, and an anion gap of 45. Most likely etiology was his
lack of insulin, in conjunction with some diarrhea and vomiting.
DKA treated successfully with insulin gtt, with complete
closure of AG. Since that time, pertinent problems have been
hypoglycemia and adjustment of his outpt insulin regimen.
Talked to his PCP about his glycemic control. PCP prefers in
this patient's case to keep him slightly higher (PCP realizes
his A1C is suboptimal, but keeps him there) as the patient has
little insight into his disease and is at greater risk to
himself if hypoglycemic based on hx of sz [**2-27**] hypoglycemia.
[**Last Name (un) **] initially recommended continuing his outpatient regimen
70/30 with 30u in AM and 32 u in PM. On this regimen, he had two
episodes of hypoglycemia with BS as low as 30, both
asymptomatic. Adjustments were made, and eventually 70/30 dose
was down to 15units in AM and PM. Unfortunately patient still
experienced episodes of hypoglycemia. Therefore, he was started
on a trial of glargine with Prandin PO with each meal in order
to streamline his regimen. However, he failed prandin treatment
and did not appear to have much beta-cell reserve in response to
this therapy. His blood sugars remained high (300-400) overnight
on this regimen, so glargine was titrated up to 18 units per
day, with fixed-dose Humalog of 8 units to be taken with each
meal (breakfast,lunch,dinner). He has done well with the
humalog, without any further hypoglycemic episodes, so he was
discharged to home with this regimen. Through an interpereter
his new regimen was outlined and it was also explained to his
niece, who speaks english,by phone. We have arranged for close
follow-up with [**Last Name (un) **] on Monday [**8-11**], in addition he also has
follow-up with his PCP [**Last Name (NamePattern4) **] [**8-11**].
2. Abdominal pain: Pt had been complaining of epigastric
abdominal pain with swallowing x couple months. Denies N/V.
Differential diagnoses primarily entertained include GERD, PUD,
diabetic gastroparesis. Pt has been on Protonix since admission
with some improvement of symptoms. H. Pylori Ab test was
negative.
2. Chest pain: Pt initially described R sided chest pain. Did
not hurt taking a deep breath. Describes it as dull, not sharp.
Denied any SOB, radiation to jaw or down arm, diaphoresis, or
nausea. Happened at rest. Likely not cardiac in origin, but
patient has multiple cardiac risk factors including DM, smoking,
HTN, and hypercholesterolemia, so he was ruled out for MI. An
EKG was done in the ED which was unchanged from previous EKGs in
[**2103**] (sinus tachycardia, normal axis/intervals, with TWI in II,
III, avF, J point elevation in V1-V4). Cardiac enzymes were
cycled. All three sets were negative. No further w/u was
performed, with intention to consider stress test if chest pain
symptoms return.
3. ARF: BUN 21/Cr 2.0 on admission, but now down to 5/0.9. ARF
was likely pre-renal and due to his DKA/dehydration.
4. Transaminitis: Mild transaminitis (ALT 43, AST 45, Alk Phos
133) on admission, now resolved.
6. h/o EtOH abuse: Pt denies any EtOH use x 1 year. Has h/o of
multiple attempts at rehab and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] admission for seizure in
setting of alcohol withdrawal - last admission 1 year ago. Pt
was monitored per CIWA scale for signs/symptoms of withdrawl,
which was negative throughout [**Hospital Unit Name 153**] stay.
7. h/o Hep B + Hep C: Documented in [**Last Name (un) **] notes, but PCP has no
record of hep B/C testing. HIV Ab negative. Would recommend
Hep B/Hep C testing by PCP as an outpatient
8. HTN: On lisinopril 10mg PO QD as an outpatient, but it was
held secondary to ARF. It was re-started at 5mg per day when his
renal function improved, however potassium was elevated at 5.2
prior to discharge so lisinopril was held. He is scheduled for
follow-up in clinic on Monday at which time he may have
potassium levels re-checked and lisinopril re-started if
tolerated.
9. Hypercholesterolemia: No record of patient's past cholesterol
levels. Lab recorded lipemic specimen on admission. Chol 144,
LDL 59, HDL 34 this AM, but TG were 309. Plans for f/u with PCP
[**Last Name (NamePattern4) **]: hypertriglyceridemia
10. Pruritis/Urticarial Dermatitis: Developed truncal mobiliform
rash w/ associated excoriations. Initial concern was for body
lice, however dermatology was formally consulted and did not
feel the findings were consistent with this, and no lice/nits
were found. Findings were felt most consistent with urticarial
type reaction and he was started on [**Doctor First Name 130**], sarna lotion,
atarax, and triamcinolone cream for relief of symptoms. He did
have improvement of symptoms with this regimen and rash resolved
as well over the next 24 hours. He will follow up with Derm as
outpatient.
Medications on Admission:
Lisinopril, Insulin
Discharge Medications:
2. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
Disp:*90 Tablet(s)* Refills:*0*
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
4. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) for 2 weeks.
Disp:*30 g* Refills:*0*
5. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
Units Subcutaneous qam.
Disp:*600 units * Refills:*0*
6. Humalog 100 unit/mL Solution Sig: Eight (8) Units
Subcutaneous with meals: breakfast, lunch,dinner.
Disp:*300 units* Refills:*0*
7. Humalog PEN
DISP: PEN FOR HUMALOG INJECTIONS
INSTRUCTIONS: USE SEPARATE SYRINGE FOR HUMALOG AND GLARGINE
INJECTIONS (DO NOT MIX HUMALOG AND GLARGINE)
REF: 0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Diabetic ketoacidosis
Urticarial Dermatitis
Secondary diagnosis:
Hypertension
Discharge Condition:
Stable. Discharged on 18 units of Glargine per day and 8 units
of Humalog with meals.
Discharge Instructions:
Please call your PCP if you develop any of the following
symptoms: fevers, chills, chest pain, shortness of breath,
nausea, vomiting, excessive thirst, excessive urination,
dizziness or any other symptoms.
Check your fingerstick blood sugars four times each day and
record the results. This will help your doctor better monitor
your diabetes regimen.
Your insulin regimen has been changed. Discontinue using 70/30
insulin. Instead, take 18 units of Lantus every morning and 8
unis of Humalog with each meal: breakfast,lunch,dinner.
Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] at 10am on Monday [**8-11**].
2. Follow-up with Dr. [**Last Name (STitle) 1789**] on Monday [**8-11**] at 2pm.
3. Provider: [**First Name11 (Name Pattern1) 306**] [**Last Name (NamePattern4) 7907**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2104-10-17**] 9:15
|
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"401.9",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
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|
3521, 8601
|
327, 334
|
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|
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|
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|
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|
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1419, 1902
|
1918, 2281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,180
| 177,409
|
37517
|
Discharge summary
|
report
|
Admission Date: [**2173-5-18**] Discharge Date: [**2173-5-24**]
Date of Birth: [**2108-5-14**] Sex: F
Service: MEDICINE
Allergies:
Banana / Melon Flavor / Avocado / IV constrast / Lorazepam
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 year old female with hx of stage [**Doctor First Name **] squamous cell cervical
cancer, status post combined chemoradiation with b/l nephrostomy
tubes and a recent history of multiple UTIS with both coag pos
staph and E.coli transferred from onc clinic to ED for
hypotension. Patient was feeling well until yesterday when
started feeling fatigue, and then had sudden onset of chills
last night with weakness and a fall onto bilateral knees on her
way to the bathroom. No LOC or head strike. This Am temp at home
was 101. Pt also had multiple bouts of explosive diarreha this
AM without abdominal pain or nausea. Later in morning was unable
to come in to onc clinic for urgent visit and was instructed on
phone to come to ER as pt was febrile to 101.5 with SBP 90's
although mentating well. Was due to have nephrostomy tube check
[**5-28**] with plan to remove L sided tube [**5-28**]. Of note, her
electrolytes have needed aggressive repletion as outpatient has
well with pt on standing K and Mag until recently when K was
stopped.
.
In the ED, initial vs were: Temp 101, HR 104, BP 76/44, RR 16,
Sats 97%. She was started on peripheral levo initially and given
Vanco/zosyn. Nephrostomy tubes have urine c/w with UTI. Lactate
initally 6 improved to 3.5 with fluids and pressors. Given
thiamine as study drug. Labs notable for Cr to 2.2 (baseline
1.1), bandemia to 10%, hypoK, hypophos, and hypoMag. Given K and
Mag in ED. BCx, UCx sent. She had a femoral CVL placed as left
IJ couldn't be obtained but was attempted. Post procedure CXR no
ptx per resident. She had received 6L of IVF by time of transfer
to floor. Pt has a port which was accessed. ? L hematoma.
Femoral line for access. On prednisone 5mg daily at baseline.
Given 125mg solumedrol in ED. Prior to leaving ED vitals showed
P 82 BP 110/40 R16 O2 sat 99%2L.
.
In the ICU, pt in NAD complaining mostly of knee pains and
tiredness. Reporting no diarrhea since this morning. BP in low
100s on 0.3 of norepi.
.
Review of sytems:
Denies dysuria, hematuria, or frequency. Reports continuing
feverish/chills sensation. Denies abdominal pain, headache,
confusion, dizziness, difficulty breathing, chest pain.
Past Medical History:
-Status post resection of a benign pituitary adenoma at age 21
at [**Hospital1 2025**] with resultant hypopituitarism; she was previously
followed at [**Hospital1 2025**], last saw Endocrinology at [**Hospital1 **]-[**Location (un) **] in [**Month (only) 547**]
[**2172**].
-Cervical cancer: followed by Dr. [**Last Name (STitle) 4149**], discovered after [**1-22**]
post-menopausal vaginal bleeding/hematuria and was found to have
a cervical mass w/ invasion of the posterior bladder wall.
Biopsies revealed a locally advanced, stage [**Doctor First Name **] squamous cell
cervical carcinoma. Underwent nephrostomy tubes [**2-23**] for
hydronephorosis. She initiated radiation therapy on [**2173-2-19**]
with her last session [**2173-4-28**]. She completed 6 sessions of
weekly cisplatin on [**2173-4-12**].
-Multiple UTIs since nephrostomy tube placement earlier this
year
-Osteoporosis
-Multiple food allergies
Social History:
She grew up in the West End of [**Location (un) 86**]. She lives in [**Location 4628**], MA
with her husband [**Name (NI) **]. They have two daughters, her eldest [**Name (NI) 1785**]
lives nearby, her [**Name (NI) 1685**] daughter [**Name (NI) 6480**] lives in New
[**Name (NI) **]. Her sister from [**Name (NI) 4565**], [**Name (NI) **], is back in
[**State 4565**]. [**Known firstname **] hopes to travel to [**State 4565**] later this
spring. The patient smoked approximately one-third to [**2-14**] pack
per day for 33 years, recently quitting. She had one alcoholic
beverage daily until her illness.
Family History:
[**Name (NI) 1094**] brother died of leukemia at age 64 in [**2164**].
Pt was a match, donated peripheral blood stem cells. Both
parents
had heart disease.
Physical Exam:
EXAM ON ADMISSION:
Vitals: T: 97.9 / BP: 133/49 / P: 81 / R: 15 / O2: 99% on RA
General: Alert, oriented although very tired, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils slightly
constricted but equal and reactive bilaterally
Neck: supple, JVP not elevated, no LAD, autramuatic
Lungs: trace crackles at R base, rest of lung fields CTAB with
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound tenderness or guarding, no organomegaly
GU: foley in place, pale urine in foley bag
Back: no pain at midline with sitting/lying movements, bilateral
CVA tenderness with light touch in areas around urostomy tubes.
Both urostomy tubes in place without surrounding
erythema/induration
Ext: warm, well perfused, 2+ pulses at DP and radial, no
clubbing, cyanosis or edema, bilateral knees are painful to
palpation just below kneecap (R>L) with small purple bruise
below R kneecap, limited active ROM due to pain with better
passive flexion and extension, no skin breaks on either knee. R
upper arm is painful to palpation on lateral aspect. No bruises
or masses noted on exam. Limited ability to raise R shoulder due
to pain.
.
Pertinent Results:
Labs on Admission:
[**2173-5-18**] 11:00AM BLOOD WBC-13.1*# RBC-2.95* Hgb-9.5* Hct-26.5*
MCV-90 MCH-32.3* MCHC-36.0* RDW-16.0* Plt Ct-169
[**2173-5-18**] 11:00AM BLOOD Neuts-83* Bands-10* Lymphs-3* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-5-18**] 11:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2173-5-18**] 07:10PM BLOOD PT-17.3* PTT-30.4 INR(PT)-1.6*
[**2173-5-19**] 05:07AM BLOOD Fibrino-509*
[**2173-5-18**] 11:00AM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2173-5-18**] 11:00AM BLOOD UreaN-16 Creat-2.2*# Na-133 K-2.8* Cl-96
HCO3-25 AnGap-15
[**2173-5-18**] 11:00AM BLOOD ALT-29 AST-38 CK(CPK)-163 AlkPhos-108*
TotBili-0.3
[**2173-5-18**] 11:00AM BLOOD Albumin-3.3* Calcium-8.4 Phos-1.1*#
Mg-1.1*
[**2173-5-18**] 11:00AM BLOOD Cortsol-6.9
[**2173-5-18**] 01:12PM BLOOD Lactate-5.9* K-3.1*
[**2173-5-18**] 11:00PM BLOOD freeCa-1.17
.
Labs on Discharge:
[**2173-5-24**] 06:45AM BLOOD WBC-9.6 RBC-3.28* Hgb-10.2* Hct-29.4*
MCV-90 MCH-31.0 MCHC-34.6 RDW-17.3* Plt Ct-123*
[**2173-5-24**] 06:45AM BLOOD Glucose-75 UreaN-11 Creat-0.9 Na-138
K-3.5 Cl-97 HCO3-32 AnGap-13
[**2173-5-24**] 06:45AM BLOOD Vanco-32.3*
.
MICROBIOLOGY:
Blood Culture, Routine (Final [**2173-5-24**]):
STAPH AUREUS COAG +.
_______________________________________________________
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---- S
VANCOMYCIN------------ 1 S
.
.
URINE CULTURE (Final [**2173-5-22**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.
ENTEROCOCCUS SP. >100,000 ORGANISMS/ML.
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
IMAGING:
CXR: No acute pulmonary process. Stable chest x-ray exam.
.
ECHO: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%). 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, but cannot be fully
excluded due to suboptimal image quality. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
Mild to moderate ([**2-14**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. No masses or
vegetations are seen on the pulmonic valve, but cannot be fully
excluded due to suboptimal image quality. There is no
pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2172-2-21**], the findings are similar but the technically
suboptimal nature of both studies precludes definitive
comparison.
.
IMPRESSION: Suboptimal image quality. No vegetations seen
.
Brief Hospital Course:
The patient is a 65 year-old female with hx of stage [**Doctor First Name **]
squamous cell cervical cancer, status post combined
chemoradiation with bilateral nephrostomy tubes admitted with
urosepsis.
.
# Urosepsis: Initially admitted to ICU, requiring pressors given
hypotension in setting of sepsis. Urinary source believed to be
most likely given positive UA and bilateral CVA tenderness. CXR
and c.diff returned negative. The patient was started on
vancomycin and cefepime empirically given recent staph aureus
UTIs and the possiblity of resistant organisms. The patient was
also given two days of stress dose hydrocortisone. The patient's
symptoms resolved with broad-spectrum antibiotics, and she was
weaned off pressors and transferred to the floor.
.
The patient's urine culture grew methicillin-resistant staph
aureus and enterococcus; her blood culture grew
methicillin-resistant staph aureus. Urology was consulted during
her stay with Dr.[**Doctor Last Name **] recommendation to keep tubes in place
until outpatient follow-up. ECHO returned negative for
vegetation. ID service was consulted. Her cefepime was
discontinued. The patient will continue a two week course of
vancomycin (through [**6-3**], two weeks through last positive blood
culture). Prior to discharge, the patient's vanco level was
greater than 30. Her dose was adjusted, and she was instructed
to skip a dose when returning home (trough to be measured by
VNA). Upon completetion of the vancomycin, she will initiate
treatment with Macrobid, which she will continue for one week
beyond removal of nephrostomy tubes. Dr. [**First Name (STitle) 1075**] of ID will oversee
this transition.
.
Prior plan was to have left nephrostogram on [**2173-5-28**] with
potential removal of tube.
.
# Status-post fall: No LOC or head strike, likely in setting of
hypotension and weakness related to sepsis. Only trauma appears
to be bilateral knees and perhaps R arm where patient caught
herself while falling. She was continued on home dose oxycodone
5mg Q6hrs PRN pain for her L back/CVA tenderness.
.
# Anemia: No evidence of bleeding on exam/history. Normal T.bili
not indicative of hemolysis. Remained stable after 2 units of
PRBCs.
.
# Elevated INR: Elevated at 1.6 at time of ICU arrival. No
evidence of DIC on lab work-up. Mild INR elevation may also be
due to recent antibiotic use wiping out gut flora and
inhibititon of vit K utilization. Started on 3 day course of Vit
K. INR trended to 1.1 at the time of discharge.
.
# Panhypopituitary: Secondary to surgery many years ago. On
synthroid and prednisone as outpatient for years. Given 2 days
of stress dose steroids, and then re-started on home prednisone
5 mg po daily dose 04/07. She was continued on home synthroid at
home dose 125mcg daily.
.
# Cervical cancer: S/p treatment with chemo and radiation. Her
last chemotherapy was on [**2173-4-12**], and her last radiation
treatment on [**2173-4-28**].
.
# Transitions of Care:
- VNA will check weekly labs prior to follow-up with ID (CBC,
chem7, vanco trough)
- ID will oversee transition to macrobid following vancomycin
completion
- Urology will evaluate/manage timing or nephrostomy tube
removal
Medications on Admission:
BACTRIM DS [**Hospital1 **] for 14 days started on [**2173-5-17**]
LEVOTHYROXINE - 125 mcg Tablet - one Tablet(s) by mouth daily
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - 2.5grams topically to
PORT site as directed as needed for prior to accessing PORT
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - [**2-14**] Tablet(s) by mouth Q6
hours and QHS as needed for anxiety, insomnia
OXYCODONE - 5 mg Tablet - [**2-14**] Tablet(s) by mouth every four (4)
hours as needed for Pain
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 packet by
mouth daily as needed for constipation
PREDNISONE - 5 mg Tablet - one Tablet by mouth daily
PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 10
mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for for
nausea
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet -
1- 2 Tablet(s) by mouth every six (6) hours as needed for
Pain/Fever
CALCIUM CARBONATE - (Prescribed by Other Provider) - 200 mg (500
mg) Tablet, Chewable - 2 Tablet(s) by mouth twice a day
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
MAGNESIUM OXIDE - (Prescribed by Other Provider; Dose adjustment
- no new Rx) - 400 mg Tablet - 1 Tablet(s) by mouth three times
a day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) appl
Topical once a day: topically to
PORT site as directed as needed for prior to accessing PORT.
3. olanzapine 2.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for anxiety.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO twice a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 10 days: Please
continue through [**6-3**].
Disp:*QS mg* Refills:*0*
13. Macrobid 100 mg Capsule Sig: One (1) Capsule PO once a day:
Please start on [**6-4**] and continue through your appointment with
Dr. [**First Name (STitle) 1075**].
Disp:*30 Capsule(s)* Refills:*0*
14. Outpatient Lab Work
Please check vancomycin trough, CBC with differential, and
chemistry panel on [**5-27**] and [**6-3**]. Please fax results to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1075**] at [**Telephone/Fax (1) 1419**] (Infectious Disease clinic).
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
- Methicillin-resistant Staph Aureus Bacteremia
- Urosepsis
.
Secondary Diagnosis:
- Cervical Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 5936**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with an
infection in your urine stream and in your blood. You were
started on antibiotics for these infections, and you improved
dramatically over the course of your hospital stay. You will
continue with antibiotic treatment after leaving the hospital as
outline below.
.
Please START the following medication after discharge:
VANCOMYCIN 750 mg every 12 hours through [**2173-6-3**]
*Please DO NOT take your evening dose on the day of discharge
([**2173-5-24**]).
.
Please STOP the following medications:
BACTRIM
MAGNESIUM OXIDE
.
On [**6-4**] (after completing vancomycin), you will begin therapy
with an oral antibiotic called Macrobid (Nitrofurantoin). You
will continue with this antibiotic likely until after your
nephrostomy tubes are removed. When you follow-up in Infectious
Disease clinic, they will help you determine the ultimate course
of antibiotics.
.
Please continue all other medications as they have been
prescribed. Should you experience any symptoms that concern you
after leaving the hospital, please call your oncologist or
return to the emergency room.
.
Followup Instructions:
Department: RADIOLOGY CARE UNIT
When: FRIDAY [**2173-5-28**] at 7:00 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: RADIOLOGY
When: FRIDAY [**2173-5-28**] at 8:30 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2173-6-11**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: SURGICAL SPECIALTIES
Specialty: Urologic Surgery
When: MONDAY [**2173-6-7**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2173-6-7**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will only see Dr. [**Last Name (STitle) 4149**] at this appointment since Dr. [**Last Name (STitle) **]
will be on vacation.
.
|
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"253.7",
"995.92",
"198.1",
"E878.3",
"038.12",
"V44.6",
"275.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
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|
8931, 11870
|
331, 337
|
15541, 15541
|
5576, 5581
|
16925, 18401
|
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|
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|
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5595, 6521
|
15556, 15668
|
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|
2558, 3473
|
3489, 4098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,823
| 144,364
|
5080
|
Discharge summary
|
report
|
Admission Date: [**2138-2-15**] Discharge Date: [**2138-2-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
colonoscopy
EGD
History of Present Illness:
As per Dr.[**Name (NI) 20920**] note
84yo man with PMH significant for cholecystectomy, bilateral hip
and knee repair, admitted with one day of melena and dropping
hematocrit. The patient reported abdominal pain beginning
earlier the evening of admission. He had one brown stool, then
shortly thereafter, one black stool. He reported feeling wobbly
on his feet and dizzy. His family brought him into the hospital.
In the ED, the patient had an NG lavage, which was negative. He
was guaiac positive. His hematocrit dropped from his baseline of
36 to 27 on arrival to the ED, and to 24 5 hours later. He was
transfused 2 units in the ED.
.
In addition to the history obtained from Dr. [**First Name (STitle) 1726**], the
patient's daughter reports the on the morning of admission the
patient was orthostatic (SBP sitting was 150, standing it was
119) and diaphoretic. The patient uses nsaids once in awhile
when he has a cold. He has no h/o ulcers, GIB, or colon CA. The
patient reports occasional shortness of breath when he walks
anywhere from 10ft to [**2-10**] a mile.
.
The patient had a colonoscopy and EGD. EGD showed antral
thickening and gastritis. Colonoscopy revealed some polyps. The
patient was transferred from the ICU to the floor and was
hemodynamically stable.
Past Medical History:
s/p cholecystectomy
s/p bilateral hip and knee repair/replacement
Social History:
no smoking, alcohol, drug use
Widowed, retired linesman, lives with daughter, no smoking,
alcohol, drug use
Family History:
many siblings in good health in 80s
Physical Exam:
Initial presentation [**2138-2-15**]
VS: T 98.9, HR 75, BP 153/73, RR 18, SaO2 99-100%/RA
Genl: NAD, pleasant older man
HEENT: NCAT, MMM
CV: RRR, nl S1, S2, III/VI holosystolic murmur
Chest: CTA bilaterally
Abd: soft, nontender, nondistended, BS+
Ext: PP 2+, no edema
Neuro: alert, conversant, appropriate
Skin: warm and dry
.
PE on tx to 11R [**2138-2-17**]
VS t97.7, bp 160/80, hr 60, r22
Gen: NAD, well-nourished man in NAD
Heart: III/VI HSM heard loudest at the apex
Abd: benign
Ext: no c/c/e
Neuro: A & O x3
Skin: wwp
Pertinent Results:
U/A negative
Pertinent labs on admission
[**2138-2-15**] 05:44PM BLOOD WBC-7.5 RBC-3.15*# Hgb-10.0* Hct-27.2*#
MCV-86 MCH-31.7 MCHC-36.7* RDW-13.9 Plt Ct-294
[**2138-2-15**] 05:44PM BLOOD Neuts-69.8 Lymphs-23.9 Monos-4.0 Eos-1.2
Baso-1.1
[**2138-2-15**] 05:44PM BLOOD PT-12.7 PTT-23.2 INR(PT)-1.1
[**2138-2-15**] 05:44PM BLOOD Glucose-101 UreaN-52* Creat-1.7* Na-141
K-4.6 Cl-105 HCO3-25 AnGap-16
[**2138-2-16**] 04:21AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
.
Labs on transfer to 11 [**Hospital Ward Name 1827**]
[**2138-2-17**] 04:00AM BLOOD WBC-5.9 RBC-3.52* Hgb-10.7* Hct-29.7*
MCV-85 MCH-30.4 MCHC-36.0* RDW-13.9 Plt Ct-198
[**2138-2-17**] 04:00AM BLOOD Plt Ct-198
[**2138-2-17**] 03:58AM BLOOD Glucose-385* UreaN-33* Creat-1.5* Na-133
K-5.1 Cl-100 HCO3-22 AnGap-16
[**2138-2-17**] 04:00AM BLOOD K-3.9
.
EGD-antral thickening and gastritis
Colonoscopy- polyps
.
Labs on Discharge
[**2138-2-19**] 01:00PM BLOOD Hct-30.3*
[**2138-2-19**] 07:15AM BLOOD Plt Ct-171
[**2138-2-19**] 07:15AM BLOOD Glucose-90 UreaN-17 Creat-1.5* Na-142
K-3.7 Cl-106 HCO3-26 AnGap-14
[**2138-2-19**] 07:15AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
.
[**2138-2-17**]
CT Abdomen w/Contrast
1. Possible antral thickening, but this is not well evaluated
given the lack of stomach distention.
2. 1.6 x 2.3 cm liver cyst.
3. 3.6-cm fusiform, infrarenal abdominal aortic aneurysm.
4. Mild thickening of the left adrenal gland, probably from
hyperplasia.
5. Pneumobilia, question previous sphincterotomy. Clinically
correlate.
6. Grade [**2-10**] anterolisthesis of L5 on S1.
.
[**2138-2-18**]
Biopsy
Gastric mucosal biopsies, two:
A. Body:
1. Small focus of intestinal metaplasia.
2. Otherwise, within normal limits.
B. Antrum:
Within normal limits.
Brief Hospital Course:
Assessment: 84yo man with no significant PMH presenting with
melena and found to be actively bleeding, thought to be active
GI bleed.
.
Plan:
.
1. GI bleed:
In the ICU the patient received 2U of PRBCS. When he was
transferred to medicine he received 1U of PRBCs. The patient
remained HD stable. His Hct was stable at 30 at the time of
discharge.
The patient had a EGD which showed gastritis and antral
thickening. A colonoscopy was showed polyps.A CT of the
abdomen was also done to rule out antral thickening, but the
study was limited due to the lack of abdominal distention.
Gastric mucosal biopsies in the body later revealed a small
focus of intestinal metaplasia and the antrum was within normal
limits.
The etiology of the patient's GIB remained unclear. The patient
was prepped for a capsule study on the day of discharge and was
scheduled to follow up in the [**Hospital **] clinic for the official report.
.
2. Acute renal failure - FeNa was 2.0. This was attributed to a
prerenal physiology in the setting of hypotension. The patient
received IV hydration prior to the CT study.
.
3. Glucose control - FS, ISS.
.
4. h/o of prostate CA - The patient was scheduled to follow up
with Dr. [**Last Name (STitle) **] for his Lupron shot at the time of discharge.
.
5.FEN - Lytes were repleted as needed. The patient was kept
NPO. His diet was later advanced as tolerated following the GI
procedures.
.
6. Ppx - IV PPI [**Hospital1 **], no sc heparin due to bleeding
.
Communication - pt's daughter
.
Code status - full
.
Medications on Admission:
Lupron injections
Discharge Medications:
1. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gastrointestinal Bleed
Discharge Condition:
Good, vitals stable, patient ambulating
Discharge Instructions:
Please seek medical services immediately if you should
experience any bleeding by mouth or per rectum, if you should
start to experience light headedness or dizziness. Please avoid
medications such as aspirin, ibuprofen or other non-steroidals.
Please continue taking your medications as prescribed.
Followup Instructions:
You are to make an appointment to followup with your PCP [**Name Initial (PRE) 176**]
1 week of discharge. At that time he/ she will need to check
your hematocrit. At the time of discharge your hematocrit was
30.
An appointment has been set for you to followup with your
gastroenterologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12427**], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2138-3-10**] 1:30
Completed by:[**2138-6-2**]
|
[
"584.9",
"285.1",
"211.3",
"585.9",
"V43.64",
"V10.46",
"211.4",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"48.36",
"45.42",
"45.16",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5966, 5972
|
4165, 5705
|
268, 285
|
6045, 6087
|
2419, 4142
|
6436, 6981
|
1822, 1859
|
5773, 5943
|
5993, 6024
|
5731, 5750
|
6111, 6413
|
1874, 2400
|
222, 230
|
313, 1591
|
1613, 1680
|
1696, 1806
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,665
| 156,663
|
24200
|
Discharge summary
|
report
|
Admission Date: [**2196-8-14**] Discharge Date: [**2196-9-16**]
Date of Birth: [**2137-5-23**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Procrit
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
cough and dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy and photodynamic therapy
Tracheostomy and PEG
History of Present Illness:
Mr. [**Known lastname 61467**] is a 59 M with known metastatic renal cell carcinoma
on daily [**Hospital 61468**] transferred from OSH [**3-4**] obstructing metastatic
disease to RML seen on bronchoscopy today. Pt reports [**3-5**] month
history of fatigue and night sweats. Also over the last few
months he has had progressively worsening cough and dyspnea on
exertion. Also few episodes of hemoptysis. Two weeks ago he
was started on antibiotics after outpatient visit for cough and
was told that he had pneumonia. He reports that CXR was not
done at this time. He felt that he never recovered from this
episode and cough worsened during the last 3 days prior to OSH
admission. One day prior to OSH admission he had severe cough
and dyspnea while driving that forced him to stop his car. He
has never had chest pain with any of this. No fevers, leg
swelling, HA, abd pain, diarrhea/N/V, dysuria. + weight loss
with start of treatement for RCC.
Past Medical History:
Metastatic renal cell carcinoma: His left renal mass was
diagnosed during workup for hypertension in [**2193-3-3**]. Known
mets to lung, liver, vertebrae. Had treatments below:
-Left nephrectomy in [**3-/2193**], which revealed a grade [**3-6**] clear
cell carcinoma.
-Interferon, administered as part of a CALGB study comparing
interferon alone with an interferon/Avastin combination at the
[**Hospital3 328**] Cancer Institute. The patient was taken off study
in
[**10/2194**] because of disease progression. He claims to have
subsequently been treated with Avastin off study.
-Radiation therapy to the left ischium.
-Zometa therapy, terminated because of a significant increase
in his creatinine.
-Nexavar begun in [**2-/2195**] and promptly terminated because of
severe gastrointestinal side effects (e.g. cramping and
diarrhea).
-High-dose interleukin-2 in [**9-/2195**], which led to transient
disease stabilization.
-[**Year (4 digits) **] begun in [**11/2195**] because of disease progression.
.
Other PMH:
-MI in [**2193**]
-HTN
-h/o DVT [**3-7**]
Social History:
history of smoking x 25 years, quit 20 years ago. + alcohol [**2-2**]
drinks/day but none in last few weeks. No drugs.
Family History:
negative for cancers
Physical Exam:
GEN: Pt is comfortable and pleasant, sitting in NAD on O2 by NC
HEENT: normocephalic, atraumatic. PERRLA, anicteric sclera, no
erythema or discharge. O/P clear
NECK: supple
CHEST: diminished breath sounds L and R bases and lateral fields
CV: reg rate, nl S1/S2, no M/R/G
ABD: nl bowel sounds, soft, NT/ND, no masses or HSM, L flank
scar. some voluntary guarding
EXT: pink, warm, good distal pulses no edema
NEURO: A&O x3, gait WNL
SKIN: no petechia, purpura, no rashes, lesions
Pertinent Results:
Summary of OSH results:
Bronchoscopy [**8-14**]: mas almost completely occluding RML takeoff
and subsegemental takeoff of RLL. Highly vascular, fragile,
bleeding mass was not obvious for risk of heavy bleeding.
Cytology, microbiology were sent off from BAL.
[**8-11**] CXR: R pleural effusion, L pleural effusion, hilar
lymphadenopathy, no congestion
[**8-11**] CT: no PE; RmL consolidation with pronounced RML
atelectasis that appears almost complete, extensive pleural and
parenchymal lesions. Pathological fracture at T12; several liver
lesions
CBC on [**8-11**] - WBC 3.1 H/H 10.4/23; plts 493; Cr 0.7 LFTs nl; tB
0.3;
Brief Hospital Course:
Respiratory Failure/Post-Obstructive PNA: The patient was
transferred to [**Hospital1 18**] OMED on [**8-14**]. Bronchoscopy showed
obstructive renal cell carcinoma metastastic endobronchial
lesions in RML, medial basilar RLL, and LLL. HE had
photodynamic therapy on [**8-19**] and subsequently developed
post-procedure respiratory distress requiring intubation on
[**8-22**]. Repeat bronchoscopies were done for tumor debridement on
[**8-22**], and clearance of secretions on [**8-23**]. Then treated with 14
day course of vancomycin for MRSA pneumonia, and also aztreonam
and cipro. Subsequently, he became volume overloaded, requiring
diuresis. His HCT drifted down to 20, and received 2 units
PRBCs on [**8-26**] and [**8-28**]; anemia presumed due to bleeding
metastases. Repeat bronchoscopy on [**8-31**] showed persistent RML
obstruction and RML pneumonia. Due to difficulty weaning from
the ventilator, he underwent trach and PEG on [**9-7**], after which
he was quickly weaned to PS and then to tracheal mask by [**9-8**].
He returned to the MICU temporarily after having pulled out his
endotracheal tube, but respiratory distress again resolved with
re-placement of the endotracheal tube. Sputum cultures from [**9-7**]
grew MRSA as well as 2 strains of Pseudomonas. Vancomycin
intravenous Q 12H and meropenem 500 mg intravenous Q6H (every 6
hours) began on [**2196-9-15**]. Please continue both antibiotics for
12 more days after discharge for 14 day course.
# Renal cell carcinoma: Metastatic as previously described.
Known mets to vertebrae, liver, lung. On [**Last Name (LF) 61468**], [**First Name3 (LF) **] continue
per primary oncologist, receives refills at home and will
continue on this.
.
# Hypertension: Continued home medications.
.
# Prophylaxis: Received heparin SC and PPI while in house.
.
# Code status: DNR but ok to intubate.
Medications on Admission:
Meds:
Home Meds:
Folic Acid 1 mg PO QD
Lisinopril 5 mg QD
Lipitor 40 QD
ASA 81 QD
Sutend 50 mg QD
Oxycontin 20 mg PO BID
Oxycodone 5 mg prn
Albuterol prn
.
Meds upon transfer:
Albuterol
Folic Acid 1 mg PO QD
Lisinopril 5 mg QD
Lipitor 40 QD
ASA 81 QD
Sutend 50 mg QD
Oxycontin 20 mg PO BID
Oxycodone 5 mg prn
Albuterol prn
Senna/colace
RISS
Levofloxacin 500 mg IV QD
Protonix
Zofran
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
7. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): HOLD for SBP <110, HR <60.
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
11. Sunitinib 50 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): Please continue for 12 more
days for 14 day course. Day one of therapy was [**2196-9-15**].
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours): Please continue for 12 more
days for 14 day course. Day one of therapy was [**2196-9-15**].
14. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q1H (every
hour) as needed for prn inability to clear mucous plug.
15. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection QID (4
times a day).
16. Morphine Sulfate 5-20 mg IV Q15 MIN prn inability to clear
mucous plug
prn inability to clear mucous plug
17. Bisacodyl 10 mg Suppository Sig: One (1) Rectal DAILY:PRN
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnoses:
1) Metastatic Renal Cell Carcinoma
2) Post-obstructive pneumonia
3) Respiratory failure s/p tracheostomy and PEG
Discharge Condition:
Stable. The patient has been tolerating tracheostomy mask. His
saturations have been in the 90s on 50% TM, requiring frequent
suctioning for clearance of secretions.
Discharge Instructions:
You were admitted for shortness of breath. You received
photodynamic therapy to treat the renal cell cancer that spread
to your lungs. You received a course of antibiotics to treat a
pneumonia. Your breathing trouble required you to be on a
breathing machine and also required you to have a breathing tube
placed in your trachea (neck). You were also given a G-tube
into your stomach to help with nutrition.
Your trach may need to be upsized from #6 back to #7 or # 8 at
rehab if suctioning and plugging continues to be a problem.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2196-9-28**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2196-9-28**]
3:00
|
[
"401.9",
"934.9",
"198.5",
"285.22",
"482.41",
"733.13",
"518.84",
"428.0",
"412",
"564.00",
"V09.0",
"197.0",
"197.7",
"482.1",
"V10.52",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.93",
"96.05",
"32.01",
"99.04",
"96.6",
"96.72",
"33.24",
"96.04",
"32.28",
"33.27",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
7874, 7946
|
3759, 5629
|
295, 356
|
8122, 8292
|
3111, 3736
|
8876, 9166
|
2575, 2597
|
6063, 7851
|
7967, 8101
|
5655, 6040
|
8316, 8853
|
2612, 3092
|
238, 257
|
384, 1340
|
1362, 2422
|
2438, 2559
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,791
| 111,465
|
13953
|
Discharge summary
|
report
|
Admission Date: [**2158-6-17**] Discharge Date: [**2158-6-21**]
Date of Birth: [**2102-1-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Babesiosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 M orthopedic physician, [**Name10 (NameIs) **] [**Name11 (NameIs) **] (good) until 7 Days PTA . 1
week prior to admission while in [**Country 18084**] he noticed sudden
onset of fatigue, no muscle pains, joint pains, denied cough,
fevers, sob, diarrhea, dysuria. On return, he had a cxr which
was negative per his report, and f/u blood work which
demonstrated intraerythrocytic parasites and he was admitted for
further treatment at an OSH.
.
While in [**Country 18084**] for 10 days, had been playing golf, no known
tick bites, however prior to trip, for the past month he had
noticed increasing fatigue, also multiple exposures to ticks,
which at [**Location (un) **], and in his gardens in [**Location (un) 1411**].
.
At OSH was noted to have WBC of 7800, 24% monos, ALT 102, AST
107, TBili 3.18 was started on clindamycin 1200mg q12h, quinine
650 PO. He was continued on clinda/quinine. Doxy was started for
possible ehrlichiosis co-infection. He was then transitioned to
atovaquone and azithromycin [**6-15**].
He was transferred to [**Hospital1 18**] [**6-17**] for possible plasma exchange
given high parasitemia (10-15% at OSH). Parasitemia here was 6%
and, in discussion with transfusion medicine and infectious
disease services, it was decided that he did not need plasma
exchange. ICU course also notable for continued high-grade
fever, CHF (received IV lasix) and hearing loss (attributed to
quinine).
Past Medical History:
MI s/p CABG
HTN
Hypercholesterolemia
Social History:
Lives at home, orthopedist at [**Hospital1 **], no smoking, social EtoH
Family History:
91 alive Father CAD, CABG, Prostate CA
[**15**] Mother deceased ALS, 1 healthy sister
Physical Exam:
VS 98.7, 102/52, 56, 18, 100%
Gen: NAD, pleasant, speaking in full sentences
HEENT: JVP nondistended, PERRL, anicteric sclera, OP Clear, no
LAD
CV: RRR no mrg
Chest: cta b/l
Ext: no c/c/e
Neuro CNII-CNXII intact, no focal deficits
Pertinent Results:
[**2158-6-21**] 05:45AM BLOOD WBC-7.3 RBC-3.63* Hgb-11.2* Hct-32.8*
MCV-91 MCH-31.0 MCHC-34.2 RDW-15.7* Plt Ct-230#
[**2158-6-20**] 05:40AM BLOOD WBC-7.1 RBC-3.45* Hgb-10.7* Hct-30.9*
MCV-90 MCH-31.1 MCHC-34.6 RDW-15.1 Plt Ct-153
[**2158-6-19**] 07:20AM BLOOD WBC-7.0 RBC-3.41* Hgb-11.0* Hct-29.9*
MCV-88 MCH-32.4* MCHC-36.9* RDW-15.0 Plt Ct-110*
[**2158-6-18**] 06:08AM BLOOD WBC-6.8 RBC-3.64* Hgb-11.7* Hct-32.3*
MCV-89 MCH-32.0 MCHC-36.2* RDW-14.8 Plt Ct-82*
[**2158-6-17**] 02:23PM BLOOD WBC-6.8 RBC-3.53* Hgb-11.2* Hct-31.6*
MCV-90 MCH-31.7 MCHC-35.4* RDW-15.2 Plt Ct-75*
[**2158-6-19**] 07:20AM BLOOD Neuts-51 Bands-1 Lymphs-25 Monos-19*
Eos-0 Baso-1 Atyps-2* Metas-0 Myelos-0 Plasma-1*
[**2158-6-19**] 07:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2158-6-21**] 05:45AM BLOOD PT-14.3* INR(PT)-1.3*
[**2158-6-19**] 07:20AM BLOOD Fibrino-779*
[**2158-6-20**] 12:35PM BLOOD Parst S-POSITIVE
[**2158-6-21**] 05:45AM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-130*
K-4.7 Cl-97 HCO3-25 AnGap-13
[**2158-6-20**] 05:40AM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-130*
K-4.1 Cl-96 HCO3-26 AnGap-12
[**2158-6-19**] 07:20AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-128*
K-4.1 Cl-94* HCO3-25 AnGap-13
[**2158-6-21**] 05:45AM BLOOD ALT-289* AST-204* LD(LDH)-732*
AlkPhos-127* TotBili-1.7*
[**2158-6-20**] 05:40AM BLOOD ALT-277* AST-243* CK(CPK)-144 AlkPhos-117
TotBili-2.0*
[**2158-6-18**] 06:08AM BLOOD ALT-269* AST-257* CK(CPK)-114 AlkPhos-114
TotBili-3.1*
[**2158-6-20**] 05:40AM BLOOD CK-MB-4 cTropnT-<0.01
[**2158-6-18**] 06:08AM BLOOD CK-MB-4 cTropnT-<0.01
[**2158-6-21**] 05:45AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.4 Mg-2.5
[**2158-6-17**] 02:23PM BLOOD TotProt-5.1* Albumin-2.4* Globuln-2.7
Calcium-7.4* Phos-1.6* Mg-2.2
[**2158-6-19**] 07:20AM BLOOD Hapto-<20*
[**2158-6-18**] 06:08AM BLOOD calTIBC-122* VitB12-615 Folate-15.6
Ferritn-GREATER TH TRF-94*
[**2158-6-17**] 02:23PM BLOOD Hapto-<20*
[**2158-6-21**] 05:45AM BLOOD Triglyc-220*
[**2158-6-18**] 06:08AM BLOOD Osmolal-268*
[**2158-6-18**] 06:08AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2158-6-18**] 06:08AM BLOOD HCV Ab-NEGATIVE
[**2158-6-19**] 07:20AM BLOOD MISCELLANEOUS TESTING-PND
[**2158-6-18**] 06:08AM BLOOD LEPTOSPIRA ANTIBODY-PND
[**2158-6-18**] 06:08AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM-PND
[**2158-6-18**] 06:08AM BLOOD HUMAN MONOCYTIC AND GRANULOCYTIC
EHRLICHIA AGENTS IGG AND IGM-PND
TTE: Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is low
normal (LVEF 50-55%) with inferior hypokinesis suggested (poor
image quality). There is no ventricular septal defect. Right
ventricular chamber size is normal. Right ventricular systolic
function is borderline normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a fat pad
CTA CHEST: There is no pulmonary embolism. Thoracic aorta is
normal in caliber and contour, without evidence of dissection or
aneurysm. Heart, pericardium, and great vessels are normal.
There is no pericardial effusion. There is no enlarged
adenopathy within the chest. Central bronchi are patent to the
subsegmental level. There is evidence of previous median
sternotomy and cardiac surgery with CABG. Lung windows
demonstrate no pulmonary nodules or focal consolidations,
although evaluation of the left lower lobe and lingula is
slightly limited due to respiratory motion artifact. There are
small bilateral pleural effusions, and minor subsegmental
atelectasis at the lung bases bilaterally. Limited views of the
upper abdomen are notable for mild splenomegaly. Osseous
structures are unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Small bilateral pleural effusions.
PORTABLE CHEST X-RAY
Recently described interstitial edema has resolved. Cardiac
silhouette remains mildly enlarged with upper zone vascular
redistribution. New discoid atelectasis developed at the left
lung base peripherally.
Brief Hospital Course:
Admitted initially to [**Hospital Unit Name 153**] then transferred to [**Hospital Ward Name 516**]
Hospitalist Service
1. Babesiosis
- ID consultation
- [**Hospital **] clinic f/u on [**6-27**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
- Patient is being continued on docycycline given we have not
recieved his leptospirosis serology. This is a less likely
co-infection but must be considered given the constellation of
Sx
- Patient to continue atovaquone and zithromax until instructed
by ID to stop
- Serial thick smears demonstrated clearing of babesia
parasites, last smear 0.2%
- Presumed etiology of hemolysis
- The infection really behaved as if the patient is asplenic,
and he is being recommended to have this worked up at his PCPs
office
- Special babesia serologies were sent to the CDC for
speciation. These were pending at discharge
2. Transaminitis
- Likely due to babesia, however several features are hard to
explain, especially his albumin of 2.4
- Given the level of transaminases his lipitor was held
- Recommend further workup at his PCP's office in [**1-28**] weeks for
repeat serologies to restart lipitor
- His bilirubins have improved steadily
3. Hemolysis NOS
- Presumed due to babesia, however further splenic workup in the
outpatient setting are recommended
- Hematocrit stabilized at 30
4. Hyponatremia
- Slowly improving, now at 130
- Recommend outpatient followup, more likely due to free water
with initially poor PO salt intake
5. Systolic CHF
- EF has improved from prior echo of 45% to new EF of > 55%
- Toprol XL was continued
- ACEI was held due to his BP being 110
- Patient will monitor his own BP at home and restart ACEI when
it > 120'
6. CAD/CABG Vessle
- Toprol XL was continued
- Lipitor was held as above
- When labs have returned to [**Location 213**] could resume aspirin
7. Benign Hypertension
- Toprol XL was continued
- ACEI was held due to his BP being 110
- Patient will monitor his own BP at home and restart ACEI when
it > 120'
Medications on Admission:
Albuterol/ipratropium
guaifensin 1200mg [**Hospital1 **] PO
doxycycline 100mg Q12H
Ibuprofen 400mg q6hrs PRN
Quinine Sulfate 650mg Q8H
Metoprolol XL 50mg DAILY
Folice Acid 1mg DAILY
MVI 1 TB
Zolpidem 10mg QHS
Ramipril 15mg DAILY
CaCarbonate 500mg [**Hospital1 **]
Omeprazole 20mg DAILY
Azithromycin 250 DAILY
Meperidine 50mg Q4Hrs PRN
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2
times a day) for 14 weeks.
Disp:*980 ml* Refills:*0*
2. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
5. Ramipril 5 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily): hold for SBP < 120.
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Babesiosis
Transaminitis
Hemolysis
Hyponatremia
Systolic CHF
CAD
Benign Hypertension
Discharge Condition:
Good
Discharge Instructions:
You are being discharged with some changes to your medications:
Do not restart your lipitor until cleared by your PCP due to
your liver enzymes
Measure your blood pressure each day and would not take your
ramapril if your blood pressure is < [**Age over 90 **]
You can continue to take your zetia
We are sending you out on doxycycline as we still do not have
your leptospirosis serologies back. Continue to take it until
you have seen the [**Hospital **] clinic
You should have a workup by your PCP for your spleen and liver
function, including why your albumin is so low.
Followup Instructions:
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2158-6-27**]
3:00 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Please make an appointment for the next 2 weeks with your PCP
[**Name9 (PRE) **],[**Name9 (PRE) 198**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 19980**]
|
[
"088.82",
"428.0",
"790.4",
"389.9",
"287.5",
"286.6",
"272.4",
"V45.81",
"401.9",
"414.00",
"276.1",
"272.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10228, 10234
|
6999, 9019
|
326, 332
|
10362, 10368
|
2300, 6976
|
10990, 11339
|
1945, 2033
|
9405, 10205
|
10255, 10341
|
9045, 9382
|
10392, 10427
|
2048, 2281
|
10456, 10967
|
276, 288
|
360, 1779
|
1801, 1840
|
1856, 1929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,984
| 152,373
|
28544
|
Discharge summary
|
report
|
Admission Date: [**2126-8-4**] Discharge Date: [**2126-9-1**]
Date of Birth: [**2087-8-22**] Sex: F
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
Intubation
Central line placement (Right IJ)
History of Present Illness:
Patient is a 38 year old female with known ETOH cirrhosis, Child
class B to C, complicated by known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia who was admitted to the [**Location (un) 47**]
ICU with hematemesis x 5 after report of drinking ETOH on
[**2126-8-3**]. An EGD performed 1 month prior was reported to
demonstrate severe esophagitis with flat varices. The patient
was on presentation normotensive but tachycardic with subsequent
development of hypotension requiring multiple fluid boluses and
RBC transfusions. Admission vitals at OSH were 97/56, 92, 20,
99.2, 99% on RA. The patient was started on an octreotide gtt as
well as a Protonix gtt, received 2U FFP for INR of 1.8 and
transused 2U PRBCs. Patient's Hct on admission was 30.3 and most
recently 29.9 after 10U PRBCs in total thus far. The patient on
[**2126-8-3**] underwent EGD with banding and sclerotherapy after
receiving 2U PRBCs and 1U platelets. The following day, this
a.m. the patient continued to have ongoing hematemsis with
additional observation of frank aspiration for which the patient
was intubated for airway protection. The patient received 1 dose
of Clindamycin for this event as well. The patient has since
undergone a second attempt of EGD with repeat banding and
sclerotherapy with visualization of failed bands from previous
EGD. The patient is now being transferred to the [**Hospital1 18**] ICU for
ongoing management and possible TIPs with IR. On transfer
patient is being maintained with IV octreotide, protonix, and
received Methylprednisolone 20mg IV x1.
Past Medical History:
ETOH cirrhosis, Child's class B to C
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea
Social History:
Reported to drink 2 glasses Vodka/day, last drink yesterday.
Patient is divorced, unemployed mother of 2, currently lives
with a friend. Reported to have had abusive partners previously.
Occasional smoking.
Family History:
Father died age 50 of MI. Mother alive and well. No fam hx of
ETOH or liver disease.
Physical Exam:
Tc- 98.8 ; BP: 117/42 ; HR: 92
Vent: 500 x 12, FiO2 .40 PEEP 5, O2 100%
.
General - Patient is a young female, jaundiced, lying in bed,
intubated + sedated
HEENT: + ETT, +crusted blood in OP, around lips.
Pupils dilated, equal, minimally reactive to light. Conjunctiva
injected bilaterally.
Neck: No JVD, supple.
Chest: CTA Anterior and Laterally, fair air movement. +blanching
spider angioma over chest
Cor: RRR, no M/R/G appreciated
Abd: moderately distended. + Striae, + fluid wave. Soft, NT,
+BS. Liver tip firm, palpable 3-4cm below costal margin.
Rectum: Notable for bright red blood per rectum - approx 150cc
on [**Male First Name (un) **] currently, small clots
Ext: Trace pedal edema, extremities cool, pulses 1+ bilaterally.
+Right fem line, intact.
Access: Right fem line, PIV x 2, foley with [**Location (un) 2452**] urine
Pertinent Results:
Updated [**2126-8-25**]
==============
Interventions:
==============
TIPS procedure [**2126-8-6**].
IMPRESSION:
1. Status post successful placement of TIPS with a 10 mm x 68
mm Wallstent lining the transparenchymal tract extending from
the right hepatic vein to the right portal vein. Post-procedure
portosystemic gradient was 5 mm.
