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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
60,180
| 176,888
|
39542
|
Discharge summary
|
report
|
Admission Date: [**2125-9-26**] Discharge Date: [**2125-10-2**]
Date of Birth: [**2104-10-31**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache.
Major Surgical or Invasive Procedure:
Formal angiography.
History of Present Illness:
This is 20 yr gentleman was stabbed on his left side of head
with
subsequent traumatic SAH with ICH and depressed skull facture.
he
received clipping around M3 with left MCA to stop bleeding. CTA
confirms that there is no aneurysm and further comfired by
conventional angiogram. Patient was discharged on [**9-19**] and then
he came to ER on [**9-21**] with complaints of bad headache and was
discharge on the same day. CT of head has no changes. patient
has
follow up diagnostic angiogram this morning, in the morning
patient states he had some headache, but he was walking and
without motor deficit. Interventional radiology performed
diagnostic angiogram and found patient has some vasospasm with
left MCA M1-M2 segment and they injected intraarterial
verapamil.
The patient is asymptomatically without no focal deficit. We
discussed the case and decide to admit to ICU service for
overnight observation.
Past Medical History:
None
Social History:
Lives with girlfriend and step-father.
Family History:
Non-contributory.
Physical Exam:
O: BP: 117/72 HR: 68 R: 16 O2Sats: 100% RA
Gen: Appears uncomfortable with ice over the L side of the head
HEENT: No scleral injection - staples over the L side of the
head
Neck: Supple.
Lungs: Clear
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Speech fluent with
good comprehension and repetition. No dysarthria or paraphasic
errors.
CN:
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: R facial with delayed excursion.
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 is [**6-13**] with 4 extremitites.
Sensation: Intact to all modalities.
DTR: B T Br Pa Ac
Right 2 2 2 1 1
Left 2 2 2 1 1
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Gait: Normal.
Pertinent Results:
[**2125-10-2**] 05:14AM BLOOD WBC-8.8 RBC-4.12* Hgb-12.2* Hct-35.7*
MCV-87 MCH-29.7 MCHC-34.2 RDW-14.4 Plt Ct-442*
[**2125-9-27**] 03:06AM BLOOD Neuts-82.5* Lymphs-10.7* Monos-4.7
Eos-1.8 Baso-0.3
[**2125-9-30**] 04:38AM BLOOD PT-13.1 PTT-27.3 INR(PT)-1.1
[**2125-10-2**] 05:14AM BLOOD Glucose-98 UreaN-14 Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
[**2125-9-27**] 03:06AM BLOOD ALT-9 AST-15 AlkPhos-72
[**2125-9-27**] 03:06AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8
CTA head
1. Previously noted vasospasm in the left MCA M1 and M2 has
largely resolved.
2. Small caliber of left ACA A1 segment, unchanged from
[**2125-9-15**].
3. Interval improvement in subarachnoid hemorrhage within left
sylvian fissure.
4. Normal perfusion study.
Brief Hospital Course:
The patient was admitted to he ICU after a scheduled follow-up
cerebral angiography showed significant vasospam in the left
MCA. He was started on fluids at 200cc/h of normal saline,
phenylephrine titrated to a systolic blood pressure of 140-160,
and nimodipine. He was monitored on EEG for early signs of
vasospam. He suffered some hypotension at weaning of fliud
therapy and given ongoing nimodipine. This resolved and the
patient was discharged on nimodipine, as below.
Medications on Admission:
None.
Discharge Medications:
1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every eight
(8) hours for 2 weeks.
Disp:*84 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Traumatic subarachnoid hemorrhage in context of:
Pentrating knife wound to head
Headache
Cerebral vasospasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with headache after a knife injury to
your head. Angiography revealed spasm of arteries, so you were
admitted for monitoring. You had no further evidence of spasm in
your brain blood vessels, likely becuase a medication was
started (see below). You will need to take this medication for a
futher two weeks. Please make an appointment to see
Neurosurgery, as below. Please make sure that you drink plenty
of water and stay well hydrated.
Followup Instructions:
Please call Neurosurgery TOMORROW:
??????Please return to the office in [**8-18**] days (from your date of
surgery) for removal of your [**Date Range 2729**] and a wound check. Although
we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Be
sure to point out any incisions, which may be covered by
clothing at the time of suture/staple removal. This appointment
can be made with the Nurse Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite a
distance from our office, please make arrangements for the same,
with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in less than 2 weeks.
??????At Dr.[**Name (NI) 9034**] discretion, you may need a CT scan of the brain
without contrast.
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,553
| 195,332
|
30567
|
Discharge summary
|
report
|
Admission Date: [**2170-4-2**] Discharge Date: [**2170-4-6**]
Date of Birth: [**2130-9-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain s/p Lap Chole
DKA
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
This is a 39 year old female with DM1 and recent episode
gallstone pancreatitis, accompanying DKA and short ICU stay at
[**Hospital3 5365**]. On [**3-18**] pt. had lap chole @ [**Hospital 392**] Hosp, sent
home same day, seen in f/u doing well. Presented [**4-2**] with abd
pain, N/V; again seen @ [**Hospital1 392**] where HIDA showed biliary leak,
patient found to be in DKA. Transferred to [**Hospital1 18**], received 5L
crystalloid in ED and begun on insulin gtt at 6U/hr. Transferred
to TICU.
Past Medical History:
PMH: DM, ^lipids, gallstone pancreatitis
PSHx: Lap CCY ([**2170-3-18**])
Social History:
[**1-2**] PPD x 15-20 years
No EtOH
Single, 3 children
Works as bartender
Family History:
N/C
Physical Exam:
98.6, 107, 132/72, 14, 100 RA, 45kg, BG 293
HEENT: anicteric, mild anxiety
CV: Reg S1, S2, tachycardia
Chest: CTA bilat., decreased at bases
Abd: soft, nondistended, focal tenderness RUQ and diffusely. Lap
surgical sites x 4 C/D/I and healing.