2. Status post exchange of right internal jugular approach
triple lumen
central venous line.
3. No post-procedural orders written.
.
EGD: [**2126-8-23**]
Blood in the lower third of the esophagus and gastroesophageal
junction
Blood in the fundus
Ulcer in the cardia (injection)
Otherwise normal EGD to second part of the duodenum.
.
Radiology:
==========
Chest X-ray [**2126-8-5**]
CHEST:
The position of the endotracheal tube and IJ line is unchanged.
Since the prior chest x-ray there has been loss of the left
hemidiaphragm suggesting atelectasis and/or consolidation in
this region. The left costophrenic angle is not seen and there
may be also an effusion present.
IMPRESSION: Left` retrocardiac opacifications.
.
Abdominal Ultrasound [**2126-8-5**]
IMPRESSION:
1. Echogenic liver with no definite focal lesions seen.
2. Patent portal vein with hepatopetal flow.
3. Mildly distended gallbladder with gallbladder wall edema and
no gallstones demonstrated. Small pericholecystic fluid is also
seen in the presence of mild-to-moderate generalized ascites.
Gallbladder wall edema may be secondary to liver disease, and is
also demonstrated in the presence of right heart failure or
hypoproteinemic state. Correlation with LFTs and clinical exam
is recommended.
4. Approximately 2 cm focal mild bulge in the contour of the
right kidney at the interpolar region is incompletely
characterized. Correlation with other cross-sectional previous
imaging if available is recommended. If none is available,
further characterization may be performed with additional cross-
sectional imaging.
.
Abdominal Ultrasound [**2126-8-13**]
IMPRESSION:
1. Cirrhotic liver with ascites and TIPS with wall-to-wall color
flow.
2. Splenomegaly.
3. Right pleural effusion.
.
Microbiology:
=============
Positive:
Urine Culture [**2126-8-17**] Yeast
Sputum culture [**2126-8-7**] and [**2126-8-9**] MRSA
.
CULTURES with no growth to date:
Central line Catheter tip Culture: [**Month (only) 462**]/13,19/[**2125**]
Blood Culture: [**Month (only) 462**]/3,6,7,8,10,16,18,19,21,22,23/[**2125**]
Urine Culture: [**Month (only) 462**]/3,4,6,8,10,18,21/[**2125**]
Ascites Culture:[**2126-8-21**]
Sputum Culture: 9/13,22/[**2125**]
C.Diff toxin negative: 9/8,16,17,19/[**2125**]
.
Blood tests:
============
On Admission:
[**2126-8-4**] 09:30PM WBC-3.5* RBC-3.01* Hgb-9.2* Hct-25.9* MCV-86
MCH-30.5 MCHC-35.5* RDW-19.5* Plt Ct-16*
[**2126-8-4**] 09:30PM PT-18.9* PTT-41.5* INR(PT)-1.8*
[**2126-8-4**] 09:30PM Glucose-136* UreaN-7 Creat-0.6 Na-141 K-3.8
Cl-107 HCO3-26 AnGap-12
[**2126-8-4**] 09:30PM ALT-26 AST-81* LD(LDH)-245 AlkPhos-70
Amylase-34 TotBili-7.4*
[**2126-8-4**] 09:30PM Albumin-2.8* Calcium-7.3* Phos-2.3* Mg-1.2*
Brief Hospital Course:
Patient is a 38 year old female with ETOH cirrhosis with known
portal [**Hospital **] transferred from OSH MICU s/p banding and
sclerotherapy x 2, now being transferred to the [**Hospital1 18**] ICU for
ongoing mangement/care and planned TIPS procedure with IR.
.
#. Variceal bleed - Initially had hematemesis, pt was intubated
HD1 for airway protection, Patient had EGD with banding and
sclerotherapy x 2 on HD2;
She was transfused four units of pRBC's, four units of FFP, and
two unit of platelets, as well as being given 10mg of sc vitamin
K over the first night of admission. On day two, her hct
remained stable throughout much of the day. However, variceal
bleed continued, it was decided that TIPS was necessary. Pt was
transfused with FFP until INR <1.5 for TIPS. She was taken to
TIPS and transferred from ICU to Hepatorenal service after 24h
stable observation. She was stable from a GIB stand point after
a transfusion of a total of 14 U in the setting of the acute
event, but she continued to be vent dependent and was found to
have a VAP from MRSA. During her MICU course she continued to be
febrile despite negative cultures for other then sputum with
MRSA and defervesced once started on Zosyn. Subsequently she was
weaned of the vent and was successfully extubated on [**8-13**] and
then transfered to the regular floor. There the pt was continued
on Vancomycin and Zosyn for a 14 day course anmd was further
diuresed. She was doing well until the [**8-19**] when she developed
fevers of unknown origin. She had a paracentesis, a CT of the
abdomen which did not reveal any infection. She was thought to
potentially have drug fever. After completion of her antibiotic
course, the low grade fevers discontinued. Hepatology followed
throughout hospital course.
Throughout hospital course: Hct checked q 2 hours until stable,
then q4h; 2 18-20 gauge PIV x 2 were maintained, active T+X,
central access, IV Protonix
.
#. ETOH - Child class B to C, MELD score 18 at OSH;patient with
reported use of 2pints Vodka/day, last drink yesterday on day of
admission; patient intubated/sedated with propofol making CIWA
assessment limited; pt was initially maintained on octreotide,
protonix, and received Methylprednisolone 20mg IV x1.
After pt stabilized, MVI/Thiamine/potassium/magnesium
supplemented. Pt was without seizures throughout
hospitalization.
.
#. ETOH [**Name (NI) 52965**] pt was maintained on lactulose when stable.
.
#. Psych - social work and psychiatry were consulted; She was
maintained on Risperidone and Citalopram when she was stable;
She never endorsed sx of major dempresssion; She was stable from
psycyiatric perspective; felt that she did not have a good
support group at home beside her roommate who is a father figure
for her; referral was made to an Etoh support group near her
home during discharge planning. She was agreeable to follow up
with them and was very hopeful for a "second chance at life".
.
#. Code: Full
Medications on Admission:
none
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*6*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH cirrhosis
Esophageal varices s/p bleed
Gastric ulcer in cardia bleed
Ventilator associated pneumonia
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if you have any vomiting of blood, blood in the
stool, dark black stool, fevers, other concerning symptoms.
Followup Instructions:
Call [**First Name8 (NamePattern2) 501**] [**Last Name (NamePattern1) 1637**], [**Telephone/Fax (1) 69143**] for a referral for ongoing
counseling and support.
|
[
"V09.0",
"518.81",
"530.10",
"303.90",
"570",
"296.80",
"780.6",
"456.20",
"291.81",
"286.7",
"571.1",
"482.41",
"E947.9",
"531.00",
"787.91",
"572.3",
"571.2",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"39.1",
"38.93",
"99.07",
"96.72",
"44.43",
"96.6",
"54.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10263, 10269
|
6350, 8138
|
281, 337
|
10419, 10426
|
3291, 5905
|
10599, 10762
|
2334, 2420
|
9361, 10240
|
10290, 10398
|
9332, 9338
|
8155, 9306
|
10450, 10576
|
2435, 3272
|
227, 243
|
365, 1978
|
5919, 6327
|
2000, 2094
|
2110, 2318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,685
| 126,509
|
31236
|
Discharge summary
|
report
|
Admission Date: [**2181-7-11**] Discharge Date: [**2181-7-20**]
Date of Birth: [**2130-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
[**2181-7-11**] Cardiac Catheterization
[**2181-7-13**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag1, SVG to Diag2, SVG to PDA), Ascending Aorta Replacement w/
24mm Gelweave Graft
History of Present Illness:
50 y/o male who presented to [**Hospital 1474**] Hospital with chief
complaint of 1 month chest tightness and SOB. At [**Hospital1 1474**], they
were concerned about some isolated ST elevation in lead V2,
started the patient on heparin gtt, nitro gtt, gave him ASA 325,
plavix 600 mg, and lopressor 2.5 and transferred him to [**Hospital1 18**].
Past Medical History:
Hypercholesterolemia, Chronic back pain, Cluster migraines,
Diverticulosis
Social History:
Works as a subcontractor installing pools
Smokes marijuana daily (1 joint at bedtime)
has history of cocaine (> 20 years ago, none since)
denies alcohol
smoked 1.5 PPD x 30 years, still smoking
Family History:
Father had CAD, had MI in his 40's, died in 60's during surgery
DM in cousins and nephew
[**Name (NI) 21206**] died of Ovarian CA
Physical Exam:
VS: T 97.3 BP 129/87 HR 57 RR 20 O2 100% 2L
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. Non-healing acnieform lesion below R lower lip.
Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple, no JVD, no carotid bruits
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no w/r/r
Abd: Soft, NT/ND. No HSM or tenderness. normoactive BS
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2181-7-11**] CARDIAC CATH: 1. Selective coronary angiography in this
right dominant system demonstrated two vessel coronary artery
disease. The LMCA had no flow limiting stenoses. The LAD had a
90% stenosis in the mid segment. The second diagonal branch had
a 90% stenosis. The LCx had a 50% stenosis in the mid segment.
The RCA had a 100% mid segment stenosis and filled distally via
L-->R collaterals. There was a 90% stenosis at the origin of
the PDA. 2. Left ventriculography demonstarted an ejection
fraction of 49% with moderate inferior hypokinesis. 3. Limited
hemodynamics demonstrated normal systemic arterial pressures
with a central aortic pressure of 129/91 mmHg. LVEDP was low
normal at 4 mmHg. There was no gradient across the aortic valve.
[**7-12**] Vein mapping: On the right, the right greater saphenous
vein is patent throughout its length. Its diameters in cm
beginning at the saphenofemoral junction and extending distally
are as follows .48, .38 .35, .30, .24, .19, 1.8 and .21. On the
left side, the left greater saphenous vein is widely patent
throughout its length. Its diameters in cm beginning at the
saphenofemoral junction extending distally are as follows .47,
.33, .31, .28, .27, .18 and 1.14.
[**7-12**] Carotid u/s: There is less than 40% right ICA stenosis and
less than 40% left ICA stenosis with antegrade flow in both
vertebral arteries [**2181-7-12**] Echo: The left atrium is normal in
size. There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is mild regional left ventricular
systolic dysfunction with focal basal inferior hypokinesis (c/w
RCA disease). The remaining segments contract normally (LVEF =
50-55 %). Transmitral and tissue Doppler imaging suggests normal
diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. 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 (1+) aortic regurgitation is seen.
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
ananterior space which most likely represents a fat pad.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2181-7-19**] 11:53 AM
CHEST (PA & LAT)
Reason: ? Pnuemonia or pulmonary edema
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p cabg with shortness of breath
REASON FOR THIS EXAMINATION:
? Pnuemonia or pulmonary edema
PA AND LATERAL VIEWS OF THE CHEST.
REASON FOR EXAM: Question of pulmonary edema.
Comparison is made with prior study dated [**2181-7-17**].
Left lower lobe retrocardiac consolidation is persistent and
consistent with pneumonia rather than atelectasis. Right lower
lobe atelectasis has improved. Bilateral small pleural effusions
have improved in the right. Cardiomediastinal contour is
unchanged. Patient is post median sternotomy and CABG. There is
no pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2181-7-20**] 06:54AM 15.4* 3.29* 9.7* 29.2* 89 29.4 33.1 14.8
609
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2181-7-19**] 06:20AM 101 17 1.0 137 4.8 100 27 15
Cardiology Report ECHO Study Date of [**2181-7-12**]
PATIENT/TEST INFORMATION:
Indication: Chest pain. Left ventricular function.
Height: (in) 69
Weight (lb): 170
BSA (m2): 1.93 m2
BP (mm Hg): 109/71
HR (bpm): 72
Status: Inpatient
Date/Time: [**2181-7-12**] at 16:12
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W042-0:00
Test Location: West [**Hospital Ward Name 121**] [**1-20**]
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 2194**]
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)
Right Atrium - Four Chamber Length: *5.2 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: *4.7 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.4 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 0.67
Mitral Valve - E Wave Deceleration Time: 260 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
regional LV
systolic dysfunction. Transmitral Doppler E>A and TDI E/e' <8
suggesting
normal diastolic function, and normal LV filling pressure
(PCWP<12mmHg). No
resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior
- hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Moderately dilated
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
GENERAL COMMENTS: Cardiology fellow involved with the patient's
care was
notified by telephone.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular
systolic dysfunction with focal basal inferior hypokinesis (c/w
RCA disease).
The remaining segments contract normally (LVEF = 50-55 %).
Transmitral and
tissue Doppler imaging suggests normal diastolic function, and a
normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and
free wall motion are normal. 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
(1+) aortic regurgitation is seen. 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 fat pad.
IMPRESSION: Symmetric LVH with mild regional systolic
dysfunction, c/w CAD.
Mild aortic regurgitation. Moderately dilated thoracic aorta.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2181-7-12**] 17:05.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 73707**] was transferred for a
cardiac cath. Cath revealed two vessel disease and pt was
referred for cardiac surgery. Prior to surgery he was worked-up
in the usual pre-operative fashion along with carotid u/s and
vein mapping. Pt was being medically managed and then began
experiencing increased angina, including at rest. He was started
on a Nitro gtt and eventually brought to the cath lab for a IABP
placement. Transferred to the CCU after IABP placement and then
on [**7-13**] he was brought to the operating room where he underwent
a coronary artery bypass graft x 4 and asc. aorta replacement.
Please see operative report for details. Following surgery he
was transferred to the CSRU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. Following extubation, pt
was c/o blurred vision and ophthalmology was consulted. They
felt pt most likely had temp. chemosis and presbyopia. On
post-op day one his IABP was removed. On post-op day two beta
blockers and diuretics were initiated and he was gently diuresed
towards his pre-op weight. Chest tubes were removed and he was
later transferred to the telemetry floor. Epicardial pacing
wires were removed on post-op day three. He required blood
transfusion on post-op day four for low HCT. He worked with
physical therapy for strength and mobility and continued to
receive aggressive pulmonary toilet. He appeared to be doing
well and was discharged home on POD #7 with VNA services and the
appropriate follow-up appointments.
Medications on Admission:
Aspirin 325mg qd, Lipitor 80mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. 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. 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*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
Disp:*56 Capsule, Sustained Release(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 400mg [**Hospital1 **] for 1 week. Then 200mg [**Hospital1 **] for one
week. Then 200mg qd until stopped by cardiologist.
Disp:*120 Tablet(s)* Refills:*1*
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-23**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
14. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Ascending Aortic Aneurysm s/p Asc. Aorta Replacement
PMH: Hypercholesterolemia, Chronic back pain, Cluster migraines,
Diverticulosis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
NEED CARDIOLOGIST (Ask PCP for referral) and see in [**1-20**] weeks
Dr. [**Last Name (STitle) 17025**] in [**12-19**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-7-23**]
|
[
"305.1",
"V17.3",
"414.01",
"997.1",
"790.29",
"724.5",
"367.4",
"V16.41",
"411.1",
"272.4",
"441.2",
"E879.8",
"427.31",
"780.6",
"V65.49",
"V18.0",
"372.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"97.44",
"88.56",
"99.04",
"39.61",
"36.15",
"37.22",
"37.61",
"88.53",
"38.45",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
13163, 13219
|
9615, 11223
|
336, 532
|
13456, 13462
|
2102, 4601
|
14176, 14493
|
1232, 1364
|
11307, 13140
|
4638, 4688
|
13240, 13435
|
11249, 11284
|
13486, 14153
|
5815, 9472
|
1379, 2083
|
281, 298
|
4717, 5789
|
560, 907
|
9504, 9592
|
929, 1005
|
1021, 1216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,533
| 105,847
|
29086
|
Discharge summary
|
report
|
Admission Date: [**2153-10-1**] Discharge Date: [**2153-10-9**]
Date of Birth: [**2099-12-25**] Sex: F
Service: NEUROLOGY
Allergies:
Augmentin / Doxycycline / Trazamine / Ambien
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
Tx from neurosurgical service s/p placement of [**Last Name (un) **] catheter
for intrathecal chemotherapy.
Major Surgical or Invasive Procedure:
[**10-2**]: Rickham Catheter Placement
History of Present Illness:
[**Known lastname 14537**] is a 53 year-old woman with h/o metastatic breast CA
to liver and brain, chronic LE weakness, ?chronic dyspnea who is
being transferred from the neurosurgical service for spinal XRT.
.
She is well known to this service from her previous
hospitalization, when she presented with urinary retention, back
pain, and worsening shortness of breath. She was started on
dexamethasone, treated for UTI, and her symptoms improved until
discharge, when she was voiding on her own and without any more
back pain. [**Known lastname 4338**] of her C-T-L spine during that hospital course
showed no cord compression, but there were three distinct
lesions noted in the thoracic cord, likely representing
metastatic disease; there was question of leptomeningeal
involvement of the tumor. Radiation oncology had been consulted
and believed the thoracic lesions were unlikely the cause of her
symptoms. They believed there was no emergent need for XRT at
the time. LP was done prior to discharge and the cytology
report is negative for malignant cells.
.
She was discharged five days ago and reports that the following
day she experienced dyspnea. She describes the sensation as
"difficulty taking a deep breath." She felt uncomfortable,
called her boyfriend, and decided to come to the emergency room.
She denies any associated symptoms, including chest pain,
palpitations, lightheadedness, or dizziness. She was admitted
to the neurosurgical service for placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
catheter.
.
On admission her neuro exam showed A&Ox3, general weakness, no
focal deficits. Placement of Rickham catheter occurred on [**10-2**].
Post-op CT looked good. She was transferred to the [**Hospital Ward Name **]
today for radiation therapy, and now she is admitted to OMED.
Past Medical History:
Past Medical History (adapted from previous admission note):
# Breast cancer metastatic to liver and brain
- HER-2 positive
- s/p mastectomy
- s/p whole brain radiation
# HTN
# h/o Cat scratch disease at 8 years old
# s/p Left groin lump excision at age 8
# s/p 2.5 liter right thoracentesis on [**2151-9-28**]
# h/o R thigh subjective weakness for ~4 years, thought to be
due to proximal muscles
# ?baseline SOB
Social History:
Currently lives in [**Location 4628**] with her boyfriend, [**Name (NI) 122**], who is
very supportive. Used to work as LNA at a rehab, but is now on
disability. Smoked 1ppd x 3 years until [**2149**] (when she moved out
of a house owned by a smoker). No EtOH currently, was previously
a social drinker. No IVDU. Divorced, one daughter (age 26).
Family History:
Mother died in 70's of lung problems, DM, HTN. Father died at 74
of Parkinson's Disease, stroke. Two brothers with obesity and
hypertension. One 26 year old daughter with cervical
abnormalities (but no cancer) since age 19. No family history of
breast, ovarian, colon cancer.
Physical Exam:
Physical Exam at Admission
Vitals T 95.5, BP 133/89, RR 16, HR 94, O2 sat 99% RA
General WDWN, NAD, breathing comfortably on RA, hoarse voice
(unchanged from prior hospitalization)
HEENT PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck supple, no thyromegaly or masses, no LAD
Cardiac RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: CTAB
Abdomen: hypoactive bowel sounds, soft, nontender
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities; strength is [**3-26**] upper and lower extremities,
although there is slight weakness of hip flexion on the LLE; her
sensation is normal; her heel-to-shin and finger-to-nose are
normal.
.
Physical Exam at Discharge
Pertinent Results:
Labs at Admission
.
[**2153-10-1**] 05:16AM PT-12.6 PTT-71.0* INR(PT)-1.1
[**2153-10-1**] 04:55AM GLUCOSE-98 UREA N-12 CREAT-0.5 SODIUM-140
POTASSIUM-3.0* CHLORIDE-102 TOTAL CO2-30 ANION GAP-11
[**2153-10-1**] 04:55AM CK(CPK)-29
[**2153-10-1**] 04:55AM CK-MB-NotDone cTropnT-<0.01
[**2153-10-1**] 04:55AM WBC-5.2 RBC-3.83* HGB-11.4* HCT-33.2* MCV-87
MCH-29.8 MCHC-34.3 RDW-13.7
[**2153-10-1**] 04:55AM NEUTS-65.2 LYMPHS-25.8 MONOS-8.3 EOS-0.6
BASOS-0.1
[**2153-10-1**] 04:55AM PLT COUNT-292
.
Studies
.
CTA Chest ([**2153-10-1**])
1. No evidence of pulmonary embolism or acute aortic process.
2. Status post right mastectomy with stable appearance of
multifocal lung
nodules and scarring within the lungs.
.
Cytology from LP ([**2153-10-1**])
ATYPICAL. A few isolated atypical cells with a moderate amount
of cytoplasm - histiocytes versus astrocytes. Small fragment of
glial tissue. Scant background lymphocytes and macrophages.
.
CT Head without contrast ([**2153-10-3**])
1. Status post placement of a ventriculostomy drain with the tip
terminating in the right lateral ventricle.
2. No evidence of increasing hydrocephalus.
3. No interval development of hemorrhage, increasing edema, mass
effect, or shift of midline structures.
4. Metastatic involvement is better evaluated on previous MR
examination.
.
[**Month/Day/Year 4338**] Brain ([**2153-10-4**])
1. Unchanged size and appearance of multiple intracranial
metastases. No new metastases identified.
2. Interval placement of a right ventriculostomy catheter with
slight interval improvement of prominence of the bilateral
ventricles.
Brief Hospital Course:
53 year-old woman with history of metastatic breast cancer to
liver and brain, transferred from neurosurgical service status
post [**Last Name (un) **] catheter (ventriculostomy tube) placement for XRT
to C7-T3 and T8-L2.
.
METASTATIC BREAST CANCER
She was transferred to the oncologic medicine service from
neurosurgery after venticulostomy tube had been placed. She
underwent follow-up LP and cytology showed atypical cells. [**Last Name (un) 4338**]
of her brain showed diffuse cerbral metastatic disease that was
unchanged from prior. She began receiving XRT to her cervical
and thoracolumbar spine. The treatment was without
complications.
.
She will receive a total of 10 radiation treatments to her
spinal cord after which she will receive intrathecal
chemotherapy. Dr. [**Last Name (STitle) 4253**] is her neuro-oncologist and will
decide on the timing of chemo. She should return to [**Hospital1 18**] for
five more radiation treatments. The directions are outlined in
the discharge orders.
.
HISTORY OF URINARY RETENTION
She has a history of urinary retention that started about three
weeks ago. The symptoms transiently resolved after steroids
were increased during her previous hospitalization. However,
she has required foley cath placement intermittently during this
admission, and her post-void residuals have been as high as 450
cc. At time of discharge foley has been replaced; her most
recent PVR was 350 cc. We are hoping that her symptoms may
improve as her metastatic CNS disease is treated.
.
HYPERTENSION
We uptitrated her home HCTZ from 25 mg to 50 mg once daily. We
also added nifedipine and uptitrated the dose to 60 mg once
daily to achieve BP goal of <130/80.
.
ANXIETY
We continued her home lorazepam dose.
.
NIGHT-TIME INSOMNIA / DAYTIME SOMNULENCE
We continued her home Ambien CR.
.
SOCIAL / HOME ISSUES
We asked social work to meet with patient to discuss home-care
issues. The consensus is that she will need home services,
including VNA and potentially meals-on-wheels and homemaker
services. In the immediate-post radiation course, she will be
discharged to rehab.
.
She was kept on a normal diet. Due to her metastatic
intracranial disease, pneumoboots rather than subcutaneous
heparin were used for venous thrombosis prophylaxis. Her code
status is full code.
Medications on Admission:
Baclofen 5 mg PO TID PRN
Lorazepam 1 mg PO every 4-6 hours as needed for anxiety.
Docusate Sodium 200 mg PO BID
Senna 1 Tablet PO DAILY
Methylphenidate 10 mg QAM
Oxycodone 5 mg po q4h prn pain (takes only rarely)
Ambien CR 12.5 mg po qhs prn insomnia
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
6. Ambien CR 12.5 mg Tablet, Multiphasic Release Sig: One (1)
Tablet, Multiphasic Release PO HS (at bedtime).
7. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
8. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO three times a day as
needed for pain.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for anxiety/ insomnia.
10. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2251**] Rehab
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Metastatic breast cancer to the central nervous system
.
SECONDARY DIAGNOSIS
Hypertension
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were hospitalized for treatment of breast cancer that had
spread to your spinal cord. You underwent a neurosurgical
procedure that will allow us access to administer chemotherapy
more easily to your central nervous system. You also underwent
radiation therapy to the spinal cord.
.
There have been several changes to your medicines. We have
added a new medicine to help control your blood pressure, and we
have changed the dose of your steroids. Your full medication
list is printed out below.
.
The neurosurgeons have given you detailed instructions regarding
the catheter that they placed during this hospitalization.
Please read the following instructions very carefully:
.
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures and/or staples have
been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
Please return to [**Hospital1 18**] for radiation treatment. You have 5 more
radiation treatments remaining. You should have transportation
coordinated so that you arrive at the [**Hospital Ward Name 332**] basement radiation
oncology department in the [**Hospital Ward Name 516**] at [**Hospital **] [**Hospital 1225**] Medical
Center on [**Location (un) **] at 9:15 AM. You will need to return
for five more treatments Wednesday thru Friday of this week and
Monday and Tuesday of next week.
Completed by:[**2153-10-9**]
|
[
"564.00",
"300.00",
"780.09",
"401.9",
"348.5",
"198.3",
"780.52",
"788.20",
"V10.3",
"197.7",
"781.2",
"359.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"02.2",
"03.92",
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
9817, 9869
|
5770, 8084
|
415, 456
|
10021, 10054
|
4139, 5747
|
12275, 12802
|
3133, 3410
|
8385, 9794
|
9890, 10000
|
8110, 8362
|
10078, 12252
|
3425, 4120
|
268, 377
|
484, 2318
|
2340, 2754
|
2770, 3117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,445
| 125,074
|
30073
|
Discharge summary
|
report
|
Admission Date: [**2172-1-18**] Discharge Date: [**2172-1-21**]
Date of Birth: [**2126-6-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain s/p STEMI (transfer from [**Hospital 1474**] Hospital)
Major Surgical or Invasive Procedure:
none - s/p stent placement at [**Hospital 1474**] Hospital
History of Present Illness:
45 yo M with hypertension who is s/p STEMI with PCI to OM1 on
[**2172-1-16**] who is now transferred for new chest pain and ECG
changes. He originally presented to [**Hospital 1474**] Hospital on the
evening of [**2172-1-16**] with acute-onset substernal and left arm
pressure starting at rest around 5pm. He was taken by EMS to
[**Hospital 1474**] Hospital and found to have ST elevations in his
inferior leads. He was taken emergently to cath where he was
found to have a diffusely-disease LCx, completely occluded OM1,
and 60% distal occlusion of his LAD. He received a Cypher stent
to his OM1 with jailing of a subbranch of his OM. Immediately
post-cath, he reports having complete relief of his chest pain
and nromalization of his ST/T-wave changes. On hospital day 2,
he reports having intermittent stabbing pain in his mid-left
chest which was relieved by IV morphine.
.
This morning, he reports having nausea/vomitting and well as a
dull, aching pain in his mid left chest which lasted 30 minutes.
He was found to have new T-wave inversions in V5-V6 and
inferiorly at this time and was transferred here for further
management. He reports that this pain is different in quality
from his original chest pain; he also reports that the pain is
worse with deep inspiration and is currently [**12-3**] out of 10
.
ROS:
Reports recent episode of L facial Zoster in 12/[**2170**]. Reports
recent diarrheal illness in late [**Month (only) 404**]. Denies recent
fevers/chills. Reports chronic low back pain.
Past Medical History:
PMH:
hypertension
arthritis (?rheumatoid arthritis)
Zoster x2
Social History:
No tobacco, rare alcohol, no drug use. Owns a retail jewelry
store. He and his wife have an 11-month old daughter.
Family History:
Father with MI in his 50s, now s/p CABG; hx HTN. Mother with hx
HTN and s/p PCI. Paternal uncle died in 40s of MI.
Physical Exam:
T 99.3 BP 115/71 HR 75 RR 12 Sat 96% on 2L nc
Gen: NAD, comfortable
HEENT/Neck: OP clear, JVP 8cm, no carotid bruits
Chest: clear to auscultation throughout; (+) nitro patch
CV: rrr, no m/r/g, non-displaced PMI
Abd: soft, NTND, nl BS, no HSM
Extr: no edema, 2+ PT/DP pulses
Neuro: A&O x3, CN 2-12 intact
Pertinent Results:
[**2172-1-18**] 04:38PM BLOOD CK-MB-22* MB Indx-4.4 cTropnT-2.74*
[**2172-1-18**] 04:38PM BLOOD ALT-31 AST-67* LD(LDH)-459* CK(CPK)-495*
AlkPhos-77 TotBili-0.8
[**2172-1-18**] 04:38PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2172-1-19**] 02:46AM BLOOD Triglyc-247* HDL-41 CHOL/HD-4.3
LDLcalc-85
.
TTE ([**2172-1-21**]):
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic
dysfunction with focal hypokinesis of the basal half of the
inferior and
inferolateral walls. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). The remaining
left ventricular segments contract normally. 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.
Brief Hospital Course:
Mr. [**Known lastname 71722**] was transferred to the [**Hospital1 18**] CCU team due to concern
for re-infarction. He arrived on a heparin drip which was
initially continued. Upon reviewing his records, history, and
physical examination, it was thought that his chest pain was
more likely musculoskeletal than anginal. His cardiac enzymes
continued to trend downwards from their peak CK of 2400 at
[**Hospital 1474**] Hospital and he was thus ruled out for ACS and the
heparin drip was stopped. He was sent out of the ICU on
hospital day #2 and monitored on the floor for 72 hours without
problem. His beta blocker and ACE-inhibitor were titrated up
and he was kept on aspirin, clopidogrel, and a high-dose statin.
A TTE prior to discharge showed inferior/inferolateral wall
motion abnormalities but no apical akinesis, and he was
discharged home with plans to follow up with his cardiologist in
[**Hospital1 1474**].
Medications on Admission:
Home Meds:
Lotril [**Hospital1 **]
celecoxib daily
Darvocet prn
Soma prn
Ambien qhs prn
.
Meds on transfer:
aspirin 325mg daily
clopidogrel 75mg daily
atorvastatin 80mg daily
metoprolol 12.5mg [**Hospital1 **]
pantoprazole 40mg daily
nitro paste
heparin gtt
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): No generic.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO every twelve (12) hours as needed for
anxiety.
Disp:*7 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial infarction
Discharge Condition:
good
Discharge Instructions:
You had a myocardial infarction or heart attack and while at
[**Hospital 1474**] Hospital had a stent placed in one of the arteries
which supplies blood to your heart. It is very important that
you take all of your medications, particularly your Plavix
(clopidogrel), after you are discharged. Discontinuing your
medication could result in formation of a clot in your new
stent.
.
Please keep all of your follow-up appointments.
.
Please call your doctor or go to the emergency room if you
develop chest pain, shortness of breath, nausea/vomiting, if you
are unable to take your medications or you develop any other
symptoms that are concerning to you.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your cardiologist, in
[**Hospital1 1474**] in [**12-3**] weeks. You should be out of work and not driving
until you see him.
|
[
"300.00",
"410.42",
"401.9",
"V45.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5760, 5766
|
3762, 4688
|
337, 398
|
5832, 5839
|
2640, 3739
|
6542, 6763
|
2179, 2297
|
4996, 5737
|
5787, 5811
|
4714, 4804
|
5863, 6519
|
2312, 2621
|
232, 299
|
426, 1944
|
1966, 2029
|
2045, 2163
|
4822, 4973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,216
| 118,426
|
44414
|
Discharge summary
|
report
|
Admission Date: [**2177-4-25**] Discharge Date: [**2177-5-2**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6780**]
Chief Complaint:
guiac + stool, weakness
Major Surgical or Invasive Procedure:
[**2177-4-29**] EGD
History of Present Illness:
This is a 89 y/o female with CRI (baseline Cr 2.8), h/o colon CA
and DVT/PE s/p IVC filter and requiring anticoagulation,
recently admitted at [**Hospital1 18**] from [**Date range (1) 95216**] for weakness and
UTI, who now re-presents with CC of weakness. At [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
was found to be hypotensive to 79/54 and HR of 88. Also found to
have guiac+ stool and melena this am in the setting of a
supratherapeutic INR. Coumadin has been held since yesterday.
Per reports, patient has had poor po intake for several days,
but labs done yesterday on [**4-24**] revealed a Cr of 2.5 (baseline),
BUN 55, WBC 10.6, Hct 35.
.
During her last admission, she was found to have ARF in the
setting of poor po intake and a UTI. Cr improved rapidly with
fluids and she was treated with ciprofloxacin for her UTI. As
her BP was slightly low to normotensive during her last stay,
her verapamil dose was decreased from 240 mg to 120 mg daily as
well as her toprol dose, which was decreased from 100 mg to 25
mg daily. Of note, the patient had watery diarrhea during her
last admission and was guiac positive, however Hct remained
stable during that time. Stool cx were negative and there no
concerning symptoms, including fevers or abdominal pain.
.
Per family, patient has been having decreased po intake for some
time now and feel that she is very dehydrated and this is why
her blood pressure was low. In addition, she has been having
diarrhea x 1 week. No n/v. They are not aware of any BRBPR or
melena.
.
In the ED, VS were T 99.8, BP 89/47, HR 70, RR 22, SaO2 96%/RA.
BP at one point low as 74/48. Patient was given 3 L NS and a
right IJ was placed for access under sterile conditions. Give 40
mg IV PPI. Her exam was significant for guiac + smear, but no
stool in the vault. had one episode of liquid melena. Patient
could not tolerate NG lavage with multiple attempts. She was
also given 5 mg SC vitamin K and 1 U FFP for reversal of her
coagulopathy (INR 4.0).
.
ROS - all negative per family
Past Medical History:
1. Hypertension
2. cecal CA s/p R colecotmy
3. CAD + MI
4. recurrent PE and DVTs
5. GERD
6. pacemaker for refractory SVT
7. diverticulosis
8. arthritis
9. CRI, baseline Cr 1.8-2.9
10. Dementia
Social History:
Recently at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], h/o short-term memory deficits at
baseline. No tobacco/EtOH/IVDU use. Has 7 children and multiple
family memebers involved in her care.
Family History:
NC
Physical Exam:
VS: Tc 97.4, BP 125/81, HR 69, RR 14, SaO2 100%/2L NC
General: Pleasant AAF in NAD, AO x 3
HEENT: NC/AT, PERRL, EOMI. MMM, OP clear
Neck: supple, no LAD or JVD
Chest: CTA-B, no w/r/r
CV: paced, no m/g/r
Abd: soft, NT/ND, NABS, +guiac in ED though no stool in vault
Ext: no c/c/e, pulses 2+ b/l
Neuro: AO x 2 (place, self). CN II-XII grossly intact. Moving
all extremities, no focal deficits.
Pertinent Results:
[**2177-4-25**] 02:10PM PT-36.4* PTT-40.8* INR(PT)-4.0*
[**2177-4-25**] 02:10PM WBC-9.9# RBC-4.18* HGB-12.8 HCT-39.1 MCV-94
MCH-30.6 MCHC-32.7 RDW-16.2*
[**2177-4-25**] 02:10PM PLT COUNT-404#
[**2177-4-25**] 02:10PM GLUCOSE-111* UREA N-84* CREAT-4.4*#
SODIUM-135 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-16* ANION GAP-22
[**2177-4-25**] 02:10PM CALCIUM-9.7 PHOSPHATE-6.0*# MAGNESIUM-2.4
.
CXR Line placement [**2177-4-25**]: IJ line in lower SVC.
.
EKG: Extensive baseline artifact. A-V sequential pacing at a
rate of 70 beats per minute. QRS axis is 0.60. P-R interval
0.18. Compared to the previous tracing of [**2177-4-9**] non-specific T
wave changes in the anterolateral leads are more apparent.
.
CXR [**2177-5-1**]: Right pulmonary artery fullness, probably unchanged.
No acute cardiopulmonary abnormality detected. Please note that
chest radiograph is insensitive for presence of pulmonary
embolism.
.
AXR [**2177-5-1**]: Non-specific air-fluid levels. No evidence of
pneumoperitoneum.
.
Gastric Biopsies: Pending
Brief Hospital Course:
This is a 89 y/o female with CAD, h/o colon CA, recurrent DVTs
and PE, now presenting with hypotension and guiac + stool on
coumadin.
.
# GI bleed - in the setting of supratherapeutic INR 4.0. Patient
initially had no active GIB after arrival to the MICU, but then
developed melena overnight. Pt received 5mg sc vitamin K, 2
units of FFPs and 2 PRBC for INR reversal. Pt received
aggressive fluids for rescuscitation and ongoing diarrhea. Pt
was also continued on IV PPI [**Hospital1 **]. GI was made aware and patient
will need an EGD, but as melena as slowed down and hct is
stable, EGD is deferred for now. After 2 more units of PRBC, Hct
remained stable. She has not required any more PRBCs since
admission. EGD performed on [**4-29**] demonstrated a small
non-bleeding ulcer in the duodenal bulb, which was biopsied (the
patient will be notified of the results of the biopsy within the
next 2 weeks).
.
# Hypotension - LIkely from GI bleeding and dehydration from
diarrhea and poor po intake. Pt was aggressively fluid
resuscitated with LR and did not require any pressors. Later,
her stool cx returned + for C. diff, explaining her ongoing
diarrhea. Flagyl was started. Antihypertensives were held.
- Antihypertensives (Toprol XL and verapamil) were held
throughout the admission and can be added back as BP or HR
permits.
.
# C. diff colitis: Stool culture was sent at admission which
returned positive for c.diff the following day. Pt was started
on Flagyl on [**4-27**], PO vancomycin was added on [**5-1**]. She should
continue for a total 14 day course (10 days after discharge).
.
# AG Metabolic acidosis - likely secondary to diarrhea + acute
on chronic renal failure. Pt was resuscitated with LR and lytes
were repleted aggressively.
.
# Cardiac - AV-paced for refractory SVT. Held BB and CCB for
hypotension and fluid resuscitated aggressively.
.
# Acute on CRF - likely pre-renal in the setting of hypotension
and decreased po intake. Her renal failure resolved with fluid
resuscitation.
.
# MS - pt at baseline per family in regards to her dementia
.
# Coagulopathy - held coumadin and reversed with vitamin K and
FFPs. She was discharged home without coumadin, as she has an
IVC filter in place and the risk associated with bleeding was
thought to be worse than the benefit of anticoagulation.
Medications on Admission:
1. Allopurinol 100 mg daily
2. Verapamil SR 120 mg daily
3. Toprol XL 100 mg daily
4. Coumadin 1 mg daily
5. Remeron 15-30 mg qhs
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
7 days: After 7 days, reduce frequency to daily.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
5. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
Duodenal ulcer
Hypotension
Upper GI bleeding
Secondary:
History of DVT's/PE on coumadin
Discharge Condition:
Stable blood pressure, stable hematocrit, no evidence of
bleeding
Discharge Instructions:
You were admitted with low blood pressure and bleeding from your
GI tract. You were given blood transfusions, and a procedure to
look at your stomach and duodenum showed a small ulcer. You
should continue to take pantoprazole twice daily for the next
week and then take it once daily indefinitely. You will be
notified of the results of the biopsies within the next few
weeks.
.
You should follow up with Dr. [**Last Name (STitle) **] within one week of leaving
rehab.
.
Please take all of your medications as prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2177-5-6**]
1:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2177-6-13**] 8:40
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2177-6-13**] 9:00
|
[
"276.51",
"414.01",
"V10.05",
"530.81",
"403.90",
"585.9",
"532.00",
"535.50",
"584.9",
"V58.61",
"276.2",
"V45.01",
"458.9",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7309, 7378
|
4290, 6614
|
242, 264
|
7510, 7578
|
3237, 4267
|
8148, 8460
|
2805, 2809
|
6795, 7286
|
7399, 7489
|
6640, 6772
|
7602, 8125
|
2824, 3218
|
179, 204
|
292, 2336
|
2358, 2553
|
2569, 2789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,341
| 169,284
|
44951
|
Discharge summary
|
report
|
Admission Date: [**2119-7-22**] Discharge Date: [**2119-7-23**]
Date of Birth: [**2048-12-26**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
70yoF with h/o CKD stage III, HTN, COPD no home O2, and recent
complicated CCU admission for NSTEMI (see below) who is admitted
to MICU with dysphagia and inability to get food/drinks PO.
After that admission, she was sent to rehab and was discharged
from there [**7-20**]. She saw [**Name8 (MD) **] NP[**Company 2316**] on [**7-21**] and reported
weakness that she related to being in a rehab for a long time,
but no other worrisome symptoms. However EKG done in the office
was apparently concerning for hyperkalemia or ischemic process,
so she was sent to the ED where she ended up getting 2 sets of
negative cardiac enzymes. Cards was consulted and did not feel
the changes represented ischemia. Of note, neither the office
EKG nor any of the EKG's done in the ED are in OMR or in the
scanned inpatient records for comparison to our MICU admission
EKG, which has grossly peaked T waves. However, a single line in
the ED attending note mentions "possible hyperacute T's." K's
were 4.3 and 4.9 in the ED.
Regardless, in the ED she ate some chicken and reports it
"didn't go through" and everything she has eaten or drank since
then doesn't go through either; she denies odynophagia, only
endorses dysphagia. She has even had difficulty getting melted
ice cream down. She has been spitting up everything she's tried
to eat, but denies gross nausea or vomiting. She went back to
the ED for these symptoms.
In the ED: 99 99 138/75 18 100%. No SOB/CP, no resp
distress. She was seen to be spitting oral secretions into a
cup. She was given Glucagon 1mg IV x2 and 4mg IV Zofran x2. She
is admitted to MICU for EGD.
Vitals before admission: 97.8 99 150/77 18 97%RA.
Of note, pt was admitted to [**Hospital1 18**] from [**7-2**] to [**7-10**] for n/v and
found to have NSTEMI with hypoxia and tachycardia. She was
admitted to CCU with STD in V3-5 concerning for anteroseptal MI,
with Trop peak 2.27. With resolution of these changes, she then
had PR depressions in inferior leads concerning for RV infarct.
Medically managed: Plavix loaded, given ASA, Heparin gtt,
Metoprolol, Simva changed to Atorva 80, Lisinopril held due to
some hypoTN and poor renal function; no cath due to respiratory
distress thought to be HF +/- PNA and persistent tachycardia
felt to be a stress test equivalent. She was also hypoxic and
with pulmonary edema thought to be NSTEMI vs COPD vs PNA (?
aspiration) - given nebs, initially given Prednisone but
stopped, diuresed with Lasix, completed course of
Vanc/Cefepime/Azithro. She had episodes of AFib that responded
to Ibutilide and Metoprolol; was not anticoagulated given Hct
drop and guaic positive stools, but was on ASA/Plavix. UCx
showed >100k vanc sensitive enterococcus, was already on Vanc
for PNA. Some hypoTN during admission, so home Nifedipine and
Clonidine were held; Metoprolol was continued, Lisinopril was
recommended but not started until f/u if Cr <1.5.
Before that, pt was admitted [**6-27**] to [**6-29**] for ARF in the setting
of infectious colitis treated with Flagyl and Moxifloxacin with
improvement of Cr with IVF's. Presently, she says all the
symptoms present during these 2 admissions are resolved
Review of systems:
Per HPI, otherwise negative for f/c/ns, pain, SOB, CP,
palpitations, nausea, abdominal pain, BM changes, dysuria or
urinary problems, vision changes, [**Name (NI) 4459**] problems, skin changes.
She endorses occasinal GERD when she eats spicy food, which is
worse with laying down, occurs a couple times per week. She's
also had a cough for the past month that started after a cough
and productive of thin phlegm; she denies any known history of
aspiration or postnasal gtt.
ROS otherwise negative
Past Medical History:
1. NSTEMI with STD's in V3-5, Trop peak 2.27; medically managed
2. Hypertension
3. CKD stage III with baseline Cr 1.2-1.4 since [**2-/2118**]
4. COPD - not on home oxygen
5. Lobular breast cancer s/p lumpectomy
6. Osteoporosis
Social History:
Works at stop and shop. Lives with husband and son and has 6
children. Use to smoke a couple packs per day - 30 pack year
history, quit 15 years ago. Denies alcohol and illicits. HCP is
daughter [**Name (NI) **] [**Name (NI) **]. Able to walk without a cane or walker.
Family History:
Father - hypertension
Mother died at 93
5 brothers and 1 sister died (does not know cause)
No kidney disease or kidney stones. No known cancers.
Physical Exam:
97 p89 145/71 22 95%RA
Thin, pleasant, sweet older lady in no distress. Appears well,
has a wet sounding cough. Appears euvolemic
EOMI, no scleral icterus, mouth with dentures in, moist to
slightly dry, no apparent lesions
Grossly rhonchorous sounding expiratory breath sounds
bilaterally, diffusely
RRR with S1/S2 audible, no apparent m/g, bilateral radials
easily palpable
Abd soft, NT ND, benign
No BLE edema noted, extremities are warm, well perfused, normal,
scattered ecchymoses
CN 2-12 grossly intact, moving all extremities, no focal neuro
deficits noted.
Pertinent Results:
145 106 30
-----------------< 73
3.8 22 1.2
WBC 8.6
Hct 26.3
Plts 286
Coags pending
CXR FINDINGS: PA and lateral views of the chest were obtained.
There is no definite radiopaque foreign body seen within the
chest. A radiodense structure in the soft tissues of the left
neck could represent the patient's earring and was seen on the
prior exam dated [**2119-7-7**]. The lungs are well expanded bilaterally
without signs of aspiration or pneumonia. No pleural effusion or
pneumothorax. Cardiomediastinal silhouette appears normal.
Overlying EKG leads are noted, somewhat limiting the evaluation.
The lungs are hyperinflated with flattened diaphragms suggestive
of underlying COPD. No pleural effusion or pneumothorax. Bony
structures are intact. Clips are noted in the right upper
quadrant.
IMPRESSION: COPD, no signs of foreign body.
EKG: NSR normal axis, 85 bpm, early RWP in V2, possible Q in
III, with very prominent T waves diffusely, and J point
elevation V2-6. Last OMR EKG of comparision [**7-7**] has T wave
peaking but not as prominently, and there is no J point
elevation. However, OMR ED notes indicate that pt was having J
point elevation and TW peaking in the ED yesterday.
Brief Hospital Course:
70yoF with h/o CKD stage III, HTN, COPD no home O2, and recent
complicated CCU admission for NSTEMI (see below) who is admitted
to MICU with dysphagia and inability to get food/drinks PO and
found on EGD to have large hiatal hernia and chicken impaction
in her esophagus requiring ICU admission for removal of food
particle.
ACTIVE ISSUES:
# Chicken impaction: GI performed EGD on patient and were able
to remove some of the obstruction and push the remaining portion
into stomach. Per GI, likely precipitating factor was large
hiatal hernia and tortuous esophagus. Patient able to s Pt was
counseled appropriately and will follow up GI in 1 month. On
EGD, patient was also noted to have gastritis and was
subsequently placed on protonix [**Hospital1 **]. Patient was advised to
remain this medication until she is seen by GI in 1 month.
# Peaked T waves: These were reportedly also seen in the office
and ED on day prior to admission. Subsequent 2 sets of cardiac
enzymes which were negative. Additionally patient was not
hyperkalemic. Cards saw patient and did not think this to be
ischemic, and she was discharged from ED. Patient on this
admission also had hyperacute T waves with normal cardiac
enzyme. Repeat EKG was normal. No further intervention was
necessary. Patient to follow up with Dr. [**Last Name (STitle) **] in near future.
INACTIVE ISSUES: No changes in medications or interventions were
necessary.
- CAD
- COPD
- Osteoporosis
- Depression
Medications on Admission:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO twice a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
6. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
8. lactobacillus rham. GG-inulin 10 billion-245 cell-mg Capsule,
Sprinkle Sig: One (1) Capsule, Sprinkle PO twice a day.
--- ? pt did not state she's taking this:
9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q8H (every 8 hours) as needed for SOB.
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
13. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Discharge Medications:
1. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO Qwednesday.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO BID (2 times a day).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Food Impaction in Esophagus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU because you had difficulty
swallowing after the eating. The GI doctors saw [**Name5 (PTitle) **] and
performed an upper endoscopy that showed that you had food stuck
in your esophagus. They were able to remove some of the food and
push some of it into your esophagus. They would like to see you
in 1 month in their office. Please call [**Telephone/Fax (1) 682**] to schedule
an appointment with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
- STARTED Protonix 40mg twice a day.
- STOPPED Ranitidine
No other changes were made to your medications.
Followup Instructions:
Please call [**Telephone/Fax (1) 682**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**].
In addition please be sure to keep the following appointments:
Department: RADIOLOGY
When: THURSDAY [**2119-8-3**] at 10:30 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
Department: CARDIAC SERVICES
When: FRIDAY [**2119-8-4**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2119-11-2**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16202**], 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
Completed by:[**2119-7-23**]
|
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"787.20",
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"553.3",
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] |
icd9cm
|
[
[
[]
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] |
[
"98.02",
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] |
icd9pcs
|
[
[
[]
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10418, 10424
|
6556, 6882
|
304, 309
|
10496, 10496
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5331, 6533
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4576, 4722
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4044, 4273
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4289, 4560
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,000
| 194,311
|
43761
|
Discharge summary
|
report
|
Admission Date: [**2197-2-5**] Discharge Date: [**2197-2-6**]
Date of Birth: [**2132-10-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
colonoscopy X2 [**2197-2-5**]
History of Present Illness:
64 y.o Male with PMH of CAD s/p multiple PCI with stenting last
in [**2191**] and on plavix, AVR and diverticulosis, had a colonoscopy
by Dr. [**Last Name (STitle) 1940**] on [**2197-1-25**] during which a 7 mm polyp in the
transverse colon was removed, now presenting with 3 days of
increasing amounts of blood in stool. In the initial days after
colonoscopy, patient had no symptoms. 3 days prior to
presentation, patient started noticing blood in his stools,
which began to increase in amount and frequency. Today, he had 8
bowel movements, all with dark clots, with no brown stool
visualized. He denies any black stools and decribes his stool as
"maroon clots." He is feeling more tired, more lightheaded, but
denies SOB or CP. He had no abdominal pain until earlier today,
when he noticed some left sided cramping, but has been able to
eat ok regardless,including dinner. The crampy feeling he
started to feel in the last few hours is [**2195-4-9**], and not
associated with movement or food intake. He feels like he wants
to pass stool, but cannot. His last BM was at 7PM. He takes ASA
and plavix, but has not had either medication today. Reportedly
says he had stopped plavix only for 2 days prior to the
procedure and restarted it right after colonoscopy.He has not
taken today's plavix or aspirin.He denies dyspepsia,
nausea/vomiting,NSAID use, alcohol use, dyspnea, chest pain,
fevers/chills, sick contacts, light headedness.
.
In [**2191**] had 2 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] placed here at [**Hospital1 **]. Hx stents X4,
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 324**] at [**Hospital1 2025**].
.
In the ED, initial VS were: 98.6 62 163/51 18 99%. The patient
had KUB which revealed no free air. GI was contact[**Name (NI) **] and the
patient was transferred to ICU for colonoscopy prep for the
AM.His Hct was noted to be 30 from 42. Heart rate in 60's though
on beta blockers.
.
On arrival to the MICU, the patient is stable, providing the
above hx.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, constipation.Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
.
Past Medical History:
Past Medical History:
History of basal cell cancer
Arthritis
Obesity
PROSTATIC HYPERTROPHY - BENIGN
DM - TYPE 2 DIABETES MELLITUS
ANEMIA - IRON DEFIC, UNSPEC
RHINITIS - ALLERGIC TO POLLEN
HISTORY SQUAMOUS CELL CARCINOMA - SKIN
HISTORY AORTIC VALVE REPLACEMENT
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
HYPERTENSION - ESSENTIAL, UNSPEC
HYPERLIPIDEMIA
DEPRESSIVE DISORDER
FAMILY HISTORY COLON CANCER
HEARING LOSS, UNSPEC
Asthma
s/p gastric bypass in [**2185**]
.
Allergies: NKDA
.
Social History: Married Retired ,Former Smoker for 25 years
pack per day , quit around 20 years ago. No alcohol use Drug
Use: No
.
Family History: CAD history in father and mother in 50's to
60's, colon cancer in family in 40's
.
Physical Exam:
Vitals: afebrile BP:137/53 P:55 R:13 18 O2: 97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, distended, bowel sounds present, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Rectal: brown stool, red blood clots, no hemmrhoids visualized
NG lavage negative for blood or cofee grounds
.
Social History:
Retired probation officer. Married. Works for the teamsters
[**Hospital1 **]. 20 pack year tob. quit 20 y.a. no EtOH x 25 years.
Family History:
Mother with CAD in her 60s, Father with CAD in 60s. Both alive
into their 80s
Physical Exam:
Physical Exam:
Vitals: afebrile BP:137/53 P:55 R:13 18 O2: 97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, distended, bowel sounds present, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Rectal: brown stool, red blood clots, no hemmrhoids visualized
NG lavage negative for blood or cofee grounds
Pertinent Results:
Admission Labs
.
colonoscopy1/1 : Impression: Diverticulosis of the sigmoid colon
and descending colon Stool in the colon The post-polypectomy
site was identified in the transverse colon. Two low risk
red-spots were seen without any active bleeding or evidence of
recent bleeding. Nevertheless, the decision was made to clip the
lesion given the patient's need to resume anticoagulation.
(endoclip)Otherwise normal colonoscopy to proximal ascending
colon A colonic loop was encountered when the proximal ascending
colon (at the IC valve) was reached. The exam was interrupted.
[**2197-2-5**] 03:36AM WBC-7.7 RBC-3.44* HGB-10.1* HCT-29.8* MCV-87
MCH-29.3 MCHC-33.9 RDW-13.4
[**2197-2-5**] 03:36AM PLT COUNT-184
[**2197-2-5**] 03:36AM PT-10.1 PTT-31.6 INR(PT)-0.9
[**2197-2-5**] 12:02AM URINE HOURS-RANDOM
[**2197-2-5**] 12:02AM URINE UHOLD-HOLD
[**2197-2-5**] 12:02AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2197-2-5**] 12:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2197-2-4**] 10:30PM GLUCOSE-238* UREA N-16 CREAT-0.7 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
[**2197-2-4**] 10:30PM estGFR-Using this
[**2197-2-4**] 10:30PM ALT(SGPT)-40 AST(SGOT)-40 ALK PHOS-87 TOT
BILI-0.1
[**2197-2-4**] 10:30PM LIPASE-50
[**2197-2-4**] 10:30PM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2197-2-4**] 10:30PM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2197-2-4**] 10:30PM WBC-8.8 RBC-3.48*# HGB-10.6*# HCT-30.1*#
MCV-87 MCH-30.5 MCHC-35.2* RDW-13.4
[**2197-2-4**] 10:30PM PLT COUNT-204
[**2197-2-4**] 10:30PM PLT COUNT-204
[**2197-2-4**] 10:30PM PT-10.9 PTT-33.1 INR(PT)-1.0
.
Discharge Labs
[**2197-2-6**] 12:40AM BLOOD WBC-6.5 RBC-3.20* Hgb-9.6* Hct-28.1*
MCV-88 MCH-30.0 MCHC-34.3 RDW-13.6 Plt Ct-157
[**2197-2-5**] 06:14PM BLOOD Hgb-9.2* Hct-26.7*
[**2197-2-5**] 07:44AM BLOOD Hgb-9.7* Hct-28.3*
[**2197-2-6**] 12:40AM BLOOD Plt Ct-157
[**2197-2-6**] 12:40AM BLOOD PT-11.0 PTT-32.0 INR(PT)-1.0
[**2197-2-5**] 03:36AM BLOOD Plt Ct-184
[**2197-2-5**] 03:36AM BLOOD PT-10.1 PTT-31.6 INR(PT)-0.9
[**2197-2-4**] 10:30PM BLOOD Plt Ct-204
[**2197-2-6**] 12:40AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9
[**2197-2-4**] 10:30PM BLOOD Glucose-238* UreaN-16 Creat-0.7 Na-132*
K-4.5 Cl-102 HCO3-23 AnGap-12
[**2197-2-5**] 03:36AM BLOOD Glucose-146* UreaN-14 Creat-0.7 Na-136
K-4.7 Cl-106 HCO3-24 AnGap-11
Brief Hospital Course:
64M with PMH of CAD s/p multiple PCI with stenting last in [**2191**]
and on plavix, AVR and diverticulosis, had a colonoscopy by Dr.
[**Last Name (STitle) 1940**] on [**2197-1-25**] presented with hematochezia.
.
#Hematochezia-The patient was hemodynamically stable. The
patient was complaining of no frank abdominal pain.No melena per
report or on physical exam. Hct had decreased from baseline Hct
recorded 1 year ago from 40 to 30.0. Given the frequency bowel
movements, recent polyp removal and antiplatelet therapy on top
of the differential was bleeding from the polyp removal site.
Diverticulosis, AVM's remained on the differential. ASA and
Plavix were held and a colonoscopy was carried out with clipping
of recent polypectomy site with stigmata of recent bleeding. His
Hct remained stable and he was discharged from the MICU to home,
with his antiplatelet therapy being restarted
.
Transitional issues
clarification of course of antiplatelet therapy given his CAD
Hct check as outpatient and PCP follow up.
Medications on Admission:
Pirbuterol (MAXAIR AUTOHALER) 200 mcg/Inhalation Inhalation
Aerosol Breath Activated 2 puffs q 4-6 hrs prn wheezing
Atorvastatin (LIPITOR) 80 mg Oral Tablet one tabe qd
Clopidogrel (PLAVIX) 75 mg Oral Tablet Take 1 tablet daily
Sertraline 100 mg Oral Tablet take 1&1/2 tabs in the evening 3
days/week and 1 tablet the other evenings. DO NOT STOP WITHOUT
CONSULTING CLINICIAN
Lisinopril 5 mg Oral Tablet 1 tablet daily
Atenolol 25 mg Oral Tablet 1 tablet daily
Sildenafil (VIAGRA) 100 mg Oral Tablet Take 1 tablet 1 hour
before sex (3 MONTH SUPPLY)
ASPIRIN 325 MG TAB 1 tablet daily. Available over the counter.
Montelukast (SINGULAIR) 10 mg Oral Tablet one tab po qd (patient
not taking)
Budesonide-Formoterol (SYMBICORT) 160-4.5 mcg/Actuation
Inhalation HFA Aerosol Inhaler Use 2 inhalations twice daily and
rinse your mouth thoroughly afterward
Fluticasone Furoate (VERAMYST) 27.5 mcg/Actuation Nasal Spray,
Suspension TWO SPRAYS TWICE DAILY
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. sertraline 100 mg Tablet Sig: 1-1.5 Tablets PO see below:
take 1and 1.5 tablets on alterbate days: 1 tablet 4 days per
week and 1.5 tablets 3 days per week.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) inhalations Inhalation twice a day: rinse mouth after use.
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. pirbuterol 200 mcg/Inhalation Aerosol Breath Activated Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
lower GI bleedin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted d/t bleeding from your lower intestine. You
underwent a colonoscopy and the area that was the likely source
of your bleeding at the site from which you had a polyp removal
was clipped. We followed your blood counts and found no evidence
of ongoing blood loss.
.
The following changes were made to your medications:
.
- Aspirin was reduced from 325mg to 81mg daily to reduce the
risk of re-bleeding.
.
Please continue to take your other medications without change.
Followup Instructions:
We have contact[**Name (NI) **] your [**Name (NI) 6435**] office and recommended that you
follow-up a blood count within 2-3 days of your discharge and a
follow-up appointment with your PCP [**Name Initial (PRE) 176**] 1 week of your
discharge. Please call your PCP's office ([**Telephone/Fax (1) 6803**]) tomorrow
morning for these appointments.
.
Please also follow-up with Dr. [**Last Name (STitle) 1940**] your gastroenterologist.
It is recommended that you have a repeat colonoscopy in 2 years.
|
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13,853
| 127,602
|
21547
|
Discharge summary
|
report
|
Admission Date: [**2165-11-3**] Discharge Date: [**2165-11-7**]
Date of Birth: [**2123-9-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
sub sternal chest pain
Major Surgical or Invasive Procedure:
cardiac cathertization
balloon pump
History of Present Illness:
42 yo f w no PMH developed severe sub-sternal chest pain at rest
for about 20 miuntes, then collasped at her place of work. She
was then transferred to the [**Hospital1 18**] ER. She was awake and still
had 10/10 chest pain. EKG in at [**Hospital1 **], her place of
employment showed dramatic ST elevationa sin V2 - V6 in inferior
limb lead St elevations. EKG at [**Hospital1 18**] ER showed ST elevations in
the precordium. She was emergently taken for cardiac cath.
Past Medical History:
none
Social History:
Works as a nurse in cardiac rehab. Originally from [**Country 7018**].
Married with 2 children. Denies alcohol, drugs, tobacco.
Family History:
No h/o MI or thromboembolic events in her family.
Physical Exam:
Vitals: T= afebrile, HR = 90, BP = 92/75 on IABP, RR = 20
General: Pleasant female sleeping, appears comfortable, NAD.
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Chest: Her chest rose and fell with equal size, shape and
symmetry, her lungs were clear to auscultation bilaterally. No
erythema around Hickmann line, non tender.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs
rubs. IAP heard
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing or edema with 2+ dorsalis pedis
pulses bilaterally. right groin with oozing from IABP.
Integument: no rash
Neuro: CN II-XII symmetrically intact, PERRLA.
Pertinent Results:
[**2165-11-3**] 06:10AM CK-MB-NotDone cTropnT-<0.01
[**2165-11-3**] 03:02PM CK-MB-314* MB INDX-29.7* cTropnT-8.1*
[**2165-11-3**] 03:02PM CK(CPK)-1057*
[**2165-11-3**] 06:10AM WBC-6.3 RBC-3.94* HGB-12.2 HCT-34.5* MCV-88
MCH-30.8 MCHC-35.2* RDW-12.3
[**2165-11-3**] 06:10AM ALT(SGPT)-13 AST(SGOT)-14 LD(LDH)-194
CK(CPK)-70 ALK PHOS-69 TOT BILI-0.3
[**2165-11-3**] 06:10AM GLUCOSE-191* UREA N-13 CREAT-0.7 SODIUM-138
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17
CHEST, SINGLE AP PORTABLE SUPINE VIEW:
The heart is not enlarged for technique. A femoral approach IABP
is present, with radiopaque tip lying along the inferior edge of
the aortic knob. Two very small radiopaque markers are
superimposed over the spine, one to the left of the T6 vertebral
body and one overlying the L3-4 disc space. These are of unknown
etiology or significance to me, but are new compared with film
from earlier the same day. Also new compared with earlier the
same day is a faint alveolar opacity superimposed over both
lungs. This most likely represents dependent atelectasis, given
its rapid evolution and absence of upper zone redistribution or
effusions. However, attention to this finding on follow-up films
is recommended to exclude a superimposed pulmonary process.
EKG: Sinus rate of 96. QRS changes V3/V4 - probably due to LVH
but consider anterior infarct Hyperacute T waves in leads V4,V5
consider acute anterior current of
injury/myocardial infarction
Cardiac Cath:
:
1. Selective coronary angiography revealed a right-dominant
system
with severe single vessel coronary artery disease. The LMCA,
LCX, and
RCA had no angiographically apparent flow-limiting stenoses. The
LAD had
a 100% occlusion in the mid vessel.
2. Resting hemodynamics demonstrated normal elevated right
sided
pressures (RV 41/13 mmHg), and elevated left sided pressures
(LVEDP 28,
mean PCWP 28 mmHg) with no gradient upon movement of the
catheter from
the ventricle back to the aorta. The cardiac index was mildly
low (2.5
l/min/m2).
3. Left ventriculography showed severe anterior hypokinesis
and
inferoapical dyskinesis (EF 30%) with severe mitral
regurgitation.
4. Acute anterior STEMI treated with primary PCA and stenting
with two
overlapping Cypher DESs (2.5x28mm and 2.5x23mm deployed at 16
atms). The
stents were postdilated with a 3.5x33 mm Highsail baloon at 16
atms (See
PTCA comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Severe mitral regurgitation.
3. Severe systolic ventricular dysfunction.
4. Acute anterior myocardial infarction, managed by acute ptca.
ECHO:
Views of left ventricular function were limited. There appeared
to be at least
mild regional left ventricular systolic dysfunction with
hypokinesis of the
lateral apex. Right ventricular chamber size and free wall
motion are normal.
The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
to severe (3+)
mitral regurgitation is seen. There is no pericardial effusion
Relook cardiac cath:
1. Resting hemodynamics demosntrated mildly elevated right and
left-sided filling pressures with a preserved cardiac output.
2. Selective coronary angiography demonstrated no significant
coronary
artery disease. The LMCA and LCX were angiographically normal.
The LAD
stents were widely patent without residual stenoses. However,
there was
a pulsatile flow pattern in the LAD with slowed flow and delayed
initiation of myocardial blush. The RCA was a small vessel that
exhibited cathter-damping, but there was no angiographically
apparent
coronary artery disease.
3. The left femoral arteriotomy site was closed with a 6
French
Angioseal device
Brief Hospital Course:
1. CAD: This patient had a large anterior MI with extensive
myocardial damage at a very young age without a strong family
history or risk factors. The primary team sent a hypercoaguable
workup which the results of were still pending on discharge. Her
peak CK was [**2125**] and peak trop was 2.86. She had a stent placed
in her LAD. During the procedue she had a very high wedge
pressure and evidence of failure. She was placed on a balloon
pump and transferred to the CCU. The balloon pump was weaned
slowly. This was complicated by an external and likely
retripenittal bleed around her balloon pump. The pump was
removed and she was transfused a unit of blood. She continued to
have chest pain for some time after her MI. A re-look cath
showed a widely patent stent. She was placed ASA, BB, Plavix.
She had an echo before her discharge which showed mild regional
left ventricular systolic dysfunction with hypokinesis of the
lateral apex with 3+ MR. She will follow up in [**Hospital 56786**] clinic.
2. Thrombocytopenia: The patient's platlets dropped from 165 on
admission to the 80's in 2 days. All heparin products were
stopped and HIT ab were sent. This was still pending on
discharge and should be followed up by her primary physcian.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*40 Tablet(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual see below as needed for chest pain: 1 - 2 tablets
every 5 minutes for maximum of 3 doses in 15 minutes.
Disp:*15 tablet* Refills:*5*
5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
anterior myocardial infarction
systolic heart failure
Discharge Condition:
good
Discharge Instructions:
Call your cardiologist if you have any chest pain or shortness
of breath.
Take all your medications as directed.
Followup Instructions:
Call Cardiac Rehab to find out details on how to join.
Make an appointment with your PCP [**Last Name (NamePattern4) **] 2 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2165-12-17**] 1:00
You will need a referral from your PCP before this appointment.
Test for consideration post-discharge: Homocysteine
Test for consideration post-discharge: Protein C
Test for consideration post-discharge: Protein S
Test for consideration post-discharge: Prothrombin Mutation
Analysis
|
[
"410.71",
"780.6",
"287.5",
"428.20",
"785.51",
"414.01",
"998.11",
"428.0",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"99.20",
"36.07",
"99.04",
"37.61",
"88.56",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
7761, 7767
|
5759, 7009
|
337, 375
|
7865, 7871
|
2013, 4407
|
8033, 8671
|
1062, 1113
|
7064, 7738
|
7788, 7844
|
7035, 7041
|
4424, 5736
|
7895, 8010
|
1128, 1994
|
275, 299
|
403, 873
|
895, 901
|
917, 1046
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,054
| 193,254
|
34778
|
Discharge summary
|
report
|
Admission Date: [**2161-8-26**] Discharge Date: [**2161-9-23**]
Date of Birth: [**2111-7-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Fall from roof
Major Surgical or Invasive Procedure:
[**2161-8-26**]
Exploratory trauma laparotomy
Insertion of left groin Cordis line
[**2161-9-1**]
Ultrasound-guided access to right common femoral vein.
Introduction of catheter into right iliac vein.
Inferior vena cavogram.
Placement of Bard due to inferior vena cava filter.
History of Present Illness:
Date: [**2161-8-27**]
Signed by [**First Name8 (NamePattern2) 12562**] [**Last Name (NamePattern1) **], MD on [**2161-8-27**] Affiliation: [**Hospital1 18**]
Called by trauma team to evaluate patient for ICP monitor
HPI: Pt is a 45 yo male w/ PMHx unknown PMHX who was working on
a roof and slipped landing on his head. There was a report that
he had focal weakness on one side of his body. He became
agitated and required intubation in the field. It was noted
that
he had blood coming out of both ears. The patient KUB was
concerning for free air in the abdomen. As a result, he was
rushed to the OR where an ICP monitor was placed. Abdomen did
not show any acute pathology. He is currently in the TICU.
Past Medical History: unknown
Medications: unknown
ALL: unknown
Family History: unknown
Social History: unknown
Physical Exam:
Past Medical History:
Non-significant, Remote tonsillectomy
Family History:
Noncontributory
Physical Exam:
Upon admission:
Vitals: T 98.5; BP 101/65; P 76; RR 19; O2 sat 99%
General: intubated, sedated
Neck: in c-collar
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: deferred
Extremities: no c/c/e.
Neurological Exam:
Mental status: intubated/sedated
Cranial Nerves: PERRL, 2-->1mm with light, + VOR, face
symmetric.
Motor/[**Last Name (un) **]: Normal bulk. Normal tone. no withdrawl to painful
stimuli
Reflexes: 1+ symmetric
Pertinent Results:
[**2161-8-26**] 11:46PM PT-15.6* PTT-38.4* INR(PT)-1.4*
[**2161-8-26**] 10:44PM GLUCOSE-164* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
[**2161-8-26**] 10:44PM ALT(SGPT)-21 AST(SGOT)-51* LD(LDH)-392*
CK(CPK)-949* ALK PHOS-45 AMYLASE-79 TOT BILI-0.7
[**2161-8-26**] 10:44PM LIPASE-20
[**2161-8-26**] 10:44PM CK-MB-20* MB INDX-2.1 cTropnT-0.06*
[**2161-8-26**] 10:44PM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-2.1*
MAGNESIUM-1.6
[**2161-8-26**] 10:44PM WBC-11.9* RBC-3.87* HGB-10.8* HCT-31.4*
MCV-81* MCH-27.9 MCHC-34.4 RDW-13.4
[**2161-8-26**] 10:44PM NEUTS-75.5* LYMPHS-21.9 MONOS-1.3* EOS-1.1
BASOS-0.2
[**2161-8-26**] 10:44PM PLT COUNT-343
[**2161-8-26**] 08:24PM TYPE-ART TIDAL VOL-630 O2-100 PO2-153*
PCO2-39 PH-7.31* TOTAL CO2-21 BASE XS--6 AADO2-537 REQ O2-87
INTUBATED-INTUBATED
[**2161-8-26**]
NON-CONTRAST HEAD CT: There are multiple fractures through the
left parietal,
occipital and temporal bones. There is an associated epidural
hematoma at the
left high parietal area measuring 8 mm in greatest diameter.
There are
subarachnoid hemorrhages layering over the frontal lobes
bilaterally with
hypoattenuation of the underlying brain suggesting contusion.
There is a 6 mm
subdural hematoma over the left occipital cortex measuring 6 mm
in greatest
diameter. Intraparenchymal hemorrhage in the posterior medial
left middle
cranial fossa is related to an adjacent fracture of the bone.
Finally there
is also a subdural or intraparenchymal hemorrhage in the right
middle cranial
fossa anterior to the right temporal lobe measuring 11 mm in
diameter. High-
density blood layers along the right leaf of the falx.
[**Doctor Last Name **]-white matter
differentiation is preserved and the ventricles are normal in
size and
configuration. There is effacement of the right
perimesencephalic cisterns
suggesting right-sided uncal herniation.
Moderate opacification of the maxillary sinuses, sphenoid
sinuses and ethmoid
air cells is present. High-density material within the sphenoid
sinuses
consistent with blood.
Slightly displaced fractures through the left parietal,
occipital and temporal
bone extend into the mastoid air cells and middle ear cavity and
there is
hemotympanum. The fracture does not extend to the carotid canal.
Multiple
left occipital bone fractures extend under the cerebellum. There
is
associated pneumocephalus and air and soft tissue swelling in
the overlying
tissues. A 9 mm subgaleal hematoma layers over the left parietal
bone. An
intracranial pressure monitor is seen in the left frontal lobe.
IMPRESSION: Extensive skull base fractures and intraparenchymal,
subarachnoid, subdural and epidural hemorrhages. There is signs
of increased
intracranial pressure and right-sided uncal herniation.
[**2161-8-26**]
NON-CONTRAST CT OF THE CERVICAL SPINE WITH CORONAL AND SAGITTAL
REFORMATS:
There are extensive skull base fractures, as described on the
prior head CT
report. There is no evidence of cervical spine fracture or
malalignment.
Vertebral body heights are maintained. There is no prevertebral
soft tissue
swelling. Prominent posterior osteophytes at C6-7 indent the
thecal sac on
the right side of the spinal canal. There is a large amount of
secretions and
blood within the oropharynx. NG tube and ET tube are in place.
The lung
apices demonstrate a chest tube overlying the left lung with a
small left
pneumothorax seen at the left lung apex. There are contusions
and asymmetric
edema in the right upper lobe with probable also partial
collapse of the right
upper lobe. There are dense atherosclerotic calcifications at
the carotid
bifurcation bilaterally. There is a comminuted fracture of the
left medial
clavicle, incompletely imaged.
IMPRESSION:
1. No cervical spine fracture or malalignment. No prevertebral
soft tissue
swelling.
2. Extensive left-sided skull base fractures as described on
concurrent CT of
the head.
3. Incompletely imaged comminuted left clavicular fracture.
4. Left chest tube and small left apical pneumothorax.
5. Right upper lobe contusions, edema, and atelectasis.
[**2161-8-26**]
CT OF THE CHEST: The heart size is normal, and there is no
pericardial
effusion or aortic injury. No mediastinal hematoma. A chest tube
is draped
over the left lung, and small- to- moderate- sized left
pneumothorax persists.
There is moderate atelectasis of the left lower lobe,
ground-glass opacities
in the left upper lobe, which may represent aspiration, and
contusions in the
right upper and lower lobes with near-complete collapse of the
right lower
lobe. The right lower lobe collapse also enhances
heterogeneously suggesting
concurrent contusion or aspiration. There is no right-sided
pneumothorax.
There are multiple fractures within the chest. These include a
comminuted
medial clavicular fracture, scapular fracture that extends to
the glenohumeral
joint and multiple left-sided rib fractures involving the
posterior and
anterior aspect of ribs two through six and only the posterior
aspect of ribs
seven through ten. No right-sided rib fractures are identified,
though there
is mild deformity of ribs four (2A, 31) five (2A, 33) as well as
old rib
fractures of ribs seven through ten on the right. No vertebral
body fractures
are identified.
CT OF THE ABDOMEN: The liver and spleen are normal. There is
extensive edema
in the gastric wall with a focal area of contrast which may
represent vascular
injury or the strange appearance of enhancing mucosa (2A, 49).
This area is
located in the fundus of the stomach and does not change in size
or
configuration on the 6-minute delayed scan suggesting that this
is not an
extravasation. An NG tube courses through the stomach,
terminating in the
antrum. The gallbladder, adrenal glands and kidneys are normal.
There is
edema in the small bowel wall, likely from fluid resuscitation.
The colon
appears unremarkable. The abdominal aorta is of normal caliber.
CT OF THE PELVIS: There is a moderate amount of free fluid in
the pelvis,
likely related to the lavage performed during recent laparotomy.
Foley
catheter and air are seen within the bladder. The sigmoid colon
and rectum
are normal.
Extensive left-sided rib fractures, left clavicular fracture and
left glenoid
fracture as described above. No additional fractures are
identified. There
are extensive degenerative changes in both hips.
There is extensive subcutaneous edema in the left chest wall
laterally and
posteriorly and extending down to the left pelvic brim.
IMPRESSION:
1. Extensive injury to the left chest including multiple rib
fractures, left
clavicular fracture, left scapular fracture extending into the
glenoid and
accompanying left-sided pneumothorax. There is moderate
persistent
pneumothorax despite chest tube placement. There is also
extensive contusion
in the right lung with collapse of the right lower lobe with
probable
contusion.
2. Extensive edema in the stomach with a small area of abnormal
enhancement
in the fundus. NG tube output should be monitored for
hemorrhage.
[**2161-9-9**]
HEAD CT without IV CONTRAST: There has been significant
improvement in
bifrontal small subarachnoid hemorrhage. The associated
component of
parenchymal contusion is less well defined. The appearance of
hemorrhage and
adjacent edema in the left temporal lobe has decreased. There is
no mass
effect or shift of normally midline structures. The parenchymal
contusion in
the anterior aspect of the right temporal lobe is also less
conspicuous.
There are no new foci of intra- or extra-axial hemorrhage. The
ventricles and
sulci are normal in size and configuration for the patient's
age.
There is no change in extensive left parietal, occipital, and
temporal bone
fractures extending into the left middle ear cavity and skull
base, with no
new fracture. There has been decrease in opacification of the
maxillary
sinuses. Mastoid air cells are again noted to be not well
pneumatized. There
is S- shaped deviation of the nasal septum, as before.
IMPRESSION:
1. Substantial interval improvement in the multifocal
parenchymal,
subarachnoid, and subdural hemorrhage, significantly decreased
in conspicuity.
2. No interval development of new mass effect or shift of
normally midline
structures.
3. Improved opacification of maxillary sinuses, with
chronic-appearing
inflammatory changes in the sphenoid sinuses and ethmoidal air
cells.
4. Extensive left parietal, occipital and temporal bone
fractures, as
before.
Brief Hospital Course:
He was admitted to the Trauma service and taken directly to the
operating room for exploratory laparotomy performed by Trauma
team and placement of an ICP bolt by Neurosurgery. There were no
intraoperative complications. He was taken to the Trauma ICU
postoperatively where he remained sedated and vented. He was
loaded with Dilantin and started on Mannitol. Serial head CT
scans were followed as well as his neurologic exam. Initially
there was small increase in subarachnoid blood, on repeat
imaging no significant changes were noted; in fact interval
improvement was shown.
He was changed to Keppra for seizure prophylaxis.
Gastroenterology was also consulted because of bleeding from his
rectum and hematocrit drop. It was felt that his bleeding and
findings on CT with gastric wall thickening were likely result
of the stress from trauma and that once all of his trauma issues
were resolved an outpatient colonoscopy is recommended. he was
placed on a PPI during his hospital stay.
Vascular surgery was also consulted for placement if an IVC
filter; this was performed on [**9-1**] without any complications.
He was evaluated by Speech for a swallow evaluation given his
cognitive status as a result of his traumatic brain injury. He
was initially placed on soft solids and nectar thick liquids. as
his mental status improved his diet was upgraded to a regular
diet with thin liquids.
Physical and Occupational therapy were consulted and did
recommend [**Hospital **] rehab; because of his lack of insurance he was
declined by all facilities who screened him. An application for
Mass Health was initiated. He continued to receive therapy
throughout his hospital stay, including cognitive rehab from
Occupational therapy. There was significant improvement in his
mental status at time of discharge. He will receive outpatient
Occupational therapy here at [**Hospital1 1170**].
A family/team meeting took place to discuss his discharge
options. His parents agreed to take him to their home and
expressed the ability to provide 24 hour supervision for him.
Medications on Admission:
None
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*10*
2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*10*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: take with food.
Disp:*90 Tablet(s)* Refills:*4*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*56 Tablet(s)* Refills:*0*
9. Outpatient Occupational Therapy
Dx: Traumatic Brain Injury
Sig: [**Hospital 6266**] rehab evaluation and treatment
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Being printed for Free Care Pharmacy.
Disp:*360 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p 20 ft Fall
Traumatic Brain Injury
Bilateral Basilar Skull Fracture
Left Posterior Subdural and Epidural Hemorrhage
Right Frontal Subarachnoid Hemorrhage
Right Basilar Pulmonary Contusion
Left Pneumothorax
Left Scapula Fracture through Glenoid
Left Clavicle Fracture
Multiple Left Rib Fractures [**2-16**]
C. Difficile Colitis
Discharge Condition:
Hemodymanically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
DO NOT drive, go out alone, drink alcohol or take any illicit
drugs.
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, and/or any other symptoms that
are concerning to you.
Continue with the Flagyl for the infection that we are treating
until the pills are all done.
Followup Instructions:
Follow up in Outpatient Occupational [**Hospital **] Clinic with
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79667**], [**Name12 (NameIs) **]/L Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2161-10-1**] 11:20. Located on [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg,
[**Location (un) **]
It is being recommended that you follow up in Behavioral
[**Hospital 878**] Clinic with either Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], call [**Telephone/Fax (1) 1690**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics in 2 weeks.
Call [**Telephone/Fax (1) 1228**] for an appointment. You may also follow up
with Dr. [**Last Name (STitle) 2719**] for your shoulder; you will need to call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks, with Dr. [**Last Name (STitle) **], Trauma Surgery, call
[**Telephone/Fax (1) 6429**] for an appointment. Inform the office that you will
need a chest xray for this appointment.
Follow up in 4 weeks in [**Hospital 4695**] clinic, call [**Telephone/Fax (1) 1669**]
for an appointment. Inform the office that you will need a
repeat non contrast head CT for this appointment.
Completed by:[**2161-10-21**]
|
[
"305.60",
"291.81",
"285.1",
"811.03",
"810.02",
"861.21",
"958.4",
"041.5",
"801.46",
"569.3",
"348.8",
"307.9",
"860.0",
"303.90",
"807.4",
"807.08",
"486",
"518.0",
"453.41",
"518.5",
"E849.8",
"008.45",
"348.4",
"E882",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.7",
"96.07",
"96.72",
"89.68",
"33.24",
"88.51",
"34.04",
"96.04",
"38.91",
"01.10",
"54.11",
"38.93",
"03.91",
"57.94",
"00.94"
] |
icd9pcs
|
[
[
[]
]
] |
14002, 14008
|
10585, 12651
|
331, 611
|
14381, 14461
|
2104, 2976
|
14890, 16237
|
1567, 1584
|
12706, 13979
|
14029, 14360
|
12677, 12683
|
14485, 14867
|
1599, 1601
|
1871, 1871
|
273, 293
|
639, 1356
|
1922, 2085
|
2985, 10562
|
1615, 1852
|
1886, 1905
|
1512, 1551
|
1464, 1473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,093
| 107,395
|
29059
|
Discharge summary
|
report
|
Admission Date: [**2164-4-2**] Discharge Date: [**2164-4-8**]
Date of Birth: [**2089-11-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lipitor
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
Tracheobronchoplasty via right thoracotomy
History of Present Illness:
The patient is a 74-year-old man who has had a chronic and
severe cough since
[**2162-12-23**]. It is severely limiting to his activities of
daily life, and he has severe dyspnea on exertion. He has had
several bouts of upper respiratory infections treated with
antibiotics. He is unable to clear his secretions readily. Mr.
[**Name13 (STitle) **] had undergone a stent trial with a Y-stent placed on
[**2164-3-6**] and noted that his breathing and cough
improved, however the stent was removed on [**2164-3-14**]. He
was recently admitted to the hospital for treatment of a left
lower lobe pneumonia., treated with antibiotics at home.
Past Medical History:
Hypertension
Hypercholesterolemia
CAD status post MI s/p CABG in [**2157**]
GERD
OSA
Tracheobronchomalacia s/p Y stent placement and removal [**3-14**]
Basal cell carcinoma of the skin
Status post resection
Squamous cell carcinoma of the skin status
post resection
Melanoma status post resection
Prostate cancer diagnosed in [**2147**] status post radical
prostatectomy Diverticular disease s/p colon resection
Cholecystectomy
Inguinal hernia repair multiple times, last time in [**2156**].
Social History:
He is married, retired, used to work in construction, drinks
alcohol socially, used to smoke 20-pack-year quit 15 years ago,
and has been exposed to asbestos.
Family History:
His father died secondary to prostate cancer, mother had
[**Name (NI) 2481**], and brother had lung cancer.
Physical Exam:
VS: T 96.6 BP 125/62 HR 72 RR 16 95% RA
General: well-nourished, well-appearing, speaking in full
sentences with occasional coughing
HEENT: NC/AT, EOMI, OP clear, MMM, anicteric
Neck: supple, no LAD, no carotid bruits
CV: RRR, normal S1/S2, no m/r/g noted
Lungs: scattered rhonchi thorughout with scattered inspiratory
wheezes
Abdomen: soft, NT/ND, normoactive BS, no masses, no rebound or
tenderness.
Ext: warm, no edema
Skin: no rashes, no lesions
Neuro: AAO x3, muscle strength 5/5 in all 4 extremities
Pertinent Results:
[**2164-4-2**] 03:32PM BLOOD WBC-9.7 RBC-3.42* Hgb-11.5* Hct-32.8*
MCV-96 MCH-33.7* MCHC-35.1* RDW-13.4 Plt Ct-250
[**2164-4-2**] 03:32PM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2164-4-2**] 03:32PM BLOOD Glucose-200* UreaN-16 Creat-0.4* Na-138
K-4.5 Cl-105 HCO3-26 AnGap-12
[**2164-4-2**] 03:32PM BLOOD Calcium-8.8 Mg-1.7
[**4-2**] CXR: Left basilar opacity is likely effusion and
atelectasis, though an infectious consolidation cannot be
excluded. Two right-sided chest tubes with no evidence of
pneumothorax. NG tube tip lies within the stomach, though the
tube could be advanced to ensure that the side hole is within
the stomach. Mediastinal and subcutaneous emphysema are
consistent with recent tracheobronchoplasty and chest tube
insertion.
[**4-3**] CXR: Status post removal of right apical chest tube, with
no residual right pneumothorax. Right basilar chest tube is
still in place. Also, status post removal of the nasogastric
tube. Otherwise, unchanged appearance since yesterday
[**4-4**] CXR: There is no pneumothorax after removal of the right
chest tube, given the limitation of patient motion. There are
small bilateral pleural effusions, possibly loculated. The aorta
remains dilated and tortuous. No new consolidations.
[**4-5**] CXR: Moderate right and small left pleural effusions are
unchanged, with apparent loculation of the right effusion
laterally. No pneumothorax is identified. Cardiac and
mediastinal contours are stable
Brief Hospital Course:
Mr. [**Known lastname 24400**] was admitted to the Thoracic Surgery service under
the care of Dr. [**Last Name (STitle) **] on [**2164-4-2**] after undergoing a
tracheobronchoplast for his tracheobronchomalacia. Please refer
to the operative note for details of this procedure.
Postoperatively, he was cared for in the CSRU.
On postoperative day one, his pain was controlled with an
epidural. His chest tube was removed. His [**Doctor Last Name **] drain remained
until POD2. He was noted to be in atrial fibrillation, and was
begun on an amiodarone and a diltiazem drip. The Diltiazem was
stopped. His rhythm had converted to sinus.
On POD3, he was transferred to the [**Wardname 836**] floor unit. His
amiodarone was converted to an oral dose of 400 mg twice a day,
to continue for a total of 7 days, and then taper to a dose of
200 mg daily. On POD4, he was seen by Physical Therapy, who
felt he may be able to go home with services, however, his wife
is currently disabled, and his family felt strongly about his
being placed in a rehabilitation facilty for a short time.
He continued to do well, and was discharged to a rehabilitation
facility on POD6.
Medications on Admission:
Lopressor 50A/25P, Norvasc 5A/2.5P, Isordil 60", Xanax 5/prn,
Citalopram 40', Detrol LA5', Omeprazole 20', Folate 1', Vit E
400', Vit C 500', ASA 81', Albuterol, Pulmoicort, Zetia 10'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
3. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
6. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Beginning after 400 [**Hospital1 **] dosing has completed.
10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
11. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO Q8H PRN as
needed.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
16. Vitamin C 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
17. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
18. Pulmicort Turbuhaler 200 mcg/Inhalation Aerosol Powdr Breath
Activated Sig: Two (2) puffs Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] [**Location (un) 5871**]
Discharge Diagnosis:
Tracheobronchomalacia
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 170**] if you develop:
--Chest pain
--Shortness of breath
--Difficulty swallowing
--Fever greater than 101.5 F
--Redness or drainage from your incision sites.
No lifting anything greater than 10 pounds for 6 weeks.
Do not drive while taking pain medication.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up
appointment in 2 weeks
|
[
"401.9",
"V45.81",
"327.23",
"V10.46",
"427.31",
"519.19",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.79",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6879, 6951
|
3857, 5027
|
309, 354
|
7017, 7024
|
2378, 3834
|
7391, 7497
|
1728, 1837
|
5261, 6856
|
6972, 6996
|
5053, 5238
|
7048, 7368
|
1852, 2359
|
248, 271
|
382, 1020
|
1042, 1535
|
1551, 1712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,841
| 183,664
|
49749
|
Discharge summary
|
report
|
Admission Date: [**2192-3-26**] Discharge Date: [**2192-3-31**]
Date of Birth: [**2142-3-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vicodin
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
admitted to rule out tuberculosis
Major Surgical or Invasive Procedure:
Exploratory Laparotmy [**3-29**]
History of Present Illness:
This is a 50 year old woman with autoimmune hepatitis/PBC
overlap syndrome on imuran and prednisone and essential
hypertension who was transferred from [**Hospital 12017**] Hospital in New
[**Location (un) **] being admitted for history of fevers, chills,
nonproductive cough and status treatment for pneumonia with no
improvement. Chest CT shows miliary lesions in lung, liver and
spleen. She will be admitted to rule out tuberculosis.
.
Patient presented to outside hospital on [**2192-3-22**] with fever,
chills and nonproductive cough. Patient reported a one week
history of easy fatigability, shorntess of breath on exertion,
pleuritic chest pain and nonproductive cough. She also developed
chills and subjective fevers. In OSH ED, chest x-ray did not
show infiltrate and blood culture grew gram positive cocci in
clusters in 1 out of 4 bottles. She subsequently went home and
returned the following morning on [**2192-3-23**] to the OSH ED, with
recurrence of chills and temp in ED measured as 103.5 rectally.
Patient was admitted for further workup. She received 2 doses of
Rocephin and has since been afebrile. Patient denies hemoptysis,
phlegm production but does have some slight nausea. Denies
contact with suspected or confirmed casese of tuberculosis. No
recent travel or pets at home. Infectious disease was consulted
and recommended treatment of CAP in an immunocompromised host.
Covered with ceftriaxone and azithromycin that was switched to
levaquin on [**2192-3-26**]. Patient continued to spike at night to temp
of 102-103. Chest/abdominal CT revealed miliary lesions in lung,
liver and spleen. She was subsequently transferred to BIMDC to
rule out tuberculosis and for further workup.
.
ROS: Denied headache, dizziness, chest pain, vomitting,
abdominal or urinary complaints.
Past Medical History:
1. autoimmune hepatitis (dx'd 30 yrs ago and has been on Imuran
and prednisone.
2. essential hypertension
3. s/p tonsillectomy
4. s/p myomectomy for uterine fibroids
5. s/p appendectomy
6. s/p liver biopsy
Social History:
Lives with husband of 26 years in [**Location (un) 82229**]. Nonsmoker and
nondrinker. No illicit drug use.
Family History:
F died at age 69 of heart disease.
Physical Exam:
101.9 98/66 104 18 95% room air
GEN: in bed under multiple covers and a down jacket
SKIN: no rashes or lesions appreciated, warm to touch
HEENT: PERRL, small white plaque on lateral sides of tongue, OP
nl, no LAD appreciated, neck supple
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
PULM: fine rales R>L, no wheeze
ABD: soft, nontender, +BS, nondistended
EXT: nonedematous, good pulses
NEURO: AOx3, nonfocal
Pertinent Results:
At OPH:
lying HR 146 BP 119/71
sitting HR 150 BP 111/80
standing HR 160 BP 94/60
.
[**2192-3-22**] WBC 2.5 Hct 31.8 Plat 94
Alb 3.0 Ca 7.8 Bili 2.3 Ast 95 Alt 75
.
[**2192-3-23**] WBC 2.6 H and H 12.2 35.1. Plat 57
N 44 Bands 37 L11 M 5 atyp lymphocytes 2 Burr cells 2+
.
Na 136 K 3.7 Cl 103 HCO3 25 BUN 13 Cr 0.8 Gluc 84
.
TP 6.7 Alb 2.7 Ca 7.9 TB 4.0
AST/ALT 97/77 (per Dr.[**Name (NI) 104008**] note, LFTs chronically
elevated)
Alk phos 86
.
urine uribilinogen 8
urine pneumococcal Ag: PND
legionella Ag: PND
mycoplasma IgM: PND
chlamydia IgM: PND
cryptococcal Ag: PND
aspergillus Ab, Ag: PND
histoplasmosis Ab: PND
urine histoplasma Ag: PND
influenza A/B: negative
Sputum cx [**2192-3-24**]: PND
Bld cxs x2 [**3-23**]: NGTD
AFB cx: PND
Urine cx [**3-23**]: NGTD
UA: negative
C diff [**3-22**]: negative
Urine cx [**3-22**]: 10-50,000 CFU g negative bacillus
Bld cxs x2 [**3-22**]: coag neg staph in 1 out of 4 bottles
.
Imaging:
CXR [**3-22**]: elevated right hemidiaphragm with atelectasis of the
right lung base
.
CXR [**3-23**]: interval presence of an increased density in the right
upper lobe which was consistent with pneumonia.
.
EKG: 135 sinus tachycardia, nl axis, no acute ST-T changes
unchanged from prior.
.
LABS At [**Hospital1 18**]: PENDING
STUDIES:
LIVER BLOOD POOL STUDY [**2192-2-24**]: Focal increased tracer uptake in
the liver which correlates with the suspicious lesion seen on
MRI, consistent with hemangioma.
.
MRI/MRA ABDOMEN [**2192-1-19**]:
Cirrhotic liver with an atypical 2.1-cm segment [**Doctor First Name 690**] lesion.
Because there has been equivocal enlargement of this lesion when
compared to prior examination, additional imaging is
recommended. Most likely this lesion is an atypical hemangioma.
A technetium-[**Age over 90 **]m-labeled red blood cell study (nuclear medicine
study) is recommended for further evaluation (this nuclear
medicine study could potentially confirm that this lesion is in
fact a hemangioma).
No other significant change from prior examination.
.
CHEST, TWO VIEWS [**2192-10-18**]: No active lung disease.
Brief Hospital Course:
Briefly, 50W w/autoimmune hepatitis/primary biliary cirrhosis
overlap syndrome on chronic immunosuppressants p/w fever,
nonproductive cough and miliary lesions in lung, liver and
spleen seen on outside chest/abd CT.
.
*. Fever: unclear etiology. Differential diagnosis includes TB,
CAP, UTI or abdominal infection. Given chronic immunosuppresion,
infectious etiology should be broad to include fungal and
parasitic infections. RUL infiltrate seen on OSH chest x-ray
suggestive of pneumonia and miliary lesions in multiple organs
suggestive of miliary TB, MAC or fungal infection.
--rec'd ceftriaxone and azithromycin [**Date range (1) 71671**] at OSH, then
changed to levaquin on [**3-26**]
--continue levaquin for now to cover CAP and atypical PNA
--f/u OSH test results
--repeat bld cxsx2, mycolytic, UA/urine cx
--induced sputum x3 to rule out TB
--repeat CXR and chest/abd CT
--respiratory precautions for now
--consult pulm in am, may need bronchoscopy if unsuccess with
induced sputums
--CIS >100.4, tylenol 325mg PRN not to exceed 2g/day
--follow fever curve
.
*. Nonproductive cough: unclear etiology. Differential diagnosis
includes GERD, asthma, post-nasal drip, pneumonia/pneumonitis,
bronchitis or upper respiratory infectio. Influenza a/b antigen
negative at OSH.
--cont levaquin for now
--induced sputum x3 to rule out TB
--PPI
--no wheezes on exam, hold off on nebs
.
*. Chronic liver disease: autoimmune hepatitis and PBC.
Continued prednisone and Imuran.
--follow LFTs
--apprec liver recs
.
*. Miliary lesion in multiple organs: Lung, liver and spleen
involvement. Differential diagnosis includes TB, atypical
mycobacteria, histoplasmosis. Less likely include other endemic
fungi (coccidioidomycosis, blastomycosis,
paracoccidioidomycosis), bacterial (legionella, nocardiosis),
viral (varicella, CMV), parasitic (toxo), neoplastic (lymphoma,
lymphangitic spread of carcinoma), sarcoid, hypersensitivity
pneumonitis, pneumoconioses.
--rule out TB
--repeat chest/abd CT
--pulm consult and consider bronchoscopy/BAL/?Bx
--consider CT guided biopsy of lesion and send for path and
microbiology
.
*. Hypertension: Continue to monitor.
.
*. FEN: cardiac healthy/diabetic diet and NPO after midnight for
possible bronch in am, replete lytes as needed, D5W w/3 amps
bicarb at 75cc/hr overnight prior to CT scan
.
*. PPX: SQ heparin, PPI, bowel regimen as needed, respiratory
droplet precautions.
On the evening of [**2192-3-27**], the pt was transferred to the MICU
for hypotensive episodes and worsening dyspnea. The hypotension
responded to fluid challenges. On [**2192-3-28**], the patient was
intubated for bronchoscopy. The bronchoalveolar lavage was
positive for pneumocystis carinii pneumonia, and the patient
remained intubated.
On [**2192-3-29**], a CT scan of the torso was performed to rule out
other causes of sepsis and respiratory failure. Initial read of
the CT showed "free air" in the pelvis. Exploratory laparotomy
performed on [**3-29**] which was found to be negative for any
intraabdominal pathology. Liver biopsies were performed.
Post-operatively the patients prior acidosis continued and
worsened, despite resucitation. Lactate climbed to 25. CVVH
was initiated and her acidosis improved, however her lactate
continued to rise. She developed a fatal arrythmia and was
pronounced dead on [**2192-3-31**]. The family declined a post-mortem
examination.
ADDENDUM: A few days after the patient expired, the final path
report on the liver biopsy showed non-Hodgkin B-cell lymphoma,
diffuse large B-cell type, high grade.
Medications on Admission:
Imuran, Prednisone, Ursodiol
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Liver failure
Spesis
MSOF
Discharge Condition:
Cardiac death
Completed by:[**2192-4-2**]
|
[
"571.49",
"995.92",
"136.3",
"200.00",
"518.81",
"571.5",
"038.9",
"276.2",
"284.8",
"584.9",
"789.5",
"571.6",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.04",
"99.04",
"96.71",
"50.12",
"54.11",
"33.24",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
8828, 8867
|
5191, 8749
|
316, 350
|
8937, 8980
|
3044, 5168
|
2547, 2583
|
8888, 8916
|
8775, 8805
|
2598, 3025
|
243, 278
|
378, 2176
|
2198, 2406
|
2422, 2531
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,087
| 133,083
|
33767
|
Discharge summary
|
report
|
Admission Date: [**2136-6-27**] Discharge Date: [**2136-7-10**]
Date of Birth: [**2055-3-30**] Sex: F
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
Intubated and sedated from [**6-28**] to [**7-6**]
History of Present Illness:
82 yo F with history of CHF, recent MVR 6 weeks ago, recently
had increased confusion and fatigue of 1 to 2 weeks. This
morning patient awoke with fatigue and dyspnea, and was brought
to [**Hospital1 18**] [**Location (un) 620**] by her son. Initially reported to [**Location (un) 620**] ED
and had an ECHO there which showed EF of 55%, new RV dilation
but otherwise intact new valve. Given her recent cardiac
surgery, the patient was transferred to [**Hospital1 18**] for further
management. The patient was also noted to have new acute renal
failure at that time with K of 7.5 and received 10 of insulin
and 60 kayexelate prior to transfer here.
.
In the ED patient was noted to have vitals upon arrival of: T
afebrile, HR 105, BP 90s/50s, O2Sat 100% on BiPAP. Cardiac
surgery assessed the patient and felt that there was not an
operable solution to her presentation. Patient coughed up
green-yellow sputum and in setting of WBC of 13, was started on
Vanc and Zosyn. She received 2L of normal saline. CXR without
obvious focal process. Patient noted to be in [**Last Name (un) **] with Cr of
2.8. Potassium was initially 6.7 and confirmatory potassium was
7.4. The patient received a further 10 of insulin and 30 of
kayexalate. Patient was hypotensive to 80s/50s at one point in
the ED and BiPAP was thought to be to blame and was removed.
Patient's BP improved; however, an ABG was 7.18/75/99. ED staff
spoke with family who confirmed a DNR status, but felt okay to
intubate. Patient was intubated in the ED. Vitals prior to
transfer to the MICU were: T afebrile, HR 105, BP 115/65, 100%
on CMV FiO2 100% (Intubated with CMV mode PEEP 5, VT400, RR 14).
.
Per son who lives with pt, according to the CCU team who at
first was to admit the patient - pt had been doing well as rehab
and home for several wks. Over last [**4-23**] D pt with worsening
fatigue, MS. Pt walking with walker ok at home, poor po but
taking v small meals (several grapes then piece of cheese).
Yesterday, seen by VNA who was not concerned. Seen several days
ago in surgery f/u where they thought her fatigue was expected.
Today, pt was very confused and so son brought her in.
.
Also, according to the CCU resident who spoke with her son who
is the healthcare proxy, they are very clear about her wishes
re: goals of care. They felt that after he contact[**Name (NI) **] his brother
by phone, [**Name (NI) **] called me back to state that he and his
brother do not want the pt to undergo more aggressive measures
at this time incl a lines, CVL, pressors, CPR, or electric
shocks. They would like her to remain DNR. For tonight, they
would like to continue ABX, mechanical ventilation and medical
tx of her [**Last Name (un) **], hyperkalemia and other issues. They will be in in
the morning to see her.
Past Medical History:
Chronic Diastolic Congestive Heart Failure
Chronic Atrial Fibrillation- s/p unsuccessful DCCV 10-15yo
Hypertension
Dyslipidemia
Mild to moderate Chronic Renal Insufficiency
Possible Amiodarone Pulmonary toxicity.
Hypothyroidism (possibly secondary to amiodarone)
History of Digitalis toxicity (likely due to inadvertent
overdose)
Possible Asthma
Extensive surgery on multiple basal cell carcinomas right arm
bilateral cataract
right total hip replacement
thyroid surgery
Social History:
Lives with: son
Occupation: retired insurance underwriter
Tobacco: 1ppd x 25 yrs, quit 30-35 yrs ago
ETOH: none
Family History:
Non contributory.
Physical Exam:
Admission PE:
VS: temp 95 hr 98 bp 85/54 rr 14% Sat 100% on 400/5/14/70%
GEN: Sedated, localizes to pain.
HEENT: PERRL. MM dry.
NECK: Distended neck veins, prominent pulsations.
PULM: Breath sounds obscured by ventilator noises, but mild
crackles heard at right lateral base.
CARD: irregularly irregular, mechanical s1, no m/r/g
ABD: Soft, NT/ND bowel sounds present.
EXT: No edema, varicose veins present. Ecchymoses on arms.
NEURO: moves all 4 extremities
.
Discharge PE:
Tm=97.6, Tc=95.4, HR=90s-110s, BP=120s-130s/60s-70s, RR=22,
POx=99% RA
GEN: Pleasant, elderly female in NAD
HEENT: EOMI, PERRL, dry MM, OP clear.
NECK: Supple
PULM: Coarse breath sounds bilaterally
CARD: Irregularly irregular, no m/r/g
ABD: Soft, NT/ND, bowel sounds present.
EXT: 1+ edema, varicose veins present. Scattered ecchymoses on
arms and legs.