Ext: No C/C/E
Rectal: Guiac negative, normal tone
Pertinent Results:
[**2170-4-2**] 07:55PM BLOOD WBC-10.8 RBC-4.51 Hgb-13.4 Hct-39.7
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.1 Plt Ct-387
[**2170-4-5**] 07:00AM BLOOD WBC-4.7 RBC-3.88* Hgb-11.4* Hct-33.2*
MCV-85 MCH-29.4 MCHC-34.4 RDW-14.4 Plt Ct-304
[**2170-4-2**] 07:55PM BLOOD Glucose-336* UreaN-11 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-10* AnGap-31*
[**2170-4-5**] 07:00AM BLOOD Glucose-89 UreaN-3* Creat-0.5 Na-135
K-4.2 Cl-102 HCO3-29 AnGap-8
[**2170-4-2**] 07:55PM BLOOD ALT-10 AST-9 AlkPhos-103 Amylase-65
TotBili-0.4
[**2170-4-5**] 07:00AM BLOOD ALT-17 AST-20 AlkPhos-165* Amylase-41
TotBili-0.4
[**2170-4-2**] 07:55PM BLOOD Lipase-91*
[**2170-4-5**] 07:00AM BLOOD Lipase-76*
[**2170-4-5**] 07:00AM BLOOD Albumin-2.7* Calcium-8.8 Phos-4.0 Mg-1.9
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2170-4-2**] 9:51 PM
IMPRESSION: S/p cholecystectomy, with linear reflectors and
dirty shadowing in the surgical bed, likely from surgical clips
and/or air. No definite focal fluid collection/biloma is seen,
though evaluation is somewhat limited, and CT would be more
sensitive to assess for this, especially as a biliary leak was
suggested by the outside hospital HIDA scan. No biliary ductal
dilatation is seen.
.
ERCP BILIARY&PANCREAS PORTABLY BY TECH [**2170-4-3**] 1:02 PM
IMPRESSION:
1. No definite contrast extravasation identified on images
provided.
Brief Hospital Course:
She was admitted to the TICU with abdominal pain and DKA.
Diabetes: She was on an Insulin ggt, IVFs, lyte replacement.
Her blood sugars quickly improved and her acidosis improved
10->17/7.33. She came off the gtt on [**2170-4-4**] and was switched to
Lantus and Humalog sliding scale.
There was a concern for a ductal leak. On [**4-2**] a HIDA (OSH): no
filling in duodenum-[**Last Name (un) **] of biliary stump or cystic duct leak.
An US ([**Hospital1 **]): no fluid collection visual., no ductal dilatation.
An ERCP on [**2170-4-3**] (in ICU)showed no obstruct/stone/no
dilatation/no biliary leak. A stent was placed at this time. Her
abdominal pain was improving at this time.
Her diet was advanced and she was tolerating a regular diet. She
continued to have some mild Right sided tenderness and back
pain.
She went for a MRCP on [**2170-4-6**] and this was negative for a leak
and the stent was widely open.
She was discharged home in good condition and will return for
stent removal in [**3-4**] weeks.
Medications on Admission:
humalog 10U [**Hospital1 **] w/ meals, lantus 14hs, lipitor 40'
Discharge Medications:
1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please take all your regular meds and any new meds as ordered.
.
Continue to ambulate several times per day.
.
Continue to monitor your blood sugars closely and follow-up with
your PCP/Endocrinologist in the next 1-2 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**3-4**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Please follow-up with ERCP in [**3-4**] weeks. Call ([**Telephone/Fax (1) 2360**] to
schedule an appointment for stent removal
Completed by:[**2170-4-6**]
|
[
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icd9cm
|
[
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[]
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[
"51.85",
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icd9pcs
|
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|
1013, 1088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,978
| 173,306
|
52662
|
Discharge summary
|
report
|
Admission Date: [**2190-2-10**] Discharge Date: [**2190-2-19**]
Date of Birth: [**2133-1-26**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 57 year old male with
end-stage human immunodeficiency virus, acquired
immunodeficiency syndrome with a multi-drug resistant
organism and a CD4 count of 59 who presented with epistaxis
and altered mental status. The patient was admitted to a
hospital in [**State 108**] from [**11-17**], to [**Month (only) 1096**] with dyspnea
and weakness and found to have an ejection fraction of 25%.
It was at that time he was started on Lasix and Aldactone.
He was readmitted in [**2189-12-10**] and had a complicated
Intensive Care Unit course requiring tracheostomy and
hemodialysis for acute renal failure. He was transferred to
[**Hospital1 **]-[**Location (un) 620**] on [**2190-1-18**], where he was weaned
off of the ventilator. His tracheostomy was removed. He was
also treated at that time for Vancomycin-resistant bacteremia
and pseudomonal pneumonia and a chronic diarrhea without a
clear source. His renal failure resolved to the point where
he no longer required hemodialysis and he was transferred to
[**Hospital3 4419**] on [**2190-2-3**]. While at
rehabilitation he developed an acute episode of epistaxis and
it was unable to be stopped with ice and compression. In
addition he had altered mental status which was difficult to
assess on top of his baseline human immunodeficiency virus
dementia. He was sent to the Emergency Department for
treatment of his acute anemia. While in the Emergency
Department, he developed hypotension with systolic blood
pressure in the 70s which did not respond to aggressive
intravenous fluid hydration and he was started on Dopamine
for pressure support and transferred to the Intensive Care
Unit.