NEURO: alert, oriented to herself and location, CN 2-12 intact,
motor strength and sensory grossly equal and intact bilaterally
Pertinent Results:
Admission Labs:
[**2136-6-27**] 11:50PM GLUCOSE-91 UREA N-77* CREAT-2.6* SODIUM-136
POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2136-6-27**] 11:50PM proBNP-[**Numeric Identifier 37531**]*
[**2136-6-27**] 11:50PM CALCIUM-8.2* PHOSPHATE-4.6* MAGNESIUM-2.5
[**2136-6-27**] 09:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2136-6-27**] 09:06PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2136-6-27**] 06:25PM GLUCOSE-76 UREA N-79* CREAT-2.8*# SODIUM-131*
POTASSIUM-6.7* CHLORIDE-99 TOTAL CO2-24 ANION GAP-15
[**2136-6-27**] 06:25PM cTropnT-0.05*
.
Discharge Labs:
[**2136-7-10**] 05:22AM BLOOD WBC-7.8 RBC-3.53* Hgb-9.5* Hct-30.5*
MCV-87 MCH-26.9* MCHC-31.1 RDW-16.8* Plt Ct-222
[**2136-7-10**] 05:22AM BLOOD Plt Ct-222
[**2136-7-10**] 05:22AM BLOOD Glucose-76 UreaN-48* Creat-2.3* Na-142
K-4.5 Cl-105 HCO3-27 AnGap-15
[**2136-7-10**] 05:22AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.3
.
[**6-27**] EKG: Baseline artifact. Atrial fibrillation with rapid
ventricular response. Diffuse ST-T wave changes. Left axis
deviation. Poor R wave progression. Cannot rule out prior
anteroseptal myocardial infarction. Compared to the previous
tracing of [**2136-5-18**] atrial fibrillation is new.
.
[**6-27**] CXR: FINDINGS: The study is compromised secondary to
respiratory motion resulting in blurring of the lung bases.
Within that limitation, lung volumes are low. The vasculature
is difficult to assess but does not appear significantly
distended or indistinct. No definite focal consolidation is
noted. There is a markedly tortuous aorta with calcified plaque
at the arch. Evidence of prior median sternotomy is again noted.
The cardiac silhouette is markedly enlarged but stable. No large
effusion is noted. No pneumothorax is seen in this upright
radiograph. Please note the patient is somewhat lordotically
positioned. Again seen is a dextroconcave scoliosis involving
the upper lumbar spine. Deformity of the included left humeral
head is again noted, though limited.
IMPRESSION:
Marked cardiomegaly. No overt edema identified.
.
[**7-2**] ECHO: The left atrium is markedly dilated. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic root is mildly 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. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen.The mitral
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients. No mass or vegetation is seen on the
mitral valve. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Dilated right ventricle with global free wall
hypokinesis. Moderate to severe tricuspid regurgitation. Normal
left ventricular cavity size with mild global hypokinesis.
Normal functioning bioprosthetic mitral valve. Pulmonary artery
systolic hypertension.
.
[**7-2**] Renal ultrasound: IMPRESSION:
1. No evidence of hydronephrosis.
2. Left renal cyst.
3. Trace free fluid within Morison's pouch.
.
[**7-7**] EKG: Atrial fibrillation with rapid ventricular response.
Poor R wave progression. Diffuse ST-T wave changes that are
non-specific. Compared to the previous tracing of [**2136-6-27**] there
is no significant diagnostic change.
Brief Hospital Course:
This is an 81 year old woman with history of CHF, MVR with PFO
repair 6 weeks ago who presents from home after 1-2 weeks of
increasing confusion and more recently shortness of breath, who
presented with respiratory failure and sepsis requiring
intubation secondary to volume overload from IV fluid
resuscitation and Pseudomonas pneumonia.
.
#. Pseudomonal pneumonia - She was initially intubated in the ED
for hypercarbic respiratory failure and was later found to have
pseudomonal pneumonia. She was initiated on
vanco/zosyn/azithromycin empirically on [**6-28**]. On [**2136-7-3**], her
antibiotic coverage was narrowed to cefepime to complete a 15
day course scheduled to end on [**7-13**]. She was extubated
successfully on [**2136-7-6**] after optimization of volume status with
diuresis. She should be continued on ipratropium nebs as needed
for shortness of breath.
.
#. Septic Shock - Likely secondary to pulmonary source as noted
above. A-line and CVL were placed for monitoring in the ICU.
She required large volume IV fluid resuscitation with boluses.
Due to persistent hypotension, she required neosynephrine for 24
hours from [**6-30**] to [**7-1**]. She was treated with antibiotics as
described above.
.
#. Delirium: The patient has waxing and [**Doctor Last Name 688**] mental status
which responds well to re-orientation. The cause is likely
multifactorial from her multiple medical comorbities in addition
to her long ICU stay. She was started on low dose Zyprexa PRN.
.
#. Acute on chronic kidney injury: Her creatinine was elevated
at 2.8 on admission and peaked at 3.7. Currently her creatinine
is down to 2.3 from a baseline of low 1s. Urine sediment
demonstrated oxalate crystals with evidence of tubular injury,
consistent with ATN. A renal ultrasound showed no
hydronephrosis. It may be that her new baseline is in the low
2s. Diuresis with Lasix should be continued according to her
volume status as described below and her creatinine should be
trended.
.
#. Acute on chronic diastolic CHF: Her last EF=45% on an ECHO
performed on [**7-2**]. She became volume overloaded during her ICU
course as a result of aggressive volume resuscitation in the
setting of sepsis. She was diuresed with Lasix aggressively and
currently appears to be euvolemic to mildly hypervolemic on
exam. She has now been transitioned to her home Lasix regimen
of 40mg twice daily. Her daily weight should be tracked closely
and her Lasix dosing should be adjusted accordingly. Her beta
blocker dosing should continue to be titrated as described
below.
.
#. Atrial fibrillation: The patient was found to have atrial
fibrillation with rapid ventricular rate on admission. She was
transitioned from her home carvedilol to metoprolol on
admission. Her metoprolol has been titrated up to 75mg TID and
her heart rate should continue to be monitored on telemetry in
order to further titrate her beta blocker to maintain a heart
rate between 60-90.
.
#. Communication: Son-[**First Name4 (NamePattern1) **] [**Known lastname **] [**Telephone/Fax (1) 78097**].
.
#. Code: Confirmed DNR/DNI
Medications on Admission:
-Aspirin 81 daily
-Carvedilol 3.125 mg Tablet [**Hospital1 **]
-Fluticasone-Salmeterol 250-50 mcg 1 inhalation [**Hospital1 **]
-Lasix 40mg [**Hospital1 **]
-Levothyroxine 25mcg daily
-Allopurinol 100mg daily
-Fosamax plus D weekly
-Oxybutynin 5mg [**1-21**] to 1 tablet [**Hospital1 **]
-Lorazepam 0.5mg HS PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): Hold for SBP < 90 or HR < 60
.
2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Fosamax Plus D 70-2,800 mg-unit Tablet Sig: One (1) Tablet PO
once a week.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety, agitation.
13. 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.
14. CefePIME 1 g IV Q24H
day 1=[**2136-6-27**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
-Pseudomonas pneumonia
-Sepsis
-Acute kidney injury
-Atrial fibrillation with rapid ventricular rate
-Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
further evaluation of increasing confusion and shortness of
breath. You were found to have a serious pneumonia that
required a stay in the intensive care unit. You needed to be
placed on a breathing machine to help you breathe. You
recovered after an extended course of antibiotics. You also
developed some kidney injury which resolved and a fast heart
rate which was controlled with medications. You also required
extra Lasix dosing to help get some extra fluid off of your
body. You should be weighed every morning and your Lasix dosing
should be adjusted accordingly at your rehab to help maintain
your weight.
.
The following changes have been made to your home medication
regimen:
-You should stop taking carvedilol, oxybutynin, lorazepam,
Cozaar, and digoxin
-You should start taking metoprolol to control your heart rate
-You should son[**Name (NI) **] taking cefepime until [**7-13**] to complete a 15
day course for pneumonia
-You should continue on a bowel regimen of docusate and senna as
needed
-You should continue ipratropium nebs as needed for shortness of
breath
-You should continue Zyprexa as needed
Followup Instructions:
You should follow-up with the physicians at the [**Hospital3 **]
facility.
|
[
"403.90",
"518.81",
"244.9",
"276.7",
"584.9",
"785.52",
"V43.64",
"995.92",
"V42.2",
"428.33",
"427.31",
"428.0",
"293.0",
"038.43",
"276.2",
"482.1",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13486, 13556
|
8740, 11843
|
279, 332
|
13762, 13762
|
4792, 4792
|
15139, 15217
|
3781, 3800
|
12206, 13463
|
13577, 13577
|
11869, 12183
|
13947, 15116
|
5454, 8717
|
3815, 4275
|
4289, 4773
|
231, 241
|
360, 3141
|
4808, 5438
|
13596, 13741
|
13777, 13923
|
3163, 3635
|
3651, 3765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,278
| 122,716
|
6425
|
Discharge summary
|
report
|
Admission Date: [**2179-9-10**] Discharge Date: [**2179-9-21**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 61 year old man with
past medical history significant for diabetes, hypertension,
and paroxysmal atrial fibrillation with episodic left upper
extremity and left lower extremity weakness and numbness,
associated with severe orthostatic hypotension.
17 days prior to transfer from the Intensive Care Unit to the
medical floor, the patient had noted sudden onset of left
facial droop for four seconds. Then, 15 days prior to being
transferred, the patient woke up from sleep at home, to go to
the bathroom and noted that his left upper extremity and left
lower extremity were weak. Specifically, the patient recalls
that his left arm, from shoulder to finger tips felt numb,
like "I had slept on it" and that he was unable to turn on
the faucet with his left hand. The patient denies any facial
weakness at this time. Whether there were lower extremity
symptoms at this time, it is unclear. Though the symptoms
resolve when he lays flat, the patient called an ambulance
and was taken to the outside Emergency Department.
At the outside Emergency Room, the symptoms recurred whenever
he stood up and resolved within two minutes whenever he laid
supine. The symptoms were accompanied by a rush of warmth
when he stood up, along with diaphoresis and nausea. Work-up
included documentation of orthostasis. Carotid ultrasound
demonstrated 40 to 60% stenosis of the right internal carotid
artery along with left intra-carotid plaque formation, normal
CT of the head and a negative transesophageal echocardiogram.
Magnetic resonance scan was not obtained due to scanner
limitations.
At the outside hospital, a right carotid endarterectomy was
recommended but the patient requested transfer to [**Hospital1 346**] instead.
The [**Hospital1 69**] hospital course has
been complicated by acute oliguric renal failure which is
believed to have been caused by over anticoagulation at the
outside hospital, resulting in a left thigh bleed and
exacerbation of the hypotensive state, secondary to treatment
with hypertensive medications and diuretics. Noted is that
the patient was actually treated with Lovenox and then
switched over to heparin at the outside hospital once his
left thigh hematoma began. The patient presented from the
outside hospital from [**2179-9-10**] with a left thigh bruise which
was later determined to be 70 cm circumference hematoma by
Doppler study done on [**2179-9-11**]. Deep vein thrombosis was also
ruled out by the ultrasound.
Unfortunately, the patient also developed acute renal failure
on top of his chronic renal failure secondary to a prerenal
state. He was treated with normal saline boluses and packed
red blood cell transfusions, since the patient's hematocrit
fell to like 22.6 on [**2179-9-11**]. The patient began producing
urine again on [**2179-9-13**] and renal function began improving,
going from 10.8 on [**2179-9-14**] to 6.8 on [**2179-9-16**]. Anticoagulation
was desired since the patient does have atrial fibrillation
and it was felt that the anticoagulation would be the best
prevention for stroke. Once the patient's hematoma
stabilized, intravenous heparin was started.
Carotid Dopplers were repeated and demonstrated a 60 to 69%
occlusion of the right internal carotid artery and left
internal carotid artery.
[**Hospital **] medical issues included gout which was being
treated by a Prednisone taper in the unit and an elevated TSH
level of 0.4 which may indicate some hyperthyroidism.
However, a T4 was checked and was found to be normal at nine.
PAST MEDICAL HISTORY: Diabetes mellitus, diagnosed 10 to 15
years ago, now causing chronic renal failure. Paroxysmal
atrial fibrillation, diagnosed in [**2177**]. Hypertension.
Hypercholesterolemia.
FAMILY HISTORY: Father and mother with coronary artery
disease and cerebrovascular accident in their 40's and 50's.
Father with alcohol problem. Mother with diabetes. Cousin
with stroke in the 40's.
SOCIAL HISTORY: He is a part owner of a paper mill and is
married to his wife, who is the health care proxy. [**Name (NI) **] denies
any tobacco or alcohol use.
MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL TO [**Hospital1 18**]:
Zestril 10 mg p.o. q. day.
Aspirin 81 mg p.o. q. day.
Glucophage 500 mg p.o. twice a day.
Lasix 120 mg p.o. q. day.
Amiodarone 200 mg p.o. q. day.
K-Dur 200 mg p.o. q. day.
Lovenox 160 mg subcutaneous twice a day.
Florinef 0.1 mg q. day.
Lopressor 25 mg p.o. twice a day.
Glucotrol XL 10 mg p.o. twice a day.
MEDICATIONS ON TRANSFER FROM THE UNIT TO THE MEDICAL FLOOR:
Insulin subcutaneous.
Amiodarone 200 mg p.o. q. day.
Protonic 40 mg p.o. q. 24 hours.
Calcium acetate 1,334 mg p.o. three times a day with meals.
Prednisone taper.
Oxycodone 5 to 10 mg p.o. q. four to six hours prn.
Ambien 5 to 10 mg p.o. q h.s. prn.
ALLERGIES:
Tylenol which causes confusion.
PHYSICAL EXAMINATION: Upon transfer from the unit to the
medical floor, physical examination revealed the following:
Blood pressure 163/79; heart rate of 93; respiratory rate of
13; oxygenation 98% on room air; temperature 98. General:
This is a pleasant, obese male, in no acute distress. HEAD,
EYES, EARS, NOSE AND THROAT: No carotid bruits are heard
bilaterally. Mucous membranes are moist. Cardiovascular:
Regular rate and rhythm, normal S1 and S2. Possible
premature beats. Systolic murmur auscultated in the right
sternal border. Lungs are clear to auscultation bilaterally.
Neurologic: The patient was awake and alert on the medical
floor. He was cooperative. Examination was normal affect.
He was oriented to person, place and date. He is quite
attentive and can spell the word "world" backwards. His
memory is two out of three words at five minutes. His
language is fluent. He has good comprehension. Naming is
intact. Fund of knowledge is normal. No apraxia or neglect
noted. Cranial nerve examination: Pupils are equal, round,
and reactive to light and accommodation. 3 to two mms
bilaterally. Extraocular movements intact with movement
normal bilaterally. Hearing is intact to finger rub
bilaterally. Tongue is midline without fasciculations.
Visual fields are full to confrontation. Sternocleidomastoid
and trapezius are normal bilaterally. Motor examination:
Normal bulk and tone bilaterally. No tremors noted. On
strength, he is [**6-14**] in the upper extremities; however, in the
lower extremities, his iliopsoas was [**5-15**] bilaterally. His
quadriceps were 4+ on the right and unable to be tested on
the left. His hamstrings were strong on the right at 5/5 but
his left hamstring could not be tested. Ankle flexors and
extensors were [**5-15**] bilaterally. His lower extremity
examination was quite limited by his gout and left thigh
hematoma. No pronator drift was noted. No sensory
examination, he is intact to light touch, pinprick, cold
temperature and vibration at the left lower leg below the
knee. His proprioception appears to be intact bilaterally.
His reflexes are [**3-16**] in the biceps, triceps, brachioradialis,
patellar and plantar bilaterally. His grasp and reflex is
absent. His right toe is downgoing and his left toe has no
response. On coordination examination, he has diminished
finger to nose to finger and rapid alternating movements on
the left. His heel to shin could not be tested due to his
lower extremity pain. His gait was not accessed, as he is
unable to walk at this point.
LABORATORY STUDIES: Upon transfer, white count was 10.9;
hematocrit of 30.5; platelets 339; PT 13.5; PTT 28.4; INR of
1.2. Sodium of 137; potassium 5; chloride 105; bicarbonate
20; BUN 66; creatinine 5.9; glucose 165; calcium 8.7;
phosphate of 5.7; magnesium of 1.7; factor 10-A less than .1.
Magnetic resonance scan shows hyper perfusion type water
shed, infarct on the right parietal cortex and sub cortex.
CT shows no progression of the large hematoma on his ankle.
His left ankle x-ray was normal.
HOSPITAL COURSE: Neurology: Watershed infarct. After
intravenous fluid and packed red blood cell transfusion, the
patient no longer became orthostatic. Once his blood
pressure was able to be stabilized with position change, he
no longer felt any neurologic symptoms. On discharge, he was
able to gain full strength, [**6-14**] in the upper extremity. He
was even able to ambulate with a walker. He, however, still
has a sensory loss in the left lower extremity, below his
knee, likely secondary to the hematoma and edema. Since the
factor 10-A level is less than .1, indicating that the
Lovenox was coming out of his system, he was started on
intravenous heparin and Coumadin. His INR didn't reach a
therapeutic level of greater than two so the intravenous
heparin was discontinued. During his neurologic recovery,
his blood pressure was maintained below 120 to 140 and sugars
were attempted to be under 200.
Given that the patient was found to have a right internal
carotid artery stenosis, carotid endarterectomy is
recommended; however, he is to continue on his Coumadin at
this time and consider surgery in the future when his renal
function has been stabilized.
Cardiovascular: Atrial fibrillation. The patient's
cardiologist, Dr. [**Last Name (STitle) **], was contact[**Name (NI) **] to see whether the
patient would be a candidate for cardioversion; however, he
recommended that the patient continue on Amiodarone for
rhythm and rate control for his atrial fibrillation. He also
recommended that the patient be on life time anticoagulation
given that he suffered a stroke while in atrial fibrillation.
Therefore, the Coumadin was started.
Renal: Acute on chronic renal failure. The patient's
creatinine slowly fell down to a creatinine of three, which
is very close to his baseline of 2.2. He is to avoid all
nephro-toxic drugs including the Metformin that he was taking
for his diabetes. According to the [**Last Name (un) 3208**] endocrinology
consult, he is not to go back on any of his oral glycemic
medications until his creatinine falls down to 1.5.
Musculoskeletal: Left leg hematoma. The left leg hematoma
did become stable and caused no further orthostatic
hypotension.
Rheumatology: Gout. The patient had completed a one week
Prednisone taper, which had started at 20 mg for gout.
However, he continues to suffer gout flare in his right ankle
and toes. Nephrology recommended that he avoid Allopurinol
and Colchicine given his tenuous renal function. We then
restarted the Prednisone taper at 20 mg over one week again
for his gout. It seems to control his gout flare at this
time.
Endocrine: Diabetes. [**Last Name (un) 3208**] endocrinology consult was
following while the patient was in the hospital. He was
switched over to a Glargine 14 units at bedtime along with an
insulin sliding scale. Again, he is not to go back on any
oral glycemic medications until his creatinine falls down to
1.5.
DISCHARGE DIAGNOSES:
Right sided parietal water shed infarction.
Right carotid stenosis.
Left thigh hematoma.
Acute on chronic renal failure secondary to hypovolemia.
Paroxysmal atrial fibrillation.
Gout.
Diabetes mellitus.
DISCHARGE MEDICATIONS:
Amiodarone 200 mg p.o. q. day.
Wolfram 2.5 mg p.o. q h.s.
Ambien 5 mg p.o. q h.s. prn.
Protonic 40 mg p.o. q. day.
Calcium acetate 667 mg two tablets with each meal.
Oxycodone 5 mg p.o. every four to six hours prn for pain.
Colace 100 mg p.o. twice a day.
Dulcolax 5 mg p.o. q. day.
Prednisone 10 mg p.o. q. day times two days and then 5 mg
p.o. q. day times two days.
Lisinopril 20 mg p.o. q. day.
Lentis 12 units subcutaneous q h.s.
Regular insulin sliding scale as follows: 5 units of regular
insulin for sugars of 161 to 200; 7 units for sugars of 201
to 250; 9 units for sugars of 251 to 300. If sugar is
greater than 300, take 11 units.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation.
FOLLOW-UP: The patient is to follow-up with his primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**], on [**2179-9-29**].
He is to follow-up with his [**Last Name (un) 3208**] nephrologist in two weeks
after discharge from the rehabilitation.
The patient is to follow-up with Dr. [**Last Name (STitle) 24735**] [**Name (STitle) 24736**] in the
stroke clinic in one month.
The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
cardiology on [**2179-12-29**].
DR.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 13-303
Dictated By:[**Doctor Last Name 24737**]
MEDQUIST36
D: [**2179-9-21**] 06:50
T: [**2179-9-21**] 05:58
JOB#: [**Job Number 24738**]
|
[
"584.9",
"427.31",
"782.7",
"250.00",
"403.91",
"E934.2",
"276.5",
"285.1",
"433.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11916, 12771
|
3897, 4083
|
11021, 11225
|
11248, 11894
|
8069, 11000
|
5005, 8051
|
155, 3677
|
3700, 3880
|
4100, 4982
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
853
| 160,617
|
30727+57715
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-5-4**] Discharge Date: [**2146-5-16**]
Date of Birth: [**2127-2-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2146-5-4**]: ORIF Left tibia with 4 compartment fasciotomies
[**2146-5-6**]: ORIF left posterior wall acetablar and closure of
fasciotomies.
History of Present Illness:
Mr. [**Known lastname 72800**] is a 19 year old who was involved in a single car
accident on [**2146-5-4**]. He stated that he felt dizzy, was
unlocking his seatbelt and lost control of his car. He hit a
guardrail and was ejected from the car. He was taken to [**Hospital 8641**]
Hospital for evaluation and then taken by [**Location (un) 86**] [**Location (un) **] to
[**Hospital1 18**] for evaluation.
Past Medical History:
migraines
Social History:
Lives with Parents in school
Family History:
Stable
Physical Exam:
Upon admission
Alert/oriented
Cardiac: SVT but hemodynamically stable
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: Left hip posterior dislocation, pain with ROM,
Lower leg swollen tense pressure 73, sensation intact, +
movement
Brief Hospital Course:
Mr. [**Known lastname 72800**] presented to the [**Hospital1 18**] via [**Location (un) **] transfer. He
was evaluated in the trauma bay by the orthopaedic and trauma
surgical teams. He was noted to be in SVT by remianed
hemodynamically stable. He was taken to the operating room for
left compartment syndromes and he underwent fasciotomies and an
left tibia nail. He tolerated the procedure well, was extubated
and transferred to the trauma ICU. In the ICU he remianed
stable. Cardiology was consulted for the SVT episodies. He was
transferred to the floor on [**2146-5-5**]. On [**2146-5-6**] he was again
taken to the operating room. He underwent a posterior wall
acetabular fracture ORIF and closure for the left tibia
fasciotomies. Also in the operating room he under went an ECHO
per cardiology, which was essentially normal. On [**2146-5-9**] a CTA
was done because of concern for a PE because of transient
hypoxia. The CTA findings were consistent with fat emboli.
Medicine was consulted and they recommended supportive
management. On [**2146-5-10**] he was transfused with 2 units of packed
red blood cells due to post operative anemia. today, 6/8/7, his
hct is 25.4.
The remainder of his hospital course was without incident. His
pain was well controlled. His labs and vitals remained stable.
He is being discharged today in stable condition.
Medications on Admission:
fioricet
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever/pain.
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
s/p MVC
Left tibia fracture
Compartment syndrome
Left posterior wall acetabular fracture
Post-operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be touchdown weight bearing with posterior hip
dilocation precautions.
Continue your lovenox as instructed
Keep your incisions clean and dry
Your sutures/staples can come out 14 days after your surgery or
at your follow up appointment.
If you notice any increased redness, driange, or swelling, or if
you have a temperature greater than 101.5 please call the office
or come to the emergency department.
Physical Therapy:
Activity: As tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing
Treatments Frequency:
Sutures/Staples can be removed 14 days after surgery or at your
follow up appointment
You may apply a dry sterile dressing daily of as needed for
comfort or drainage
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] in 2 weeks, please call
[**Telephone/Fax (1) 1228**] to schedule that appointment.
Please follow up with your primary care physcian for a stress
test as per cardiology.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2146-5-13**] Name: [**Known lastname 12118**],[**Known firstname **] Unit No: [**Numeric Identifier 12119**]
Admission Date: [**2146-5-4**] Discharge Date: [**2146-5-16**]
Date of Birth: [**2127-2-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7332**]
Addendum:
Mr. [**Known lastname **] was not discharged on [**2146-5-13**] as he was not offered
a bed. His weekend was uneventful. On [**2146-5-16**] his sutures were
removed. He is being discharged today in stable condition.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 4415**]
[**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern1) 7334**] MD, [**MD Number(3) 7335**]
Completed by:[**2146-5-16**]
|
[
"788.20",
"808.0",
"958.1",
"427.89",
"E816.0",
"286.6",
"958.92",
"808.2",
"823.20",
"287.5",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.39",
"83.14",
"79.36",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5223, 5458
|
1281, 2651
|
284, 432
|
3443, 3452
|
4245, 5200
|
963, 971
|
2710, 3195
|
3309, 3422
|
2677, 2687
|
3476, 3895
|
986, 1258
|
3913, 4032
|
4054, 4222
|
237, 246
|
460, 868
|
890, 901
|
917, 947
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,301
| 119,072
|
48499
|
Discharge summary
|
report
|
Admission Date: [**2109-12-2**] Discharge Date: [**2109-12-7**]
Date of Birth: [**2037-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72M h/o CHF (EF 20%), EtOH abuse, CRI s/p renal artery stent,
AAA repair, clean cath [**2106**], lost to follow-up [**2108**] with med
non-compliance x 1 year presents with acute onset SOB at 6pm
[**2109-12-2**] in the setting of chronically worsening DOE x 6 months.
.
One year ago he states that he ran out of meds and did not
schedule a follow-up appointment. At baseline he is not active
but claims he can climb 1 flight stairs without stopping. 1
pillow orthopnea and denies PND or ankle edema. Does not follow
Na-restricted diet.
.
The evening of admission he was having a heated discussion with
his wife regarding his medical conditions when he became
'stressed' and acutely SOB. Called EMS who found SaO2 84% on
room air, RR 40, HR 130's, SBP 170's. Denies CP or palpitations
but was noted to be cool, pale, and diaphoretic with bilateral
crackles on lung exam. Put on NRB and given nitro sl x 2. On
arrival to the ED, SaO2 90% on 100% NRB, SBP 170's, and ECG with
SVT 180's. Given lopressor 5mg IV x 1 and HR decreased to 100's.
Repeat ECG revealed likely atrial tachycardia with frequent
PAC's. Given 40mg IV lasix, combivent nebs, lopressor 25mg po,
levalbuterol, and nitro gtt with SBP decrease to 91/58. ABG was
7.19/72/175 and he was started on BiPAP. Repeat ABG 7.36/39/134.
Admitted to CCU for further management.
.
No palpitations, lightheadedness, syncope, or claudication.
Reports [**2113-1-28**] stable exertional chest pain x 6 months. 20 pound
weight gain over the past 3 years.
Past Medical History:
CHF (EF 20%)
EtOH abuse
AAA graft c/b left renal artery obstruction s/p stent ([**2106**])
CRI (baseline Cre 1.5-1.7)
remote h/o PD due to carbon tetrachloride poisoning
Social History:
Married, lives in 3 story house. Retired engineer. Quit tobacco
and EtOH in [**2106**]. 70 pack-year smoking history. h/o heavy EtOH
abuse x 20 years. No illicits.
Family History:
Father with CAD s/p CABG
Physical Exam:
T 95.7 HR 91 BP 128/77 RR 18 SaO2 100% on BiPAP
General: WDWN, pleasant, mild respiratory distress, +BiPAP
HEENT: PERRL, EOMi, anicteric, OP clear
Neck: supple, trachea midline, no masses, no LAD, no carotid
bruits
Cardiac: irregular, s1s2 normal, no m/r/g, unable to assess JVP
Pulmonary: b/l crackles lower 1/3rd lung fields, no wheezes
Abdomen: +BS, soft, obese, nontender, no HSM
Extremities: cool, 1+ DP and PT pulses, no edema, no femoral
bruits
Neuro: A&Ox3, speech clear, moves all extremities
Pertinent Results:
Hematology:
[**2109-12-2**] 07:50PM BLOOD WBC-17.9* RBC-4.75 Hgb-14.6 Hct-42.4#
MCV-89 MCH-30.8 MCHC-34.5 RDW-16.2* Plt Ct-309
[**2109-12-6**] 06:20AM BLOOD WBC-10.0 RBC-4.31* Hgb-13.1* Hct-38.0*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.0* Plt Ct-206
[**2109-12-2**] 07:50PM BLOOD PT-12.1 PTT-22.9 INR(PT)-1.0
[**2109-12-6**] 06:20AM BLOOD PT-12.3 PTT-26.3 INR(PT)-1.1
[**2109-12-6**] 06:20AM BLOOD Plt Ct-206
.
Chemistry:
[**2109-12-2**] 07:50PM BLOOD Glucose-206* UreaN-22* Creat-1.5* Na-139
K-4.2 Cl-102 HCO3-24 AnGap-17
[**2109-12-6**] 06:20AM BLOOD Glucose-89 UreaN-44* Creat-1.8* Na-140
K-4.0 Cl-99 HCO3-29 AnGap-16
[**2109-12-2**] 07:50PM BLOOD ALT-13 AST-19 CK(CPK)-63 AlkPhos-117
TotBili-0.5
[**2109-12-3**] 04:57AM BLOOD CK(CPK)-83
[**2109-12-2**] 07:50PM BLOOD Lipase-80*
[**2109-12-2**] 07:50PM BLOOD CK-MB-NotDone
[**2109-12-2**] 07:50PM BLOOD cTropnT-<0.01
[**2109-12-3**] 04:57AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2109-12-2**] 07:50PM BLOOD Albumin-4.2 Calcium-9.0 Phos-5.3* Mg-2.0
[**2109-12-3**] 04:57AM BLOOD %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE
[**2109-12-3**] 04:57AM BLOOD Triglyc-93 HDL-34 CHOL/HD-4.6 LDLcalc-105
[**2109-12-2**] 08:07PM BLOOD Type-ART pO2-175* pCO2-72* pH-7.13*
[**2109-12-2**] 10:36PM BLOOD Type-ART pO2-134* pCO2-39 pH-7.36
[**2109-12-2**] 09:02PM BLOOD Lactate-2.0
.
ECG ([**2109-12-2**]): atrial tachycardia, 107 bpm, freq PAC's, PR
interval 200ms, Q's III/AVf, PRWP, no ST or T changes; similar
to [**11-29**] ECG
.
CXR, portable ([**2109-12-2**]): Mild/moderate interstitial and alveolar
pulmonary edema.
.
TTE ([**2109-12-3**]):
EF 20%. The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed. Right ventricular chamber size
and free wall motion are normal. The aortic root is moderately
dilated. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The mitral regurgitation jet
is eccentric. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2105-12-23**],
left ventricular systolic function appears similar. Mitral
regurgitation is now more prominent. Estimated pulmonary artery
systolic pressure is now higher.
.
Prior studies -
.
Cath ([**3-1**]):
COMMENTS:
1. Selective coronary arteriography of this right dominant
system revealed evidence of mild coronary artery disease.The
left main coronary artery was free of stenosis. The LAD and the
circunflex system had no angiographic evidence of flow limiting
lesions.The right coronary artery had a proximal 20% stenosis
followed by a 40% distal flow limitation. The left main coronary
artery was engaged with a JL5 catheter.
2.Left ventriculogram revealed no significant mitral
regurgitation.
There was evidence of severe left ventricular dyfunstion with
global
hypokinesis and a calculated ejection fraction of 20%.
3. Resting hemodynamics showed elevated left heart filling
pressure with a mean end-diastolic filling pressure of 28mmHg.
There was evidence of mild pulmonary hypertension with mean PAP
of 30mmHg.
4.Aortogram revealed a desdending infrarenal aneurysm measuring
5cm in diameter.
FINAL DIAGNOSIS:
1. Angiographic evidence of mild coronary artery disease.
2. Severe global systolic and distolic dysfunction.
3. Infrarenal aortic aneursym.
4. Mild pulmonary hypertension.
.
TTE ([**11-28**]):
EF 20%. The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is severe global left
ventricular hypokinesis. Right ventricular chamber size is
normal. Right ventricular systolic function appears depressed.
The aortic root is moderately dilated. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
72M h/o CHF (EF 20%), EtOH abuse, CRI s/p renal artery stent,
AAA repair, med non-compliance with chronically worsening DOE x
6 months presented with acute onset SOB and SVT.
.
# Dyspnea: likely due to acute-on-chronic CHF exacerbation in
setting of med and dietary non-compliance followed by poorly
compensated rapid SVT leading to flash pulm edema. improved on
BiPAP, eventually weaned to off supplemental oxygen with
diuresis and rate-control.
.
# SVT: likely atrial tachycardia per EP consult. initially
rate-controlled with IV metoprolol. pt had one brief
asymptomatic 3 min episode atrial tach 2 days prior to
discharge. no further episodes on telemetry. rate controlled
with metoprolol, switched to toprol XL prior to discharge. EP
suggests first optimizing CHF management and then considering EP
study if further episodes. he was discharged with an oupatient
event monitor and EP follow-up.
.
# CHF: EF 20%. likely etiology is EtOH; unlikely ischemia prior
clean cath. extremely volume overloaded at presentation
triggered by med and diet noncompliance. responded well to
diuresis with IV lasix. dry weight approximately 200 lbs.
nutrition consult was performed for low-Na dietary teaching.
social work consult for treatment compliance. discharged on
lasix, beta blocker, and ACEi. consider adding [**Male First Name (un) 2083**] antagonist
as outpatient. may also benefit from ICD given low EF.
.
# CAD: no flow limiting lesions on cath [**2106**]. complains of
stable exertional angina x months in setting of likely worsening
CHF. cardiac enzymes negative x 2. started on ASA 81mg qd.
fasting lipid panel well-controlled. consider outpatient stress
test if angina persists after CHF optimized.
.
# CRI: [**2-28**] renal artery obstruction from AAA graft s/p stent.
baseline Cre 1.5-1.7. Cre 1.8 at discharge in setting of
starting ACEi and aggressive diuresis.
.
# ?DM2: no prior diagnosis but initial random blood sugar >200
so concern for undiagnosed condition; however fasting <100 the
following day so the patient is not diabetic. HgbA1c 5.8%.
discontinued FSBG qid and HISS.
.
# Leukocytosis: unclear etiology, may be reactive [**2-28**] recent
stress. no infiltrate on CXR and U/A negative. no other
localizing signs infection. remained afebrile and WBC count
resolved.
.
# COPD: no documented PFTs but long smoking history. combivent
nebs prn. discharged on atrovent prn. consider outpatient PFTs.
.
# EtOH abuse: last drink reported [**2106**]. no signs EtOH
withdrawal.
.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Lasix 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnoses
1)Congestive heart failure exacerbation
2)Supraventricular tachycardia
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications as prescribed.
2)2gm sodium diet; fluid restriction
3)Measure weights daily, call your doctor if increase > 3 pounds
4)You are being started on several new medications: Aspirin,
Toprol XL, Lisinopril, and Lasix
5)You will be discharged home with a heart monitor, which you
will be instructed to use.
6)Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
1)Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your new PCP, [**Name10 (NameIs) **] [**Hospital1 18**]
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Bldg. [**Telephone/Fax (1) 250**] Wed [**2110-1-29**] 8:30 am.
2) Please call [**Telephone/Fax (1) 250**], to schedule an appointment with any
primary care physician at [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital Ward Name 23**], within [**1-28**]
weeks of leaving the hospital today.
3)Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2109-12-30**] 1:00. Dr. [**First Name (STitle) 437**] is a cardiologist that
specializes in heart failure.
4)Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2110-1-29**] at
2:00 pm. Dr. [**Last Name (STitle) **] is a cardiologist that specializes in
heart rhythms.
5)Please make a follow up appointment with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 7236**] upon discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"414.01",
"413.9",
"428.0",
"427.0",
"496",
"425.5",
"585.9",
"584.9",
"518.81",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10413, 10471
|
7204, 9696
|
334, 341
|
10604, 10613
|
2828, 6316
|
11192, 12451
|
2264, 2290
|
9751, 10390
|
10492, 10583
|
9722, 9728
|
6333, 7181
|
10637, 11169
|
2305, 2809
|
275, 296
|
369, 1873
|
1895, 2067
|
2083, 2248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,599
| 198,476
|
26424
|
Discharge summary
|
report
|
Admission Date: [**2183-8-19**] Discharge Date: [**2183-9-5**]
Date of Birth: [**2111-6-19**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Rifampin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Vertigo, nausea, vomiting, headache
Major Surgical or Invasive Procedure:
Bilateral suboccipital craniectomy, Microscopic resection of
cerebellar metastasis with left-sided removal of cerebellar
tonsil and right-sided partial cerebellar tonsil removal,
Pericranial duraplasty, Right-sided high frontal EVD placement
[**2183-8-22**]
Esophagogastroduodenoscopy and PEG placement [**2183-9-3**]
History of Present Illness:
This is a 72 yo M with a 128 pack year history of smoking who
presents with new headache and vomiting. Patient states that he
has had a headache at the back of his head for the last week. He
states that the headache is continuous and is not associated
with a particular time of day. He states that he has been
vomiting for the last week. His nausea comes and goes. He also
reports one day of dry heaves. The patient states that he has
had a cough for a long time, predating these symptoms, and that
he produces clear phlegm. The patient has had dizziness ever
since his fall and subsequent neurosurgeries in [**2181**]. He also
notes a 90lb weight loss in the last year. Pt initially
presented to [**Hospital3 15286**] for work-up of his symptoms and
was found to have a left 3cm cerebellar mass, edema, and mild
hydrocephalus on imaging. Mr. [**Known lastname 65215**] was transferred to [**Hospital1 18**]
for further work-up of this mass.
Past Medical History:
1. MDR E. Coli and Pseudomonal Catheter Associated Sepsis/UTI
2. Acute Renal Failure.
3. Urinary Retention.
4. Meatal Tear.
5. Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**]
6. ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**]
7. CSF Leak - Wound infection s/p drainage and dural repair
[**2182-2-9**]
8. Incision and drainage and hardware exchange [**2181-2-12**]
9. MRSA Meningitis/MRSA Pneumonia
10. Diastolic Heart Failure.
11. Non-ST Elevation Myocardial Infarction
12. Coronary Artery Disease s/p CABG x 3
13. Left Occipital Stroke vs MRSA Cerebritis
14. Pulmonary Embolism/RLE DVT - Provoked
15. Non-Sustained Ventricular Tachycardia
16. Hypersensitivity Desquamative Dermatitis (Rifampin vs
Vancomycin)
17. BUE Paresis - mild, BLE paresis L>R.
18. GI Bleed.
19. Nosocomial LLL Pneumonia
20. Anemia - multifactorial: Illness, blood loss, CKD.
21. Stage III Sacral Ulcer.
22. MRSA/VRE Colonization
23. Candidemia
24. Pseudomonal line sepsis.
25. Diabetes Mellitus Type II.
26. Hypertension
27. Hypercholesterolemia
28. L3-L4 Fusion
29. BPH
30. Chronic Kidney Disease Stage III with Proteinuria (baseline
cr
Social History:
Former tobacco use - quit 26 yrs ago, did smoke 4 ppd x 32 yrs
Alcohol - quit 26 yrs ago
Married, 2 daughters, 3 grandchildren
Chares multi-family home with daughter
Retired [**Name2 (NI) 29798**]
Family History:
Sister died of cancer.
2 brothers and father died of MI.
Physical Exam:
VS: 97.8 47 137/57 16 97% 2L
Gen: comfortable, pleasant, NAD
HEENT: pupils: 2.5-->1.5mm bilaterally, EOMI
Neck: supple
Lungs: CTAB
CV: RRR, nl S1 and S2
Abd: +BS, S/ND/NT
Ext: warm and well-perfused
Neuro:
MS: Awake and alert, cooperative with exam, normal affect
Orientation: Oriented to person, place, and date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial nerves:
I: not tested
II: PERRL, visual fields full to confrontation
III, IV, VI: EOMI bilaterally without nystagmus
V, VII: facial strength and sensation intact and symmetric
VIII:hearing intact to voice
IX, X: palatal elevation symmetrical
[**Doctor First Name 81**]: sternocleidomastoid and trapezius normal bilaterally
XII: tongue midline without fasciculations
Motor: Decreased muscle tone LLE. No abnormal movements or
tremors. No pronator drift.
D B T Gr IP Q H TA [**Last Name (un) 938**] GS
R 5 5 5 5 5 5 5 2 5 4+
L 5 5 5 5 4 5 5 2 4- 4+
Sensation: Intact to light touch bilaterally.
Toes down-going bilaterally.
Coordination: normal on FNF, rapid alternating movements, heel
to shin.
Pertinent Results:
[**2183-8-20**] 12:42AM BLOOD WBC-8.8# RBC-4.07* Hgb-11.8* Hct-35.0*
MCV-86 MCH-28.9 MCHC-33.6 RDW-14.5 Plt Ct-121*
[**2183-8-20**] 12:42AM BLOOD Neuts-81.6* Bands-0 Lymphs-13.5*
Monos-1.6* Eos-3.2 Baso-0.2
[**2183-8-20**] 12:42AM BLOOD PT-13.6* PTT-35.5* INR(PT)-1.2*
[**2183-8-20**] 12:42AM BLOOD Glucose-172* UreaN-24* Creat-1.6* Na-139
K-4.4 Cl-106 HCO3-25 AnGap-12
[**2183-9-2**] 08:20AM BLOOD ALT-10 AST-13 LD(LDH)-184 AlkPhos-70
Amylase-42 TotBili-0.8
[**2183-9-2**] 08:20AM BLOOD Lipase-19
[**2183-8-20**] 12:42AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.7
[**2183-9-2**] 08:20AM BLOOD calTIBC-170* VitB12-866 Folate-GREATER TH
Ferritn-364 TRF-131*
[**2183-8-29**] 02:56AM BLOOD Phenyto-<0.6*
Studies:
[**2183-8-20**] Head CT w/o contrast: IMPRESSION: 2.5 cm left cerebellar
mass with somewhat hypodense appearance, with vasogenic edema
and mass effect to the fourth ventricle, new since prior study.
The finding is suspicious for either metastasis or primary tumor
of the cerebellum.
[**2183-8-20**] Chest/Abd/Pelvis CT:
IMPRESSION:
1. Multiple new noncalcified pulmonary nodules since [**2182-4-15**]. Given the history of malignancy, these are highly
concerning for primary metastatic lesions.
2. Centrilobular emphysema with upper lobe predominance.
3. Well-defined 1.6 cm lesion in segment VII of the liver,
which appears
stable in size compared to [**2182-4-15**]. Additional 2-mm
hypoattenuating lesion in segment V is too small to
characterize.
4. Multiple hypoattenuating lesions in the left kidney too
small to
characterize.
5. Prominence of number of paraaortic lymph nodes which however
do not meet CT size criteria for pathologic enlargement.
6. Cortical defects involving the lateral aspects of both iliac
bones, this is of uncertain significance, possibly related to
prior bone donor sites or could be related to prior infection.
Please correlate clinically.
7. Degenerative changes of the lumbar spine most severe at
L5/S1 and DISH of the thoracic spine.
8. Penile implants.
[**2183-8-21**] Head MR:
IMPRESSION: A 3.1 x 2.9 x 2.8 cm enhancing well circumscribed
centrally
cavitating mass of the left cerebellum with minimal surrounding
T2
hyperintensity which is superficially located but appears to be
intraaxial. The differential includes lymphoma, metastasis, or
possibly hemangioblastoma. Given the minimal amount of
peritumoral edema despite the large size, lymphoma is favored.
[**2183-8-22**]: Cerebellar mass pathology:
DIAGNOSIS:
#1, CEREBELLAR MASS BIOPSY (including intraoperative smear and
frozen section): METASTATIC POORLY DIFFERENTIATED CARCINOMA with
PROMINENT NEUROENDOCRINE FEATURES.
#2, CEREBELLAR MASS RESECTION: METASTATIC POORLY DIFFERENTIATED
CARCINOMA with PROMINENT NEUROENDOCRINE FEATURES.
NOTE: The tumor is densely cellular and poorly differentiated.
The smear shows a nearly non-cohesive tumor composed of cells
with minimal to no discernable cytoplasm but with large nuclei
having a salt-and-pepper chromatin. Necrotic cells are
interspersed with viable one. Permanent sections reveal a
prominent organoid growth pattern. Tumor cells display molding.
Many organoid nodules have a necrotic center. This pattern of
growth and the cytology indicate the tumor is a
neuroendocrine-type metastatic carcinoma. The histology and the
chest CT finding of multiple pulmonary nodules are consistent
with a lung primary, although metastases to lung and brain from
another primary cannot be excluded. Confirmatory stains are
pending. The results will be issued in an addendum.
ADDENDUM: The tumor immunoreacts strongly with chromogranin,
CAM5.2, CK7, MNF-116, and TTF-1. It fail to react with CK7 and
synaptophysin. These results support the original diagnosis of a
metastatic poorly differentiated carcinoma with neuroendocrine
features, most likely from a lung primary.
[**2183-9-1**] CXR: New infiltrate in mid lung field suggestive of
aspiration
pneumonitis.
[**2183-9-2**] CXR: There is an increase in the left lower lobe
predominantly retrocardiac consolidation not fully imaged on the
current chest radiograph suggesting worsening of infection
and/or aspiration pneumonia. There is also increase in the right
middle lobe opacity obscuring the right heart border. Giving
the presence of the multiple pulmonary opacities during the
course over the last two weeks with their rapid development and
relatively rapid resolution they may represent recurrent
episodes of aspiration. Superimposed infection as was mentioned
cannot be excluded.
Brief Hospital Course:
Mr. [**Known lastname 65215**] is a 72M with multiple medical programs who presents
from an outside hospital with chief complaint of ataxia,
vertigo, nausea, and vomiting, and found to have a cerebellar
mass. His hospital course by problem is as follows:
# L cerebellar metastasis with presumed primary lung cancer:
On [**8-18**], the pt had been intermittently ataxic and was vomiting
at home. He was admitted to [**Hospital3 **], where CT head
showed cerebellar mass, and he was subsequently transferred to
[**Hospital1 18**] on [**8-19**] for further workup. At [**Hospital1 18**], he had CT body
performed, which showed multiple lesions in the lungs, liver,
kidney, bone (though the lesions in the liver, kidney, bone
cannot definitely be attributed to cancer). On [**8-22**], he underwent
resection of the 2.5 cm L cerebellar mass without neurologic
complication. Mass pathology showed metastatic poorly
differentiated carcinoma with prominent neuroendocrine features,
most likely from a lung primary. He was started on decadron to
minimize brain edema. Over the next week after surgery, his
nausea and vomiting was much improved, but he developed vocal
cord paralysis with subsequent aspiration pneumonia and PEG tube
placement (see below). In terms of his cancer, it was felt that
the patient could not being systemic therapy until he had
recovered from his surgery and until his infection had resolved.
Heme-onc recommended follow-up in the Thoracic Onc
multidisciplinary clinic as an outpatient, and he will also
receive follow-up in the Brain [**Hospital 341**] Clinic and with Dr.
[**Last Name (STitle) 3929**] in Rad Onc. This was discussed with his family on [**9-4**]
at a family meeting, and they are aware that the cancer cannot
be cured and are very supportive and cooperative. The pt will
continue oral decadron until he is seen by the brain tumor
clinic and further arrangements are made.
# Vocal cord paralysis/Pneumonia/Nutrition:
The pt has experienced vocal cord paralysis in the past as a
consequence of intubation, and the problem has resolved in [**1-18**]
weeks. Unfortunately he again developed vocal cord paralysis
after intubation for his neurosurgery on [**8-22**]. On [**9-1**], he
deveoped fever to 102.4, tachycardic to 130s, hypoxemic to 91%
sat on 70% shovel mask, SBP 120/60, and lethargy and confusion
per his daughters. After 30 [**Name2 (NI) **] of confusion, he regained normal
mental status again. He was found to have a UTI and PNA, likely
aspiration secondary to his vocal cord paralysis. He was
transfered to the MICU and started on Zosyn. ORL saw him and
recommended PPI [**Hospital1 **] and PEG placement for nutrition. The PEG was
placed on [**9-3**] without complications. On [**9-4**], the pt was stable
for transfer to the floor, as he was afebrile with normal WBC
and breathing comfortably on 0-2L O2. He received clears and
pills through his tube for the first 24 hrs, then started tube
feeds on [**9-5**] (started at 20 cc/hr, increase by 20cc q6 hrs to
goal of 80 cc/hr). He will continue his 2-week course of Zosyn
until [**9-14**] (started on [**9-1**]). On discharge, the pt was in good
condition for transfer to rehab, and had O2 sat of 96% on 2L. He
will follow up with ORL as an outpatient.
# UTI:
Pt found to have a UTI on [**9-1**] (as mentioned above) while foley
was in place. Pt prefered foley as he had a history of urinary
retention, but agreed to d/c on [**9-5**]. He was treated with Zosyn.
# DM2:
Pt is controlled with oral hypoglycemics at home. In the setting
of decadron use, he briefly needed insulin gtt for
hyperglycemia, but was weaned from this on [**9-3**]. He was
transfered to the floor on NPH plus humalog sliding scale, [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recs. He will likely need to continue insulin while on
decadron as an outpatient.
# Hypertension:
Pt's BPs have been under control on this admission, so he has
not been placed on his home antihypertensives. This will need to
be monitored at rehab, as he will likely need to be restarted on
his BP meds in the future.
# Anemia:
Hct on this admission has been 29-35, similar to or slightly
improved from his baseline. This is likely secondary to chronic
disease given his Fe studies and normal B12 and folate levels.
Hct was stable on this admission, no transfusion was necessary.
# Renal failure:
Pt has a history of acute renal failure. Cr ranged from 1.1-1.9,
with baseline apparently 0.7-1.1 (though difficult to determine
from record given numerous episodes of acute renal failure).
This was felt to be of prerenal etiology. On discharge, Cr was
mildly elevated to 1.3, likely because the pt had recently been
NPO with vocal cord paralysis and had only just had PEG tube
placed. We expect this to resolve at rehab as he begins tube
feeds. Recommend adequate hydration.
Medications on Admission:
Cimetidine 400mg [**Hospital1 **]
Finasteride 5mg daily
Aspirin 81mg daily
Simvastatin 20mg daily
Doxycycline 100mg [**Hospital1 **]
Folic acid 1mg daily
Glipizide EA 2.5mg daily
Magnesium oxide 400mg daily
Metoprolol 12.5mg [**Hospital1 **]
Ursodiol 300mg [**Hospital1 **]
Flomax 0.4mg qHS
Discharge Medications:
1. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-21**]
hours as needed for pain. Tablet(s)
4. Morphine 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every
4 hours) as needed for pain: Please give only if oral pain meds
do not work.
5. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 10 days: Please
continue until finished with 2-week course on [**2183-9-14**].
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qAM: Please give with breakfast.
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous qPM: Please give with dinner.
8. Insulin Lispro 100 unit/mL Solution Sig: 1-20 units
Subcutaneous three times a day: Please give with meals according
to sliding scale.
9. Cimetidine 400 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Lung cancer with metastasis to the cerebellum
Pneumonia
Urinary tract infection
Secondary:
Hypertension
Anemia
Diabetes Mellitus II
History of MRSA infection
Discharge Condition:
Good.
Discharge Instructions:
You were admitted for difficulty walking (called ataxia) and
vomiting. It was found that you have a mass in your cerebellum
that was cancer, which likely started in your lung. The mass in
your cerebellum was removed successfully, though unfortunately
you developed vocal cord paralysis from intubation. Because of
this paralysis, you likely aspirated which caused you to develop
a pneumonia. This pneumonia, plus a urinary tract infection,
caused you to develop high fevers, so you were transfered to the
intensive care unit. There, you were given antibiotics and you
recovered well. You were transfered to the medicine floor where
you continued to do well, and were sent to [**Hospital **] rehab in
good condition.
In terms of your medications, you will continue taking oral
decadron to decrease the swelling in your brain. You will stay
on this medication until you see the doctors at the [**Name5 (PTitle) **] [**Hospital 341**]
Clinic, when they may decide to change or stop this medication.
Also, you will continue to take the antibiotic Zosyn for your
pneumonia and urinary tract infection.
You will also continue to take insulin while you are on
decadron, as that medicine can increase your sugars.
Followup Instructions:
You have an appointment with an Ear, Nose, and Throat physician,
[**Last Name (NamePattern4) **]. [**First Name (STitle) **], on [**2183-9-10**] at 1:45PM at [**Location (un) **], [**Location (un) 16824**] ([**Telephone/Fax (1) 2349**]).
You have an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) 3929**] of Radiation
Oncology on [**2183-9-11**] at 11AM in the [**Hospital Ward Name 332**] Basement of the [**Hospital **]
Hospital ([**Telephone/Fax (1) 9710**]).
You have an appointment at the Brain [**Hospital 341**] Clinic on [**2183-9-15**] at
3PM on the [**Location (un) **] of the [**Hospital Ward Name 23**] building at the [**Hospital **] Hospital
([**Telephone/Fax (1) 1844**]).
You have an appointment at the Thoracic Oncology
[**Hospital 32535**] Clinic ([**0-0-**]) on [**2183-9-16**] at 10:30AM on
[**Hospital Ward Name 23**] bldg [**Location (un) **], Reception area A at the [**Hospital **] Hospital.
You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2455**]
([**Telephone/Fax (1) 38490**]) on [**2183-9-17**] at 11:40AM at [**Hospital1 3494**] Internal
Medicine Associates.
|
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4,916
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30317
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Discharge summary
|
report
|
Admission Date: [**2182-3-13**] [**Month/Day/Year **] Date: [**2182-3-26**]
Date of Birth: [**2109-11-29**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Hypotension
Acute abdomen
Major Surgical or Invasive Procedure:
Exploratory Lap, Sigmoid colectomy w/ Hartmann's procedure
History of Present Illness:
72 yo female who presented to the Emergency Room with
hypotension and
peritonitis. She had developed the acute onset of abdominal
pain on the morning of the day of admission. This was
preceded by 24 to 48 hours of vague nonspecific abdominal
pain. She had taken nothing by mouth for at least 24 hours
prior to admission. At the time of admission to the emergency
department, she appeared predominantly dehydrated with dry
mucous membranes. In the emergency department, a central
access was obtained, as well as a Foley catheter. She was
administered broad spectrum antibiotics. Immediately upon
surgical consultation, she was found to have an acutely tender
abdomen which was also distended. Her hemoglobin and hematocrit
were concentrated and her white count was elevated. Her coags
were within normal limits and it was decided at this time to
take her to the operating room with her consent, as well as the
consent of her family for an exploratory laparotomy.
Past Medical History:
Type II DM
CAD - s/p CABG
Family History:
Noncontributory
Pertinent Results:
[**2182-3-13**] 11:52PM GLUCOSE-145* UREA N-28* CREAT-1.4* SODIUM-143
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-18* ANION GAP-19
[**2182-3-13**] 11:52PM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-2.1
[**2182-3-13**] 11:52PM WBC-11.0 RBC-4.22 HGB-12.5 HCT-37.9 MCV-90
MCH-29.7 MCHC-33.0 RDW-15.3
[**2182-3-13**] 11:52PM PLT COUNT-427
[**2182-3-13**] 11:52PM PT-16.5* PTT-30.5 INR(PT)-1.5*
[**2182-3-13**] 11:52PM FIBRINOGE-511*
[**2182-3-13**] 07:53PM TYPE-ART PO2-112* PCO2-37 PH-7.33* TOTAL
CO2-20* BASE XS--5
[**2182-3-13**] 07:53PM LACTATE-4.4*
CT ABDOMEN W/O CONTRAST; CT ABDOMEN W/CONTRAST
Reason: r/o splenic or subphrenic abscess: IV contrast only
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman s/p diverticular perf s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with
elevate WBC and PLTs
REASON FOR THIS EXAMINATION:
r/o splenic or subphrenic abscess: IV contrast only
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: CT torso dated [**2182-3-25**].
COMPARISON: CT torso dated [**2182-3-19**].
INDICATION: 72-year-old female status post diverticular
perforation with Hartmann's pouch, elevated white blood cells.
Rule out splenic or subphrenic abscess.
TECHNIQUE: Axial imaging was obtained through the chest,
abdomen, and pelvis after the uneventful intravenous
administration of 130 cc of nonionic contrast. No oral contrast
was administered. In addition, coronal and sagittal reformats
were performed.
Direct comparison is made to CT of the torso dated [**2182-3-19**].
CT OF THE CHEST WITH IV CONTRAST: There is no mediastinal,
hilar, or axillary lymphadenopathy. There is coronary artery
calcification. There is no pericardial effusion. The right
pleural effusion is decreased in size along with decreased right
lower lobe atelectasis. There has been slight increase in size
in the left pleural effusion and left lower lobe atelectasis.
Since the prior examination, there has been interval improvement
in the biapical ground-glass opacities seen on prior exam.
CT ABDOMEN WITH IV CONTRAST: There is a midline abdominal
incision. The liver, spleen, pancreas, adrenal glands, and
kidneys are unremarkable. The gallbladder is collapsed. Again
seen is a small subhepatic fluid collection which is not
significantly changed since the prior examination. There is
unchanged perisplenic fluid. The bowel is normal in caliber.
Again seen is fat stranding of the mesentery consistent with
post-surgical changes. There is a colostomy in the left lower
quadrant. No drainable fluid collections are demonstrated. There
is unchanged fluid surrounding loops of small bowel in the left
lower quadrant. There is no free intraperitoneal gas or
lymphadenopathy.
FINDINGS FOR CT OF THE PELVIS: Again seen is air within the
bladder which may be secondary to Foley catheterization. The
uterus is unremarkable. There is redemonstration of a loculated
cystic lesion within the right adnexa further followup with
pelvic ultrasound is recommended given patient's age. Chain
staples are demonstrated in the region of the Hartmann's pouch.
No drainable fluid collections are demonstrated within the
pelvis. There is no lymphadenopathy.
BONE WINDOWS: Multilevel degenerative changes are demonstrated
at the spine. No suspicious lytic or blastic lesions are
demonstrated.
IMPRESSION:
1. Improving ground-glass opacities in the upper lobes since the
prior examination.
2. Decreased right pleural effusion and right lower lobe
atelectasis.
3. Increased left pleural effusion.
4. No drainable fluid collections within the abdomen or pelvis.
Overall, there is no significant change since the prior
examination.
5. Stable right adnexal cysts. As stressed on prior examination
given patient's age, followup with pelvic ultrasound is
recommended.
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2182-3-19**] 11:04 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: please eval for leak vs. abscess
Field of view: 44 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman s/p diverticular perf s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
REASON FOR THIS EXAMINATION:
please eval for leak vs. abscess
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 72-year-old woman status post diverticular
perforation and Hartmann's. Please evaluate for leak or abscess.
COMPARISON: Chest x-ray from one day prior.
TECHNIQUE: Multidetector CT scanning of the torso was performed
after oral and intravenous contrast. Coronal and sagittal
reformations were obtained.
CT OF THE CHEST: A right-sided PICC terminates at the cavoatrial
junction. Endotracheal tube tip terminates in the trachea. A
nasogastric tube is seen in the esophagus extending into the
stomach. There is a left subclavian central venous catheter with
its tip terminating in the left brachiocephalic vein.
No pericardial effusion is seen. There is coronary artery
calcification involving the right coronary and left anterior
descending coronary arteries. The great vessels appear
unremarkable apart from an atherosclerotic calcification of the
aortic arch and descending aorta. Multiple small lymph nodes are
seen in the paratracheal and prevascular regions. No pathologic
lymphadenopathy is appreciated.
The upper lobes demonstrate peripheral ground-glass opacities.
In the lower lobes, there is extensive atelectasis and small
bilateral pleural effusions.
CT OF THE ABDOMEN: The liver, gallbladder, adrenal glands,
spleen, pancreas, and kidneys appear unremarkable. There is a
moderate amount of ascites, with some of it appearing loculated,
for example posteromedially to the liver and anterior to the
spleen. The loops of small bowel are normal in caliber. There is
a large defect along the midline of the anterior abdominal wall
consistent with recent surgery. No foci of intraperitoneal air
are seen any longer. The abdominal aorta is of normal caliber,
without atherosclerotic calcifications. No drainable fluid
collections are seen. There is some fluid also seen at the root
of the mesentery, just anterior to the aortic bifurcation. There
is nonspecific mesenteric stranding. A left colostomy is seen.
Multiple left- sided colonic diverticula are seen. Multiple
small mesenteric lymph nodes are seen, the largest in the
periportal region measures 11 mm in short axis. Multiple small
retroperitoneal lymph nodes are also seen which do not meet
criteria for pathologic enlargement.
CT OF THE PELVIS: There is a large amount of nondependent air
within the bladder lumen as well as a Foley catheter. The uterus
appears unremarkable. There is a 2.5-cm thick-walled adnexal
cyst on the right, as well as smaller right ovarian cysts. The
rectosigmoid stump appears unremarkable. A suture line is
identified. There is some ascites fluid tracking into the
pelvis, surrounding loops of bowel. Just inferior to the
left-sided ostomy, there is subcutaneous fluid, likely
postoperative. Multiple small inguinal and pelvic lymph nodes do
not meet criteria for pathologic enlargement. There is
superficial subcutaneous edema.
OSSEOUS STRUCTURES: There is multilevel degenerative change of
the spine. No concerning lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Ground-glass opacity in the upper lobes of the lung could
represent asymmetric pulmonary edema or infection.
2. Bilateral moderate pleural effusions with associated lower
lobe atelectasis.
3. No drainable fluid collections in the abdomen or pelvis.
Postoperative changes as described above. Small amount of
ascites, some of which may be loculated posterior to the liver.
4. Right adnexal cysts. This is an abnormal finding in a woman
of this age, and followup pelvic ultrasound is recommended to
further evaluate.
Brief Hospital Course:
She was admitted to the Surgery Service under the care of Dr.
[**Last Name (STitle) **]. She was taken to the operating room for exploratory
laparotomy, sigmoid resection and [**Doctor Last Name 3379**] procedure. There
were no intraoperative complications. Postoperatively she
remained in the Surgical ICU for over 1 week; was placed on
Levo/Flagyl/Vanco and remained intubated for nearly her entire
ICU stay. A VAC dressing was placed at 125 mmHg and this remains
in place; the VAC dressing was changed on day of [**Doctor Last Name **].
Intermittently she ran high fevers with elevated white count;
she underwent repeat abdominal imaging to assess for any fluid
collections; none were identified. Her antibiotics have since
been discontinued and her white count has been trending
downward:
19.2* on [**3-26**]
20.7* on [**3-25**]
24.2* on [**3-24**]
22.2* on [**3-23**]
22.3* on [**3-22**]
25.1* on [**3-21**]
27.2* on [**3-20**]
28.7* on [**3-19**]
She was eventually extubated and transferred to the regular
nursing unit. She continues to require diuresis with Lasix given
that she is still fluid positive; her foley catheter remains in
place for accurate monitoring of her fluid status.
Wound care/ostomy nursing were consulted and followed her
throughout her stay for her skin and ostomy needs (See Ostomy
Note).
Nutrition services were also consulted given that her
nutritional status was [**Doctor Last Name 37282**] than optimal. Calorie counts were
initiated (Page 2 Nutrition). She was placed on diabetic free
shake supplements tid.
A Speech and Swallow bedside evaluation was done; it was
determined that she can have thin liquids, soft consistency diet
with supervision at meal time. Her pills can be given whole.
Physical and Occupational therapy were consulted and have
recommended acute care rehab stay.
Social work was also consulted given her recent acute
hospitalization and also for the recent loss of her husband
approximately 1 month ago.
She will require follow up with her primary care doctor for a
finding on pelvic CT where a right adnexal cyst was found.
Pelvic ultrasound is being recommended.
Medications on Admission:
Insulin
Metformin
Zoloft
Lopressor
Zetia
Tricor
[**Doctor Last Name **] Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical three
times a day: Apply to affected areas.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb rx
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold fro HR <60; SBP <110.
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. GlipiZIDE 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Oxycodone 5 mg Tablet Sig: [**12-18**] - 1 Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation.
18. Regular insulin siding scale Sig: One (1) dose four times
a day as needed for per sliding scale: See attached sliding
scale.
19. Lantus insulin Sig: Thirteen (13) Units at bedtime.
[**Month/Day (2) **] Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
[**Location (un) **] Diagnosis:
Perforated Diverticulitis
[**Location (un) **] Condition:
Stable
Followup Instructions:
Follow up with Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]., General Surgery, in 1
week. Telephone number [**Telephone/Fax (1) 600**] to schedule an appointment.
Location [**Hospital **] Medical Bldg, [**Last Name (NamePattern1) **]. [**Apartment Address(1) **] G, [**Location (un) 86**],
MA
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2182-3-26**]
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[]
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[
"96.72",
"46.13",
"38.93",
"96.6",
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icd9pcs
|
[
[
[]
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9278, 11411
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1507, 2188
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51,783
| 146,582
|
51321
|
Discharge summary
|
report
|
Admission Date: [**2194-9-17**] Discharge Date: [**2194-9-22**]
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Right thoracocentesis
Right Pleurex Catheter placement
History of Present Illness:
[**Age over 90 **]-year-old man with Afib and recurrent malignancy-related right
pleural effusion, awaiting pleurex catheter placement, who was
transferred from MICU s/p therapeutic R thoracentesis for
dyspnea. The patient's oncologic history is significant for
CLL/SLL, metastatic prostate cancer, and a lesion consistent
with renal cell carcinoma being followed by observation since
[**2191**]. Over the past year he has had multiple admissions, most
recently two weeks prior to admission, for recurrent right
pleural effusion thought to be malignancy related. He has had
multiple therapeutic thoracenteses, and he is scheduled for an
[**9-19**] Pleurex catheter placement.
.
He presented to the [**Hospital1 18**] ED on [**9-17**] with dyspnea. His initial
vitals were T 97.6 P 96 BP 122/54 R 24 and O2 sat 87% on RA.
CXR showed large R pleural effusion and new mild pulmonary
edema. He was placed on a nonrebreather and O2 sat increased to
100%. He was eventually weaned to 4 L NC, breathing comfortably
and able to speak in full sentences, and was transferred to the
ICU for monitoring. In the ICU ABG was performed:
7.53/37/63/32. He was given lasix 40 mg at 1530 but only
produced 750 cc of UOP so 80 mg was given again at 10 pm to meet
1 L/day goal, producing another 450 cc of UOP. He had persistent
RR in 30's and was advanced to BIPAP for 4 hours beginning at 12
AM on [**9-18**]. In the morning he underwent therapeutic R
thoracentesis that yielded 1200 cc of yellow fluid. His
respiratory function improved and he was weaned to 4 L O2. His
most recent vitals from the MICU at 1700 were 96.8 72 106/48 21
92%/4L. He currently reports 0/10 pain from his procedure and
reports being thirsty.
.
Of note, the patient has a history of Afib and has been holding
his coumadin for a scheduled outpatient pleurex catheter
placement on [**2194-9-20**] and has an INR from [**9-18**] of 1.2. The
patient also reports recently developing increased nocturia, had
developed lower leg edema over past year that has resolved with
starting diuretics. He sleeps on two pillows, and has some
increased exertional dyspnea that he notices when walking. He
has lost 10 lbs over the past two weeks, coinciding with an
increase to his home Torsemide dosage after his last
hospitalization.
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. In [**2178**], he was diagnosed with CLL/SLL and has intermittently
received treatment with Leukeran since [**2185**]. He has had
occasional skin manifestations with infiltration by low-grade
lymphoma cells; however, by and large, his skin lesions have
largely been related to eczematoid skin lesions.
2. In [**2180**], metastatic prostate cancer on Casodex since [**2176**].
His PSA has been rising since [**86**]/[**2192**].
3. Stage I adenocarcinoma of the sigmoid colon s/p complete
resection of carcinoma in [**2187**], no recurrence since that time.
4. In [**1-/2192**], MRI for chronic kidney disease revealed a 9 mm
nodule at the medial aspect of the left renal cyst consistent
with a small renal cell carcinoma being followed by observation
alone.
5. He has had multiple admissions to the hospital for varicella
and for pneumonia.
In [**6-/2194**], he was admitted after being found to have a right
pleural effusion and was found to have anterior mediastinal
retrocrural lymphadenopathy. Given the potential risk of
complications and the very likely diagnosis of lymphoma, a
decision was made to not to perform a lymph node biopsy in the
mediastinum.
.
PAST MEDICAL HISTORY:
# CLL likely transformed to lymphoma
# Small renal cell carcinoma, being observed
# Metastatic prostate cancer as above
# Hx stage I colon cancer - s/p L colectomy, no recurrence
# Stage IV chronic kidney disease with baseline creatinine 2.5
# Hypertension
# Reported history of congestive heart failure (no recent
documentation of type or EF), records not available in our
system
# Paroxysmal atrial fibrillation, on chronic warfarin
.
PAST SURGICAL HISTORY:
1. Cardiac angioplasty - ~ [**2187**]
2. Left colectomy for treatment of colon cancer.
3. Squamous cell carcinoma removal.
Social History:
Former judge and was active in [**Location (un) 86**] politics. Two daughters,
5 grandchildren, WWII veteran in engineering corps in Europe.
Family History:
Father with brain aneurysm (ruptured) at age 63. Brother with
brain aneurysm at age 70. Mother died of "old age" age [**Age over 90 **].
Physical Exam:
Physical Exam:
Vitals: 99.3 132/70 89 22 91%/2.5L O2, 0/10 pain
General: NAD, speaking in full sentences, alert and oriented
HEENT: Normal conjunctiva, dry mucosa
Neck: JVD
Lungs: bibasilar crackles, no wheezes/rhonchi appreciated.
Increased respiratory discomfort with lowering of bed.
CV: RRR, normal S1 S2, no MRG
Abdomen: soft, NTND, BS+
Back: dressing on R flank C/D/I
Ext: Warm, well perfused. No edema, DP 2+
Pertinent Results:
Admission Labs:
[**2194-9-17**] 02:30AM PT-14.8* PTT-24.9 INR(PT)-1.3*
[**2194-9-17**] 02:30AM PLT COUNT-130*#
[**2194-9-17**] 02:30AM NEUTS-70.9* LYMPHS-15.6* MONOS-10.0 EOS-1.9
BASOS-1.7
[**2194-9-17**] 02:30AM WBC-4.0 RBC-3.69* HGB-10.5* HCT-30.2* MCV-82
MCH-28.3 MCHC-34.7 RDW-16.0*
[**2194-9-17**] 02:30AM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.2
[**2194-9-17**] 02:30AM estGFR-Using this
[**2194-9-17**] 02:30AM GLUCOSE-119* UREA N-52* CREAT-2.2*
SODIUM-132* POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-26 ANION GAP-17
[**2194-9-17**] 07:00AM URINE HYALINE-<1
[**2194-9-17**] 07:00AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2194-9-17**] 07:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2194-9-17**] 07:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2194-9-17**] 07:00AM URINE OSMOLAL-327
[**2194-9-17**] 07:00AM URINE HOURS-RANDOM UREA N-520 CREAT-62
SODIUM-24 POTASSIUM-45 CHLORIDE-23
[**2194-9-17**] 03:38PM O2 SAT-86
[**2194-9-17**] 03:38PM LACTATE-0.9
[**2194-9-17**] 03:38PM TYPE-ART PO2-52* PCO2-36 PH-7.53* TOTAL
CO2-31* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2194-9-17**] 04:00PM O2 SAT-88
[**2194-9-17**] 04:00PM LACTATE-1.2
[**2194-9-17**] 04:00PM TYPE-ART O2 FLOW-6 PO2-56* PCO2-37 PH-7.53*
TOTAL CO2-32* BASE XS-7 COMMENTS-NASAL [**Last Name (un) 154**]
[**2194-9-17**] 04:09PM VoidSpec-CLOTTY SPE
[**2194-9-17**] 04:59PM O2 SAT-90
[**2194-9-17**] 04:59PM LACTATE-1.1
[**2194-9-17**] 04:59PM TYPE-ART O2 FLOW-6 PO2-63* PCO2-37 PH-7.53*
TOTAL CO2-32* BASE XS-7 COMMENTS-NASAL [**Last Name (un) 154**]
[**2194-9-17**] 09:19PM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2194-9-17**] 09:19PM GLUCOSE-126* UREA N-54* CREAT-2.3* SODIUM-135
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-27 ANION GAP-17
Imaging:
CXR [**2194-9-17**]
1. New mild pulmonary edema.
2. Persistent large right and small left pleural effusions, with
compressive atelectasis, particularly on the right, and [**Month/Day/Year 1192**]
cardiomegaly.
3. Osteoarthritic spurring is noted in the right shoulder.
CXR [**2194-9-18**]
FINDINGS: As compared to the previous radiograph, a right-sided
pleural catheter has been inserted. The extent of the
pre-existing right pleural effusion has substantially decreased.
There is no evidence of pneumothorax.
The lung volumes have increased. The extent of the left-sided
pleural effusion has also minimally decreased. Unchanged
[**Month/Day/Year 1192**] cardiomegaly and minimal overhydration.
Discharge Labs:
[**2194-9-22**] 06:50AM BLOOD WBC-4.4 RBC-3.84* Hgb-10.6* Hct-32.2*
MCV-84 MCH-27.7 MCHC-33.1 RDW-15.7* Plt Ct-116*
[**2194-9-22**] 06:50AM BLOOD Plt Ct-116*
[**2194-9-22**] 06:50AM BLOOD Glucose-102* UreaN-60* Creat-1.9* Na-134
K-3.8 Cl-96 HCO3-27 AnGap-15
[**2194-9-22**] 06:50AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.2
Brief Hospital Course:
[**Age over 90 **]yo man w Aifb and recurrent malignancy-related right pleural
effusion s/p pleurex catheter placement on [**9-20**] transferred from
MICU s/p therapeutic R thoracentesis for dyspnea, now being
diuresed
.
# HYPOXIA:
The patient arrived with dyspnea and O2 sat of 87% on room air.
This was attributed to a combination of R malignant pleural
effusion and pulmonary edema secondary to acute on chronic
diastolic heart failure. He was placed on a non-rebreather in
the ED, where he improved significantly, with O2 sat of 100%.
He was then transferred to the MICU for observation. There he
was aggressively diuresed with IV lasix, which improved his
respiratory status and facilitated transition to a short course
of BIPAP. On ICU day 2, he underwent therapeutic R
thoracentesis, yielding 1200 cc of yellow fluid. He was then
transferred to the floor, where he was comfortably breathing on
2.5 L O2 and with O2 sat >90%. He subsequently underwent
placement of R Pleurex catheter, which he tolerated well. By
the time of discharge he was breathing comfortably on room air
and could ambulate with good O2 saturation >90%.
.
# CHF
Similar to his prior hospitalization on [**9-4**], the patient
presented with acute on chronic diastolic heart failure (ECHO on
[**9-4**] demonstrated preserved systolic function). On admission
he presented with bilateral pulmonary edema, JVD, and orthopnea
on exam; he had no lower extremity pitting edema. He was
diuresed with IV lasix as discussed above and transitioned to PO
Torsemide 40 mg [**Hospital1 **].
.
# Afib:
Remained hemodynamically stable for the course of the
hospitalization on his home dose of metoprolol. Coumadin was
held in the setting of the patient's Pleurex catheter placement
and subsequently restarted at his home dose as detailed below.
He was discharged with a subtherapeutic INR of 1.0 without a
bridge given his CHADS2 score of 2.
.
# CKD STAGE IV:
His creatinine rose from 2.2 upon admission to a peak of 2.4 as
a result of aggressive diuresis. The patient's home dose of
sevelamer was continued without changes.
.
# CAD:
No changes were made to the patient's home doses of nifedipine,
metoprolol and pravastatin.
# Chronic issues:
No changes were made to the patient's gout or hypothyroid
medications.
Medications on Admission:
1. torsemide 20 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day): take 2 tablets in the morning and 1 tablet at night.
Disp:*90 Tablet(s)* Refills:*2*
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.25 Tablet Sustained Release 24 hr PO DAILY (Daily).
8. nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. pravastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR). - NOTE HOLDING FOR PROCEDURE
12. warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA). - NOTE HOLDING FOR PROCEDURE
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. darbepoetin alfa in polysorbat 200 mcg/mL Solution Sig: One
(1) mL Injection once a month.
18. triamcinolone acetonide 0.1 % Lotion Sig: One (1)
application Topical twice a day.
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
4. pravastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO DAYS ([**Doctor First Name **],TU,TH,SA).
10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS
(MO,WE,FR).
11. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every
other day.
12. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Diastolic Heart Failure with Diastolic
Dysfunction
Recurrent Bilateral Pleural Effusion (R>L) now s/p Right Pleurex
Catheter Placement
.
Secondary Diagnosis:
Paroxysmal Atrial FIbrillation, now back on coumadin (was
stopped for procedure)
CLL likely transformed to lymphoma
Small renal cell carcinoma, being observed
Metastatic prostate cancer
Hx stage I colon cancer - s/p L colectomy, no recurrence
Stage IV chronic kidney disease with baseline creatinine 2.5
Hypertension
Mild MR
[**First Name (Titles) **] [**Last Name (Titles) **]
Primary Diagnosis:
Acute on Chronic Diastolic Heart Failure with Diastolic
Dysfunction
Recurrent Bilateral Pleural Effusion (R>L) now s/p Right Pleurex
Catheter Placement
.
Secondary Diagnosis:
Paroxysmal Atrial FIbrillation, now back on coumadin (was
stopped for procedure)
CLL likely transformed to lymphoma
Small renal cell carcinoma, being observed
Metastatic prostate cancer
Hx stage I colon cancer - s/p L colectomy, no recurrence
Stage IV chronic kidney disease with baseline creatinine 2.5
Hypertension
Mild MR
[**First Name (Titles) **] [**Last Name (Titles) **]
Discharge Condition:
Stable, breathing comfortably on room air, able to walk with
good sats in the [**Doctor Last Name **].
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 656**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of
breath and on physical exam and chest x-ray we found that you
had fluid "inside" your lung as well as "around" your lung. Your
oxygen level was low and the emergency room doctors were
concerned that they admitted you to the intensive care unit. In
there, you required oxygen, medication through your vein (lasix
or furosemide) to get rid of the fluid as well as a
thoracocentesis (drainage of the fluid around your lung).
Subsequently, you were transferred to a regular medicine floor
where we continue giving you lasix through your veins and
weaning the oxygen. You also underwent the placement of the
pleurex catheter in the right of your chest so we can drain the
fluid in the future.
We had to stop your coumadin for the procedures you underwent.
We recently re-started it and you MUST follow your INR next week
and fax the results to your PCP.
Your medications were changed as follows:
* We stopped the coumadin in the hosptial and recently
re-started it. You will need to have you INR drawn early next
week (Tuesday or Wednesday)
* We stopped your spironolactone given that your potassium was
slightly high in the hospital. You will need to have your in
your PCPs office within the next week (or with your oncologist)
and then talk to them about re-starting this medication, which
protects your heart and building up fluid.
* We slightly increased your torsemide to two 20 mg tablets
twice a day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
If you develop worsening of your breathing, severe shortness of
breath, decrease in your ability to move and do your daily
activities call your doctor.
Dear Mr. [**Known lastname 656**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of
breath and on physical exam and chest x-ray we found that you
had fluid "inside" your lung as well as "around" your lung. Your
oxygen level was low and the emergency room doctors were
concerned that they admitted you to the intensive care unit. In
there, you required oxygen, medication through your vein (lasix
or furosemide) to get rid of the fluid as well as a
thoracocentesis (drainage of the fluid around your lung).
Subsequently, you were transferred to a regular medicine floor
where we continue giving you lasix through your veins and
weaning the oxygen. You also underwent the placement of the
pleurex catheter in the right of your chest so we can drain the
fluid in the future.
We had to stop your coumadin for the procedures you underwent.
We recently re-started it and you MUST follow your INR next week
and fax the results to your PCP.
Your medications were changed as follows:
* We stopped the coumadin in the hosptial and recently
re-started it. You will need to have you INR drawn early next
week (Tuesday or Wednesday)
* We stopped your spironolactone given that your potassium was
slightly high in the hospital. You will need to have your in
your PCPs office within the next week (or with your oncologist)
and then talk to them about re-starting this medication, which
protects your heart and building up fluid.
* We slightly increased your torsemide to two 20 mg tablets
twice a day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
If you develop worsening of your breathing, severe shortness of
breath, decrease in your ability to move and do your daily
activities call your doctor.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2194-9-24**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2194-9-24**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2194-9-24**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.4",
"511.81",
"403.90",
"V10.05",
"189.0",
"428.0",
"204.10",
"427.31",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
13195, 13252
|
8141, 10337
|
223, 280
|
14441, 14544
|
5186, 5186
|
18287, 19212
|
4592, 4730
|
12212, 13172
|
13273, 13273
|
10451, 12189
|
14695, 18264
|
7799, 8118
|
4290, 4417
|
4760, 5167
|
176, 185
|
308, 2597
|
14040, 14420
|
5203, 7782
|
13865, 14019
|
14559, 14671
|
10353, 10425
|
3830, 4267
|
4433, 4576
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,538
| 139,886
|
22631
|
Discharge summary
|
report
|
Admission Date: [**2139-3-8**] Discharge Date: [**2139-3-17**]
Date of Birth: [**2092-10-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy
History of Present Illness:
46-year-old male unrestrained driver status post motor vehicle
crash (SUV vs tree), spidered windshield, +airbag, +EtOH, right
ant. scalp lac. Transferred from OSH for further management. In
ED, GCS 14, complaining of abdominal and chest pain. Imaging
positive for mesenteric hematoma and right 5/6/7th & left
7/8/9th rib fractures, possible right apical pulmonary
contusion. Labs revealed pancreatitis. Admitted to trauma.
Past Medical History:
None
Social History:
1. EtOH
2. Denies drug abuse
3. Lives with wife
Family History:
NC
Physical Exam:
On arrival:
VS: T 100.2 BP 131/77 HR 106 RR 19 sat 99%
GEN: Alert, EtOH, mod. distress, in pain
HEENT: PERLA, EOMI, R ant scalp lac, c-collar
CARDIO: S1S2, RRR
PULM: CTAB, no crepitus
[**Last Name (un) **]: soft, distended, NT, guaiac neg, normal rectal tone, FAST
neg
ORTHO: pelvis stable, nontender extremities, R flank abrasions,
warm, dry
NEURO: GCS 14, moves all extremities symmetrically
Pertinent Results:
[**2139-3-8**] 02:40AM WBC-12.8* RBC-4.21* HGB-13.4* HCT-39.2*
MCV-93 MCH-31.8 MCHC-34.2 RDW-13.0
[**2139-3-8**] 02:40AM PLT COUNT-202
[**2139-3-8**] 02:40AM PT-13.6 PTT-33.0 INR(PT)-1.2
[**2139-3-8**] 02:40AM ASA-NEG ETHANOL-252* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-3-8**] 03:01AM GLUCOSE-130* LACTATE-3.2* NA+-141 K+-4.4
CL--104 TCO2-21
[**2139-3-8**] 02:40AM UREA N-11 CREAT-1.0
[**2139-3-8**] 02:40AM CK(CPK)-237* AMYLASE-264*
[**2139-3-8**] 02:40AM CK-MB-4 cTropnT-<0.01
[**2139-3-8**] 10:00PM GLUCOSE-145* UREA N-14 CREAT-0.8 SODIUM-136
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-11
[**2139-3-8**] 10:00PM AMYLASE-268*
[**2139-3-8**] 10:00PM LIPASE-260*
[**2139-3-8**] 10:00PM CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-1.7
##
CT c-spine [**2139-3-8**]:
1. There is no evidence of fracture or dislocation.
##
CT chest/[**Last Name (un) 103**]/pelvis [**2139-3-8**]:
1. Mesenteric hematoma. Bowel injury has to be considered.
2. Multiple bilateral rib fractures.
3. There is no evidence of free air or free fluid in the
abdomen.
4. Lung contusion.
##
CT [**Last Name (un) 103**] [**2139-3-9**]:
1) Mesenteric hematoma just inferior and anterior to the
pancreas is unchanged in size. This could be related to
pancreatic or bowel injury.
2. New small amount of free fluid in the abdomen in the right
paracolic gutter and around the liver is concerning.
3) Unchanged rib fractures.
Brief Hospital Course:
NEURO: Mr. [**Known lastname 12130**] was admitted to the TSICU for close
monitoring of his hematocrit, pancreatic tests and pulmonary
function. His mental status remained clear and he did not
exhibit any deterioration in his neurological function.
##
ORTHO: The patient's rib fractures and pulmonary contusion were
managed with aggressive pain control, incentive spirometry and
regular nebulizers. Analgesics included dilaudid injections as
needed, then was placed on a PCA and ultimately received an
epidural when his spine was cleared. This achieved good pain
control but caused alterations in his mental status in the form
of visual hallucinations, disorientation and paranoia
particularly at night. Prior to discharge, the epidural was
removed and the patient was placed on toradol, tylenol and prn
percocets. this was well tolerated and his mental status
subsequently cleared.
##
[**Last Name (un) **]: Mr. [**Known lastname 12130**] was taken to the OR on HD#2 after developping
tachycardia and worsening abdominal pain. No bowel, pancreatic,
hepatic injuries were found. His amylase and lipase levels
progressively decreased over the course of his hospital stay.
The patient continued to complain of mild-moderate abdominal
pain. This improved after his drain was removed on HD#9. His
incision site remained clean and his bowel function returned on
HD#7. The patient's staples were removed on the day of his
discharge, POD#8.
##
ETOH: The patient was placed on a CIWA scale and given ativan as
needed for withdrawal symptoms. Social work was consulted and
followed the patient throughout his stay. The patient admitted
to having a problem with alcohol and, although having greatly
decreased his alcohol intake over the past few years, continued
to go out on binges with his friends. [**Name (NI) **] received phone numbers
for detoxification centers and other organizations which he
agreed to contact upon discharge. He acknowledged the danger he
placed himself and others in and promised to cut down and
eventually quit drinking altogether.
##
The patient was discharged home on HD#10 in stable condition
with instructions to return to clinic for follow up evaluation.
Medications on Admission:
None
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for 4 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Multiple rib fractures
2. Mesenteric hematoma
3. EtOH abuse
Discharge Condition:
Good
Discharge Instructions:
you were hospitalized in the trauma service for injuries you
sustained during your motor vehicle crash. you were diagnosed
with multiple rib fractures and a bruise in your bowel. you
underwent a surgical procedure to explore your belly. this did
not reveal any worrisome findings. your rib fractures were
addressed with pain medications, nebulizers and breathing
exercises. you were also found to have high levels of pancreas
enzymes which indicate an inflammation of this organ. this was
likely due to your alcohol intake. your gallbladder ultrasound
did not show any stones.
please stop drinking alcohol as this has serious effects on your
health and may threaten the life of others.
please follow up with Dr. [**Last Name (STitle) **] in [**7-12**] days [**Telephone/Fax (1) 1864**].
also, please call your primary care provider to schedule [**Name Initial (PRE) **]
follow up visit within 1-2 weeks.
take your medications as prescribed.
call your doctor or go to the ER if you develop:
* uncontrolled pain
* nausea/vomiting
* dizziness/lightheadedness
* blood in stool
* any worrisome symptoms
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1864**] Appointment
should be in [**7-12**] days
2. Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Telephone/Fax (1) 6803**]
Completed by:[**2139-3-17**]
|
[
"861.21",
"807.06",
"863.89",
"E823.0",
"577.1",
"305.00",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"54.11",
"38.93",
"99.04",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
5396, 5402
|
2814, 4993
|
333, 360
|
5509, 5515
|
1355, 2791
|
6665, 6946
|
922, 926
|
5048, 5373
|
5423, 5488
|
5019, 5025
|
5539, 6642
|
941, 1336
|
274, 295
|
388, 813
|
835, 841
|
857, 906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,262
| 124,023
|
40555
|
Discharge summary
|
report
|
Admission Date: [**2168-3-16**] Discharge Date: [**2168-3-22**]
Date of Birth: [**2083-10-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Weakness and hypotension
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intra-aortic balloon pump placement
Intubation/extubation
Ventricular septal defect closure device placement
History of Present Illness:
84 year old female with hx of HTN, HL, and Parkinson's disease
(diagnosed 4-5 years ago) presents with fatigue/weakness and
ongoing chest pain. The history is provided by her daughter and
husband. The chest pain started about 2 days ago, described as
across the chest and thought to be attributable to reflux. The
pain improved with Maalox after the first occurrence. However,
it recurred over the next 2 days until the day of admission,
unclear if it was precipitated by any particular activity. No
shortness of breath, palpitations, nausea/vomiting, claudication
symptoms. The AM of admission, she did not want to get out of
bed and felt extremely weak. She was oriented, but speaking
with understandable words, but did not make any sense. Her
weakness was not localized to a side of the body or the face.
Her husband was unable to get her up, so he called their
daughter, who went to the house and was concerned enough about
her to call 911.
.
Of note, she does have a history of falls, thought to be
vasovagal in origin, but taken off her amlodipine recently for
concern of hypotension. She is independent of ADLs at baseline
and has never been hospitalized. She has undergone work-up for
her Parkinson's disease and per her daughter, she has had
increasing dementia over the past few months.
.
In the ED, initial vitals were 97.3, 118, 80/65, 16 and 96% on
4L. She was noted to have STEMI in inferior leads and STE in
V4R when posterior leads were placed. She received ASA in the
ambulance en route, integrilin bolus, Plavix 600mg, and heparin.
Her BP dropped to 68/48 and she was given a total of 2L bolus
of NS. She was then sent to the Cath lab for emergent
intervention.
.
She arrived to the Cath lab with systolic BPs down to the 60s,
resuscitated with IVF initially, then started on dopamine, with
resulting SBPs to 80s. She was quite somnolent and there was
concern for her abiilty to protect her airway. Anesthesia
intubated her and a IABP was placed given persistent
hypotension. Only other intervention during cath was a POBA of
the RCA (prox 70% stenosis, now 40%). The patient's clinical
status did not improve and a TEE showed a likely VSD, so a
LV-gram was done, showing a large VSD. No closure was done at
this point, with plans to return for percutaneous closure.
.
.
Review of systems could not be performed on patient due to
intubation/sedation. Per daughter, 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.
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
Parkinson's disease with dementia
IBS
Basal/squamous cell CA of face
Rheumatoid arthritis
Vasovagal syncope
Tonsillectomy ([**2120**])
Social History:
She lives with her husband [**Name (NI) **] (s/p CVA in [**2158**] with residual
aphasia), independent of ADLs. She has 2 daughters [**Name (NI) **] and
[**Name (NI) 2563**].
-Tobacco history: none
-ETOH: occasional beer, every now and then
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Notable for HTN and DM.
Physical Exam:
On admission:
VS: T=96.1, BP=103/64, HR=125, RR=17, O2 sat=none taken (on
400/18/12/100%)
GENERAL: elderly, ill-appearing female, intubated, mildly
sedated. Not following commands. Responds to noxious stimuli.
HEENT: NCAT. Sclera anicteric. PERRL (3->2mm). Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Laceration over hard palate, some tears and old blood over lips.
NECK: Supple without JVD.
CARDIAC: heart sounds obscured by IABP sounds, no m/r/g
appreciated without thrill over sternum. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Breath
sounds obscured by IABP, but audible bilaterally with diffuse
rhonchi.
ABDOMEN: Soft, NT/ND. Abd aorta not enlarged by palpation. No
abdominal bruits.
EXTREMITIES: No c/c. Trace LE edema. Cold extremities. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: increased muscle tone throughout, pupils equal and
reactive, CNs grossly intact, reflexes not tested. Sedated, not
following commands.
On discharge: deceased
Pertinent Results:
On admission:
[**2168-3-16**] 09:15AM BLOOD WBC-14.5* RBC-3.88* Hgb-12.5 Hct-38.7
MCV-100* MCH-32.2* MCHC-32.2 RDW-13.2 Plt Ct-162
[**2168-3-16**] 09:15AM BLOOD Neuts-89.2* Lymphs-7.3* Monos-2.9 Eos-0.1
Baso-0.1
[**2168-3-16**] 09:15AM BLOOD PT-13.0 PTT-63.9* INR(PT)-1.1
[**2168-3-16**] 09:15AM BLOOD Glucose-268* UreaN-34* Creat-2.1* Na-138
K-4.3 Cl-100 HCO3-16* AnGap-26*
[**2168-3-16**] 02:51PM BLOOD ALT-376* AST-765* LD(LDH)-[**2087**]*
CK(CPK)-2293* AlkPhos-69 TotBili-2.5*
[**2168-3-16**] 09:15AM BLOOD CK-MB-118* MB Indx-5.3
[**2168-3-16**] 09:15AM BLOOD cTropnT-6.71*
[**2168-3-16**] 02:51PM BLOOD Calcium-8.1* Phos-3.8 Mg-2.3
[**2168-3-16**] 10:05AM BLOOD Type-ART pO2-276* pCO2-22* pH-7.30*
calTCO2-11* Base XS--13
[**2168-3-16**] 01:28PM BLOOD Lactate-2.6*
CBC
[**2168-3-16**] 09:15AM BLOOD WBC-14.5* RBC-3.88* Hgb-12.5 Hct-38.7
MCV-100* MCH-32.2* MCHC-32.2 RDW-13.2 Plt Ct-162
[**2168-3-17**] 03:07PM BLOOD WBC-11.8* RBC-3.35* Hgb-10.9* Hct-32.5*
MCV-97 MCH-32.6* MCHC-33.6 RDW-13.8 Plt Ct-85*
[**2168-3-18**] 03:57PM BLOOD WBC-12.7* RBC-3.61* Hgb-11.6* Hct-33.5*
MCV-93 MCH-32.2* MCHC-34.7 RDW-15.3 Plt Ct-115*
[**2168-3-20**] 05:13AM BLOOD WBC-13.0* RBC-3.58* Hgb-11.5* Hct-33.2*
MCV-93 MCH-32.2* MCHC-34.7 RDW-15.6* Plt Ct-86*
[**2168-3-22**] 03:45AM BLOOD WBC-17.2* RBC-3.54* Hgb-11.5* Hct-33.5*
MCV-95 MCH-32.4* MCHC-34.2 RDW-15.0 Plt Ct-111*
Chem-7
[**2168-3-16**] 02:51PM BLOOD Glucose-210* UreaN-33* Creat-1.7* Na-139
K-4.5 Cl-111* HCO3-18* AnGap-15
[**2168-3-18**] 04:02AM BLOOD Glucose-234* UreaN-43* Creat-1.3* Na-137
K-3.7 Cl-110* HCO3-18* AnGap-13
[**2168-3-21**] 04:31AM BLOOD Glucose-191* UreaN-81* Creat-2.3* Na-134
K-3.9 Cl-108 HCO3-18* AnGap-12
[**2168-3-22**] 03:45AM BLOOD Glucose-236* UreaN-100* Creat-3.0*
Na-132* K-4.6 Cl-105 HCO3-12* AnGap-20
LFTs
[**2168-3-16**] 02:51PM BLOOD ALT-376* AST-765* LD(LDH)-[**2087**]*
CK(CPK)-2293* AlkPhos-69 TotBili-2.5*
[**2168-3-20**] 05:13AM BLOOD ALT-225* AST-144* AlkPhos-121*
TotBili-3.5* DirBili-2.7* IndBili-0.8
[**2168-3-22**] 03:45AM BLOOD ALT-1233* AST-3308* TotBili-3.0*
DirBili-2.2* IndBili-0.8
Cardiac enzymes
[**2168-3-16**] 09:15AM BLOOD cTropnT-6.71*
[**2168-3-16**] 02:51PM BLOOD CK-MB-143* MB Indx-6.2* cTropnT-10.52*
[**2168-3-17**] 04:02AM BLOOD CK-MB-115* MB Indx-5.4 cTropnT-11.60*
MICROBIOLOGY:
URINE CULTURE (Final [**2168-3-20**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2168-3-18**] 8:21 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2168-3-20**]**
GRAM STAIN (Final [**2168-3-18**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2168-3-20**]):
SPARSE GROWTH Commensal Respiratory Flora.
IMAGING:
Pre-closure TTE:
There is a postinfarction muscular ventricular septal defect
(VSD) measuring 1.6cm in maximum diameter located in the mid LV
septum, with torrential flow from left to right ventricle.
Overall left ventricular systolic dysfunction is moderately
depressed (LVEF= 40-45 %) with severe mid to distal septal
hypokinesis/akinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the presence of VSD and
intraaortic balloon support]. There is moderate to severe right
ventricular free wall hypokinesis. There are simple atheroma in
the descending thoracic aorta down to 45cm from incisors. An
intraaortic balloon pump is seen in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**11-29**]+) mitral regurgitation is seen. Tricuspid valve is normal.
There is no pericardial effusion.
IMPRESSION: Large ventricular septal defect in the muscular
portion of the mid inferior LV septum. The narrowest part of the
VSD is on the right ventricular side of the interventricular
septum and measures approximately 0.8cm. On the left ventricular
side of the septum, the defect is approximately 1.6cm. Moderate
regional left ventricular systolic dysfunction consistent with
inferior infarction. Moderate to severe right ventricular
systolic dysfunction.
Post-closure TTE:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with inferior dys/akinesis, inferolateral
hypo/akinesis and inferoseptal akinesis. There is an inferobasal
left ventricular aneurysm. The right ventricular chamber size is
normal with focal basal free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-29**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
at least moderate pulmonary artery systolic hypertension. There
is a very small pericardial effusion.
An Amplatzer closure device is seated across the inferior
portion of the interventricular septum and no definite residual
VSD flow is detected by color Doppler.
FINAL Catheterization reports pending upon patient's death.
Available in [**Hospital1 18**] records.
EKG:
Atrial fibrillation with rapid ventricular response.
Inferolateral myocardial infarction. Since the previous tracing
of [**2168-3-18**] atrial fibrillation has replaced sinus tachycardia.
Brief Hospital Course:
84 year old female with hx of HL, HTN, and Parkinson's disease
presented with extreme fatigue and weakness. EKG showed
inferior STEMI and she was taken straight to the cath lab where
an RCA occlusion was noted, intervened upon with balloon
angioplasty. It also showed evidence of RV infarction with VSD
on catheterization/LV-gram. One day later, this was closed with
an Amplatzer device and her blood pressures were maintained on
norepinephrine, vasopressin, and an intra-aortic balloon pump.
Dobutamine was also tried in order to improve cardiac output,
but we were unable to wean her off pressors. Decreasing the
ratio of the balloon pump resulted in uptitration of pressors.
[**Doctor Last Name **] then developed atrial arrhythmias resulting in hemodynamic
instability, for which cardioversion was attempted, complicated
by an episode of ventricular tachycardia, which she was shocked
out of. Her atrial fibrillation returned and continued despite
amiodarone gtt. She then developed septic shock with likely
pulmonary and GU involvement, for which antibiotics were
started. An acute transaminitis heralded the beginning of shock
liver along with her elevated creatinine and worsening metabolic
acidosis, signaling worsening multi-organ failure and continued
cardiogenic/septic shock. Lab findings also indicated the
likely presence of DIC. After a family meeting during which her
poor prognosis and lack of improvement were discussed, the
decision was made to slowly withdraw care. She passed away
shortly thereafter, at 12:40pm on [**2168-3-22**]. The family agreed to
an autopsy.
Medications on Admission:
ASA 81mg daily
Simvastatin 20mg daily
Zoloft 50mg daily
Aricept 5mg daily
Sinemet 10/100mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Inferior myocardial infarction
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
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"287.5",
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icd9cm
|
[
[
[]
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[
"88.56",
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"00.40",
"00.66",
"37.61",
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"96.6",
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icd9pcs
|
[
[
[]
]
] |
13103, 13112
|
11330, 12928
|
330, 464
|
13186, 13191
|
5083, 5083
|
13243, 13342
|
3796, 3908
|
13075, 13080
|
13133, 13165
|
12954, 13052
|
13215, 13220
|
3923, 3923
|
3327, 3332
|
5054, 5064
|
266, 292
|
492, 3228
|
5098, 11307
|
3363, 3499
|
3250, 3306
|
3515, 3780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,362
| 144,641
|
33066
|
Discharge summary
|
report
|
Admission Date: [**2179-8-15**] Discharge Date: [**2179-8-18**]
Date of Birth: [**2158-5-11**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Headache, N/V, hypertension
Major Surgical or Invasive Procedure:
Peritoneal Dialysis
24hour stay in the Medical Intensive Care Unit
Peritoneal Tap
Peritoneal Dialysis 5x daily
History of Present Illness:
Ms. [**Known lastname 76867**] is a 21 year old female with MPGN s/p renal
transplant ([**7-13**]) and recurrent MPGN with recent removal of
transplanted kidney admitted for headache, nausea, vomiting, and
hypertensiuon. Of note, she has been admitted several times
since spring [**2178**] for hypertensive emergency and for generalized
tonic clonic seizures at the end of [**Month (only) 596**]. She has been on
peritoneal dialysis for several months; her HD catheter was
removed in past few weeks. The patient noted headache last night
"all over" her head, as per usual headache associated with
elevated blood pressure. She was nauseous and vomited X 1 during
the day on Sunday, and then presented to the emergency room.
.
In the ED, initial BP 227/148 (L 230/150, R 215/143), HR 69. She
received multiple doses of IV labetalol (20 mg IV X 2, 40 mg IV
X 2, 60 mg IV X 1, while awaiting labetalol gtt), with minimal
improvement in BPs to 218/150s. She received two doses 10 mg IV
hydralazine as well. HR up to 100s over course of ED stay. She
received a total of 3 mg dilaudid in the ED for headache as well
as zofran 4 mg X 2 and compazine 10 mg IV X 1 for nausea. She
took her home meds of clonidine 0.1 mg, metoprolol 150 mg po,
losartan 100 mg PO, and hydralazine 50 mg PO. She also received
benadryl 25 mg PO X 2 for pruritis.
.
On arrival to the ICU, the patient is arousable to voice but not
giving detailed information (cannot give details on
administering her PD). She denies pain. She relates that the
headache started last evening and she vomited this evening. She
denies missing doses of any medication. The patient's mother
(via phone) states that the patient was feeling well until
yesterday when she developed headache. Her mother relates that
since her nephrectomy, she has felt better in general with
better blood pressures. No preceding fever, difficulty
breathing, chest pain, abdominal pain per the patient and her
mother.
Past Medical History:
* MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two year. In
[**6-/2178**] pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative Hep C, Hep B, [**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of [**Year (4 digits) **]. Outpatient neprhologist Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] & Dr.
[**Last Name (STitle) 118**]. S/p nephrectomy of transplanted kidney on [**2179-7-7**] per
Dr. [**First Name (STitle) **].
* Peripheral edema and abdominal striae [**1-9**] steroids
* HTN [**1-9**] steroids and renal disease, multiple admissions for
hypertensive emergency.
* Hemolytic Anemia - previously seen by heme/onc who felt it was
[**1-9**] to malignant hypertension.
* Migraines
Social History:
Lives at home with [**Month/Day (2) **], brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit
drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VS: T 98.2 BP 157/107 P 102 R 17 O2 95% RA
GEN: eyes closed, will open when asks, no acute distress, lying
in bed, drowsy
[**Name (NI) 4459**]: EOMI, pupils small but reactive bilaterally, sclerae
anicteric, sclerae injected bilaterally. OP clear, MMM.