PAST MEDICAL HISTORY: End-stage human immunodeficiency virus
acquired immunodeficiency syndrome, CD4 count of 59, viral
load greater than 100,000. He was diagnosed in [**2175**], failed
multiple heart regimens. He had Pneumocystis carinii
pneumonia in [**2181**]. Type 2 diabetes. Acquired
immunodeficiency syndrome-related lymphoma, status post CHOP
with six cycles in [**2184**] and intrathecal Cytarabine, human
immunodeficiency virus cardiomyopathy with an ejection
fraction of 25%, pancytopenia, status post appendectomy,
status post tonsillectomy, depression, history of fatty
liver, history of Clostridium difficile colitis, recent
history of acute renal failure requiring temporary
hemodialysis.
ALLERGIES: Sulfa causes a rash.
MEDICATIONS ON ADMISSION: Neurontin 100 mg t.i.d., Opium 1
ml t.i.d., Ativan 1 mg q. 4 hours prn, Neupogen 480 q. day,
magnesium oxide 400 q.i.d., Loperamide 1 to 2 mg q. 4 hours
prn, Klonopin 0.25 q. AM, Azithromycin 1250 mg q. Monday,
Bactrim single strength daily, Coreg 50 b.i.d., Protonix 40
daily, sodium bicarbonate 250 t.i.d., NPH insulin 5 units q.
AM.
FAMILY HISTORY: Mother had leukemia. Father died of a
cerebrovascular accident.
SOCIAL HISTORY: The patient drinks one to two drinks per
week, smoked three packs per day for 20 years, quit smoking
ten years ago. He has lived with his partner of 40 years.
PHYSICAL EXAMINATION: Temperature 99.3, heart rate 98, blood
pressure 80/44, respiratory rate 16, on oxygen saturation
100% room air. General: Chronically ill-appearing man,
cachectic, frequently screaming, redirectable, though
confused. Head, eyes, ears, nose and throat: Left nares
filled with blood and clot, no active bleeding, right nares
without evidence of bleeding. Pupils, pinpoint bilaterally.
Extraocular muscles intact. Dry mucosal membranes. Supple
neck, no lymphadenopathy. Evidence of prior tracheostomy.
Chest, crackles at the left base, decreased breath sounds at
the right base. Left chest, tunnel catheter for hemodialysis
without evidence of infection. Cardiovascular examination,
tachycardiac, loud S2, no murmurs appreciated. Abdomen,
soft, nontender, nondistended, positive bowel sounds, guaiac
negative stool. Extremities, no lower extremity edema.
Calf, muscle wasting, skin, warm and dry. Neurological
examination, oriented to self, place "[**Hospital3 **]" and year.
Cranial nerves II through XII grossly intact. Positive
asterixes, moves all four extremities, but not cooperative
with examination. Skin, Stage 1 decubitus ulcer over the
sacrum, no signs or symptoms of infection.
LABORATORY DATA: White blood cell count 7, hematocrit with a
drop to 26 from 29 down to 21, platelets 70, MCV 92, sodium
138, potassium 3.9, bicarbonate 19, BUN 34, creatinine 1.3,
ALT 38, AST 76. Chest x-ray showed congestive heart failure,
new right upper lobe nodular density. Computerized
tomography scan of the sinuses revealed no obvious neoplastic
source for the epistaxis.
HOSPITAL COURSE: 1. Epistaxis - The patient was seen by
Otorhinolaryngology in the Emergency Department. There was
no evidence of posterior pharyngeal or posterior nasal
bleeding. Silver nitrate and topical cocaine were applied in
the Emergency Department, and the bleeding stopped. However,
secondary to his acute anemia, the patient required blood
transfusion with 3 units of packed red blood cells. He also
received six packs of platelets in the Emergency Department
for his acute anemia in the setting of thrombocytopenia.
2. Hypertension - The patient was transiently placed on
Dopamine for pressure support when his hypertension did not
respond to fluid resuscitation in the Emergency Department.
He was admitted to the Medical Intensive Care Unit over night
for hemodynamic monitoring. The patient was quickly weaned
off of Dopamine the following day and was transferred to the
floor.
3. Congestive heart failure - Several hours after being
transferred to the floor the patient developed acute
respiratory distress with hypoxia. At that time his oxygen
saturation was in the mid 80s on room air. He was tachypneic
with a respiratory rate of approximately 50. He had clinical
evidence for congestive heart failure and flash pulmonary
edema, and appeared to be in a combined cardiogenic and
septic shock. The patient was at that time treated for both
with a progressive diuresis, nitroglycerin and morphine. In
addition he was dosed with Zosyn and Vancomycin for potential
nosocomial infections of either a pulmonary or a
gastrointestinal source. After approximately 36 hours, the
patient had diuresed and his respiratory status slowly
improved. The patient no longer required intravenous Lasix
and he was started on Metronidazole to treat a Clostridium
difficile infection.
4. Clostridium difficile infection - The patient will be
discharged on a course of oral Metronidazole to treat his
Clostridium difficile infection. He will take an additional
ten days to complete a 14 day course.
5. Code status/goals of care - The patient had multi-drug
resistant human immunodeficiency virus with human
immunodeficiency virus acquired immunodeficiency
syndrome-related lymphoma and cardiomyopathy. After multiple
discussions with the [**Hospital 228**] health care proxy [**Name (NI) **]
[**Name (NI) 108665**], the medical team, social work and case
management, the goals of care were shifted to comfort
measures. It was felt that the patient's life expectancy was
less than six months at this time and that he would not
benefit from aggressive treatment. The patient will be
treated with oral morphine and Ativan for comfort and
agitation, and will complete a course of antibiotic treatment
for Clostridium difficile infection. He will be discharged
to a hospice facility or a skilled nursing facility with
hospice benefit.
CONDITION ON DISCHARGE: Fair with life expectancy of four to
six months.
DISCHARGE STATUS: To hospice or skilled nursing facility
with hospice benefits.
DISCHARGE INSTRUCTIONS: Please follow with primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**], [**Telephone/Fax (1) 457**] if you have any
questions.
DISCHARGE DIAGNOSIS:
1. End-stage human immunodeficiency virus.
2. Acquired immunodeficiency syndrome.
3. Acquired immunodeficiency syndrome-related lymphoma.
4. Human immunodeficiency virus cardiomyopathy.
5. Congestive heart failure with an ejection fraction of
25%.
6. Pancytopenia.
7. Type 2 diabetes.
8. Hypertension.
9. Human immunodeficiency virus dementia.
10. Renal insufficiency.
11. Clostridium difficile colitis.
MEDICATIONS ON DISCHARGE:
1. Metronidazole 500 mg p.o. t.i.d. for ten days.
2. Lorazepam 1 to 2 mg sublingual q. 4-6 hours prn or
agitation or anxiety.
3. Olanzapine disintegrating tablet, 5 mg p.o. q.h.s.
4. Morphine Sulfate, oral solution 10 to 20 mg p.o. q. 2-4
hours prn for pain or shortness of breath.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-378
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2190-2-18**] 11:32
T: [**2190-2-18**] 12:09
JOB#: [**Job Number 108666**]
|
[
"008.45",
"042",
"707.0",
"458.9",
"284.8",
"V66.7",
"428.0",
"285.1",
"425.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2952, 3018
|
8024, 8438
|
8464, 8986
|
2598, 2935
|
4824, 7658
|
7840, 8003
|
3219, 4806
|
170, 1827
|
1850, 2571
|
3035, 3196
|
7683, 7815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,499
| 175,054
|
5283
|
Discharge summary
|
report
|
Admission Date: [**2181-5-23**] Discharge Date: [**2181-5-26**]
Service:
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 84 year old
[**Doctor First Name **] speaking gentleman with a history of severe interstitial
lung disease, congestive heart failure, coronary artery
disease and chronic renal failure who experienced worsening
shortness of breath over the day prior to admission. The
patient at home had oxygen saturations in the 70s on 3.5
liters by nasal cannula and right-sided chest pain. The
patient had been drinking Ensure the few days prior to
admission. In the Emergency Room the patient was diagnosed
with presumed congestive heart failure exacerbation and
worsening of his interstitial lung disease. He received
Lasix and was admitted to the Medical Intensive Care Unit for
further treatment.
PHYSICAL EXAMINATION: The patient was well-appearing elderly
man in mild respiratory distress. Sclera were clear. Neck,
notable for jugulovenous distension and tenderness in his
right calf. His chest showed audible crackles bilaterally
but cleared anteriorly. His cardiac examination was normal
S1 and S2, II/VI holosystolic murmur at the apex. His
abdomen was benign with mild hepatomegaly. His extremities
showed trace bilateral pedal edema and neurologically he was
intact.
LABORATORY DATA: The patient had an elevated white count of
19.1, hematocrit of 38.4, platelets 264. Chem-7 134, 5.5,
95, 24, 58, 119, 274. The patient's INR was noted to be 7.4.
Creatinine kinase was 71, troponin was 3.7. His
electrocardiogram was ventricularly paced in 70's, no
ischemic changes. His chest x-ray showed diffuse alveolar
interstitial changes, likely superimposed congestive heart
failure or interstitial lung disease.
HOSPITAL COURSE: 1. Pulmonary - The patient suffers from
respiratory distress, likely secondary to both congestive
heart failure and worsening of his interstitial lung disease.
This has been an acute and chronic progression of this
disease which is likely a terminal process. Despite
aggressive treatment with Prednisone and antibiotics, the
patient was aggressively diuresed for congestive heart
failure component, continued on his Prednisone and treated
with Nitroglycerin drip, Captopril, Digoxin, Azithromycin,
Ceftriaxone and Morphine. He continued to have significant
oxygen requirement and intermittently complained of shortness
of breath. After extensive conversations with the family it
was agreed that the patient would be taken home for home
hospice care given the likely terminal prognosis and
progression of his interstitial lung disease and congestive
heart failure, and the fact that there was little medical
treatment that we could provide at this point to cure this
condition.
2. Cardiac - The patient has a history of coronary artery
disease and congestive heart failure. He was treated with
Nitroglycerin, Lasix and Morphine. The Nitroglycerin drip
was weaned off and the patient was started on Nitroglycerin
patch. When the Nitroglycerin drip was turned initially the
patient experienced some right-sided neck pain and chest
tenderness that possibly could have been ischemic in origin.
The patient requires aggressive treatment with Morphine,
Nitroglycerin and ACE inhibitor to minimize his discomfort
related to the ischemic pain. In addition, the patient has a
history of paroxysmal atrial fibrillation which was
supertherapeutic in his INR. The Warfarin was discontinued
on his admission and was not restarted given the hospice
disposition.
CONDITION ON DISCHARGE: Poor.
DISCHARGE STATUS: To home hospice.