RESP: CTAB no w/r/r
CV: RRR 2/6 SM LUSB no rubs
ABD: Soft ND + BS no rebound or guarding, PD catheter in place
in LLQ
EXT: Warm well perfused, no peripheral edema
SKIN: diffuse excoritations no focal rashes
NEURO: EOMI, pupils small but reactive bilaterally, facial
expressions intact & symmetric, tongue midline with full motion,
shoulder shrug intact, facial sensation intact to light touch,
strength 4+/5 in bilateral biceps, triceps, intrinsic hand
muscles, hand grip, ankle dorsiflexion & plantarflexion, & hip
flexion, sensation in bilateral extremities intact to light
touch, toes equivocal, biceps reflexes 2+ bilaterally, patellar
reflexes not elicited
Pertinent Results:
Labs on Admission [**2179-8-15**]:
WBC-9.2# - Neuts-71.5* Lymphs-12.8* Monos-6.7 Eos-8.1* Baso-1.0
Hgb-11.8* Hct-35.9*
Plt Ct-226
Glucose-85 UreaN-67* Creat-10.9*# Na-137 K-5.9* Cl-96 HCO3-22
AnGap-25* Calcium-9.1 Phos-10.4*# Mg-1.5*
PT-12.5 PTT-23.1 INR(PT)-1.1
.
Labs on Discharge [**2179-8-18**]:
WBC-5.6; Neuts-71.9* Lymphs-10.5* Monos-5.9 Eos-11.0* Baso-0.7
Hgb-10.7* Hct-33.4*
Plt Ct-288
Glucose-102 UreaN-51* Creat-10.7* Na-137 K-4.9 Cl-95* HCO3-26
AnGap-21*
Calcium-9.3 Phos-10.7* Mg-2.6
.
Other Pertinent Labs:
CKMB and Tropn T unelevated
LFTs WNL
Peritoneal Fluid:
WBC-18* RBC-57* Polys-0 Lymphs-36* Monos-63* Eos-1*
Gm stain - no organisms no polys
Culture - no growth final
********************Studies*******************
[**2179-8-16**] CXR - FINDINGS: In comparison with study of [**7-7**],
there is again substantial enlargement of the cardiac
silhouette, accentuated by the low lung volumes. Mild
indistinctness of pulmonary vessels may reflect some
overhydration. No evidence of acute focal pneumonia. No evidence
of dialysis catheter.
[**2179-8-16**] CT Head - FINDINGS: There is no evidence of
hemorrhage, edema, or mass. The sulci and ventricles are normal
in caliber and configuration. The visualized mastoid and ethmoid
air cells and paranasal sinuses are clear. There is no fracture
or soft tissue abnormality noted. IMPRESSION: No acute
intracranial process.
Brief Hospital Course:
[**Known firstname **] is a 21 yo F with history of ESRD on PD s/p failed renal
tx after recurrence of MPGN, with recurrent admissions for
hypertensive urgency, who again presented during this admission
with hypertensive urgency.
In the [**First Name8 (NamePattern2) **] [**Known firstname 76880**] BP could not be well controlled with
periodic doses of Labetalol and Hydralazine. She also had
difficulty taking her home anti-HTN meds due to nausea and
vomiting. She was transferred to the MICU where her BP required
up to 8mg/hr on labetalol drip, intermittent Norvasc, and a
Clonidine patch to achieve adequate control. She was restarted
on all her home po BP meds overnight, and on [**8-16**] the labetalol
gtt was stopped. She was stable and tolerating her home meds by
the time of transfer to the floor later that afternoon with BPs
in the 150s/90s.
In regards to her ESRD, [**Known firstname **] received PD while in the MICU.
The first night PD was performed per patient's home manual dwell
(per mother & prior PD orders in POE, 2.5% diasylate, used 4
hour dwells per recent admission instructions). Once known, she
was transitioned to her outpatient PD settings of 2.5%, 4.25%,
2.5%, 4.25%, 2.5% alt doses with 1 hr each. Nephrology follwed
her during this hospitalization and added aluminum hydroxide to
usual regimen of renagel for increased her phos.
[**Known firstname 76880**] HA and nausea were treated with Percocet and Zofran
respectively and on the morning of discharge she was much
improved with near resolution of her symptoms once her BP was
well-controlled.
The plan at time of discharge was for [**Known firstname **] to follow-up with
her primary care nephrologist as well as Neurology for her HAs.
She remained full code throughout this hospitalization.
Medications on Admission:
Medications at home (confirmed with patient's mother):
lisinopril 40 mg once a day
losartan 100 mg b.i.d.
metoprolol 150 mg b.i.d.
Zofran as needed
Nephrocap daily
clonidine 0.1 mg tablet three times a day
hydralazine 50 mg three time a day
amlodipine 10 mg daily (resently chated to Isaradipine)
renagel
Discharge Medications:
1. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
10. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed: for
nausea/vomiting. Place under-tounge and allow to dissolve. If
more than 3 doses in one day - Please call doctor.
11. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: Please see doctor if >3 tabs
needed in one day or if pain not relieved by [**Known firstname **].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertensive Urgency; End Stage Renal Disease
secondary to membranoproliferative glomerulonephritis
Secondary: Migraine Headache, Depression
Discharge Condition:
Improved
Patient is ambulating independently and tolerating PO fluids and
food without nausea and vomiting.
Discharge Instructions:
You were hospitalized for hypertensive urgency. This means that
your blood pressure was dangerously high. You were treated for
a short time in the Medical Intensive Care Unit so that we could
give you blood pressure lowering medicines in your veins. Once
your nausea and vomiting resolved we were able to give you your
usual home medicines by mouth again.
Your pressure has been well controlled on your home medicines
today and your headache, nausea, and vomiting have resolved. We
feel at this point, that you are safe to go home.
**If you experience worsening headache, nausea, vomiting, blurry
vision, chest pain, racing heart beat, stomach pain/abdominal
tenderness, fever or any other concerning symptoms, please call
your primary care doctor for advice or report to the Emergency
Room for assitance.**
Please continue to take all of your home medications the way
that you were at home. We have not changed the doses or the
frequency of your meds.
In addition we are sending you home with some medications to use
as needed for management of headache (Percocet) and nausea
(Zofran). Also, please schedule and attend the follow-up
visits listed below to ensure the best medical management.
Followup Instructions:
Call and arrange to have appointments within the next two weeks
or as soon as possible with the following specialists:
1) [**Hospital 10701**] Clinic with Dr. [**Last Name (STitle) 118**]
[**Telephone/Fax (1) 60**]
Ask to speak c 'Kerry' or whoever is covering for her
2) [**Hospital **] [**Hospital **] Clinic
[**Telephone/Fax (1) 8302**]
3) [**Hospital **] [**Hospital 875**] Clinic
Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]
Tuesday, [**8-24**] @ 7:30pm
If you wish to cancel/re-schedule, please call in advance
[**Telephone/Fax (1) 8302**]
Completed by:[**2179-9-15**]
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48,863
| 109,878
|
40020
|
Discharge summary
|
report
|
Admission Date: [**2117-10-29**] Discharge Date: [**2117-11-9**]
Date of Birth: [**2059-10-30**] Sex: M
Service: MEDICINE
Allergies:
Terazosin / Carbamazepine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Upper GI Bleed and Hypotension
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy x 2
Tracheal Intubation/Mechanical Ventilation
Central venous catheter placement
Arterial line placement
History of Present Illness:
Mr. [**Known lastname 88028**] is a 57 year old man with h/o afib on Coumadin,
pacemaker, CAD s/p stents x2, CVA, seizures, HLD, HTN, asthma,
arthritis on NSAIDs, who was transferred from an OSH with chest
pain after choking, found to have atrial flutter, hypotension,
acute renal failure, and hematemesis.
.
The patient was in his usual state of health when he choked on
some canned tuna in the morning. He later felt fatigued and
developed substernal chest pain. He also had epigastric
discomfort. He initially presented to [**Hospital3 **] around
3pm, where he was found to be in aflutter with RVR (HR 140s). He
was given Metoprolol 5mg with subsequent hypotension (SBP 60s).
BP did not improve with 1LNS. At 6:45PM, the patient vomited a
large amount of bright red blood. NGT was placed with bloody
output. He was pale and continued to be hypotensive. Labs were
notable for WBC 19.3, HCT 35.7, INR 3.1, Cr 1.9 (baseline 0.9),
Trop I <0.06, Lactate 6.9. He was given Vitamin K 10mg SC x1,
Protonix 40mg IV, 1unit pRBCs, and 1unit FFP.
.
Of note, he has a several month h/o epigastric discomfort in the
setting of NSAID use (Aleve x years). He had an EGD 4 months ago
that was unremarkable. He continued to use NSAIDs during this
time.
.
In the ED, initial vs were: T 97.2 HR 107 BP 88/41 RR 34 O2sat
100%4LNC. The patient appeared very pale on arrival. He
continued complaining of epigastric pain. Exam notable for
pallor and abdominal distension. Labs notable for HCT 18.4, INR
3.9, Cr. 1.5. Patient was given 3units pRBCs, 1unit FFP, 2 packs
of platelets, 2LNS. Repeat HCT 24.3. Patient was seen by GI in
the ED - will hold on scope until AM given stable BP. Also had
an episode of dark red bowel movement. Vitals prior to
transfer: HR 120 BP 116/87 RR 21 O2sat 100% *LNC.
.
On the floor, the patient was hemodynamically stable. He
complained of large amounts of gas in his abdomen. He had
another dark bloody bowel movement. No fevers, chills, abdominal
pain, nausea, vomiting, shortness of breath, chest pain. No h/o
GI bleeds, no known h/o cirrhosis. Does have past h/o EtOH use.
Past Medical History:
Afib/flutter
s/p pacemaker x13years
CAD s/p stents x2
CVA
Seizure
HLD
HTN
Asthma
Colonic polyps
Arthritis
Bipolar/Manic d/o
Social History:
Lives with his girlfriend. Uses walking stick when hiking.
- Tobacco: none
- Alcohol: past use, quit 7 years ago, 2-6 beers/day
- Illicits: past marijuana, rare cocaine use
Family History:
Dad and 3 siblings with DM
Physical Exam:
Admission Physical Exam:
Vitals: T 97.4 HR 102 BP 126/73 RR 22 O2sat 100% 4LNC
General: alert, oriented, shallow quick breaths
HEENT: sclera anicteric, dry MM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Abdomen: distended, tympanic, nontender, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: 2+ pulses, no clubbing, cyanosis or edema
.
Discharge Physical Exam:
Vitals: T 99.8, HR 74, BP 110-120/68-72, RR 18, SO2 100%RA
GEN: AAOx2-3, comfortable appearing, NAD
HEENT: pupils equal and reactive to light
CV: RRR, normal S1, S2 with no m/r/g
RESP: unlabored breathing, mild patch wheezing
ABD: S/NT/ND, BS+, no TTP
EXT: warm, well-perfused, non-erythematous LUE
NEURO: CN II-XII intact, moving all extremities
Pertinent Results:
Admission Results:
.
[**2117-10-29**] 08:40PM BLOOD WBC-11.6* RBC-2.15* Hgb-6.4* Hct-18.4*
MCV-86 MCH-29.9 MCHC-34.9 RDW-13.9 Plt Ct-183
[**2117-10-29**] 09:45PM BLOOD WBC-12.7* RBC-2.72*# Hgb-8.2*# Hct-24.3*#
MCV-89 MCH-30.0 MCHC-33.6 RDW-14.1 Plt Ct-149*
[**2117-10-29**] 08:40PM BLOOD PT-37.6* PTT-37.0* INR(PT)-3.9*
[**2117-10-29**] 08:40PM BLOOD Plt Ct-183
[**2117-10-30**] 01:29AM BLOOD Fibrino-159
[**2117-10-30**] 05:07AM BLOOD Fibrino-140*
[**2117-10-29**] 08:40PM BLOOD Glucose-120* UreaN-29* Creat-1.5* Na-144
K-4.4 Cl-118* HCO3-15* AnGap-15
[**2117-10-30**] 01:29AM BLOOD Glucose-108* UreaN-35* Creat-1.3* Na-142
K-5.2* Cl-115* HCO3-21* AnGap-11
[**2117-10-29**] 08:40PM BLOOD ALT-15 AST-20 AlkPhos-31* Amylase-40
TotBili-0.4
[**2117-10-30**] 03:38PM BLOOD LD(LDH)-245 CK(CPK)-522* TotBili-1.4
[**2117-10-30**] 05:07AM BLOOD cTropnT-0.04*
[**2117-10-30**] 03:38PM BLOOD CK-MB-12* MB Indx-2.3 cTropnT-0.06*
[**2117-10-31**] 04:19AM BLOOD cTropnT-0.03*
[**2117-10-29**] 08:40PM BLOOD Albumin-2.2* Calcium-6.4* Phos-1.8*
Mg-1.4*
[**2117-10-30**] 03:38PM BLOOD Hapto-<5*
[**2117-10-29**] 08:50PM BLOOD Glucose-117* Lactate-5.1* Na-139 K-4.2
Cl-119* calHCO3-15*
[**2117-10-29**] 09:49PM BLOOD Glucose-134* Lactate-3.9* K-6.0*
[**2117-10-30**] 01:35AM BLOOD Lactate-2.4*
[**2117-10-30**] 05:23AM BLOOD Lactate-2.0
[**2117-10-31**] 04:37AM BLOOD Lactate-1.3
.
EKG ([**10-29**]): Atrial tachycardia or flutter with variable block.
Non-specific ST-T wave
changes. A single ventricular premature beat is noted. No
previous tracing available for comparison.
.
CXR ([**10-29**]): No focal consolidation. Nasogastric tube is seen
in the upper esophagus, but cannot be followed reliably into the
stomach due to underpenetration.
.
CXR ([**10-30**]): As compared to the previous radiograph, there is a
newly appeared complete left lower lobe atelectasis. In
addition, a small left pleural effusion is seen.
Otherwise, the radiograph is unchanged. The monitoring and
support devices
are constant. Unchanged size of the cardiac silhouette.
Unchanged absence of
parenchymal opacities in the right lung.
.
EKG ([**11-1**]): Probable atrial flutter with 4:1 block. Early R
wave progression. Since the
previous tracing of [**2117-10-31**] the ventricular rate has decreased.
Otherwise, findings are unchanged.
.
CXR ([**11-3**]): Left lower lobe aeration is improving, small left
pleural effusion stable. Upper lungs clear. Mild cardiomegaly
unchanged. ET tube and transvenous right atrial and right
ventricular pacer leads in standard placements. No pneumothorax.
.
EKG ([**11-4**]): Atrial flutter with ventricular paced rhythm. Since
the previous tracing of [**2117-11-1**] ventricular paced rhythm is now
present.
.
EKG ([**11-5**]): Atrial flutter with rapid ventricular response.
Diffuse non-specific ST-T wave
changes. Compared to the previous tracing of [**2117-11-4**]
ventricular pacing is not seen on the current tracing.
.
CXR ([**11-4**]): As compared to the previous radiograph, there is
minimally increasing mainly perihilar opacity, potentially
reflecting mild-to-moderate pulmonary edema. As compared to the
previous radiograph, there has also been an increase in the
extent of the retrocardiac atelectasis. The presence of a small
left pleural effusion cannot be excluded.
.
CXR ([**11-5**]): Mild pulmonary edema which developed on [**11-4**]
and perihilar consolidation in the left mid lung have both
cleared. Although the heart size is normal
there is still pulmonary vascular engorgement suggesting
elevated left atrial pressure. There is no pneumothorax or
pleural effusion. Nasogastric tube passes into the stomach and
out of view. Transvenous right atrial and ventricular pacer
leads are in standard placement.
.
EKG ([**11-7**]): Atrial flutter with controlled ventricular
response. Compared to tracing #1
ventricular response is slower.
.
Discharge Labs:
.
[**2117-11-9**] 06:23AM BLOOD WBC-8.5 RBC-3.43* Hgb-9.9* Hct-29.9*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.3 Plt Ct-296#
[**2117-11-9**] 06:23AM BLOOD PT-12.7 PTT-22.8 INR(PT)-1.1
[**2117-11-9**] 06:23AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-139
K-4.0 Cl-107 HCO3-24 AnGap-12
[**2117-11-9**] 06:23AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9
Brief Hospital Course:
57 year old man with h/o afib/flutter on Coumadin, pacemaker,
CAD s/p stents x2, prior CVA, seizures, HLD, HTN, asthma,
arthritis on NSAIDs, who was transferred from an OSH with
hematemsis.
.
#. GIB: Pt with brisk upper GI bleed - HCT dropped from 35 at
the OSH to 18 here, despite transfusion of 1unit pRBCs. Initial
thought to be peptic ulcer disease, given h/o epigastric
discomfort and long term NSAID use. No h/o GI bleeds or
cirrhosis. Pt has received Pt has received 18 units pRBCs, 9
units FFP, and 3 packs of platelets during the admission.
Recieved 2 EGD's which failed to visualize a lesion, therefore a
gastric dieulafoy lesion was on top of the differential.GI
placed the patient as high risk for bleeding on anticoagulation
and the decision to restart anticoagulation should be made by
cardiology. The patient was placed on a PPI gtt which was later
transitioned to the IV BID. Held Coumadin, ASA, Plavix. Upon
transfer to the floor, the patient was transitioned to an oral
PPI, which he was discharged on. ** The patient should follow up
with his outpatient cardiologist to determine which
anti-platelet agents and anti-coagulants should be restarted **
.
# Citrobacter Pneumonia: The patient was intubated early in his
hospitalization for airway protection. Several days into his
hospital course the patient developed fevers and sputum, urine
and blood cultures were performed. The initial sputum culture
grew Citrobacter koseri that was sensitive to Cefepime, which
the patient was started on. CXR demonstrated evidence concerning
for a left-sided infiltrate but also a small pleural effusion.
The patient was treated with Cefepime throughout his
hospitalization. Repeat CXR prior to discharge revealed
resolution of the pulmonary edema and only minimal evidence of
the possible infiltrate seen early in his hospitalization. The
patient needed an additional seven days of Cefepime following
discharge to complete his course of antibiotics for his
hospital-acquired pneumonia and was discharged to an extended
care facility where his antibiotics would be completed.
.
#. Blood Pressure: The patient was initially hypotensive on
admission in the setting of his upper gastrointestinal bleed.
His hypotension improved with fluid and blood products. Post
extubation, the patient SBP reached the 170s and his HR reached
the 120s. The patient was started on Metoprolol 25mg PO TID
prior to transfer to the medicine service. Blood pressure and
heart rate control were achieved on this regimen, which the
patient was discharged on.
.
#. Chest pain: Patient had atypical chest pain prior to
admission admission. Trop-I were less than 0.06 at OSH. Repeat
troponin testing at [**Hospital1 18**] were 0.01 on admission with the
following subsequent changes while in the medical ICU, 0.03 -->
0.06 --> 0.03. These mild elevations were seen in the setting of
acute renal failure and the patient's upper GI bleed. Repeated
EKG testing revealed non-specific ST-T changes that persisted
throughout the patient's hospitalization. No outside/old EKGs
were available for comparison. The patient remained chest pain
free throughout his hospitalization. No acute interventions were
sought. As per below, the patient's anti-coagulation was held
but the patient was started on Aspirin 81 mg daily. Of note, the
patient had known CAD with 2 bare metal stents in place that
were from several years prior. Of concern, the patient was
admitted on Coumadin, Aspirin and Clopidogrel. Given the timing
of the patient's stent placement and apparent duration of
Clopidogrel therapy, this medication was not restarted during
this hospitalization. The patient was given a follow up
appointment the day after discharge with his Cardiologist to
discuss what anti-coagulation and anti-platelet therapies the
patient needed to be continued on.
.
#. Afib/flutter: The patient's home Metoprolol was discontinued
on arrival to the hospital because of hypotension. The patient
was started on Metoprolol Tartrate 25 mg PO TID once his
hypotension resolved and his gastrointestinal bleeding resolved.
The patient was intermittently in atrial fibrillation/flutter in
the throughout his stay. The patient's Coumadin was held given
recent GI bleed. Per above, the patient was discharged with a
follow up appointment with his cardiologist the day after
discharge.
.
#. UTI: Given the patient's fevers, his urine was cultured early
in his hospitalization at the same time his sputum was cultured.
Klebsiella pneumoniae was cultured and grew 10,000 to 100,000
CFU/mL. The patient most likely acquired the infection from his
foley. The baceria was sensitive Cefepime, which the patient
would complete the appropriate course for while being treated
for his pneumonia as per above.
.
#. Acute Renal Failure: The patient's serum creatinine was
elevated to 1.9 at OSH from a baseline 0.9. Given the patient's
UGIB and hypotension on admission, the most likely etiology was
pre-renal renal failure. The patient's renal failure responded
to volume resuscitation with intravenous fluids and blood
products. His serum creatinine was 0.8 at discharge.
.
#. Hyperlipidemia: Stable. Simvastatin was restarted on transfer
to the floor.
.
#. Psych: Stable. The patient's anti-psychotics were restarted
on transfer to the floor. ** The patient's anticipated time in
rehabilitation is less than one month. **
Medications on Admission:
Coumadin 7.5mg PO qhs
ASA 81mg PO daily
Plavix 75mg PO daily
Toprol 50mg PO daily
Lisinopril 10mg PO daily
Ziprasidone 80mg PO BID
Adderall 10mg PO daily
Lamictal 100mg PO daily
Simvastatin 40mg PO daily
Abilify 5mg PO
Buspirone 10mg PO TID
Glucosamine
Aleve x several years
MSM (methylsulfonylmethane)
Discharge Medications:
1. cefepime 2 gram Recon Soln Sig: One (1) infusion Intravenous
every twelve (12) hours for 7 doses.
Disp:*7 doses* Refills:*0*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Abilify 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Glucosamine Oral
7. methylsulfonylmethane Oral
8. Adderall 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day). Tablet(s)
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
Upper GI bleed
Pneumonia
.
Secondary Diagnoses:
Asthma
Hyperlipidemia
Bipolar Disorder
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:
Mr. [**Known lastname 88028**]:
.
You were brought to the hospital because of a upper
gastrointestinal bleed which caused your blood pressure to
decrease. You were cared for in the medical ICU and received
blood transfusions and respiratory assistance with mechanical
ventilation. You improved with these therapies. Two endoscopies
could not visualize a source for your bleeding from your
stomach. You will need to follow up with the gastroenterology
department as an outpatient. There was also some concern over
the Coumadin, Plavix and Aspirin that you were taking when you
were admitted to the hospital as these increase your risk of
gastrointestinal bleeding. You need to follow up with your
cardiologist to determine which of these medications should be
continued.
.
We made the following changes to your home medication list:
.
1. Stop Coumadin 7.5 mg by mouth at night until you follow up
with your outpatient cardiologist.
2. Stop Plavix 75 mg by mouth daily until you follow up with
your outpatient cardiologist.
3. Stop Toprol XL 50 mg by mouth daily.
4. Start taking Metroprolol tartrate 25 mg by mouth three times
a day. Your outpatient cardiologist may adjust this medication.
5. Start taking Omeprazole 40 mg by mouth once a day. This
medication will help to protect your stomach.
6. Start Cefepime 2 gram solution. Give one infusion
intravenously every twelve hours for 7 doses. Begin the evening
of [**11-9**].
.
No other changes were made to your medications.
Followup Instructions:
Please keep all follow up appointments as below.
.
1.
Cardiology
Dr. [**Last Name (STitle) **]
[**Hospital3 **]
3:45 PM
([**Telephone/Fax (1) 40360**]
.
2.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2117-11-23**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2117-11-13**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"45.13",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14768, 14841
|
8079, 13443
|
318, 451
|
14991, 14991
|
3849, 7707
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
2732, 2906
|
3482, 3830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,419
| 170,460
|
14624
|
Discharge summary
|
report
|
Admission Date: [**2197-4-26**] Discharge Date: [**2197-5-7**]
Date of Birth: [**2122-12-18**] Sex: M
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Aorto [**Hospital1 **]-iliac occlusive disease and right
iliac artery aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 74 year old
nondiabetic white male with coronary artery disease,
hypertension, hypercholesterolemia, who was transferred from
[**Hospital6 204**] in [**2196-7-9**], to [**Hospital1 346**], with an acute myocardial infarction
and complete heart block which required the placement of
temporary pacing wires. During cardiac catheterization at
[**Hospital1 69**], the patient was found
to have a right iliac artery aneurysm and was stented prior
to cardiac catheterization. The patient subsequently
underwent a coronary artery bypass graft times two on
[**2196-7-27**]. Postoperatively, he had an isolated episode of AV
dissociation and was evaluated by the electrophysiology
service. Study revealed inducible ventricular tachycardia
and the patient underwent an internal cardiac defibrillator
and pacemaker placement on [**2196-7-28**].
Following recovery from his coronary artery bypass graft, the
patient is admitted for elective repair of his 3.0 centimeter
right common iliac artery aneurysm as well as an aorto
bifemoral bypass graft for bilateral claudication.
PAST MEDICAL HISTORY:
1. Coronary artery disease; myocardial infarction [**2187**],
myocardial infarction [**7-10**]; coronary artery bypass graft
times two [**7-10**], at [**Hospital1 69**].
2. Complete heart block, permanent pacemaker placement
[**2196-7-28**].
3. Inducible ventricular tachycardia; internal cardiac
defibrillator placement, [**2196-7-28**].
4. Hypertension.
5. Hypercholesterolemia.
6. Chronic low back pain.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times two on [**2196-7-25**], by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
2. Pacemaker and internal automatic cardiac defibrillator
placement on [**2196-7-28**].
FAMILY HISTORY: The patient's sister is status post coronary
artery bypass graft and is in her 80s.
SOCIAL HISTORY: The patient is a retired plumber. He lives
with his wife. [**Name (NI) **] quit smoking approximately ten years ago
after one pack per day times fifty years. He has one
alcoholic drink per day on average.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metoprolol 50 mg p.o. twice a day.
2. Enalapril 5 mg p.o. twice a day.
3. Norvasc 2.5 mg p.o. once daily.
4. Hydrochlorothiazide 12.5 mg p.o. once daily.
5. Lasix 20 mg p.o. once daily.
6. Lipitor 40 mg p.o. once daily.
7. Aspirin one p.o. once daily.
8. Multivitamin one p.o. once daily.
9. Doxepin 4 mg p.o. q.h.s.
PHYSICAL EXAMINATION: Vital signs revealed pulse 59, blood
pressure left arm 187/80, height five feet seven inches,
weight 160 pounds. In general, the patient is alert,
cooperative white male in no acute distress. Head, eyes,
ears, nose and throat - The pupils are equal, round, and
reactive to light and accommodation. Sclera anicteric. Neck
reveals no lymphadenopathy or thyromegaly. Carotids
palpable. No bruits. Chest - The heart is regular rate and
rhythm without murmur. The lungs are clear bilaterally. The
abdomen is soft, nontender, no hepatosplenomegaly. Rectal
examination was deferred. Extremities no edema. Palpable
femoral pulses bilaterally, left stronger than right.
Dorsalis pedis pulses palpable bilaterally. Neurological
examination is nonfocal.
LABORATORY DATA: On admission, [**2197-4-19**], white blood cell
count 7.7, hemoglobin 15.0, hematocrit 43.8, platelet count
179,000. Prothrombin time 11.9, partial thromboplastin time
24.8, INR 0.9. Sodium 140, potassium 3.8, chloride 97, CO2
30, blood urea nitrogen 33, creatinine 1.3, glucose 85.
Chest x-ray showed no acute pulmonary disease.
Electrocardiogram showed a regular AV sequential pacing.
Pacemaker rhythm.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2197-4-26**], following an aorto bifemoral bypass graft and right
iliac artery aneurysm repair. The surgery was complicated by
considerable intraoperative bleeding with an estimated blood
loss of five liters. The patient was resuscitated with
packed red blood cells, platelets, cryoprecipitate, and
crystalloid for a total of approximately 20 liters.
Postoperatively, the patient's feet were equally warm and he
had palpable posterior tibialis pulses. The patient was
started on perioperative Kefzol. The electrophysiology
service disabled his ICD which had been set for a heart rate
of 60. At the end of surgery, they reprogrammed his ICD for
pacing at 70 instead of 60.
The patient remained intubated and sedated on Propofol
because of respiratory compromise from massive fluid
resuscitation. Chest x-ray showed bilateral pleural
effusions and moderate congestive heart failure immediately
postoperatively.
The patient was transferred to the Surgical Intensive Care
Unit where aggressive pulmonary toilet was maintained and
aggressive diuresis with intravenous Lasix was continued.
Diamox was added on postoperative day number six for 48 hours
and then both Diamox and Lasix were stopped. The patient
continued to diurese on his own. The patient was extubated
on [**2197-5-3**]. While the patient was intubated, he also had a
nasogastric tube in place. TPN had been started on [**2197-5-3**].
However, on the day following extubation, the patient had
some bowel sounds and so sips of clear liquid were started.
The following day the patient's diet was advanced and the day
after that the patient was able to tolerate a regular diet.
His TPN was then stopped.
Postoperatively, the patient had several fever spikes.
Sputum cultures, grain stain showed gram negative rods. The
patient was started on a ten day course of Levofloxacin and
Vancomycin. Cultures finally grew E. coli. There were no
gram positive cocci. Vancomycin was stopped. The patient
will be discharged home to complete a ten day course of
Levofloxacin.
Physical therapy evaluated the patient for full weight
bearing ambulation. Home physical therapy evaluation was
recommended by the VNA.
At the time of discharge, the patient's abdominal and groin
incisions were clean, dry and intact. His abdominal staples
were removed and the incision was Steri-stripped at the time
of discharge. His groin staples will remain for two more
weeks. His feet were equally warm with palpable posterior
tibialis pulses.
The patient will follow-up with Dr. [**Last Name (STitle) **] in the office on
Thursday, [**2197-5-11**]. He will follow-up with his cardiologist,
Dr. [**Last Name (STitle) 12167**], within two weeks of discharge because of change
in his blood pressure medications during hospitalization.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. once daily for six more days.
2. Lopressor 25 mg p.o. twice a day.
3. Lasix 20 mg p.o. once daily.
4. Atorvastatin 40 mg p.o. once daily.
5. Aspirin 325 mg p.o. once daily.
6. Darvocet N-100 one tablet p.o. q6hours p.r.n. pain.
CONDITION ON DISCHARGE: Satisfactory. Discharge home with
VNA services.
PRIMARY DIAGNOSES:
1. Aorto [**Hospital1 **]-iliac disease and right iliac artery aneurysm.
2. Aorto bifemoral bypass graft and right iliac artery
aneurysm repair on [**2197-4-26**].
SECONDARY DIAGNOSES:
1. Significant intraoperative bleeding.
2. Respiratory compromise secondary to fluid resuscitation
resulting in prolonged intubation.
3. E. coli pneumonia.
4. Lack of nutrition secondary to intubation; TPN started.
5. Coronary artery disease.
6. Hypertension.
7. Hypercholesterolemia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2197-5-9**] 20:05
T: [**2197-5-9**] 20:36
JOB#: [**Job Number 43111**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.46",
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icd9pcs
|
[
[
[]
]
] |
2064, 2149
|
6852, 7115
|
2439, 2769
|
3994, 6826
|
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|
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|
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|
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|
277, 1357
|
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|
2166, 2413
|
7140, 7376
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,592
| 104,400
|
36591
|
Discharge summary
|
report
|
Admission Date: [**2198-8-31**] Discharge Date: [**2198-10-15**]
Date of Birth: [**2137-9-5**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pneumonia, pancreatic pseudocyst
Major Surgical or Invasive Procedure:
[**2198-9-4**]- Aborted PEG placement
[**2198-9-5**]- GJ tube placement
8/10,14,28,25/09- Laparoscopic pancreatic necrosectomy and
drainage tube placement
History of Present Illness:
Pt is a 60 yo F transferred from [**Hospital3 **] for
management of complicated pancreatitis as well as possible
pnuemonia. Transferred for worsening respiratory status as well
as failure to progress w/ pancreatitis/pseudocyst tx. Pt was
originally admitted on [**2198-6-8**] for gallstone pancreatitis,
complicated by infected pseudocyst, pneumonia, ARDS and
persistent fevers. She has failed multiple ERCP stent
palacements. Per OSH records, she developed fever to 101.8 and
white count of 16.8 today prior to transfer to [**Hospital1 **]. Her
amylase/lipase have normalized. The patient underwent
tracheostomy on [**2198-7-12**] and was weaned from the vent on [**2198-7-24**],
and has been stable on trach mask w/ 10L O2. Of note, pt has
been treated for VRE and CDiff during her extended
hospitalization.
Past Medical History:
-Prior left foot surgery for a heel spur
-no other PMH prior to gallstone pancreatitis
-as above: ARDS, PNA, gallstones, pancreatitis, pseudocyst,
tachy-brady syndrome
Social History:
Patient is engaged and her fiancee is her health care proxy.
She denies tobacco, EtOH, or IVDU.
Family History:
Noncontributory.
Physical Exam:
VS 96.4 92 104/60 20 100%TM
Gen: A&O, NAD, Trached
Neuro: CN II-XII grossly intact
HEENT: NCAT, Anicteric
Card: RRR -mgr
Pulm: + Ronchi bilat, Diffuse crackles
Abd: Soft, NTND, 3 drains in place draining brown fluid, GJ
clamped
Ext: No cyanosis, clubbing, or edema
Skin: No ulcers
Pertinent Results:
[**2198-8-31**] 10:51PM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-270* ALK
PHOS-170* AMYLASE-31
[**2198-8-31**] 10:51PM LIPASE-27
[**2198-8-31**] 10:51PM ALBUMIN-2.0* CALCIUM-8.8 PHOSPHATE-3.5
MAGNESIUM-2.2 IRON-37
[**2198-8-31**] 10:51PM calTIBC-117* FERRITIN-GREATER TH TRF-90*
[**2198-8-31**] 10:51PM TRIGLYCER-78
[**2198-8-31**] 10:51PM WBC-13.5* RBC-2.82* HGB-8.3* HCT-27.7* MCV-98
MCH-29.4 MCHC-29.9* RDW-15.7*
[**2198-8-31**] 10:51PM PLT COUNT-530*
[**2198-8-31**] 10:51PM PT-13.4 PTT-24.3 INR(PT)-1.1
[**2198-8-31**] 11:24PM URINE HYALINE-[**4-5**]*
[**2198-8-31**] 11:24PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
Brief Hospital Course:
Briefly, this is a 60F with gallstone pancreatitis [**6-9**] with
unsuccessful ERCP
complicated by ARDS (now s/p trach) and severe pancreatitis
resulting in multiple pseudocysts with prolonged, intermittent
fevers. Was at [**Hospital 8**] Hospital/[**Hospital1 **] for extended period
with VRE from pseudocysts, pseudomonas PNA and UTI (treated with
amikacin, details unclear), and c diff treated with oral vanco.
Was transferred to [**Hospital1 **] for futher management and possible cyst
gastrectomy.
The patient was admitted from OSH at the beginning of [**Month (only) 216**],
expressing suicidal ideation, refusing ventilator, refusing
surgery. Per psychiatry evaluation, patient having delirium,
currently denying suicidal ideation and expressing desire to go
ahead with further medical/surgical interventions.
Over the ensuing days, her affect improved, the suicidal
ideation ceased, and she agreed to treatment of her
pancreatitis. Upon transfer, was thought to be poor candidate
for cyst gastrostomy, and has been managed with multiple
pseudocyst
debridements - OR on [**9-10**] (placement of two drainage and
irrigation systems), [**9-14**] (necrosectomy), [**9-18**] (necrosectomy),
[**9-25**] (laparoscopic necrosectomy, 2 L flank drains placed, others
not changed, of note there was a concern for a possible enteric
fistula based on the nature of the drainge). She was found to
have stool leakage and then then underwent a CT scan which
revealed a pancreaticocolonic fistula. No small bowel fistula
was ever identified on Small Bowel Follow Through study. Based
on this finding, she was made NPO and put on TPN, which she
needs to continue on until surgical follow up.
She also underwent GJ tube placement on [**2198-9-5**]. The GJ is not
currently being used and should be clamped until after her
follow up visit.
As far as her infectious disease course during this
hospitalization, pseudocyst cultures have grown heavy
pseudomonas and sparse enterococcus. She had a BAL with 10-100K
oral flora and >100k pseudomonas ([**Last Name (un) 36**] to pip-tazo, tobra, but
intermed to meropenem and R to cipro). C diff was negative x 3
but was sent here on oral vancomycin and finished a 14 day
course.
She was on linezolid/meropenem/oral vanco then changed to
linezolid/pip-tazo/tobra (conventional dosing)/oral vanco. Based
on sensitivities of the pseudomonas and the enterococcus, was
then on a course of dapto, zosyn, tobramycin. At that time,
adequate drainage was in place after drains placed in OR, and
remaining positive cultures of drain fluid most likely
represented colonization rather than infection, and so once
completed over 14 days of antibiotics, they were discontinued on
[**9-20**].
Had a possible VAP with RLL infiltrate/collapse, BAL [**9-1**] done
and with 2+polys, grew pseudomonas, treated with zosyn and
inhaled tobra initially, and then iv tobra, and completed a
treatment course on [**9-13**] in case of a VAP or aspiration pna.
Antibiotics were then resumed when there was evidence of colonic
fistula formation. At the time of discharge, she was on IV
Ciprofloxacin and IV Tobramycin, which she should continue for 2
weeks until surgical follow up.
Medications on Admission:
-Albuterol/Ipratropium -4 puffs TID
-Ferrous Sulfate 325mg daily
-Lovenox 40mg SC daily
same medications on transfer:
-Guaifenesin 200mg q4hrs PRN
-Tylenol 650mg q6hrs PRN
-Albuterol INH, 4 puffs qhour PRN
-Lactobacillus Acidophilis/lactinex -1 tablet daily
-Miconazole 2% ointment PRN
-Octreotide acetate 100 mcg SC TID
-olanzapine 10mg PO qhs
-Protonix 40mg IV BID
-Vitamin A&D external cream PRN
-Zinc oxide ointment PRN
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for For
wheezes.
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
3. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours) for 2 weeks.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for secretions.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
9. Hydromorphone (PF) 1 mg/mL Syringe Sig: [**2-2**] Injection Q4H
(every 4 hours) as needed for pain.
10. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for pain.
11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain .
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Ondansetron 8 mg IV Q8H:PRN nausea
14. Tobramycin Sulfate 80 mg/8mL Solution Sig: 90 mg
Intravenous every eight (8) hours for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Gallstone pancreatitis, pseudocysts percutaneously, and
pneumonia s/p tracheostomy as well as waxing mental status,
perc/lap necrosectomy x 4
Discharge Condition:
Good, meeting discharge criteria, stable respiratory status with
trach mask, NPO and chronically on TPN at baseline.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-15**] lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
* Monitor your incision for signs of infections
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
Followup Instructions:
Call Dr.[**Name (NI) 5067**] office at ([**Telephone/Fax (1) 6347**] to schedule a follow up
appointment in 2 weeks.
|
[
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"577.1",
"041.04",
"V45.01",
"518.83",
"E879.8",
"577.0",
"577.2",
"E849.8",
"348.30",
"V64.2",
"574.20",
"518.0",
"783.3",
"599.0",
"482.1",
"519.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.32",
"96.72",
"00.14",
"52.09",
"97.23",
"33.24",
"38.93",
"52.22",
"99.15",
"52.01"
] |
icd9pcs
|
[
[
[]
]
] |
7776, 7831
|
2625, 5817
|
300, 459
|
8017, 8136
|
1955, 2602
|
10240, 10360
|
1620, 1638
|
6291, 7753
|
7852, 7996
|
5843, 5936
|
8160, 10217
|
1653, 1936
|
228, 262
|
487, 1299
|
5961, 6268
|
1321, 1491
|
1507, 1604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,547
| 186,418
|
8002
|
Discharge summary
|
report
|
Admission Date: [**2177-4-6**] Discharge Date: [**2177-4-20**]
Date of Birth: [**2112-1-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
confusion, weight gain
Major Surgical or Invasive Procedure:
Paracentesis
Right Internal Jugular Central Line
TIPS revision
Intubation
TPA infusion
History of Present Illness:
Mr. [**Known lastname 28650**] is a 65 yo male with ulcerative colitis and
cirrhosis from NASH on the liver transplant list who was
transferred from [**Hospital 11066**] Hospital after presentation on the
evening of [**4-5**] for increasing abdominal distention and 13 lbs.
Weight gain over the past 3 weeks. In the ED at [**Hospital 11066**]
Hospital, T 97.8, BP 165/91, HR 82, spO2 99% on RA. He was given
Lasix 80 mg IV and Morphine 4 mg IV x 1. BG 439. He was
transferred to [**Hospital1 18**] for further care.
.
On arrival to our ED, T 98.9, BP 144/78, HR 104, RR 28, SpO2 96%
on RA. Patient was found to be confused and CT head was
performed. A paracentesis was attempted but unsuccessful due to
inability to penetrate the subcutaneous tissue. Patient was
treated empirically for SBP with Vancomycin 1 gram and Zosyn 4.5
gram.
.
On arrival to the floor, he passed an unquantified "large
amount" of bright red blood from his rectum. The aide states
that she did not visualize any stool in the toilet and only
blood. At the time of this interview, patient does not recall
what prompted him to go to the hospital. He states he feels
fine. He denies abdominal pain, fevers, chills, SOB, or any
episodes of BRBPR at home.
Past Medical History:
-HTN
-DMII - takes insulin at home, diagnosed [**2168**]
-Cirrhosis - diagnosed by biopsy in [**2168**], thought secondary to
NASH, c/b ascites and LGIB s/p TIPS [**2176-12-3**] and s/p ablation of
three grade I esophageal varices
-S/p tonsillectomy
-Ulcerative colitis dx [**2176**] (thought to be the cause of LGIB)
Social History:
Lives alone, wife died in [**2168**]. Smoked for 33 yrs X 1ppd and
quit [**2160**]. Does not drink alcohol, no drugs. He has two
daughters who visit him frequently. Retired in [**1-/2177**], formerly
a vice president in manufacturing.
Family History:
HTN, Pancreatic CA
Physical Exam:
On admission:
VITALS: T 96.7, BP 148/76, HR 97, RR 22, SpO2 98% on RA
GENERAL: ill-appearing elderly [**Male First Name (un) 4746**], no acute distress
HEENT: sclera anicteric, EOMI, PERRL, OP clear without lesions
NECK: No cervical lymphadenopathy, + JVD, no carotid bruit
CARD: RRR, normal S1/S2, no m/r/g
RESP: CTA bilaterally, no wheezes/rales/rhonchi
ABD: Soft, distended with shifting dullness and positive fluid
wave, no tenderness to deep palpation, no rebound or guarding
RECTAL: frank BRBPR
BACK: No spinal tenderness, no CVA tenderness
EXT: 2+ pitting edema to knees
NEURO: CN II-XII, Oriented to person, but not place or date.
Pertinent Results:
LABS ON ADMISSION:
.
BLOOD
[**2177-4-6**] 03:15AM BLOOD WBC-19.3*# RBC-4.08* Hgb-11.8* Hct-36.7*
MCV-90 MCH-28.9 MCHC-32.1 RDW-14.4 Plt Ct-110*#
[**2177-4-6**] 03:15AM BLOOD Neuts-92.4* Lymphs-4.3* Monos-3.0 Eos-0.3
Baso-0.1
[**2177-4-6**] 03:58PM BLOOD PT-19.9* PTT-29.2 INR(PT)-1.9*
[**2177-4-6**] 02:30AM BLOOD Glucose-334* UreaN-37* Creat-1.5* Na-134
K-4.5 Cl-103 HCO3-23 AnGap-13
[**2177-4-6**] 02:30AM BLOOD ALT-33 AST-28 CK(CPK)-41 AlkPhos-169*
TotBili-2.2*
[**2177-4-6**] 02:30AM BLOOD Calcium-8.9 Mg-1.6
.
URINE
[**2177-4-6**] 09:32AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2177-4-6**] 09:32AM URINE RBC-689* WBC-12* Bacteri-FEW Yeast-NONE
Epi-1
.
ASCITES
[**2177-4-6**] 03:36PM ASCITES WBC-4600* RBC-2200* Polys-83* Lymphs-2*
Monos-15*
[**2177-4-6**] 03:36PM ASCITES TotPro-0.3 Glucose-365 LD(LDH)-88
Amylase-12 Albumin-<1.0 Triglyc-75
.
LABS ON DISCHARGE:
[**2177-4-20**] 08:40AM BLOOD WBC-7.8# RBC-3.36* Hgb-10.2* Hct-30.7*
MCV-91 MCH-30.3 MCHC-33.2 RDW-18.4* Plt Ct-71*#
[**2177-4-20**] 08:40AM BLOOD PT-28.7* PTT-49.6* INR(PT)-2.9*
[**2177-4-20**] 08:40AM BLOOD Glucose-114* UreaN-53* Creat-2.0* Na-141
K-4.3 Cl-105 HCO3-22 AnGap-18
[**2177-4-20**] 08:40AM BLOOD ALT-13 AST-17 AlkPhos-61 TotBili-5.6*
[**2177-4-20**] 08:40AM BLOOD Albumin-5.2* Calcium-10.0 Phos-2.7 Mg-2.0
.
MICROBIOLOGY:
Bl Cx, Urine Cx - negative
Sputum ([**4-7**]) - MRSA
.
.
CARDIOLOGY:
EKG - Sinus tachycardia with monomorphic ventricular premature
beats. Left axis deviation. There may left atrial abnormality.
(A wave appears bifid in lead II). Compared to the previous
tracing of [**2177-1-16**] ventricular premature beats are now seen.
Other findings are similar.
.
.
RADIOLOGY:
.
CXR ([**4-6**]): IMPRESSION: No acute cardiopulmonary process. The
previously noted right lower lobe opacity has now resolved.
.
Abd U/S ([**4-6**]):
IMPRESSION:
1. Occlusion of TIPS and portal vein.
2. Cirrhosis, ascites and splenomegaly.
.
Abd U/S ([**4-19**]):
IMPRESSIONS:
1. Patent TIPS with velocities as described above. Globally,
these have
overall increased relative to the prior exam.
2. No flow within the left portal vein, as previously. Remainder
of hepatic
vasculature is patent.
3. Moderate ascites.
.
TIPS REDO ([**Date range (1) 26511**]):
Portal venogram, angioplasty of TIPS to 10 mm, thrombolysis of
TIPS and portal vein with angiojet, placement of infusion
catheter within
TIPS, angioplasty of portal vein to 12 mm. The patient is to
return tomorrow for reimaging following TPA infusion tonight.
Plan to possibly embolize existing large gastric varix at that
time.
.
KUB [**4-11**]:
IMPRESSION: Limited study due to ascites. Within this
limitation, non-
specific bowel gas pattern.
Brief Hospital Course:
In short, Mr [**Known lastname 28650**] is a 65M w DM2, Ulcerative Colitis and
cirrhosis [**2-3**] NASH s/p TIPS c/b portal hypertensive colopathy
and esophageal varices, admitted w confusion, weight gain,
abdominal distention, found to have TIPS occlusion, which likely
precipitated the ascites accumulation c/b SBP and hepatic
encephalopathy, with hospital course further c/b BRBPR s/p MICU
stay.
.
# Hepatic encephalopathy: likely from acute processes
(infection, TIPS occlusion, possible UC flair, hepatic
encephalopathy). Improved after re-opening TIPS and treating
SBP. Also continued lactulose and rifaximin with good effect.
.
# TIPS occlusion: On admission, patient had an ultrasound with
doppler which showed occlussion of TIPS and portal vein. Patient
went to IR and was intubated for the procedure. Underwent
angiojet, TPA, and dilation. After the procedure he was
extubated, became agitated and saturations were low, he was
re-intubated for concern of protection of airway. He underwent a
CTA of the chest to r/o PE as cause of hypoxia which showed no
PE and significant atelectasis. He was admitted to the MICU.
The CT also demonstrated likely infiltrate consistent with
pneumonia. He was started on vancomycin/cefepime then switched
to vancomycin/cetriaxone with good effect. Upon leaving the
MICU he was stable on nasal cannula. He was also continued on a
heparin gtt with good effect. He was transitioned to lovenox
which was initially well tolerated but eventually resulted in
thrombocytopenia (drop to 20 from baseline of 50-70). Given
this it was felt that the risk of bleeding was too great with
the lovenox and the patient was discharged without
anticoagulation. Of note, his auto-anticoagulation is much
higher at this point than on admission (INR now 2.9 and 1.9) .
There was discussion on the inpatient service of a potential
retrialing of the lovenox as an outpatient as well as frequent
ultrasounds.
.
# SBP: Patient had a paracentesis on admission [**4-6**] which showed
4600 WBC (83%PMN) consistent with SBP, he had been treated
empirically with CTX. He was given vancomycin/CTX for both
pneumonia and SBP for which he was to complete a 10 day course.
.
*GIB: Pt develop BRBPR likely [**2-3**] combination of portal
colopathy, UC in setting occluded TIPS with increased pressures.
Hct dropped from 36 to 23, received 5 units PRBCs in total. His
Hct stabilized thereafter. Colonoscopy done showed improved
colitis but did not show bleeding varices.
.
# Respiratory failure: clear CXR on admission, intubated
electively for procedure and failed extubation in setting
agitation and concern for airway protection. CTA showed no
evidence of PE but there is concern for aspiration and
pneumonia, significant atelectasis. He was treated for
pneumonia and was successfully weaned from the vent, extubated
on [**2177-4-10**].
.
# DM2: difficult to control given the acute processes and
steroids started for [**Last Name (LF) **], [**First Name3 (LF) **] pt was started on an insulin gtt.
He was eventually switched to glargine with HISS. However, his
blood sugars required further titration upon discharge from the
MICU. He was eventually discharged on glargine 26 units and
aggressive humalog sliding scale.
.
# Ulcerative colitis: started on steroids (prednisone 40mg
daily), switched to IV solumedrol given NPO and contraindication
to NG/OG in setting multiple anticoagulants. Was switched back
to prednisone on discharge from the MICU and tapered gradually
to 7.5 mg daily which was well tolerated by the patient. As
well he was started on azathioprine and balsalazine. Repeat
colonoscopy showed no current colitis.
.
# Acute Renal Failure: After his TIPS occluded and was
re-opened, he went into acute renal failure with Cr increasing
to 2.9. Renal ultrasound showed no hydronephrosis. Urine
electrolytes and culture were equivocal. The cause was thought
to be contrast induced nephropathy vs. hepatorenal syndrome. He
was supported with IVF and started on albumin 50g IV BID. His
Cr stabilized at 2.9. Octreotide and midrodrine were held upon
transfer from the MICU and his d/c creatinine was baseline.
.
# Cirrhosis [**2-3**] NASH: Continued rifaximin/lactulose with good
effect. Held diuretics given acute renal failure. Diuresed
prior to d/c and discharged with weight of 113.6kg.
Medications on Admission:
Clotrimazole troche 5x/day
Avodart 0.5 mg daily
Lasix 20 mg daily
Lantus 30 units qHS
HISS
Mesalamine 2400 mg PO BID
Omeprazole 20 mg [**Hospital1 **]
Prednisone 40 mg daily
Propanolol 20 mg [**Hospital1 **]
Spironolactone 50 mg daily
Detrol LA 4 mg daily
Ursodiol 300 mg [**Hospital1 **]
Calcium carbonate 500 mg TID
Vitamin D
Century senior MVI
Ferrous sulfate 325 mg daily
Loperamide 2 mg [**Hospital1 **]
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
Disp:*120 Troche(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Balsalazide 750 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
Disp:*1 bottle* Refills:*1*
9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itching.
Disp:*1 tube* Refills:*0*
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): to have at least 3 bowel movements a day.
Disp:*1 large bottle* Refills:*2*
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itching: Apply to
affected area sparing face and skin folds.
Disp:*1 pound jar* Refills:*0*
16. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Six (26)
units Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
18. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
19. Humalog 100 unit/mL Solution Sig: as dir Subcutaneous four
times a day: Please use the sliding scale provided.