DISCHARGE DIAGNOSIS:
1. Severe interstitial lung disease
2. Congestive heart failure
3. Paroxysmal atrial fibrillation
4. Hypertension
5. Chronic renal insufficiency
DISCHARGE MEDICATIONS:
1. Fluoxetine 10 mg p.o. q.d.
2. Prednisone 60 mg p.o. q.d.
3. Bactrim one DS tablet three times a week, Monday,
Wednesday and Friday
4. Digoxin 125 mcg p.o. q.d.
5. Nitroglycerin patch 0.6 mg per hour, transdermal to be
changed every 24 hours, titrate to no chest pain
6. Lasix 80 mg p.o. q.d.
7. Captopril 25 mg p.o. t.i.d.
8. Dextran 70/HPM cell one to two drops ophthalmic prn
9. Morphine Sulfate 15 mg p.o. q. 12 hours
10. Roxanol 20 mg per ml solution, 5-20 mg p.o. q. 2 hours as
needed for shortness of breath, cough or pain
11. Thiamine Sulfate .125 mg tablet q. 4 hours as needed for
congestion
12. Acetaminophen 650 mg suppository q. 4-6 hours as needed
for fever and pain
13. Ativan 1 to 2 tablets 2 mg q. 4-6 hours prn anxiety and
restlessness
14. Oxygen titrated to comfort via shovel mask or
nonrebreather
15. AVHRGL which is Ativan, Haldol, Benadryl, Reglan
combination one by mouth q. 4 hours prn nausea and vomiting
FOLLOW UP PLANS: The patient will have hospice care at home.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2181-5-25**] 16:35
T: [**2181-5-25**] 18:43
JOB#: [**Job Number 21554**]
|
[
"403.91",
"414.01",
"515",
"428.0",
"427.31",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3844, 5112
|
3670, 3821
|
1821, 3580
|
899, 1803
|
102, 123
|
152, 876
|
3605, 3649
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,423
| 123,642
|
14274
|
Discharge summary
|
report
|
Admission Date: [**2171-9-30**] Discharge Date: [**2171-10-5**]
Date of Birth: [**2119-5-27**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 52-year-old male
with a known history of hypertension, hypercholesterolemia
and a former smoker with known coronary artery disease. He
has had prior RCA stenting x 2 in [**2164-3-11**] with no re-
flow. He now presented on [**2171-9-23**], prior to admission
with unstable angina, positive exercise tolerance test. He
was referred for cardiac catheterization which revealed a
right dominant lesion and severe 2 vessel disease with 95%
proximal LAD lesion, 80% diagonal 1 lesion although left
circumflexi was normal. Right coronary artery had a total
occlusion in the proximal portion. He suffered a prior
myocardial infarction at age 45.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post RCA stenting x 2.
2. Myocardial infarction.
3. Hypercholesterolemia.
4. Hypertension.
MEDICATIONS: Medications prior to admission were as follows:
1. Metoprolol 25 mg PO twice a day.
2. Lisinopril 10 mg PO daily.
3. Lipitor 20 mg PO daily.
4. Multivitamin single tablet daily.
5. Aspirin 650 mg PO daily.
6. Fluoxetine 20 mg PO daily.
7. Lorazepam 1.5 to 2.0 mg PO q at bedtime
FAMILY HISTORY: He has a positive family history of coronary
artery disease, both parents had myocardial infarction in
their 50s. He is married and works as Assistance Service
Manager.
REVIEW OF SYMPTOMS: He had no history of TIAs,
cerebrovascular accident, melena or GI bleed.
PREOPERATIVE LABORATORY DATA: White blood cell count 8.3,
hematocrit 40.4, platelet count 151,000, PT 12.5, PTT 26.0,
INR 1.0. Urinalysis negative. Sodium 138, K 4.4, chloride
104, bicarb 24, BUN 18, creatinine 0.9 with blood sugar of
166. ALT 21, AST 19, CK 157, alkaline phosphatase 58, amylase
67, total bilirubin 0.6, CK 157, MB 2, with a troponin of
less than 0.01. Albumin 4.2, HBA1C 5.7%.
Preop chest x-ray showed no evidence of any acute
cardiopulmonary process. He was referred to Dr. [**First Name (STitle) **]
[**Name (STitle) **], for coronary artery bypass grafting and he was
admitted as a same-day admission on [**2171-9-30**], when he
underwent coronary artery bypass grafting x 2 with left
internal mammary artery to the LAD, vein graft to the
diagonal by Dr. [**Last Name (STitle) **]. He was transferred to the
cardiothoracic ICU in stable condition on Neo-Synephrine drip
of 0.5 mcg per kg per minute and propofol drip at 30 mcg per
kg per minute. He was extubated later that evening on the
same operative day. He was neurologically intact. He was
alert and oriented. He remained on Neo-Synephrine and on the
following morning, postoperative day 1, he was weaned off his
Neo-Synephrine. He was in sinus rhythm at 85 and had blood
pressure of 101/51. Postoperative labs showed white blood
cell count 20.9, hematocrit 29.4, K 3.9, creatinine 0.8. He
continued on his perioperative Ancef.
PHYSICAL EXAMINATION: Height is 5 feet 9 inches and his
weight is 215 lbs. He had few wheezes at the left base. His
heart was in regular rate and rhythm. His abdomen was
slightly distended and firm. His extremities were cool with
1+ bilateral peripheral edema. His sternal and leg incisions
were clean, dry, and intact with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in his
left saphenectomy site.
He was begun on Lasix diuresis, started on beta blockade with
Lopressor. His chest tubes were discontinued and he was
transferred out to floor 2. On floor 2, he began to work with
the nurses and physical therapist on ambulating and
increasing his activity tolerance. He had some decreased
breath sounds at the bases, again on postoperative day 2. His
abdomen was soft and distended with faint bowel sounds but he
was passing flatus. His Foley was discontinued and he did
void spontaneously. His epicardial pacing wires were removed.
He was restarted on his Lipitor and other preoperative
medications. His metoprolol was increased to 25 mg PO twice a
day. He remained in sinus rhythm with good blood pressure of
123/76.
On postoperative day 3, Mr. [**Known lastname **] actually did level 5
activity level. He was transitioned to Tylenol No. 3 for pain
management. He remained somewhat tachycardic with a heart
rate in the 90's to 100s but in sinus rhythm with a normal
blood pressure. His metoprolol was increased to 100 twice a
day with a plan to be discharged over the next day or two.
On postoperative day 4, he was saturating 93% on room air
with blood pressure of 147/90, heart rate 94. He was alert
and oriented. His lungs were completely clear. Discharge
planning continued. His Lasix was decreased to PO dosing. He
continued to do extremely well with significant amount of
ambulating all over the unit.
On postoperative day 5, his examination was unremarkable. He
was in sinus rhythm at 82, blood pressure 120/80, saturating
95% on room air. His weight was down to 94.5 kg and his
examination was completely unremarkable. His incisions were
clean, dry and intact. He was discharged home with VNA
services in stable condition on [**2171-10-5**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 2.
2. Myocardial infarction.
3. Hypercholesterolemia.
4. Status post RCA stents x 2.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg PO twice a day x 7 days.
2. Potassium chloride 20 mEq PO twice a day x 7 days.
3. Colace 100 mg PO twice a day.
4. Zantac 150 mg PO twice a day.
5. Enteric coated Aspirin 81 mg PO once a day.
6. Lipitor 20 mg PO once a day.
7. Fluoxetine 20 mg PO once a day.
8. Tylenol No. 3 one to two tablets PO p.r.n. q4 hours for
pain.
9. Metoprolol 100 mg PO twice a day.
10. Lisinopril 5 mg PO once a day.
11. Ferrous gluconate 300 mg PO once a day.
12. Vitamin C 500 mg PO twice a day.
The patient was instructed to follow up with Dr. [**Last Name (STitle) **] at 4
weeks for postoperative surgical visit and to see his primary
care physician, [**Name10 (NameIs) **], [**Name11 (NameIs) **] in 2 weeks and to see his
cardiologist two weeks post discharge.
DISCHARGE DISPOSITION: He was discharged home in stable
condition on [**2171-10-5**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2171-10-18**] 14:38:07
T: [**2171-10-19**] 00:30:12
Job#: [**Job Number 42400**]
|
[
"272.0",
"413.9",
"V17.3",
"401.9",
"V45.82",
"414.01",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6194, 6496
|
1305, 2979
|
5213, 5370
|
5393, 6170
|
3002, 5192
|
165, 835
|
857, 1288
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,857
| 141,494
|
49565
|
Discharge summary
|
report
|
Admission Date: [**2102-9-17**] Discharge Date: [**2102-9-27**]
Date of Birth: [**2018-9-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Acute respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 84M s/p right hemicolectomy on
[**2102-7-16**] for massive lower GI bleed complicated by ARDS and acute
renal failure presents with Afib in RVR and fever of 102.
Patient's initial hospital course was prolonged due to ARDS with
fibroproliferation and difficulty to wean from vent with
tracheostomy placement, acute renal failure with uremic
encephalopathy requiring CVVH, and poor po intake requiring PEG
placement. Patient was recently readmitted from [**Date range (1) 103670**] for
Afib with RVR, fluid overload, and dilirium. All cultures at
that time have returned negative, including c diff. Since his
discharge, his trach was changed and patient was back to
baseline mental status until 3 days ago. 3 days prior to
admissiont the patient developed fevers to 101.8 with worsening
dilirium. Blood cultures were obtained at rehab and are negative
to date. Per records, the patient had develop frank pus from his
ostomy site, but a pneumonia could not be ruled out. The patient
was started on emperic coverage of meropenem, vancomycin, and
flagyl. The patient also concurrently developed afib with RVR to
140s and was given metoprolol and diltezem for rate control. 1
day prior to admission, the nodal agents were held due to
hypotension of 80/40's. He was given fluid bolus and responded
well per rehab records. He then developed O2 desaturation to mid
80's and was transfered to [**Hospital1 18**]. The patient's mental status
had been waxing and [**Doctor Last Name 688**] for the past 3 days per the patient
son and wife. Although the patient denies any new symptoms when
he initially spiked a fever. Denied CP, abdominal pain, dysuria.
.
In the ED, the patient presented with inital vitals of 98.2
110/53 150 26 100%. He was started on a amiodarone gtt and
subsequently develop hypotension to the 60's/30's. He was givn a
500 cc bolus. The patient was then started on a Levo gtt. A CTA
torso showed possible pna, but no obvious GI absess or evidence
of GI infection. Blood cultures were obtained. He recieved
cefipime, vancomycin and levoquin. He was also givena total of
1.5 L of NS. He was then transferred to the MICU.
.
After arrive to the MICU the patient initial vitals were: 100.2,
74, 87/39, 23 98% on vent (CMV 400x14, FIO2 of 60%, PEEP of 5).
Past Medical History:
Basal cell carcinoma s/p mohs resection
Diverticulosis
CAD s/p PCI in [**2087**] with stent placement to the LAD
Social History:
Married, lives in a townhouse w his wife. Retired businessman
Family History:
Aunt w diverticulitis, but no other colorectal disease that he
knows of. Father died on an unknown cancer, mom lived to 85.