Disp:*qs * Refills:*2*
20. Outpatient Lab Work
Please total bilirubin, creatinine, INR, CBC. Send results to
Dr. [**Last Name (STitle) 696**] at ([**Telephone/Fax (1) 1582**]
Discharge Disposition:
Home With Service
Facility:
VNA of southeastern mass
Discharge Diagnosis:
Occluded TIPS
Portal vein thrombosis
Spontaneous bacterial peritonitis
Hospital acquired pneumonia
Allergic drug reaction
Fluid overload
Secondary: End stage liver disease
Discharge Condition:
Improved mentation, afebrile
Discharge Instructions:
You were admitted to the hospital with abdominal distention and
confusion. We found that you had an occluded TIPS, which likely
caused accumulation of abdominal fluid complicated by infection
and confusion. For the treatment of the occluded TIPS you had
an intervension which removed the clot in your TIPS. This was
complicated by the placement of the breathing tube briefly and
the development of mild pneumonia.
Your hospital course was complicated by allergic reaction to a
medication (likely secondary to either vancomycin or
ceftriaxone) however, we are not sure which medication. As well
in the attempt to treat the blood clot in your liver we briefly
started you on lovenox. With this, you had a drop in your
platelets and thus we did not feel it was safe to continue on
lovenox. Thus you will be discharged without anticoagulation.
While you were here you had a colonoscopy which showed
significant improvement of your colitis. Thus we have been
able to decrease your prednisone to 7.5 mg daily. As well you
were started on azathioprine and Balsalazide for the continued
control of your colitis.
Your medication changes include:
Starting:
Balsalazide 750 mg three times daily (for colitis)
Azathioprine 100 mg daily(for colitis)
Lactulose 1-3 times daily for at least 3 BM a day (to prevent
hepatic encephalopathy)
Rifaximin 600 mg twice daily (to prevent hepatic encephalopathy)
Humalog sliding scale (for insulin management)
Decreasing:
Prednisone to 7.5 mg daily
Stopping:
Mesalamine
Please go to the ER if you have any fever, chills, chest pain,
shortness of breath, confusion, dizziness, increased rash or any
other concerning symptoms
You should continue on the creams for your rash.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2177-4-25**] 1:00
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2177-6-23**] 9:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2177-7-3**] 8:30
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-3**] weeks,
call for an appointment at [**Telephone/Fax (1) 28651**]
Completed by:[**2177-4-24**]
|
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31,709
| 101,360
|
31215
|
Discharge summary
|
report
|
Admission Date: [**2113-10-8**] Discharge Date: [**2113-10-12**]
Date of Birth: [**2046-9-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 67 y/o woman with PMH of diverticulitis, colitis,
and recent IMI s/p BMS to the RCA who presents with 5-6 episodes
of bright red blood per rectum. The patient initially presented
to [**Hospital3 **] on [**10-3**] with diffuse chest
pressure; at that time, she was found to have an inferior MI
with 100% RCA occlusion. She received a bare metal stent to the
RCA. Following her original cath, she had ongoing dyspepsia and
was sent to [**Hospital1 2025**] for repeat catheterization on [**10-6**] which did not
show any new blockage or instent thrombosis. She was discharged
on [**10-7**] on aspirin, plavix, lopressor, and captopril.
.
This morning at about 4:30 am, the patient woke up with
abdominal cramping which is usual for her. She had one large
bowel movement with some "dark" blood per her report. Her
abdominal cramping resolved but she had [**4-27**] more dark bloody
stools. At that time, she returned to [**Hospital3 **]
where she received 1 U PRBCs and was subsequently transferred to
[**Hospital1 18**]; she requested this as she has had a 1-year history of
diarrhea and was recently referred to Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) 6880**].
.
In our ED, initial vitals were T 98.3, HR 66, BP 125/90, with O2
sat 100% on RA. She refused NG lavage in the emergency room and
was seen by GI who are planning a colonoscopy tomorrow. She was
given 40 mg PO protonix and 75 mg plavix as well as 1 mg ativan.
She received 1 L NS and her 2nd unit of PRBCs prior to transfer
to the [**Hospital Unit Name 153**].
.
On arrival to the [**Hospital Unit Name 153**], the patient states that her abdominal
pain is much improved. She feels thirsty and hungry. She denies
lightheadedness and dizziness. She also denies chest
pain/pressure, nausea, vomiting, dyspnea, orthopnea, dysuria,
hematuria, and lower extremity swelling. She has had blood in
her stools a long time ago secondary to hemorrhoids; she states
that the blood in her stools at that time was much brighter.
Past Medical History:
* CAD - cath [**2113-10-3**] revealing 100% rca occlusion subsequently
stented with BMS, 60% LAD occlusion; peak enzymes CK 1111, CKMB
155, MB fraction 128% trop T 3.09 on [**10-4**]
* Chronic diarrhea - X 1 year, h/o diverticulitis,
intussusception in [**2113-7-23**]
* Endometriosis
* h/o oophorectomy
* h/o arrhythmia (? no further info in chart, on atenolol
previously)
Social History:
She lives alone. Her daughter is with her in the hospital today.
Ms. [**Known lastname **] works as the assistant registrar at [**University/College **] school. She smokes [**1-24**] ppd X 35 years. She drinks 2-3
glasses of wine nightly.
Family History:
+ for ovarian ca in mother, + breast CA in daughter, two aunts;
father passed away from leukemia
.
Physical Exam:
PE: T: 98.4 BP: 127/55 HR: 70 RR: 14 O2 99% RA
Gen: Pleasant, well appearing female in NAD
HEENT: No conjunctival pallor. No scleral icterus. MM slightly
dry. OP clear.
NECK: Supple, No LAD, JVD < 10 cm. No thyromegaly.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: clear to auscultation bilaterally, no wheezing or
crackles
ABD: normoactive bowel sounds, no tenderness to palpation
throughout, no rebound, no guarding
EXT: warm, well perfused througout, DP pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. speaking
clearly and in full sentences, moving all extremities without
difficulty
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2113-10-8**] 11:15AM BLOOD WBC-6.8 RBC-2.97* Hgb-9.7* Hct-28.1*
MCV-95 MCH-32.6* MCHC-34.5 RDW-15.8* Plt Ct-252
[**2113-10-8**] 11:15AM BLOOD PT-12.3 PTT-26.0 INR(PT)-1.1
[**2113-10-8**] 11:15AM BLOOD Glucose-85 UreaN-23* Creat-1.0 Na-144
K-4.7 Cl-108 HCO3-27 AnGap-14
[**2113-10-8**] 11:15AM BLOOD ALT-23 AST-33 LD(LDH)-237 CK(CPK)-173*
AlkPhos-50 Amylase-61 TotBili-0.4
ECG ([**2113-10-8**]): Sinus rhythm. Minor T wave abnormalities.
Brief Hospital Course:
1. Diverculosis with hemorrhage: the patient received PRBC
transfusion with stabilization of her hemoglobin. On discharge,
her hemoglobin had been stable for 36 hours. Gastroenterology
was consulted, and outpatient follow up was arranged. No further
studies were done given the multiple colonoscopies done
recently.
2. Recent inferior myocardial infarction, status post RCA bare
metal stent: the patient was maintained on her aspirin,
clopidogrel, and metoprolol. As she was in the low end of the
normotensive range, her captopril was put on hold. She had no
cardiac symptoms or issues this hospitalization, and serial
cardiac enzymes were negative.
Medications on Admission:
ASA 325 daily
plavix 75 mg daily
lopressor 25 [**Hospital1 **]
prilosec 40 mg daily
captopril 6.25 TId
carafate 1 gm TID
zocor 40 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain/
pressure: [**Month (only) 116**] repeat two times. If chest pain/pressure persists,
go to the emergency room.
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diverticular hemorrhage
2. Recent inferior myocardial infarction, status post RCA stent
3. Endometriosis
4. Chronic diarrhea
Discharge Condition:
Stable, without melena or hematochezia
Discharge Instructions:
Please go to the emergency room if you develop chest pain, chest
pressure, palpitations, or persistent shortness of breath. If
you begin to pass blood in your stool, you should also seek
urgent medical evaluation.
Followup Instructions:
1. Make a follow up appointment with your cardiologist within
the next 2 weeks.
2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Date/Time:[**2113-11-1**] 10:00
3. Make a follow up appointment with your primary care physician
[**Name Initial (PRE) 176**] 2 weeks.
|
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icd9cm
|
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[
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icd9pcs
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|
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|
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6414, 6713
|
3025, 3126
|
5212, 5910
|
5960, 6090
|
5048, 5189
|
6176, 6391
|
3141, 3886
|
230, 244
|
317, 2354
|
2376, 2752
|
2768, 3009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,135
| 176,757
|
39719
|
Discharge summary
|
report
|
Admission Date: [**2177-11-2**] Discharge Date: [**2177-11-11**]
Date of Birth: [**2121-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
56 year old Portuguese-speaking M with an inoperable pancreatic
cystadenocarcinoma s/p recent admission for pneumonia now p/w
increased abd pain, urinary frequency, confusion/disorientation,
+/- weakness. Afebrile at home. He did have a slow fall to the
ground at home yesterday but there was no head injury. Per pt,
his daughter gives him pain medication 2 times a day (PO
dilaudid prescribed q3H prn). Of note, celiac nerve block was
attempted during last admission and was not able to be completed
[**1-28**] anatomic difficulties w/cystic nature of CA. The patient
was discharged on [**10-30**] on his home pain regimen, on which his
pain was well controlled throughout his entire last admission.
.
Upon presentation to the ED, VS were: 100.2 103 148/99 18 100%.
Exam was nonfocal; he was guiac negative. Labs were reportedly
at baseline. U/A was negative for infection. CXR and CT scan did
not reveal any new/acute changes from prior. While in the ED, he
did have a T of 100.2. He was cultured and given vanco and zosyn
along with 2L NS. He is being admitted for pain control and
respite for his family. VS prior to d/c 99 102 110/70 20 100%
RA.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea or abdominal pain. No dysuria. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. No feelings of depression or anxiety. All other
review of systems negative.
Past Medical History:
Mr. [**Known lastname **] has a history of chronic pancreatitis and pseudocyst
development. He underwent a cyst jejunostomy with Roux-en-Y in
[**Country 4194**] in [**2177-2-24**] and was hospitalized following this for
acute on chronic pancreatitis with pseudocyst formation. He was
given TPN and supportive treatment while awaiting maturation of
the pseudocyst and
potential surgical intervention. During that admission a CT of
the abdomen/pelvis was reported to show a 16 x 8.6 x 16cm
multi-loculated cystic mass essentially replacing the entire
pancreas. He was transfered to [**Hospital1 18**] for further evaluation and
management. It was determined that this lesion was inoperable
due to encasement of the blood vessels. He underwent EUS and
had an FNA [**2177-9-11**], which demonstrated atypical cells,
concerning for a mucinous neoplasm. He underwent ERCP on
[**2177-9-17**] which showed malignant cells consistent with
adenocarcinoma. Tissue biopsy has not been feasable due to the
location/nature of the mass.
.
Other Past Medical History:
- [**2170**] - cholecystectomy for gallstone pancreatitis and
subsequently developed a pseudocyst.
- [**2-/2177**] he was reported to have undergone cyst jejunostomy with
Roux-en-Y in [**Country 4194**].
- Hypertension
- Splenectomy secondary to trauma, [**2146**]
Social History:
Mr. [**Known lastname **] is married and has three children. He has been
employed as a publicist for a television station in [**Country 4194**]. He
reports having used alcohol socially up until two years ago. He
denies tobacco or illicit drug use. He lives near [**Location (un) 86**] with
his wife and daughter.
Family History:
No known family history of pancreatic disease. No family history
of disease he reports.
Physical Exam:
VS: 97.5, 145/90, 103, 16, 99% RA
GEN: Chronically ill appearing gentleman, laying in bed in NAD,
A&Ox2 (self, hospital, year [**2166**], month [**Month (only) 359**])
HEENT: EOMI, PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. Crescendo systolic murmur best heard at
RUSB, no gallops/rubs.
Pulm: CTAB, no crackles or wheezes
appreciated.
Abd: Firm abdominal mass palpable in epigastric region. No
apparent organomegaly. NT, appears distended, tympanitic; no
rebound.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact with exception of visual field
testing which was deferred but no gross abnormalities in vision
appreciated.
Pertinent Results:
Imaging:
[**2177-11-2**] CXR: No acute cardiopulmonary process.
.
[**2177-11-2**] CT A/P: Large multiloculated known cystic neoplasm
centered within the expected region of the pancreas, with
replacement of the entire normal pancreatic parenchyma and
extension into all of the adjacent organs, that overall is
stable in both extent and size since examination from
[**2177-10-26**]. Associated biliary dilation and obstruction with
nonvisualization of the distal main portal vein, splenic vein
and SMV. No new cystic areas that would be concerning for new
abscess formation.
.
[**2177-11-3**] CXR: No evidence of acute process.
.
[**2177-11-4**] head MRI:
1. Sequelae of microvascular ischemia.
2. No evidence of intracranial lesions to suggest metastatic
disease.
.
[**2177-11-7**] CXR: No acute cardiopulmonary abnormality.
.
Micro:
[**2177-11-10**] MRSA-PENDING
[**2177-11-8**] BLOOD CULTURE-PENDING
[**2177-11-8**] BLOOD CULTURE-
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS SP..
PRELIMINARY SENSITIVITY These preliminary
susceptibility results
are offered to help guide treatment; interpret with
caution as
final susceptibilities may change. Check for final
susceptibility
results in 24 hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
LEVOFLOXACIN---------- R
VANCOMYCIN------------ R
[**2177-11-3**] BLOOD CULTURE-NEG
[**2177-11-3**] URINE CULTURE-NEG
[**2177-11-3**] BLOOD CULTURE-NEG
[**2177-11-2**] URINE CULTURE-NEG
[**2177-11-2**] BLOOD CULTURE-NEG
.
Labs on admission:
[**2177-11-2**] 01:24AM BLOOD WBC-10.9 RBC-3.34* Hgb-9.8* Hct-30.9*
MCV-92 MCH-29.3 MCHC-31.7 RDW-17.0* Plt Ct-903*
[**2177-11-2**] 01:24AM BLOOD Neuts-58 Bands-0 Lymphs-24 Monos-14*
Eos-0 Baso-1 Atyps-3* Metas-0 Myelos-0
[**2177-11-2**] 01:24AM BLOOD Glucose-152* UreaN-6 Creat-0.5 Na-131*
K-4.0 Cl-97 HCO3-23 AnGap-15
[**2177-11-2**] 01:24AM BLOOD ALT-20 AST-31 LD(LDH)-206 AlkPhos-557*
TotBili-1.4
[**2177-11-2**] 01:24AM BLOOD Lipase-8
[**2177-11-3**] 07:10AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8
[**2177-11-2**] 01:24AM BLOOD Osmolal-272*
[**2177-11-7**] 09:00PM BLOOD Type-ART pO2-32* pCO2-42 pH-7.45
calTCO2-30 Base XS-4
[**2177-11-2**] 01:23AM BLOOD Lactate-2.3*
Brief Hospital Course:
56 Portuguese-speaking M w/inoperable pancreatic
cystadenocarcinoma s/p recent admission for PNA and pain control
now p/w increasing abdominal pain with temp elevation noted
while in the ED. Patient developed hypoxia, likely [**1-28**]
aspiration event this [**Hospital **] transferred to ICU where he was
emergently intubated; unable to contact pt's wife immediately,
pt made DNR after discussion w/Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from ethics prior to reaching pt's wife. [**Name (NI) 1094**] wife
was able to come in for family meeting this afternoon, pt made
CMO. After made CMO, the patient was terminally extubated and
was placed on a dilaudid drip. The patient's condition declined
and he passed away on [**2177-11-11**]
.
# Suicidal ideation: Pt w/attempted suicide w/butter knife
during admission. Psych consulted, they do not feel that pt is
safe to go home as he states that he has been thinking of
suicide for the past 2-3 months and is no longer afraid of
dying. They recommend admission to hospice or psych hospital. Pt
was started on ritalin and mirtazapine with improvement per
psych recs. [**Name (NI) 1094**] wife was working on finding a private nurse to
take care of pt while she was at work during the week.
.
# Transient hypoxia: Pt had episodes of hypoxia to 70s, improved
to 90%s w/facemask. CXR negative, likely [**1-28**] aspiration. Had
resolved until day of transfer to ICU w/ambulatory sats in 90s
on RA. 85% on RA this AM prior to transfer.
.
# Fever: Tm 101.4 the evening of [**11-8**], pan cultured, 1/2 blood
culture positive for VRE. Patient was recently discharged on
home PO regimen of cefpodoxime 100 mg [**Hospital1 **] and doxycycline 100mg
[**Hospital1 **] for 8 days for PNA seen on chest CT; d/c'd [**2177-11-3**]. UCx
negative x 2, BCx +GPC from [**11-8**]. CXR neg. Vancomycin started
on [**2177-11-9**]. Elevated LFTs noted on labs, however within the
range of prior values.
.
# Abdominal pain: This is likely all related to disease, pain
regimen was changed 4 days prior to last admission, pain poorly
controlled at home, prn medications given [**Hospital1 **] when prescribed
q3H. Pt denied pain and nausea during his last admission; may
be likely due to the fact that he was relatively inactive or the
recent change in his pain regimen may have been in effect. We
attempted to have GI place a celiac nerve block during last
admission, as planned as an outpatient on [**11-13**]. However, upper
GI endoscopy was performed without celiac block [**1-28**] to the
cystic masses per GI. Pain well controlled on current regiment
of increased home reg of fentanyl patch 175mcg/hr q72 hrs,
gabapentin 400mg TID, started MS IR 15mg q4H prn and Tylenol
235mg TID with PPI and simethicone. Standing compazine with
morphine sulfate to prevent nausea, zofran prn. We held dilaudid
[**1-28**] concern for associated mental status changes
.
# Confusion: Pt's MS improved during admission, was A&O [**1-29**]
prior to day of ICU transfer; likely [**1-28**] medication, infection,
tumor. Change in MS the AM of ICU transfer likely [**1-28**] to
hypoxia, bacteremia. MRI head was neg for any intracranial
process.
.
# Weakness: Per pt's daughter, +/- weakness, stable from prior
to last admission.
Pt evaluated by PT, determined that pt did not need for PT upon
discharge prior to ICU transfer.
.
# Pancreatic cancer: As per pt's primary oncologist, treating
with Gemcitabine as an outpatient without available surgical or
XRT options at time of admission. Per primary oncologist, would
not continue chemotherapy at this time with current MS changes
and frequent admissions for pain crisis. We continued Compazine,
Zofran and Creon.
Medications on Admission:
1. famotidine 20 mg Tablet [**Hospital1 **]
2. fentanyl 100 mcg/hr Patch 72 hr apply with 50mcg patch for a
total
of 150mcg/hr
3. fentanyl 50 mcg/hr Patch 72 hr to be used with 100mcg/hr
patch
for total dosage of 150mcg/hr
4. gabapentin 300 mg PO three times a day.
5. hydromorphone 4 mg Tablet [**1-29**] tab PO Q3H as needed for pain.
6. lipase-protease-amylase 6,000-19,000 -30,000 unit Capsule,
Delayed Release(E.C.) PO three times a day: with meals.
7. ondansetron HCl 4 mg Tablet PO every eight (8) hours.
8. polyethylene glycol 3350 17 gram/dose Powder PO Daily prn
constipation.
9. prochlorperazine maleate 10 mg Tablet Q8H prn nausea.
10. zolpidem 10 mg qhs prn insomnia.
11. acetaminophen 325 mg 2 Tablet PO TID prn pain
12. docusate sodium 100 mg PO BID
13. senna 8.6 mg Tablet [**Hospital1 **] prn constipation.
14. simethicone 80 mg Tablet [**Hospital1 **] prn gas
15. cefpodoxime 100 mg [**Hospital1 **] for 8 days.
16. doxycycline hyclate 100 mg [**Hospital1 **] for 8 days.
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): apply with 75mcg patch for a
total of 175mcg/hr.
Disp:*10 Patch 72 hr(s)* Refills:*2*
3. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*qs 1 month* Refills:*2*
4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours).
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
Disp:*qs 1 month* Refills:*0*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day as needed for indigestion.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
11. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): apply with 100mcg patch for a
total of 175mcg/hr .
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
13. morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt passed away
Discharge Condition:
Patient passed away
Discharge Instructions:
pt passed away
Followup Instructions:
patient passed away
|
[
"401.9",
"V49.86",
"E935.2",
"486",
"292.81",
"799.02",
"157.8",
"995.91",
"338.3",
"V66.7",
"276.1",
"V62.84",
"518.81",
"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13651, 13660
|
6927, 10685
|
324, 336
|
13718, 13739
|
4489, 5427
|
13802, 13824
|
3709, 3798
|
11726, 13628
|
13681, 13697
|
10711, 11703
|
13763, 13779
|
3813, 4470
|
5471, 6221
|
1537, 2015
|
276, 286
|
364, 1518
|
6235, 6904
|
3097, 3363
|
3379, 3693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,764
| 124,306
|
38472
|
Discharge summary
|
report
|
Admission Date: [**2127-6-25**] Discharge Date: [**2127-6-29**]
Date of Birth: [**2066-2-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Demerol
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pressure/angina
Major Surgical or Invasive Procedure:
[**2127-6-25**] CABGx 3 (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
61 year old female that in [**Month (only) 404**]
started to feel pressure in her mid sternal area for a couple of
days this occurred off and on with rest and exertion, it went
away for a couple of weeks. The chest discomfort returned after
a
couple of weeks and she went to see her PCP he then transferred
her to Good [**Hospital 39888**] hospital to rule out an MI. She states
after walking approx 40-50 feet or walking up one flight of
stairs she gets shortness of breath. Upon resting after
approximately 5-6 minutes her breathing returns to normal.
There was also one occurrence she was on her way into CVS and
got
very dizzy and unbalanced on her feet, she sat down and within
the 5 minutes she felt ok. Patient c/o of left lower extremity
pain, relating this to her neuropathy. She under went stress
test
that was positive and cath showed 3VD. Referred for CABG.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes mellitus
Coronary artery disease s/p stent in [**2120-10-1**]
Bilateral Carotid stenosis less than 50%
myocardial infarction
Hepatitis C
Hypothyroidism
Vertigo
GERD
S/p partial hysterectomy and oophorectomy
Skin CA removed from right inner thigh [**2122**]
Anxiety
Arthritis
Sciatica
Neuropathy
Past Surgical History
Tonsillectomy
Adenoidectomy
Rhinoplasty [**5-/2087**]
Social History:
Lives with: alone - has home health aide daily and RN weekly
(International Health Solutions)
ETOH: large amounts on weekends - stopped 7 years ago
Tobacco: 30 year pack history quit 7 years ago
Marjuana - quit 7 years ago
Family History:
Mother had an MI in her late 70's, Grandfather
died at the age of 59 of an MI
Physical Exam:
Pulse: 70 Resp: 18 O2 sat: 100
B/P Right: 139/74 Left: 146/75
Height: 168 cm Weight: 72.6 kg
General: NAD pleasant and talkative
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 none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact yes
Pulses:
Femoral Right: perclose s/p cath Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: none Left: none
Pertinent Results:
PRE-BYPASS: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. Mild to
moderate ([**2-8**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate thickening of
the mitral valve chordae. Mild to moderate ([**2-8**]+) mitral
regurgitation is seen.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolic function.
2. Tranisent 2-+ MR immediately afte4r separation from CPB,
which improved to [**2-8**]+ MR over a few minutes without any
inotropic support.
3. Mild to moderate AI
4. Intact aorta
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2127-6-25**] 14:22
Brief Hospital Course:
Admitted [**6-25**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. Wean from pressors and ventilator. Was
extubated on POD#1. Chest tubes and wires were removed per
protocol. She was transferred from the ICU to the stepdown unit
for ongoing care. She was started on betablockers, statin
therapy and diuresed toward her preop weight. She was evaluated
by physical therapy and initially thought to be appropraite for
rehab but as her hospital course continued her level of
functioning improved drammaticaly and she was cleared for
discharge to home by Dr. [**Last Name (STitle) **] on POD#4. Her son will assist
her at home and she will have vNA and home health aid services.
Medications on Admission:
BUTALBITAL-ASPIRIN-CAFFEINE - (Prescribed by Other Provider) -
50 mg-325 mg-40 mg Capsule - one Capsule(s) by mouth every 4
hours as needed do not exceed 6 tablets in one daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - one Tablet(s) by mouth daily patient stopped her plavix
on [**2127-6-10**] patient instructed to continue plavix on [**2127-6-12**]
DICLOFENAC SODIUM - (Prescribed by Other Provider) - 75 mg
Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth
twice
daily
GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule -
3
(Three) Capsule(s) by mouth twice daily
GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
(One) Tablet(s) by mouth daily
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet
-
one Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2
(Two) Tablet(s) by mouth twice daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - one Capsule(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
one Tablet(s) by mouth dailly
VENLAFAXINE [EFFEXOR XR] - (Prescribed by Other Provider) - 75
mg Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth
twice daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one
Tablet(s) by mouth daily
Plavix - last dose: 75 mg [**6-16**]
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Pre-op dose was 1000mg [**Hospital1 **].
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Facility:
[**Hospital 27838**] Rehabilitation & [**Hospital **] Care Center - [**Hospital1 1474**]
Discharge Diagnosis:
CAD s/p cabg x3,s/p stent in [**2120-10-1**]
Hypertension
Hyperlipidemia
Diabetes mellitus
Bilateral Carotid stenosis less than 50%
myocardial infarction
Hepatitis C
Hypothyroidism
Vertigo
GERD
S/p partial hysterectomy and oophorectomy
Skin CA removed from right inner thigh [**2122**]
Anxiety
Arthritis
Sciatica
Neuropathy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assist
Incisional pain managed with dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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 Wed [**7-30**]/ @ 1:15 pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) 29247**] in [**2-8**] weeks
Cardiologist Dr. [**Last Name (STitle) 7047**] in [**2-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone
fax
Completed by:[**2127-6-29**]
|
[
"530.81",
"244.9",
"433.10",
"070.54",
"285.9",
"272.4",
"250.00",
"414.01",
"300.00",
"424.0",
"412",
"V45.89",
"433.30",
"355.9",
"413.9",
"287.5",
"424.1",
"401.9",
"716.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8020, 8139
|
3959, 4737
|
330, 393
|
8507, 8726
|
2794, 3509
|
9570, 10254
|
1984, 2064
|
6315, 7997
|
8160, 8486
|
4763, 6292
|
8750, 9547
|
2079, 2775
|
269, 292
|
421, 1294
|
1316, 1727
|
1743, 1968
|
3520, 3936
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,277
| 111,447
|
6604
|
Discharge summary
|
report
|
Admission Date: [**2200-5-18**] Discharge Date: [**2200-5-30**]
Date of Birth: [**2140-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Wheezing and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo man with severe asthma who originally presented w/ 3 days
of worsening dyspnea c/w prior exacerbations, now transferred to
the Medicine team for ongoing care. He had asthma exacerbation 3
wks ago requiring prednisone taper, which he completed about 1
wk ago. Over the past few days, he has had productive cough and
pleuritic chest pain, but no F/C. Went to [**Location (un) **] HC on day
of admission and was treated w/ albuterol/atroven nebs and
solumedrol, but symptoms were unrelieved, prompting referral of
pt to the [**Hospital1 18**] ED. In ED, he was placed on continuous nebs and
given prednisone 40 mg, then admitted to the [**Hospital Unit Name 153**] for ongoing
care.
On arrival to the [**Hospital Unit Name 153**], ABG was 7.29/47/83, which was concerning
for respiratory fatigue. He was treated w/ heliox and
eventually offered BiPAP, though he refused BiPAP treatment.
Though he was afebrile, empiric treatment for CAP was begun w/
ceftriaxone and azithromycin. He was found to have RSV
infection on viral culture, which is a likely explanation for
his current asthma exacerbation. His respiratory status
improved steadily until the present time, when he is transferred
to the Medicine team for ongoing care.
Currently, the pt complains of ongoing dyspnea and cough that
are moderately controlled w/ nebulized albuterol. He complains
of lumbar back pain that is partially relieved by percocet.
Denies any fever, chills, abd pain, nausea, vomiting, diarrhea,
constipation, hematochezia, and melena.
Past Medical History:
1. MRSA lung abscess in [**3-14**] s/p tx with linezolid
2. Asthma FEV1 35% FVC 50%, intubation x 1
3. HTN
4. PAF
5. h/o pleural effusion
6. cocaine abuse
7. chronic pain
8. Adm [**3-14**] for syncope in setting of cocaine use, ruled out for
MI.
9. Negative HIV [**2-11**]
10. Laminectomy [**7-15**] yrs ago
Social History:
cocaine abuse, last used 6 day PTA. Lives with fiance. Denies
tobacco, denies any IVDU in past or present.
Family History:
Denies CAD, CA, DM. Brother with lymphoma.
Physical Exam:
VS T 98.0, BP 142/80, HR 89, RR 18, O2 sat 98% 4L/m
Gen: disheveled man sitting up in bed eating dinner, speaking in
full sentences in NAD
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD, no LAD
CV: reg s1/s2, no s3/s4/m/r
Pulm: fair air movement throughout; diffuse exp wheezing w/
prolonged exp phase, no crackles
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B, 1+ pitting edema to the mid-leg B
Neuro: CN 2-12 intact, alert and oriented x 3, strength 5/5
throughout UE/LE B
Pertinent Results:
[**2200-5-19**] 04:45AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
[**2200-5-23**] 05:22AM BLOOD WBC-11.6* RBC-4.47* Hgb-13.6* Hct-40.8
MCV-91 MCH-30.5 MCHC-33.4 RDW-14.5 Plt Ct-245
[**2200-5-23**] 05:22AM BLOOD Plt Ct-245
[**2200-5-23**] 05:22AM BLOOD Glucose-83 UreaN-20 Creat-0.9 Na-140
K-3.8 Cl-96 HCO3-37* AnGap-11
[**2200-5-23**] 05:22AM BLOOD Calcium-9.7 Phos-2.7 Mg-2.1
CXR: Cardiac and mediastinal contours are normal. The lungs are
clear. Pulmonary vasculature is normal. The osseous structures
are unremarkable. There is apparent gynecomastia.
EKG: Sinus rhythm. Modest low amplitude lateral T waves - are
nonspecific and may be within normal limits. Since previous
tracing of [**2200-3-12**], lateral T wave amplitude lower.
Rapid Respiratory Viral Antigen Test (Final [**2200-5-20**]):
Positive for Respiratory Syncytial viral antigen.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
Brief Hospital Course:
1. Asthma Exacerbation: Pt's nasal washings returned positive
for RSV. On admission he had marked wheezing and poor air
movement, with ABG of [**2142-9-4**]/83. He gradually improved on
solumedrol, continuous nebs, advair, singulair, heliox, Azithro
(5 days) and Ceftriaxone. Pt did not require intubation, and
his nebs were spaced out to q4hrs. Pt's breathing was
comfortable and non-wheezy by HD#5 when observed from the door,
however, pt appears to exagerate end-expiratory wheezing and
laboured breathing when approached. He was felt to have a
component of psychogenic dyspnea overlying his asthma
exacerbation. He was slowly titrated down on his steroid dose,
and he frequently requested to be placed on higher doses of
steroids despite an improving exam and vitals. Eventually, he
had both subjectively and objectively improved to the point
where he was tolerating oral steroids and was able to be
discharged home on a taper with plans to follow-up with his
outpatient pulmonologist.
2. Psych/Neuro: Cocaine Abuse and Opioid Dependence. Pt's urine
tox screen was positive for cocaine and opioids. Pt was
requiring two percocets every 4 hours for low back pain s/p
laminectomy. Attempts to wean his percocets were made in effort
to minimize suppression of his cough. However, pt was unhappy
with this recommendation and insisted on his usual dose of
percocets, stating that the wheezing/coughing greatly
exacerbated the back pain. He was seen by the addictions
consult and social work while he was an inpatient; their
discussions culminated in an agreement that Mr. [**Known lastname **] would seek
outpatient counseling for his substance abuse difficulties,
which are both worsened by and worsen his chronic pain.
He was discharged on a brief course of oxycodone/acetaminophen,
with the understanding that should he have ongoing pain
medication requirements, he would need to finally establish a
primary care physician; he has been stating that this is
something he would do, but has failed to do so for months. He
was provided with multiple names and numbers of providers in his
area, and he informed the team that he was dedicated to being
seen by one of them.
3. Hypertension: Pt was hypertensive on admission in setting of
his acute asthma exacerbation. He continued to be hypertensive
and HCTZ was started, with a good effect and was tolerated well.
His electrolytes and renal function remained stable on this new
medication, and he was advised to see a primary care doctor to
follow both this and his numerous other medical issues.
Medications on Admission:
Singulair
Advair
Flovent
Albuterol
Percocet
Recent prednisone taper
Discharge Medications:
1. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
2. Guaifenesin 100 mg/5 mL Liquid Sig: 5-10 MLs PO q4-6h prn.
[**Known lastname **]:*50 ML(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed.
[**Known lastname **]:*1 MDI* Refills:*0*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*qs 1 month supply* Refills:*0*
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
[**Hospital1 **]:*30 Capsule(s)* Refills:*0*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day:
for 2 days ([**Date range (1) 25243**]), then 5 tabs daily for 2 days
([**Date range (1) 25244**]), then 4 tabs daily for 2 days (4/26/05-4/27), then 3
tabs daily for 2 days ([**6-5**]/-[**6-6**]), then 2 ts daily for 2 days
([**Date range (1) 25245**]), then 1 tab daily for 2 days ([**Date range (1) 25246**]).
[**Date range (1) **]:*42 Tablet(s)* Refills:*0*
15. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
[**Date range (1) **]:*1 MDI* Refills:*0*
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed.
[**Date range (1) **]:*qs one month* Refills:*0*
17. one touch ultra lancets
use as directed
[**Date range (1) **]: 90
refills: 0
18. one touch ultra test strips
use as directed
[**Date range (1) **]: 90
refills: 0
19. space chamber
use as directed
[**Date range (1) **]: 1
refills: 0
20. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 5 days.
[**Date range (1) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: asthma exacerbation
Secondary: acute bronchitis, hypertension, hyperglycemia
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed. You have been started
on lisinopril and hydrochlorothiazide for high blood pressure.
Please follow-up as below. It is very important that you
follow-up with a new primary care physician.
[**Name10 (NameIs) 357**] check your blood sugars 2-3 times a day before meals. If
your fingersticks are persistently >250, please call your
primary care physician (see below)
Followup Instructions:
1) Pulmonary
- you will be contact[**Name (NI) **] by the pulmonary clinic regarding an
appointment with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 575**]. If you have not heard
from them in the next week, please call [**Telephone/Fax (1) 612**].
2) Primary care: If you are unable to establish a new primary
care physician at [**Name9 (PRE) **] Care (1- [**Last Name (un) **]
[**Last Name (un) 25247**], East [**Numeric Identifier 25248**]) as you plan to, you have been schedule
for a new patient appointment as below:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 25249**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2200-6-4**] 1:30
|
[
"V58.67",
"401.9",
"305.60",
"482.9",
"E932.0",
"304.00",
"493.92",
"251.8",
"724.5",
"518.82",
"V02.59",
"584.9",
"300.00",
"466.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9407, 9413
|
3991, 6554
|
347, 354
|
9543, 9549
|
2951, 3968
|
10003, 10740
|
2383, 2428
|
6673, 9384
|
9434, 9522
|
6580, 6650
|
9573, 9980
|
2443, 2932
|
275, 309
|
382, 1909
|
1931, 2241
|
2257, 2367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,017
| 114,886
|
40331
|
Discharge summary
|
report
|
Admission Date: [**2106-11-24**] Discharge Date: [**2106-12-3**]
Date of Birth: [**2082-11-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
jaundice after blunt trauma
Major Surgical or Invasive Procedure:
aspiration and drainage of hepatic fluid collection
endoscopic retrograde cholangiopancreatography
R tube thoracostomy
History of Present Illness:
24M s/p blunt liver and spleen injury, managed non-operatively
with IR guided embolization. Doing well at home, and felt
better, tolerating food, until the patient noticed that he
became frankly jaundiced. Patient presented to his pcp and told
to report to the ED for definitive care. Today he is noticably
jaundiced with a tbili of 6.7. otherwise, the patient notes
fevers to 101 within the last twenty-four hours, but he has
otherwise felt great and done well.
Interventional Procedure from previous admission: IR placed 4
coils to 2 branches of replaced R hepatic artery, L hepatic gel
foam, 1 upper splenic branch coil + gel foam.
Past Medical History:
Non contributory
Social History:
Lives with wife. + etoh use, denies illicts
Family History:
Non contributory
Physical Exam:
Afebrile, hemodynamically stable
A+Ox3, NAD clearly icteric
CTAB
RRR
distended and firm but mildly tender diffusely, no peritoneal
signs, no guarding, no rebound
Pertinent Results:
[**2106-11-24**] 06:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2106-11-24**] 06:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-8* PH-7.0
LEUK-NEG
[**2106-11-24**] 06:40PM URINE RBC-[**2-26**]* WBC-[**2-26**] BACTERIA-OCC YEAST-NONE
EPI-<1
[**2106-11-24**] 04:03PM LACTATE-1.5
[**2106-11-24**] 03:55PM GLUCOSE-99 UREA N-16 CREAT-0.7 SODIUM-124*
POTASSIUM-3.6 CHLORIDE-85* TOTAL CO2-28 ANION GAP-15
[**2106-11-24**] 03:55PM ALT(SGPT)-499* AST(SGOT)-119* ALK PHOS-148*
TOT BILI-6.7* DIR BILI-4.1* INDIR BIL-2.6
[**2106-11-24**] 03:55PM LIPASE-31
[**2106-11-24**] 03:55PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2106-11-24**] 03:55PM WBC-15.5* RBC-3.69* HGB-11.5* HCT-31.8*
MCV-86 MCH-31.0 MCHC-36.1* RDW-13.0
[**2106-11-24**] 03:55PM NEUTS-72* BANDS-1 LYMPHS-11* MONOS-12* EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2106-11-24**] 03:55PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
[**2106-11-24**] 03:55PM PLT SMR-NORMAL PLT COUNT-352#
[**2106-11-24**] 03:55PM PT-12.9 PTT-22.6 INR(PT)-1.1
BCx [**2106-11-24**]: Coag neg staph [**12-26**] sets only
RUQ U/S [**2106-11-24**]: 1. Large hematoma involving the right lobe of
the liver, in the region of the known lacerations. Echogenic
foci within the region of hematoma compatible with gas likely
related to recent gelfoam embolization. Biloma cannot be
excluded on this imaging study. 2. Large amount of complex fluid
within the abdomen, compatible with hemoperitoneum. 3. Probable
sludge within the gallbladder. 4. No intra- or extra-hepatic
biliary ductal dilatation.
CTAP [**2106-11-25**]: 1. Status post embolization of several hepatic
arterial branches as well as splenic artery branches.
Post-procedural changes are noted in the liver including air
within the embolized hepatic parenchyma. 2. No evidence for
biliary obstruction from the known hematoma. 3. Hemoperitoneum
is slightly increased in size from prior study; however, this
likely represents continuous bleeding before the embolization
procedure. 4. Hematoma of the right adrenal gland is stable. 5.
New bilateral pleural effusion, moderate on the right and small
on the left with complete atelectasis of the right lower lobe
and mild atelectasis of the left lower lobe
CT guided aspiration [**2106-11-25**]: Technically successful
percutaneous transhepatic aspiration of right liver
laceration/hematoma yielding 1-2 cc of bloody aspirate, specimen
sent to microbiology as above.
[**Month/Day/Year **] [**2106-11-26**]: Successful biliary cannulation. Extravasation was
noted from at least three smaller biliary radicles off the right
intrahepatic duct. This is consistent with bile leak status post
blunt trauma to the liver and known liver laceration. Successful
sphincterotomy to faciliatate stent placement. Two 7cm by 10FR
Cotton [**Doctor Last Name **] biliary stent were placed successfully in the main
duct. Otherwise normal [**Doctor Last Name **] to third part of the duodenum
CTAP [**2106-12-1**]: 1. Stable right liver lobe hematoma extending into
the subphrenic space. 2. Unchanged hemoperitoneum. 3. Stable
left upper pole splenic laceration.
Brief Hospital Course:
Mr. [**Known lastname 88473**] was admitted to the Acute Care Surgery Service
with hyperbilirubinemia and general feeling of unwellness. A RUQ
ultrasound showed a large fluid collection around his lacerated
liver. Blood cultures from [**2106-11-24**] grew out coag neg staph and
he was placed empirically on vanc/zosyn for fevers. He underwent
IR drainage of the perihepatic fluid collection on [**2106-11-25**]. On
[**2106-11-26**], he underwent [**Date Range **] which demonstrated extravasation from
at least three smaller biliary radicles off the right
intrahepatic duct, consistent with bile leak status post blunt
trauma to the liver and known liver laceration. He had a
sphincterotomy and placement of two 7cm by 10FR Cotton [**Doctor Last Name **]
biliary stents in the main duct to decompress the biliary tree.
After the procedure, he developed respiratory distress but was
able to be extubated in the PACU. A CXR showed a large R pleural
effusion for which a R chest tube was placed. He ultimately
improved in the ICU and was advanced to regular diet and
transferred to the floor. He was offered surgery to deal with
his large perihepatic hematoma, but as he appeared to remain
stable, he opted to hold off on surgical exploration at that
point. As his chest tube output decreased, it was placed on
water seal and then removed, with a small, stable residual
post-pull pneumothorax. As he was feeling better and did not
desire surgical options at that time, he was discharged home on
[**2106-12-3**] with close follow up in the Acute Care Surgery Clinic.
He agreed to return should any further problems arise and so was
sent out.
Medications on Admission:
percocet
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA & Hospice
Discharge Diagnosis:
s/p tractor rollover accident
liver laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for abdominal pain and
underwent drainage of a collection around your liver as well as
an [**Location (un) **] which showed some small bile leaks due to your recent
tractor accitdent.
Followup Instructions:
You have a follow up appointment in Acute Care Surgery Clinic
next Tuesday at 2:15 PM on the [**Location (un) **] of the [**Hospital **] Medical
Office Building at [**Last Name (NamePattern1) 439**], [**Location (un) 86**], MA
You also have an appointment for [**Location (un) **] to determine status of
your bile leak as outlined below:
Provider: [**Name Initial (NameIs) **] 2 ([**Hospital Ward Name **] 4) GI ROOMS Date/Time:[**2106-12-28**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2106-12-28**] 1:00
|
[
"864.05",
"789.59",
"864.01",
"E929.1",
"868.02",
"518.5",
"868.03",
"511.9",
"782.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.71",
"51.85",
"96.04",
"50.91",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
7220, 7289
|
4734, 6374
|
332, 452
|
7380, 7380
|
1453, 4711
|
7773, 8379
|
1238, 1256
|
6433, 7197
|
7310, 7359
|
6400, 6410
|
7531, 7750
|
1271, 1434
|
265, 294
|
480, 1120
|
7395, 7507
|
1142, 1160
|
1176, 1222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,551
| 115,511
|
44905
|
Discharge summary
|
report
|
Admission Date: [**2106-1-9**] Discharge Date: [**2106-1-12**]
Date of Birth: [**2030-9-2**] Sex: F
Service: NEUROLOGY
Allergies:
Urispas / Atorvastatin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 y RHW had supper with her husband at 6 pm, she went to
the bedroom and was getting into her bed. She slid to the floor
but did not hit her head. Her husband went to find her, and he
tried to ask her questions, but she responded to him in garbled
speech. She also could not get up from the floor.
Past Medical History:
-paroxysmal atrial fibrillation, not on anticoagulation
-hypertension
-hypercholesterolemia
-hypothyroidism
-low back pain
-depression/anxiety
-history of basal cell carcinoma removed from left cheek
-history of multiple skeletal fractures
-history of left hip fracture, status post left ORIF
Social History:
She lives at home with her husband. She is a former hospital
secretary at [**Hospital1 18**]. She has a distant but brief history of
tobacco use. Denied alcohol or illicit drug use.
Family History:
Multiple family members with cardiac disease.
Physical Exam:
NIH SS:
1a. Level of Consciousness: 0
1b. LOC questions: 2
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 1
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 2
10. Dysarthria: 2
11. Extinction and inattention: 1
total score: 13
Vitals: T 96.4, BP 157/93, HR 87, RR 21, SpO2 97%
General: no obvious bruises
CVS: PSM in the mitral area, no carotid bruits, no peripheral
edema
Resp: Lung bases are clear
GI: soft, non-tender, normal bowel sounds
Neurologic examination:
Mental status: Awake and alert, cooperative with exam.
Completely
aphasic, could not read, neglects things on her right.
Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields - right inferior temporal field cut.
Extraocular movements intact bilaterally without nystagmus.
Sensation intact V1-V3. Profound right facial droop. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
Sternocleidomastoid and trapezius full strength bilaterally.
Tongue midline (compensating for the facial droop), movements
intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. right pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 5 5 5 5 5 5 5 5 5 5 5 5
L +4 -5 5 5 5 5 +4 -5 -5 5 5 5
Sensation: Intact to light touch, pinprick. Extinction to DSS on
the right.
Reflexes: 2+ on the right, and 2 on the left. Right-Babinski.
Coordination: finger-nose-finger, heel to shin ataxic on the
right.
Gait:could not assess
Pertinent Results:
[**2106-1-12**] 06:30AM BLOOD WBC-10.4 RBC-3.85* Hgb-12.9 Hct-35.0*
MCV-91 MCH-33.6* MCHC-37.0* RDW-13.4 Plt Ct-228
[**2106-1-11**] 06:00AM BLOOD WBC-8.7 RBC-4.07* Hgb-13.2 Hct-37.5
MCV-92 MCH-32.6* MCHC-35.3* RDW-13.3 Plt Ct-256
[**2106-1-10**] 02:52AM BLOOD WBC-11.5* RBC-3.62* Hgb-11.8* Hct-33.3*
MCV-92 MCH-32.5* MCHC-35.3* RDW-13.2 Plt Ct-226
[**2106-1-9**] 08:05PM BLOOD WBC-11.5* RBC-4.29 Hgb-13.5 Hct-39.1
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.3 Plt Ct-258
[**2106-1-12**] 06:30AM BLOOD PT-16.8* INR(PT)-1.5*
[**2106-1-11**] 06:00AM BLOOD PT-14.3* INR(PT)-1.2*
[**2106-1-10**] 02:52AM BLOOD PT-14.7* PTT-26.4 INR(PT)-1.3*
[**2106-1-9**] 08:05PM BLOOD PT-13.9* PTT-27.4 INR(PT)-1.2*
[**2106-1-9**] 08:05PM BLOOD Fibrino-346
[**2106-1-12**] 06:30AM BLOOD Glucose-101 UreaN-16 Creat-1.5* Na-140
K-3.6 Cl-105 HCO3-24 AnGap-15
[**2106-1-11**] 06:00AM BLOOD Glucose-102 UreaN-15 Creat-1.4* Na-143
K-3.7 Cl-110* HCO3-24 AnGap-13
[**2106-1-10**] 02:52AM BLOOD Glucose-122* UreaN-22* Creat-1.5* Na-138
K-3.6 Cl-106 HCO3-23 AnGap-13
[**2106-1-9**] 08:05PM BLOOD UreaN-24* Creat-1.9*
[**2106-1-10**] 02:25PM BLOOD CK(CPK)-60
[**2106-1-10**] 02:52AM BLOOD ALT-12 AST-19 CK(CPK)-46 AlkPhos-77
[**2106-1-9**] 08:05PM BLOOD Lipase-47
[**2106-1-10**] 02:52AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2106-1-11**] 06:00AM BLOOD Albumin-3.7 Calcium-8.9 Phos-2.6* Mg-2.0
[**2106-1-10**] 02:52AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Cholest-188
[**2106-1-10**] 02:52AM BLOOD Triglyc-97 HDL-52 CHOL/HD-3.6 LDLcalc-117
[**2106-1-10**] 02:52AM BLOOD TSH-1.5
[**2106-1-9**] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2106-1-9**] 08:13PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-48* pH-7.35
calTCO2-28 Base XS-0
[**2106-1-9**] 08:13PM BLOOD Glucose-147* Lactate-1.6 Na-141 K-3.8
Cl-101
[**2106-1-9**] 08:13PM BLOOD Hgb-14.3 calcHCT-43 O2 Sat-82 COHgb-2
MetHgb-0
[**2106-1-9**] 08:13PM BLOOD freeCa-1.16
CTA [**2106-1-9**]: CONCLUSION:
1. Large acute left middle cerebral artery distribution infarct.
2. Thrombotic or embolic occlusion of the left middle cerebral
artery with
reconstitution of flow distally.
3. Anterior communicating artery aneurysm.
4. Possible cavitary lesion in right upper lobe, requiring more
extensive
assessment.
NCHCT [**2106-1-10**]: No intracranial hemorrhage or significant edema
status post TPA
administration. Hyperdense clot noted within the left M1 segment
appears
resolving when compared to pre-treatment scan on [**2106-1-9**]
CT CHEST [**2106-1-10**]:
IMPRESSION:
1. 9 mm right upper lobe nodule with fissural traction, could be
inflammatory, scar or lung cancer, should be followed shortly in
three months.
2. Scattered 6 mm and less lung nodules, should also be
followed. 9 x 3 left
lower lobe nodule could be atelectasis, could be evaluated by
supplemented
prone images on next follow up.
3. Almost complete resolution of septal thickening, likely due
to resolving
interstitial edema.
4. Upper lobe predominant centrilobular nodules, could be due to
respiratory
bronchiolitis.
5. Hyperdense liver, could be due to amiodarone use or iron
loading. Liver
hypodensity too small to characterize, likely a cyst.
7. L1 compression fracture, unchanged since [**2103**].
8. Right breast macrocalcification, likely benign, should be
correlated
with regular mammogram.
TTE [**2106-1-12**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**2-11**]+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
This 75 yo woman was admitted with acute aphasia as a code
stroke and was found to qualify for thrombolyis with IV tPa. Her
CT and CTA confirmed the presence of acute Lt MCA clot and
partial occlusion, most likely cardioembolic given HX of Afib
without
anticoagulation. Her deficit was mild and improving after the
scan. She continued to improve after tPA, and she was able to
name , read repeat with only mild paraphasic error. Weakness
improved as well (facial weakness and mild drift but no
extremities weakness). She was started on Coumadin and
instructed to follow up with her PCP for measurement of her INR.
Her lipids were elevated, but she had not tolerated a statin in
the past so she was started on zetia 10 mg daily. Her echo
showed no evidence of PFO, thrombus, or atheroma. Nonetheless, a
cardioembolic source was suspected in her case. As part of her
initial CTA neck, there was an incidental finding of a potential
lung lesion and therefore a CT chest was pursued which showed
some scattered nonspecific nodules which she was instructed to
have followed with another CT in 3 months. There were also
breast calcifications present for which she was set up with an
appt for a mammogram. On discharge her neurological exam was
significant for mild right upper motor neuron facial weakness
and mild right pronator drift.
Medications on Admission:
L-thyroxine 75 mcg
Rhythmol SR 325 mg [**Hospital1 **]
Metoprolol 100 mg [**Hospital1 **]
Quinapril 20 mg [**Hospital1 **]
Coumadin (not been taking the medication)
Paroxetine
Omega 3
vitamin D
ASA 81 mg
Centrum silver
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime): Should be
discontinued once INR>2.
4. Propafenone 225 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
5. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: Take
2 tabs at bedtime on [**1-12**]. Then on [**1-13**] and thereafter take
only 1 tab at bedtime until instructed otherwise by your PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary diagnosis:
Cerebral Infarction
atrial fibrillation
secondary diagnosis:
hypercholesterolemia
hypertension
hypothyroidism
chronic low back pain
Discharge Condition:
Stable. Mild right upper motor neuron facial weakness and mild
right pronator drift.
Discharge Instructions:
You have been restarted on Warfarin, a blood thinning
medication, since you are at risk for future cardioembolic
strokes with your atrial fibrillation. You need to have your
blood checked frequently (at least twice a week) at your PCP's
office with your goal INR is 2 to 3.
You should make sure when starting any new medications that the
prescribing physician is aware that you are on Warfarin to avoid
any drug-drug interations. They should also touch base with
your primary care physician [**Name Initial (PRE) 96060**].
Since you have not tolerated taking a statin in the past, we
have instead started you on a cholesterol lowering medication
called Zetia.
Please take medications as prescribed.
Please keep your follow-up appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 19196**]
Date/Time:[**2106-1-15**] 9:00AM
You should have your blood drawn at this visit to check your INR
level and have your Warfarin dose adjusted as needed. Goal INR
[**3-15**].
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2106-3-9**] 11:40
Provider: [**First Name8 (NamePattern2) 4267**] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 2574**]
Date/Time: [**2106-2-16**] 2:00PM
Imaging: Chest CT without contrast Phone: [**Telephone/Fax (1) 327**]
Date: [**2106-4-11**]
Please call to schedule a follow-up image during the month of
[**Month (only) 958**] to follow-up pulmonary nodules that were incidentally seen
on your chest CT from this admission.
Imaging: Mammogram Phone: [**Telephone/Fax (1) 327**]
Please call to schedule a mammogram within 2 weeks of discharge
to follow-up microcalcifications that were incidentally noted on
your chest CT.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2106-1-19**]
|
[
"V10.83",
"244.9",
"401.9",
"V15.81",
"434.11",
"V58.61",
"272.0",
"427.31",
"923.03",
"924.00",
"427.32",
"724.2",
"E888.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
9736, 9794
|
6992, 8325
|
300, 307
|
9990, 10077
|
2960, 6969
|
10871, 12119
|
1169, 1216
|
8594, 9713
|
9815, 9815
|
8351, 8571
|
10101, 10848
|
1231, 1790
|
243, 262
|
335, 636
|
1952, 2941
|
9896, 9969
|
9834, 9875
|
1829, 1936
|
1814, 1814
|
658, 953
|
969, 1153
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,775
| 186,198
|
13505
|
Discharge summary
|
report
|
Admission Date: [**2166-9-20**] Discharge Date: [**2166-10-2**]
Date of Birth: [**2087-4-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever, nausea/vomiting, metal status change
Major Surgical or Invasive Procedure:
Right IJ
Transesophageal echocardiogram
History of Present Illness:
79 year old female with involved cardiac history (status post 4
vessel CABG with EF <25%) who was admitted to the intensive care
unit for change of mental status and sepsis. She was otherwise
well until she had an acute episode of increased mental status
changes accompanied by fever, chills, nausea, and non-bloddy,
nonbilious vomiting. She had no cough, chest pain or pressure,
abdominal pain, shortness of breath. Initially in the emergency
department, she was febril but normotensive. She was started on
levofloxacin and metronidazole for questionable pneumonia on
chest x-ray. Later in the ED, she dropped her pressure to 80s
systolic. She received 3 L of IV fluid ressuscitation. A
femoral line was placed and she was started on norepinepherine
and an insulin drip. Within 10 hours, blood cultures in the ED
grew out 4/4 bottles of gram positive cocci and she was started
on vancomycin. Of note, the patient had had a rencent dental
procedure.
Past Medical History:
1. Coronary artery disease; s/p CABG X4 [**2161**]; s/p PCA with stent
to D1
- [**1-9**] ETT: 8.75 min [**Doctor Last Name 4001**] protocol (~5.5 METS). LV
dysfunction in the absence of angina or ischemic EKG
2. Cardiomyopathy EF 20%
- [**2166-9-22**] TTE: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA moderately dilated, severe
global LV hypoK, RV sys fxn borderline normal, trace AR, 3+ MR,
3+ TR, no mass/vegetation visualized.
- AICD
3. Hypertension.
4. Hypercholesterolemia.
- [**2166-9-19**]: chol 164, TG 148, HDL 47, LDL 83
5. Type II DM c/b nephropathy and retinopathy
- [**2166-9-19**] HgbA1C 6.1%
6. h/o AF w/ RVR in post-op period; s/p cardioversion
7. Anemia: HCT 28-31
- iron studies [**2-6**] low iron, TIBC/ferritin nl
- [**9-10**] vit B12/folate wnl
8. Chronic renal insufficiency: baseline Cr 1.4-1.6
9. Gastroesophageal reflux disease.
10. Status post cholecystectomy.
11. Status post hernia repair.
12. History of E alloantibody with hemolytic reaction to blood
transfusions requiring E negative blood.
Social History:
The patient is a widow. She lives alone, but her daughter is
extremely involved in her life and able to provide a great deal
of assistance to her mother, she lives with her over the
weekends. +Tob 2ppd x 15 yrs, quit 40 years ago. Occasional
small amounts of [**Doctor First Name **] with dinner.
Family History:
Noncontributory
Physical Exam:
Temp 97.3
BP 121/41
Pulse 61
Resp 16
O2 sat 100 on 2L
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVD 10 cm, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**1-18**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Pertinent Results:
11.5>31.1<158
N:90.9 L:6.3 M:2.6 E:0.2 Bas:0.1
.
[**Age over 90 **]|103|49/99
4.9|25|1.8\
Ca:9.2 Mg:2.2 P:2.9
.
PT:13.8 PTT:21.1 INR:1.3
.
UA dipstick negative
.
Lactate: 2.9
.
Cortisol:34.2
Cortisol 30 minutes post cosyntropin:44.6
Cortisol 60 minutes post cosyntropin:47.9
.
EKG: Normal sinus, normal axis and intervas with old Q-waves in
III and AVF.
.
CXR: Small bilateral pleural effusions and probable pulmonary
edema. No definite evidence of pneumonia.
Brief Hospital Course:
79 year-old female with severe coronary artery disease,
congestive heart failure, type I diabetes, who was admitted for
bacteremia and sepsis.
.
1. Sepsis: On admission, she was febrile and hypotensive. She
had been started on pressors in the emergency room; however, the
pressors were stopped on arrival to the intensive care unit.
Her blood pressure was supported with IV fluid boluses. Within
10 hours, her blood cultures grew out 4/4 bottles on gram
positive cocci that were later found to be staph aureus that
were sensitive to gentamicin and oxacillin. She had been
initially treated empirically with vancomycin, but was switched
to gentamicin and oxacillin once the sensitivities were back.
The source of her bacteremia was unclear. [**Name2 (NI) 227**] her history of
abdominal abscess, she had an abdmonial CT that was negative.
She had both a transthoracic and a transesophageal
echocardiogram that were negative for vegetations or involvement
of the AICD wires. However, given that she had high grade
bacteremia with unknown source and has foreign body AICD wires
implanted, she was treated for presumed endocarditis despite
negative echocardiogram studies. ID and EP have been following
the pt. The consensus among the teams is that the pt is to
finish a six week course of oxacillin. She is to have a
follow-up appointment 2 weeks with then device clinic two weeks
after finishing her course of oxacillin. At that time it will be
dtermined whether the pt is to have her pacer removed.
2. Congestive heart failure: She has poor systolic function with
an ejection fraction of 20-25%. During her initial volume
ressucitation, she received 5 L of IV fluids. On hospital day
2, she became acutely short of breath with an oxygen saturation
in the low 80s and required a non-rebreater mask to maintain
oxygenation. A chest x-ray was showed severe pulmonary edema
and a large right-sided pleural effusion. An electrocardiogram
was unchanged from prior. Her oxygenation improved with
furosemide. We have continued to diurese her with standing po
lasix and iv lasix prn. Her exam has continued to improve from
her period of desaturation.
.
3. Atrial fibrillation: On hospital day 3, she had several
episodes of atrial fibrillation with rapid ventricular rate.
During one episode, the atrial fibrillation triggered
ventricular taycardia. Her AICD fired on three occasions. She
was loaded with IV amiodarone and then transitioned to a 7 day
course of an oral amiodarone load. Her AICD was interegated and
reprogrammed not better distinguish between supraventricular
tachycardias and ventricular tachycardias. On hospital day 4,
she had two additional episodes of atrial fibrillation with
rapid ventricular rate that were broken with IV metoprolol.
She remained hemodynamically stable during those events. She
had new Q-waves in I and AVL that reversed once she was no
longer in atrial fibrillation.
.
4. Acute on chronic renal insufficiency: Her baseline creatinine
is between 1.4-1.6. On admission, she had an elevated
creatinine above her baseline that was attributed to
hypoperfusion. Her creatinine improved toward her basline with
fluid resuscitation. On hospital day 4, she had worsening of
her renal failure in the setting of hypotension with IV
amiodarone load for which she was started on phenylepherine. As
evidenced by an acute rise in her lactate, she was thought to be
hypoperfusing her organs in the setting of being intravascularly
volume depleted and on phenylepherine. She was quickly weaned
off of the pressor and volume ressuscitated with IV fluids.
After this episode, she remained oliguric for 36 hours, which
was attributed to ATN. Her creatinine peaked at 3.6 from 2.0.
She began autodiuresing and her creatinine trended down. Her
creatinine has stabilized at around 1.8. Her medications doses
were all renally dosed and adjusted for the changed in her renal
function.
.
5. Metabolic acidosis: On admission, she had a metabolic gap
acidosis that was attricuted to lactic acidosis. This improved
with IV fluid ressuscitation. With the episode of acute
oliguric renal failure, she again had a metabolic gap acidosis
that was attributed to both an uremic and lactic acidosis. This
acidosis improved with resolution of her ATN.
.
6. Diabetes: She has type I diabetes. During the acute phase of
her illness, she required an insulin drip to maintain adequate
glucose control. She was later transition to her home glargine
and a regular insulin sliding scale.
.
7. Anemia: She has anemia with a baseline hematocrit of 30.
During this admission, she required 2 units of red cells for a
hematocrit of 23. There was no evidence of ative bleeding or
hemolysis. She was maintained on her outpatient ferrous
sulfate.
.
8. Thrombocytopenia: Her platelets trended down from 150 on
admission to a low of 49 on hospital day 5. Given that she had
been exposed to heparin a HIT antibody was sent and heparin was
stopped. New medications during this admission that could
contribute to thrombocytopenia included gentamicin and
amiodarone. These medications were continued since her platelet
count trended back up. Her HIT antibody is negative. Her
platelets have been slowly recovering and are presently at 79.
9. Transaminitis. Patient had an acute elevation in her
transaminases, thought to be secondary to acute episode of
hypoperfusion. It is unlikely that she had a viral hepatitis. We
followed LFTs daily which trended down.
.
9.GERD: She was maintained on pantoprazole.
.
10. FEN: She was maintained on a diabetic and cardiac healthy
diet. Her electrolytes were repleted. She was given IV fluid
boluses as above for volume ressuscitation.
.
11. Prophylaxis: She was maintained on a PPI, bowel regimen, and
subcutaneous heparin, which was switched to pneumoboots when her
platelets trended down. As her HIT ab came back negative, she
was resumed on SQ heparin.
.
12. Access: She initially had peripheral IV access. A right IJ
was placed when she was started on a pressor in the setting of
hypotension from IV amiodarone load. She also had a left
arterial line placed at that time. Those lines have been d/c'd.
.
13. Code: full
.
Medications on Admission:
Lopressor 100 mg [**Hospital1 **]
Lipitor 40 mg
Amlodipine ? dose
Lasix 40 mg daily
Aspirin 81
Prevacid
Lantus 18 units at night and Humalin sliding scale
Plavix 75 mg
Iron, Ca, Vitamin E, MVI
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold sbp <100.
12. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) grams
Injection Q4H (every 4 hours) for 5 weeks: through [**2166-11-4**] to
complete 6 weeks of antibiotics .
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous qAC and qhs: Please see attached sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: MSSA bacteremia
Secondary: sepsis,congestive heart failure, non-ST elevation MI,
acute renal failure, transaminitis, thrombocytopenia, coronary
artery disease, hypertension, hypercholesterolemia, diabetes,
atrial fibrillation, anemia
Discharge Condition:
Stable
Discharge Instructions:
Please follow-up with shortness of breath, chest pain, fevers,
chills.
Followup Instructions:
1) Cardiology: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 3183**]) [**2166-11-4**] 2:30 p.m.
- should have TSH/Free T4 checked within 6 weeks following
discharge
- given recently started on amiodarone, should have outpatient
PFTs
- consider restarting lipitor once LFTs normalize
2) Infectious disease:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2166-11-11**] 10:00
3) Electrophysiology: Dr. [**Last Name (STitle) **] 6-8 weeks following discharge.
You should be contact[**Name (NI) **] with this appointment. If you do not
hear from his office within 1-2 weeks, please call
([**Telephone/Fax (1) 2934**]) to schedule an appointment.
4) Primary Care: Please follow-up with your primary care
physician [**Name Initial (PRE) 176**] 1-2 weeks following discharge
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"518.82",
"276.52",
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.04",
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
11918, 11990
|
3924, 10108
|
331, 372
|
12277, 12286
|
3439, 3901
|
12405, 13450
|
2766, 2783
|
10352, 11895
|
12011, 12256
|
10134, 10329
|
12310, 12382
|
2798, 3420
|
248, 293
|
400, 1361
|
1383, 2436
|
2452, 2750
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,722
| 171,338
|
40618
|
Discharge summary
|
report
|
Admission Date: [**2166-7-1**] Discharge Date: [**2166-7-5**]
Date of Birth: [**2120-12-10**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Stabbing
Major Surgical or Invasive Procedure:
Emergent median sternotomy and decompressive laparotomy,
exploration of the chest and mediastinum and repair of right
ventricular laceration at the apex, closure of the previous left
emergent left thoracotomy ([**2166-7-1**])
Chest wash out and closure of median sternotomy incision
([**2166-7-5**])
History of Present Illness:
45M was stabbed in the right chest [**2166-7-1**] and "found down"
pulseless without a BP, hypoxic for at least 10-15 minutes
duration. Arrived pulseless to OSH on [**Hospital3 4298**] at
~6:19pm with a documented pulse of 40, 10 minutes later with
heavy bleeding from the chest. BP was 58/36. At the OSH ED a
thoracotomy performed with [**Last Name (un) **] put into the right ventricle
and he was trasfered to [**Hospital1 18**] urgently last evening on pressors.
En route via [**Location (un) **], SBP in the 50s most of the way. He had
an episode of v-fib which responded to cardioversion. Upon
arrival, initial vitals systolic BP 60s-80s, HR 80-120, O2 sat
40s-60s and he was described as intubated with b/l dilated
pupils with cool body temperature and no movement seen.
Resuscitated aggressively with 15L crystalloid. He was taken
directly to the OR for sternotomy and repair of the RV. There
was a concern for abdominal compartment syndrome as respiratory
status declined with increasing abdominal distention and
improved from sats in the 0s to 90s after cavity opened. Abdomen
and chest remain opened.
Past Medical History:
PMH: diverticulosis
PSH:
- emergent colectomy and [**Last Name (un) **] for perforated diverticulitis
about 9 months ago
- colostomy takedown about 4 months ago
Social History:
Divorced. He has two children (age 7 and 10) with former wife.
Girlfriend has been at the bedside. Sister in [**Name2 (NI) **]. Has
girlfriend [**Name (NI) **] [**Name (NI) 20932**]. Stabbed by ex-wife's husband.
Family History:
Non-contributory
Physical Exam:
(on admission)
PE: systolic 60s-80s, HR 80-120 O2 sat 40s-60s
Intubated
b/l dilated pupils
L anterior thoracotomy site with lung parenchyma exposed under
sponges
abdomen is distended and firm, has old midline scar and ? ostomy
scar
no edema
entire body is cool, no movement seen
Pertinent Results:
CT head ([**2166-7-4**]) - Diffuse cerebral edema with downward
transtentorial herniation and bilateral hypodensity of the
globus palladi, consistent with anoxic brain injury.
EEG ([**2166-7-2**]) - This is an abnormal video EEG due to the
presence of a low voltage, poorly organized background which
reached briefly up to 4 Hz
frequency, which represents a severe encephalopathy. The
beginning of
the recording showed generalized periodic epileptiform
discharges or
GPEDs which occurred up to 1 Hz frequency which represents
generalized
cortical irritability; however, these could not be appreciated
in the
latter third of the recording, which could be due to a
pharmacologic
effect or clinical deterioration. These findings are consistent
with the
patient's history of anoxia. There were no electrographic
seizures seen.
Brief Hospital Course:
The patient was admitted to the CVICU for further management
post-operatively. His chest and abdomen remained open. He was
kept intubated and sedated. He was taken back to the operating
room on [**7-3**] for chest closure and abdominal closure with a
[**State 19827**] patch. Intra-op TEE shows severe RV hypokinesis,
preserved LV function with good EF. He was transferred to the
Trauma ICU for further managment. Sedation was held and the
patient failed to respond appropriately. Pupils remained
pinpoint. Neurology was consulted and a head CT was obtained
which demonstrated diffuse cerebral edema with transtentorial
herniation consistent with anoxic brain injury. EEG was obtained
which per Neurgoloy showed not much cerebral activity (3 Hz
activity) and indicated severe encephalopathy and an extreme
poor prognosis. Their opinion was that brain is essentialy
damaged to the point where he is unable to mount any activity.
This was discussed with the patient's sister and girlfriend and
on [**2166-7-4**] they elected to make the patient DNR. The
patient's children were brought in to see him and on [**2166-7-5**]
he was made CMO, and expired shortly thereafter.
Medications on Admission:
None
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"V49.86",
"562.10",
"E966",
"790.01",
"345.3",
"854.05",
"348.4",
"958.5",
"518.4",
"570",
"958.93",
"348.5",
"568.0",
"V66.7",
"958.4",
"780.33",
"860.3",
"348.30",
"861.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"54.25",
"38.93",
"34.02",
"96.04",
"89.19",
"33.22",
"38.91",
"54.11",
"96.72",
"37.49",
"88.72",
"54.62",
"54.59",
"34.79"
] |
icd9pcs
|
[
[
[]
]
] |
4638, 4647
|
3371, 4551
|
311, 613
|
4698, 4707
|
2522, 3348
|
4763, 4773
|
2187, 2205
|
4606, 4615
|
4668, 4677
|
4577, 4583
|
4731, 4740
|
2220, 2503
|
263, 273
|
641, 1753
|
1775, 1938
|
1954, 2171
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,516
| 187,749
|
18839+57012
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-7-20**] Discharge Date: [**2137-8-7**]
Date of Birth: [**2064-10-24**] Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Right lower extremity pain/swelling, acute on chronic renal
failure
Major Surgical or Invasive Procedure:
Right internal jugular line
IVC filter
HD tunneled line catheter
History of Present Illness:
72M with a history of CVA, PVD, COPD, CKD admitted with RLE
pain/swelling and [**Last Name (un) **]. The patient saw his pcp two days ago,
noticed to have increased swelling of his legs, was started on
Bactrim and Keflex for ? cellulitis. He lives with his son and
was sent here for further eval for worsening RLE pain with
movement.
.
In the ED, the patient underwent LENIs and was found to have a
right popliteal DVT with adjacent collaterals and probable area
of recannulization suggest subacute/chronic nature. He was
given 1 dose of vancomycin and a bolus of heparin (not
continued). He was also found to have an elevated creatinine
from 4.8 to 5.6 and hyperkalemia from 5.9 to 6.2. EKG showed
NSR without spiked T waves (not confirmed, EKG not sent to
floor). Patient was given 15gm Kayexelate. He was also given
1L IVF for ? prerenal physiology. Of note patient has recently
seen a nephrologist at [**Hospital1 18**] for discussion of hemodialysis
initiation. Patient has been referred for HD access.
.
On transfer to ICU, VS: 96.3 63 144/60 17 100%RA. Patient
complains of pain in his right leg. Pain exacerbated by
ambulation. On admission, patient declines fevers, chills,
nausea, vomiting, CP, SOB, headaches, change in vision,
abdominal pain. He has not urinated today. At baseline, he
urinates small amounts 3-4 times daily.
.
Past Medical History:
1. R thalamic and L pontine stroke - [**9-8**]
2. PVD - mulitple bypass surgeries
3. CKD - baseline Cr ~2.5
4. DM - insulin dependent
5. Hypercholesterolemia - not on statin
6. Paroxysmal Afib - on Coumadin
7. hx of compression fractures in [**2122**]
8. Peripheral neuropathy
9. HTN
10. Colonic polyps
11. Anemia
12. patent foramen ovale
13. rhabdomyolysis [**2140-1-10**]. ?COPD but not O2 dependent
15. s/p b/l cataract surgeries and laser tx
16. s/p open appendectomy for mucinous neoplasm
Social History:
Mr. [**Known lastname **] is a retired roofer. He has a history of heavy alcohol
consumption, but is now sober. He smokes 5 cigarettes daily. The
patient lives with his handicapped son, while his son [**Name (NI) **]
visits daily to ensure he is taking his medications.
Family History:
Strong family history of type II diabetes mellitus
Physical Exam:
Admission Exam:
VS: 96.3 63 144/60 17 100%RA
Gen: Alert, mildly confused, laying in bed in NAD
HEENT: MMM, sclera anicteric, no lymphadenopathy or thyromegaly
Card: Normal S1, S2, no murmurs, rubs or gallops
Resp: Mild expiratory wheezes bilaterally
Abd: Obese, soft, non-tender, surgical hernia on right side of
abdomen - reducible
Ext: right posterior calf with erythematous, edematous area,
tender to palpation
Discharge Exam:
97 154/66 58 18 98RA
Gen: Alert, AOx3, laying in bed in NAD
HEENT: MMM, sclera anicteric, no lymphadenopathy or thyromegaly
Card: Normal S1, S2, no murmurs, rubs or gallops
Resp: CTA bilaterally
Abd: Obese, soft, non-tender non-distended, surgical hernia on
right side of abdomen - reducible
Ext: right posterior calf tender to palpation, not erythematous
or indurated
Pertinent Results:
Labs on admission:
[**2137-7-20**] 12:55PM BLOOD WBC-11.3* RBC-2.45* Hgb-8.0* Hct-23.2*
MCV-95 MCH-32.9* MCHC-34.7 RDW-17.4* Plt Ct-408
[**2137-7-20**] 12:55PM BLOOD PT-13.7* PTT-27.2 INR(PT)-1.2*
[**2137-7-20**] 12:55PM BLOOD Glucose-125* UreaN-69* Creat-5.6* Na-133
K-6.2* Cl-104 HCO3-17* AnGap-18
[**2137-7-20**] 12:55PM BLOOD Glucose-125* UreaN-69* Creat-5.6* Na-133
K-6.2* Cl-104 HCO3-17* AnGap-18
[**2137-7-20**] 07:12PM BLOOD Calcium-8.3* Phos-8.0* Mg-1.6 Iron-PND
[**2137-7-20**] 01:19PM BLOOD Lactate-1.1
Discharge Labs:
[**2137-8-7**] 06:35AM BLOOD WBC-8.9 RBC-3.16* Hgb-10.1* Hct-28.5*
MCV-90 MCH-32.0 MCHC-35.5* RDW-17.4* Plt Ct-226
[**2137-8-6**] 03:16PM BLOOD WBC-7.1 RBC-3.23*# Hgb-10.5*# Hct-28.9*#
MCV-90 MCH-32.4* MCHC-36.1* RDW-17.0* Plt Ct-194
[**2137-8-5**] 06:25AM BLOOD WBC-11.0 RBC-2.04* Hgb-6.9* Hct-18.7*
MCV-92 MCH-33.9* MCHC-37.1* RDW-17.8* Plt Ct-268
[**2137-7-29**] 07:05AM BLOOD Neuts-57.1 Lymphs-26.3 Monos-4.4
Eos-11.7* Baso-0.5
[**2137-7-28**] 06:40AM BLOOD Neuts-55.2 Lymphs-27.8 Monos-4.2
Eos-12.4* Baso-0.4
[**2137-8-7**] 06:35AM BLOOD Glucose-164* UreaN-24* Creat-3.4*# Na-135
K-3.4 Cl-99 HCO3-31 AnGap-8
[**2137-8-5**] 06:25AM BLOOD UreaN-11
[**2137-8-7**] 06:35AM BLOOD Calcium-8.0* Phos-4.3# Mg-1.7
Imaging:
LENIs ([**2137-7-20**])
Right popliteal DVT, possibly subacute or older noting adjacent
collaterals and possible recannulization, but recent on-site of
clot is not excluded.
MAPPING VENOUS DUP UPPER EXT BILATERAL ([**2137-7-22**])
1. Patent bilateral subclavian, cephalic and basilic veins.
2. Patent bilateral brachial and radial arteries. Please note
that there are two right brachial arteries, an anatomical
variant.
Brief Hospital Course:
72 yo M with Stage IV CKD who presents with RLE edema and
erythema admitted to MICU for hyperkalemia and EKG changes.
#RLE erythema and edema -
Patient received LENIs in ED for RLE edema and erythema found to
have right popliteal DVT with recanulization and collaterals,
likely chronic. Patient received heparin bolus and placed on
heparin drip. Coumadin was not started because of the potential
for tunneled cath placement for HD initiation. He did receive 1
dose of Vanco in the ED, antibiotics not continued because
erythematous changes likely [**1-2**] DVT rather than infectious. He
was continued on a heparin drip following transfer out of the
MICU to the medicine floor. It was decided in conjunction with
the PCP that the patient was a poor long term anticoagulation
candidate given his multiple falls. A removable IVC filter was
placed on [**2137-7-23**], and anticoagulation was stopped. His RLE at
the time of discharge was stable and tender to palpation.
.
#Acute on Chronic Kidney disease, ESRD.
The patient was originally planned for vein graft in [**Month (only) 462**]
for initiation of dialysis. The acute component of kidney
injury likely side effect of bactrim/keflex in addition to a
possible prerenal etiology. The patient underwent upper
extremity vein mapping, but it was decided not to place a
fistula during this hospitalization given his other acute
medical issues. Renal was consulted who initially wanted to
delay HD initiation, however it became clear that this was not a
possibility. He underwent a HD tunneled line catheter placement
on [**2137-7-23**] and HD was initated on [**2137-7-24**]. He continued to get
HD throughout the remainder of his hospital course. On [**8-6**] he
self d/c'd his HD catheter, and went to IR to place another also
on the R side but with a different tunnel.
#Hyperkalemia -
Due to acute on chronic kidney disease, he has had prior
hyperkalemic labs as an outpatient for which he received
Kayexalate. Patient received Kayexalate 15 g x 2, with
appropriate stooling and labs showed drop in K. Patient had
evidence of ?peaked T waves on EKG in MICU, he received Ca-Gluc
and Kayexalate, potassium fell and he has been stable without
EKG changes. On the floor, the patient continued to have
increased levels of potassium without EKG changes. His labs
improved following dialysis.
#Anemia -
Required multiple transfusions at HD (last on [**8-5**] for HCT 18,
repeat 28). Normocytic anemia likely related to decreased
erythropoetin production in the setting of ESRD. No evidence of
bleeding on exam. Iron studies ordered revealed increased
levels of ferritin consistent with anemia of chronic disease.
His HCT stabilized in the upper 20s by the time of discharge.
He did not receive further PRBC transfusions.
#Diabetes -
Patient with chronic DM II on insulin. Was placed on ISS with
plan to restart long acting upon discharge. He had a few
episodes of asymptomatic hypoglycemia, the most severe being
around 39 prior to breakfast. He receieved 0.5 amp of dextrose
and his FS responded accordingly. He was discharged to rehab on
an ISS as he was only requiring ~4-6u of humalog total daily,
and his home NPH was stopped.
Medications on Admission:
Meds (as of [**7-17**]):
Medications - Prescription
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day bp
*dose increase*
CEPHALEXIN - 500 mg Capsule - 1 Capsule(s) by mouth four times a
day x 10 days
CITALOPRAM - 10 mg Tablet - 1 Tablet(s) by mouth once a day,
CLONIDINE - 0.1 mg/24 hour Patch Weekly - apply qwk for htn
FENOFIBRATE MICRONIZED - 200 mg Capsule - one Capsule(s) by
mouth
once a day
FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth daily
GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth at bedtime
for itch due to kidney failure
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - sliding scale
ut dict1 as needed for sq injection dm
LISINOPRIL - 5 mg Tablet - one Tablet(s) by mouth daily
METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice
a day bp
NORTRIPTYLINE - 50 mg Capsule - 1 Capsule(s) by mouth at bedtime
for nerve pain foot pain from diabetes
PERCOCET - 5-325MG Tablet - TAKE [**12-2**] BY MOUTH EVERY 6 HOURS AS
NEEDED FOR PAIN OF GANGRENE
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1
Tablet(s) by mouth twice a day x 10 days
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply twice a day
affected area
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day prevention stroke
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - ut
dict once a day for dm
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day as needed for constipation
INSULIN SYRINGES (DISPOSABLE) - Syringe - inject q hs dm [**12-2**]
cc
ultrafine II BD u100
LANCETS [ONE TOUCH ULTRASOFT LANCETS] - (Dose adjustment - no
new Rx) - Misc - check four times a day or more often ut dict
dm
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
38units before breakfast, and supper DM, adjust ut dict
OMEGA-3 FATTY ACIDS-FISH OIL - 360 mg-1,200 mg Capsule - 1
Capsule(s) by mouth twice a day prevention stroke, chol
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous qac: As directed by sliding scale.
5. nortriptyline 50 mg Capsule Sig: One (1) Capsule PO at
bedtime.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
8. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
9. ethacrynic acid 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for pruritis.
17. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every Tuesday).
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 246**] Nursing Center - [**Location (un) 246**]
Discharge Diagnosis:
Primary diagosis:
End stage renal disease
.
Secondary diagnoses:
Deep vein thrombosis
Anemia
Hyperkalemia
Diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during this admission. You
were admitted because you had pain and swelling in your right
lower leg. We found that there was a clot in one of your veins
and we started you on anticoagulation so that the clot would not
expand. We then placed a filter in your inferior vein cava, a
vein that drains the blood from both of your legs so that it
would stop pieces of the clot from reaching your lungs. This
filter should be removed in the coming months.
We also found that you had high levels of potassium in your
blood which can be bad for your heart. We felt this was due to
your kidneys not functioning properly. We spoke to your
nephrologist and decided that it would be best to initiate
dialysis during this admission. You had what is called a
hemodialysis tunneled line catheter placed, which is a temporary
line for dialysis. You will need a more permanent way to
undergo dialysis placed in the future.
We hope you continue to feel better.
Medication changes:
START-
clonidine patch 0.2 every week
ethacrynic acid 25 PO BID
sevelamer 1600 PO TID with meals
toprol XL 150 PO QD
nephrocaps 1 PO QD
Please STOP:
Furosemide
Fenofibrate
clonidine 0.1 patch
keflex
bactrim
lisinopril
metoprolol 100 twice per day
NPH insulin
Please continue to take all other medications as directed
Followup Instructions:
Department: RADIOLOGY
When: FRIDAY [**2137-8-9**] at 1 PM
With: VASCULAR STUDY [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: FRIDAY [**2137-8-9**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2137-9-26**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Known lastname **],[**Known firstname **] E. Unit No: [**Numeric Identifier 9673**]
Admission Date: [**2137-7-20**] Discharge Date: [**2137-8-7**]
Date of Birth: [**2064-10-24**] Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**Doctor First Name 376**]
Addendum:
Brief Hospital Course:
Positive PPD: Upon workup for outpatient dialysis, a PPD was
placed which showed ~1.5-2inch of erythema and hard induration.
Pt states that he does not know anyone with TB, and has very few
risk factors for TB. Denied cough, nightsweats or fever. Chest
xray appears normal, without any evidence for apical infiltrate
or scarring. No intervention was undertaken as this was likely
indicative of past exposure and not active disease.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 824**] Nursing Center - [**Location (un) 824**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**]
Completed by:[**2137-8-9**]
|
[
"585.6",
"427.89",
"276.7",
"294.8",
"V58.67",
"453.41",
"682.6",
"403.91",
"285.21",
"250.00",
"288.3",
"584.9",
"V45.11",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"38.95",
"38.7",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15684, 15911
|
15225, 15661
|
366, 433
|
12317, 12317
|
3545, 3550
|
13887, 15202
|
2640, 2692
|
10426, 12035
|
12170, 12214
|
8467, 10403
|
12502, 13524
|
4076, 5220
|
2707, 3132
|
12235, 12296
|
3148, 3526
|
13544, 13864
|
259, 328
|
461, 1818
|
3564, 4060
|
12332, 12478
|
1840, 2336
|
2352, 2624
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,374
| 116,961
|
23124+57337
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-12-13**] Discharge Date: [**2108-12-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Syncope, bradycardia, and hypotension
Major Surgical or Invasive Procedure:
Right central line placement and removal.
Arterial line placement and removal.
History of Present Illness:
Pt is a 87 yo male with h/o HTN, severe MR, who presents from
[**Hospital1 1501**] following syncopal episode w/ bradycardia and hypotension.
Per report, patient was was working with PT/OT when he slumped
in a chair with decreased MS (unable to follow commands,
somnolent, able to open eyes). His SBP was noted to be 74/37 and
HR was 46. FS was 114. EMS admistered atropine x 2 which raised
pt's HR to 60, and SBP to the 60s.
In the ED vital signs were : T 98.8, HR 60s-70s, bp 94/64, resp
24 100% NRB. He received ASA 325 X 1, Atropine 1 mg IV X 1, and
levofloxacin 500 mg IV X 1, 2L NS. Dopamine was initiated for
hypotension and titrated up to 7.5. EKG showed irregular HR and
0.[**Street Address(2) 1755**] depressions in V4-V6. A Head CT was obtained, which
showed showed subacute external capsule infarcts. In the MICU
Neurology was consulted who recommended an MRI which showed
nothing acute. Cardiology was consulted for bradycardia and
hypotension, however A line was placed and BPs were ~20 pts
higher than cuff, and thus unlikely pt was hypotensive. Pt was
easliy weaned off dopamine. He was then transferred to the
regular medicine floor.
Past Medical History:
1) HTN
2) Paget's disease
3) Severe MR [**Last Name (Titles) **] 67%
4) PUD
5) HAV
6) ERCP s/p sphincterotomy in [**2099**] for CBD stone
-- c/b choledochalduodenal fistula [**2103**]
7) s/p appy
8) Depression
9) H/o EtOH abuse
10) newly diagnosed dementia
11) Chronic LFT abnormalities.
Social History:
Pt lives at the [**Hospital3 4414**] Rehab Center for one month (previously
he lived alone). He has two sons and twelve grandchildren.
Retired worker at paper company. Quit smoking at 35. History of
EtOH [**3-5**] whiskeys x 4-5 days per week. No history of black outs.
No IVDU.
Family History:
Non-contributory
Physical Exam:
Upon transfer to the regular medicine floor
VS: T: 97.2 m; BP: 120/80 (112-124/60-80); P: 60-64; RR: 20; O2:
96 on 3L I/O 700 cc out 8 hours
Gen: Elderly male, nonsensicle in NAD
HEENT: [**Name (NI) **] pt does not follow direction to open
Neck: right central line in place. No JVD
CV: III/VI holosystolic murmur at apex and at LLSB. RRR S1S2.
Lungs: right basilar rales. Pt could not take in deep breaths on
direction
Abd: +BS. soft, nt, nd.
Ext: DP 1+. No edema.
Pertinent Results:
Labs on admission:
[**2108-12-12**] 01:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2108-12-12**] 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2108-12-12**] 01:42PM GLUCOSE-103 LACTATE-2.0 NA+-138 K+-4.2
CL--106 TCO2-28
[**2108-12-12**] 01:40PM UREA N-16 CREAT-0.9
[**2108-12-12**] 01:40PM CK(CPK)-29* AMYLASE-45
[**2108-12-12**] 01:40PM CK-MB-NotDone cTropnT-<0.01
[**2108-12-12**] 01:40PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.7
[**2108-12-12**] 01:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-12-12**] 01:40PM WBC-4.2 RBC-2.71* HGB-7.9* HCT-24.8* MCV-92
MCH-29.2 MCHC-31.9 RDW-14.4
[**2108-12-12**] 01:40PM PLT COUNT-207
[**2108-12-12**] 01:40PM PT-13.8* PTT-32.9 INR(PT)-1.2
[**2108-12-12**] 01:40PM FIBRINOGE-359
_____________________
Labs on discharge:
[**2108-12-18**] 06:22AM BLOOD WBC-5.3 RBC-3.96* Hgb-11.5* Hct-35.7*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.6 Plt Ct-246
[**2108-12-18**] 06:22AM BLOOD Glucose-95 UreaN-14 Creat-0.5 Na-142
K-4.4 Cl-109* HCO3-26 AnGap-11
[**2108-12-18**] 06:22AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
______________________
Other:
[**2108-12-17**] 06:48AM BLOOD Triglyc-73 HDL-55 CHOL/HD-2.2 LDLcalc-50
[**2108-12-13**] 03:20AM BLOOD TSH-0.99
[**2108-12-13**] 03:20AM BLOOD Cortsol-32.8*
[**2108-12-13**] 10:15AM BLOOD Cortsol-32.4*
[**2108-12-13**] 10:47AM BLOOD Cortsol-34.6*
_____________________
Cardiac enzymes:
[**2108-12-12**] 01:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2108-12-13**] 03:20AM BLOOD cTropnT-0.03*
[**2108-12-16**] 01:35AM BLOOD CK-MB-4 cTropnT-0.14*
[**2108-12-16**] 01:00PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2108-12-17**] 06:48AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2108-12-16**] 06:30AM BLOOD CK(CPK)-62
[**2108-12-16**] 01:00PM BLOOD CK(CPK)-59
[**2108-12-17**] 06:48AM BLOOD CK(CPK)-29*
_____________________
Radiology:
CT Head without contrast [**2108-12-12**]-IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Chronic external capsule infarcts.
3. Mottled appearance of the vertex of the skull, which may be
of no clinical significance. A bone scan can be performed to
evaluate for conditions such as Paget's disease.
_____________________
MRA Brain without contrast [**2108-12-14**]-FINDINGS: The major
tributaries of the circle of [**Location (un) 431**] are patent motion. Decreased
signal in the proximal basilar may be due to turbulent flow or
patient motion. No other areas of abnormality are identified.
There is no significant stenosis or aneurysmal dilatation.
Within the limits of coverage of this study, no sign of
arterial-venous malformation is apparent.
IMPRESSION:
1. No evidence of acute infarction.
2. Chronic microvascular infarcts in the periventricular white
matter.
3. Areas of susceptibility in the occipital lobes and right
parietal and temporal lobes may represent mineralization versus
chronic small vessel hemorrhage.
4. Patent circle of [**Location (un) 431**]. Slight irregularity of proximal
basilar artery may be secondary to turbulence or patient motion.
_____________________
Chest AP [**2108-12-15**]-Since the prior study, there has been removal
of the right subclavian line. There is no evidence of
pneumothorax. There has been worsening in the degree of diffuse
bilateral pulmonary infiltration associated with bilateral
pleural effusion. Cardiomegaly is unchanged.
IMPRESSION:
1) Interval removal of the right CVP line.
2) Worsening congestive heart failure.
Brief Hospital Course:
1. [**Name (NI) **]
Pt was maintained on pressors (dopamine) in the MICU for one
day. Differential diagnosis on admission included adrenal
insufficiency, hypothyroidism, sepsis (although no clear
source), myocardial ischemia (minor ST abnormalities noted), and
decreased volume status. Pt was likely volume deplete in the
setting of decreased PO intake and anemia.
Discussed by possible diagnosis:
a. Arrythmia/Bradycardia/[**Name (NI) **] Pt received atropine x 2 without
large response. Two sets of cardiac enzymes were normal and
initial EKG showed lateral ST depressions. Echocardiogram
revealed the presence of a preserved EF 70%, moderate AS, 2+ MR,
[**12-2**]+ TR. Electrophysiology consulted on pt and there was no
indication for a pacemaker. Pt was kept on telemetry without
incident in the MICU. CHF was not evident on initial physical
exam. Once an a-line was placed, BPs were 20 points higher than
on cuff pressure.
b. Hypothyroidism-TSH was normal
c. Adrenal insufficiency- Cortisol stimulation test was 32-->34.
Pt was initially started on dexamethasone in the MICU but this
was d/cd when pt came to the floor without incidence.
d. [**Name (NI) 15305**] Pt was afebrile throughout and cultures were
negative.
e. Volume depletion-Pt was hypovolemic in the setting of both
decreased PO intake and a chronic anemia. Pt was aggressively
fluid resuscitated in the MICU and also received 2 units of
pRBCs for volume increase. BPs came up to systolic 110s-130s on
the floor.
2. CHF/[**Name (NI) 12329**] Pt was volume resuscitated in the MICU and required
lasix as evidence of volume overload. Based on oxygen
requirement of 3 L NC(previously not on oxygen) and wheezing, as
well as CXR, pt was overloaded. He was slowly diuresed with
lasix ~10 mg IV per day. Additionally, ACE inhibitor was added
back slowly as pt had been hypotensive on admission. Upon
discharge, pt is satting in the mid-90s on room air and is
euvolemic. Goal should be to keep pt even at this point.
Pt had one acute episode of SOB where he required diureses, and
with EKG showing further lateral depressions and increased
troponins to .16. CKs were flat and this was in the setting of
CHF exacerbation and demand ischemia. EKG returned more to
baseline.
3. Anemia-
Reported baseline of pt's HCT is 27-29 and was 24.8 on
admission. He was guaiac (-) here with no obvious source of
bleeding. Pt with history of "slow GI bleed" with negative
colonoscopies in the past (per report). He was transfused 2
units pRBC on admission for volume resuscitation and Hct bumped
>5 points. Iron studies show iron deficiency anemia with low
iron and low ferritin and pt was continued on iron.
4. Endocrine- Cortisol was 32 and post-stimulation was 34. He
was started on dexamethasone in the MICU. Upon transfer to the
floor, steroids were d/cd.
5. Delirium- Upon transfer to the floor, per family, pt was not
at his baseline. He was speaking non-sensibly. Normally pt is
conversant and can recognize family which he was not able to do.
In the MICU, pt received valium for agitation. On the floor,
benzodiazepines were stopped, pt's foley was d/cd, and we tried
to orient pt to day/night. He was also started on Seroquel [**Hospital1 **].
On discharge, pt is again oriented to place, time (year and
season) and was conversant, making sense. While pt was
delirious, he required a 1:1 sitter as he pulled at lines.
6. Subacute infarcts- Head CT showed subacute capsular infarcts.
Pt was seen by neuro and had MRI which showed old infarcts and
thus nothing further was done.
7. History of EtOH abuse- There were no symptoms of withdrawal.
Pt was kept on thiamine and folate here.
8. F/E/[**Name (NI) **] Pt was seen by speech and swallow who recommended thin
liquids pureed solids. He was also seen by nutrition who added
boost supplements.
9. Prophylaxis- On Lovenox at [**Hospital1 1501**] and subcutaneous heparin here.
Continued PPI. Pt received Pneumovax vaccine prior to discharge.
10. [**Name (NI) 59529**] Pt with dementia, continued Aricept. Also with
depression continued lexapro here. We also added Seroquel
low-dose [**Hospital1 **].
11. [**Name (NI) 12010**] Pt with Right subclavian line put in MICU which was
d/cd on floor. Otherwise had peripheral IVs.
12. Code Status: Pt was DNR/DNI. This was discussed with son [**Name (NI) **]
[**Name (NI) **], HCP.
Medications on Admission:
Lisinopril 10 mg qday
ASA 81 mg qday
Folate 1 mg qday
Thiamine 100 mg qday
Lexapro 10 mg qday
Lovenox 30 mg qday
Aricept 5 mg qday
Protonix 20 mg qday
Iron 325 mg qday
Levoquin ([**Date range (1) 59530**])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lexapro 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Furosemide 20 mg Tablet Sig: 0.5 (half) Tablet PO once a
day: 10 mg qday.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 59531**] REHAB
Discharge Diagnosis:
Primary Diagnosis:
Hypotension
Congestive Heart Failure
Delirium
Secondary Diagnosis:
Anemia
Depression
Dementia
Discharge Condition:
[**Name (NI) 23148**] Pt is normotensive and is oriented again. He has been
stabilized on his medications.
Discharge Instructions:
-Please call your doctor or go to the emergency room immediately
if you have problems breathing, shortness of breath, chest pain,
Seizure, feel dizzy or lightheaded, or any other health concern.
-You should weigh yourself daily. Call your doctor if your
weight increases or decreases by 3 pounds.
Followup Instructions:
-You should call your doctor (PCP) and set up an appointment
within 2 days of discharge.
-Pt needs to have his hearing aid reconfigured and hearing
retested.
-Per the nursing facility
Name: [**Known lastname **],[**Known firstname 5088**] Unit No: [**Numeric Identifier 10919**]
Admission Date: [**2108-12-13**] Discharge Date: [**2108-12-18**]
Date of Birth: [**2021-8-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1513**]
Addendum:
Lab addendum:
Iron studies:
calTIBC Ferritn TRF
324 23* 249
Lipid panel:
Triglyc HDL CHOL/HD LDLcalc
731 55 2.2 50
____________________
Microbiology:
[**2108-12-13**]- BCx x 2- No growth to date
[**2108-12-13**]- UCx- No growth
[**2108-12-16**]-UCx- contamination
[**2108-12-16**] BCx x 2- NGTD
[**2108-12-16**]- UCx- staph coagulase negative
[**2108-12-17**]- BCx- NGTD
U/A [**2108-12-13**]- Negative
U/A [**2108-12-16**]- Negative
Discharge Disposition:
Extended Care
Facility:
[**Hospital 10920**] REHAB
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**]
Completed by:[**2108-12-18**]
|
[
"276.5",
"780.2",
"280.0",
"396.3",
"294.8",
"244.9",
"398.91",
"397.0",
"427.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13734, 13945
|
6279, 10622
|
302, 382
|
12206, 12314
|
2708, 2713
|
12661, 13711
|
2188, 2206
|
10878, 11972
|
12069, 12069
|
10648, 10855
|
12338, 12638
|
2221, 2689
|
4221, 6256
|
225, 264
|
3632, 4204
|
410, 1564
|
12156, 12185
|
12088, 12135
|
2727, 3613
|
1586, 1876
|
1892, 2172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,217
| 139,246
|
41052
|
Discharge summary
|
report
|
Admission Date: [**2196-3-16**] Discharge Date: [**2196-3-24**]
Service: SURGERY
Allergies:
Cipro / Quinolones
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
S/P Fall
Major Surgical or Invasive Procedure:
Pelvic arteriogram [**2196-3-16**]
History of Present Illness:
89F s/p mechanical fall at home. Taken to OSH where CT showed
right superior and inferior pubic rami fractures with an
associated hematoma tracking up the rectus sheath measuring 10 x
3.5 x 6. The patient was hypotensive with low BP's in the
80s-90s at the OSH. She was given blood for a HCT 28.1 and
transferred to [**Hospital1 18**] for further management. Head CT at the OSH
was negative.
Past Medical History:
PMH: crohn's, bell's palsy, HTN, glaucoma
PSH: unknown
Social History:
No tobacco, no ETOH, lives alone
Family History:
non-contributory
Physical Exam:
Temp:96.4 HR:80 BP:98/58 Resp:16 O(2)Sat:100
Constitutional: Awake alert and oriented
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
There is no tenderness to palpation of the posterior
cervical C-spine
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Pelvic: Tenderness to palpation over the anterior pelvis
Extr/Back: Distal sensation and capillary refill are intact
in both lower extremities
Neuro: Speech fluent
Psych: Normal mood
Pertinent Results:
IMAGING:
[**2196-3-16**] CTA torso:
1. Right superior pubic ramus fracture with associated complex
fluid collection seen along the anterior abdominal wall and
within the right side of pelvis, consistent with hematoma.
Findings are stable and unchanged when compared to prior
imaging. No evidence of active arterial extravasation on this
study. However, this is within the limits of suboptimal IV bolus
timing and acute extravasation cannot be fully excluded;
however, given that the size of the hematomas have not changed
significantly since the prior examination, these are likely
stable.
2. There is infrarenal abdominal aortic aneurysm measuring
maximum 4.3 in
anterior-posterior diameter and 4.3 cm in transverse diameter.
2. There is infrarenal abdominal aortic aneurysm measuring
maximum 4.3 in
anterior-posterior diameter and 4.3 cm in transverse diameter.
[**2196-3-16**] Pelvic arteriogram
Unsuccessful right common femoral artery access. Successful left
common femoral artery access with a pelvic arteriogram
performed. AP and
oblique projections did not demonstrate evidence of active
contrast
extravasation at this time. No further intervention was
performed. The
patient tolerated the procedure well, and there were no early
complications.
[**2196-3-18**] CXR :
Pulmonary vasculature previously engorged on [**3-16**], is now
normal to
slightly increased in caliber. There is no pulmonary edema.
Pleural effusion is small on the left, if any. Heart size
normal. Left subclavian line ends close to the superior
cavoatrial junction. No pneumothorax or mediastinal widening.
Brief Hospital Course:
The patient was admitted to the ACS service was taken for urgent
IR angio given that there was active extravasation seen on her
CTA torso. However, they did not visualize any active bleeding
and no intervention was performed.
Post-procedure, the patient was admitted to the TSICU for close
monitoring. Serial hcts were checked. These initially remained
stable but then began trending down during the latter part of
the day on post-procedure day 1 to a nadir of 21.3. She was
transfused two units of blood and one unit of platelets (for a
platelet count of 49) and her post-transfusion bumped
appropriately to 31.7.
Hemodynamically, the patient remained stable. Her diet was
liberalized and she tolerated a regular diet without problems.
She transferred to a regular floor bed on [**3-18**]. Pt did spike a
fever up to 101.3 once on the floor.
On [**3-19**] Pt continued to be HD stable. HCT remained stable. Pt did
begin to show sign of delirium and agitation which was addressed
with Zyprexa. Cultures and CXR were obtained and pt was started
on empiric vanc/zosyn.
On [**3-20**] pt continued to wax and wane. A geriatric consult was
obtained, and Seroquel was started instead of Zyprexa. Her blood
cultures were preliminarily negative as was her urine culture.
A sputum culture could not be obtained but the working diagnosis
was pneumonia based on a slightly elevated WBC and increased
opacity of the left lower lobe on chest xray.
She developed ATN on [**2196-3-21**] possibly from the dye load from the
angiogram. Her urine output was adequate with additional IV
hydration and gradually it declined. Her admission creatinine
actually was 1.5 but it decreased to a low of 1.0. Her
Vancomycin was stopped in order to eliminate nephrotoxic drugs
and she continued to improve.
The Physical Therapy service recommended short term rehab to try
to increase her mobility and endurance.
Medications on Admission:
macrobid 100'', pepcid 20', vitC 500', combigan 0.2-0.05% 1gtt
each eye'', proair, caltrate 800 + VitD 1'', timoptic 0.5mg eye
gtt 1gtt each eye', miabalicin spr 200 1 spray daily per nostril
alternating,
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): Both eyes.
4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-17**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]
Discharge Diagnosis:
S/P Fall
1. Right superior/inferior rami fracture
2. Pneumonia
3. Acute blood loss anemia
4. Delirium
5. Acute renal failure/ATN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital after falling and you have a
pelvic fracture.
* Your blood count has been stable and the Orthopedic doctors
[**Name5 (PTitle) 9004**] [**Name5 (PTitle) **] to bear weight as long as the pain is tolerable.
* You also have been treated with antibiotics for pneumonia.
* Continue to eat well and stay hydrated.
* Your kidney function wasa bit abnormal in the hospital
probably from the contrast dye used during some of your xrays.
It is getting better and actually is back to normal.
* You are being transferred to rehab to try to increase your
mobility and endurance prior to returning home.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-18**] weeks.
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 4 weeks.
Completed by:[**2196-3-24**]
|
[
"997.5",
"285.1",
"293.9",
"555.9",
"401.9",
"808.2",
"E947.8",
"E888.9",
"584.5",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.49",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5864, 5949
|
2991, 4884
|
233, 270
|
6122, 6122
|
1377, 2968
|
6948, 7190
|
837, 856
|
5140, 5841
|
5970, 6101
|
4910, 5117
|
6298, 6925
|
871, 1358
|
185, 195
|
298, 691
|
6137, 6274
|
713, 770
|
786, 821
|
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