Pertinent Results:
[**2102-9-25**] 05:05AM BLOOD WBC-13.3* RBC-3.37* Hgb-10.5* Hct-31.4*
MCV-93 MCH-31.1 MCHC-33.4 RDW-15.8* Plt Ct-441*
[**2102-9-24**] 05:43AM BLOOD WBC-11.3* RBC-3.20* Hgb-9.7* Hct-29.7*
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.6* Plt Ct-408
[**2102-9-18**] 02:31AM BLOOD Neuts-78.2* Lymphs-12.5* Monos-5.2
Eos-4.0 Baso-0.2
[**2102-9-25**] 05:05AM BLOOD Plt Ct-441*
[**2102-9-24**] 05:43AM BLOOD Plt Ct-408
[**2102-9-24**] 05:43AM BLOOD PT-16.9* PTT-25.4 INR(PT)-1.5*
[**2102-9-23**] 04:19AM BLOOD Plt Ct-454*
[**2102-9-23**] 04:19AM BLOOD PT-19.9* PTT-25.1 INR(PT)-1.8*
[**2102-9-20**] 04:35AM BLOOD PT-62.3* PTT-36.5* INR(PT)-6.9*
[**2102-9-22**] 02:36AM BLOOD Fibrino-747*#
[**2102-9-25**] 05:05AM BLOOD Glucose-132* UreaN-30* Creat-0.8 Na-144
K-4.3 Cl-105 HCO3-31 AnGap-12
[**2102-9-24**] 05:43AM BLOOD Glucose-97 UreaN-31* Creat-0.8 Na-145
K-4.5 Cl-106 HCO3-31 AnGap-13
[**2102-9-23**] 04:19AM BLOOD Glucose-145* UreaN-33* Creat-0.9 Na-146*
K-4.3 Cl-106 HCO3-31 AnGap-13
[**2102-9-17**] 07:56PM BLOOD ALT-19 AST-69* AlkPhos-121 TotBili-0.4
[**2102-9-25**] 05:05AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.1
[**2102-9-24**] 05:43AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1
[**2102-9-20**] 04:35AM BLOOD Vanco-24.3*
[**2102-9-19**] 05:59AM BLOOD Vanco-38.9*
[**2102-9-18**] 01:04AM BLOOD Type-ART Temp-37.8 Rates-14/20 Tidal
V-400 PEEP-5 FiO2-60 pO2-215* pCO2-31* pH-7.44 calTCO2-22 Base
XS--1 -ASSIST/CON Intubat-INTUBATED
[**2102-9-17**] 10:22PM BLOOD pO2-110* pCO2-32* pH-7.46* calTCO2-23
Base XS-0 Comment-GREEN TOP
[**2102-9-20**] 04:47AM BLOOD Lactate-1.8
[**2102-9-17**] 09:29PM BLOOD K-4.6
[**2102-9-17**] 07:56PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2102-9-17**] 07:56PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2102-9-17**] 07:56PM URINE RBC-2 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
[**2102-9-17**] 07:56PM URINE CastHy-53*
[**2102-9-17**] 07:56PM URINE Mucous-OCC
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2102-9-21**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2102-9-18**] 2:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2102-9-20**]**
GRAM STAIN (Final [**2102-9-18**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
[**2102-9-18**] 2:31 am SWAB Site: ABDOMEN Source:
Line-central.
**FINAL REPORT [**2102-9-22**]**
GRAM STAIN (Final [**2102-9-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2102-9-22**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance 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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 4 S
VANCOMYCIN------------ 1 S
Chest X-ray [**9-20**]:
IMPRESSION:
Findings consistent with stage III SLAC wrist, with marked
radiocarpal and
DRUJ osteoarthritis. Probable DISI deformity.
ECHO [**9-18**]:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. The right ventricular cavity is
dilated with borderline normal free wall function. There is
abnormal septal motion/position. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Brief Hospital Course:
#. Hypotension- The patient became hypotensive to 80's/40's on
the day of admission in the setting of afib with RVR to 160's,
but responded well to gentle fluid bolus. He had an A-line
placed. He was put on levophed. His urine output was inadequate
so he was given IVF and pRBCs. On [**9-18**], his amiodarone gtt was
transitioned to PO amiodarone as described below. He had an ECHO
which showed a preserved EF (>55%). When his blood pressure
stabilized, he was started on gentle diuresis with lasix. His
urine culture showed no growth. His central line and A-line were
discontinued on [**9-22**] and his blood pressure remained stable
throughout his hospital course.
.
#. Fever - Two days prior to admission, the patient spiked a
fever to 101.8 and was started on broad spectrim abx (vanc,
zosyn, levaquin) to cover both GI sources and PNA. His initial
sputum gram stain and his mini-BAL did not show any organisms.
His fever curve trended downwards and he continued to be
afebrile throughout the rest of his MICU stay at which point the
antibiotics were disconinued.
.
# A.fib with RVR. The patient has afib at baseline. He was found
to have a supratherapeutic INR so his coumadin was held and he
was given 10mg vitamin K. When his INR became therapeutic, his
coumadin was restarted initially at 1mg and when there was not
an adequate rise in INR, it was increased to 2mg. He was
initially loaded with 400mg amiodarone [**Hospital1 **] x 1 week. At the time
of discharge, he will be receiving 400mg amiodarone daily x 1
week at which time he will transition to his maintenance dose of
200mg amiodarone daily. His diltiazem was increased to 60mg qid.
.
# Respiratory failure- likely related to PNA and afib with RVR
and poor forward flow. He was given significant IVF so there is
likely an element of fluid overload as well. He was continued on
his ventilator and eventually diuresed when his BP became more
stable. He had an ECHO on [**9-19**], the results of which are
described above. He was taken off the ventilator on [**9-21**] and he
did well. He had a passy-muir valve placed and was able to
phonate.
.
#. Altered Mental Status- intermittent and mostly at night,
likely due to delirium related to medications and/or infection.
He was given zyprexa 5mg [**Hospital1 **] and haldol prn for agitation.
.
# s/p hemicolectomy: His wound was in the process of healing by
secondary intention and appeared healthy. No apparent signs of
infection. He was continued on cholestyramine.
.
# Hypothyroidism - continue on levothyroxine 25 mcg
.
# Anemia: his hct dropped after surgery and he is likely still
in the recovery phase. He received 2 u pRBCs. His hematocrits
remained stable during the remainder of his MICU stay.
.
#Wrist pain - pt was complaining of R wrist pain. He had a wrist
x-ray which showed a Grade III SLAC (scapholunate advanced
collapse). Hand surgery was consulted and they felt there were
no emergency interventions at this time. He was given a brace.
Medications on Admission:
albuterol / ipratropium q6h
cholestyramine 4g qd
diltiazem 30 mg q6h
finasteride 5mg qd
zosyn 3.375 q6h (started [**9-5**])
vancomycin 1000 mg qd (started [**9-5**])
Vancomycin 125 mg qid (started [**9-6**])
warfarin 3 mg qd
levothyroxine 25 mcg qd
lidocaine patch qd
lactobacillus bulgaricus 1 tab qd
artificial tears
maalox/simethicone
glucagon as needed for hypoglycemia prn
acetominophen 650 q6 prn
albuterol prn
Discharge Medications:
1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-27**]
Drops Ophthalmic PRN (as needed) as needed for dryness and
irritation.
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation,
anxiety.
7. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO every 4-6 hours as needed for pain.
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: Take until [**9-27**].
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start taking on [**10-5**].
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
13. diclofenac sodium 1 % Gel Sig: Two (2) GM Topical twice a
day: Apply to right wrist.
14. diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours: Hold for SBP < 100, HR < 60.
15. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO twice a day: Hold for LBM.
16. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Three
Hundred (300) mg PO once a day.
17. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection every twelve (12) hours.
18. multivitamin Liquid Sig: Five (5) mL PO once a day.
19. potassium chloride 10 % Liquid Sig: Forty (40) mEq PO once a
day.
20. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO once a day.
21. Senokot 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
22. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four
(4) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
23. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: Take from [**9-28**] to [**10-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Atrial fibrillation
Hypotension
Anemia
Discharge Condition:
Mental Status: oriented x 3
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 because you were having a
rapid heart rate. You were started on a medication called
amiodarone to control your heart rate. Your heart rate
improved, and you should follow up with your cardiologist. Your
coumadin dose was also adjusted because your levels were too
high. You should continue to have your coumadin levels
monitored.
You were also treated with antibiotics for infection because you
were having fevers, likely due to a pneumonia. You completed
your course of antibiotics while in the hospital. If you
develop new fever after leaving the hospital, please call your
doctor.
You were also evaluated by a hand specialist because you were
having right wrist pain. You had an x-ray which showed severe
arthritis of your wrist. You were given a hand splint which
may help your wrist pain. You can follow up in the orthopedics
clinic for further evaluation of your wrist.
Please note the following changes to your medications:
-START taking amiodarone: you should continue taking 400mg twice
daily through [**9-27**], then decrease to 400mg daily for 7 days
(through [**10-4**]), then decrease dose to 200mg daily
-continue diltiazem 60mg q6 hours as you were doing previously
-DECREASE coumadin to 2mg daily, and have your blood levels
monitored regularly by your physician
[**Name10 (NameIs) 8983**] taking lisinopril
-STOP taking metoprolol
-STOP taking metronidazole
It was a pleasure taking care of you at [**Hospital1 18**], and we wish you a
speedy recovery.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2102-10-20**] at 1:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"416.8",
"562.10",
"038.9",
"V58.61",
"300.00",
"427.31",
"V45.82",
"V45.3",
"716.93",
"486",
"V44.0",
"995.92",
"285.9",
"785.52",
"286.9",
"244.9",
"V44.1",
"518.84",
"584.5",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13284, 13355
|
7710, 10685
|
327, 334
|
13438, 13438
|
3032, 7687
|
15149, 15436
|
2887, 3013
|
11153, 13261
|
13376, 13417
|
10711, 11130
|
13607, 14556
|
14585, 15126
|
262, 289
|
390, 2654
|
13453, 13583
|
2676, 2791
|
2807, 2871
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,591
| 192,474
|
49584
|
Discharge summary
|
report
|
Admission Date: [**2118-3-8**] Discharge Date: [**2118-3-14**]
Service: Purple surgery. #58
HISTORY OF PRESENT ILLNESS: This [**Age over 90 **] year old female presents
with four days of diarrhea and two days of bloody diarrhea.
In the Emergency Department, the patient felt left sided
chest pain, left jaw pain which is resolved by the time she
was admitted to the Surgical Intensive Care Unit. The
patient is without complaints at this time.
PAST MEDICAL HISTORY:
1. Diverticulosis.
2. Gastroesophageal reflux disease.
3. Cerebrovascular accident with residuals.
4. Cholangitis.
5. Hypertension.
6. Osteoporosis.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Endoscopic retrograde cholangiopancreatography.
3. Sphincterotomy.
MEDICATIONS:
1. Colace.
2. Multi-vitamin.
3. Lopressor.
4. Protonix.
5. Trazodone 25 mg q h.s.
6. Nicardipine 30 mg three times a day.
7. Colace 100 mg twice a day.
ALLERGIES: Aspirin, unknown reaction. Penicillin, unknown
reaction.
PHYSICAL EXAMINATION: Pupils are equal, round, and reactive
to light and accommodation. Extraocular movements intact.
Regular rate and rhythm, positive S1 and S2. Coarse breath
sounds bilaterally. Nontender, nondistended abdomen with
bowel sounds. Extremities were unremarkable. Cranial nerves
2 through 12 were intact.
LABORATORY DATA: White blood cell count of 5.1. Hemoglobin
of 11.7. Hematocrit of 35.0. Platelets 227. Troponin was
negative at less than 0.01. Coagulation studies 13, 22.5 and
1.2. Albumin 3.3. Sodium of 139; chloride 109; BUN 18;
potassium of 3.7; bicarbonate of 3.7. Creatinine 0.8.
Glucose 99. Lactate 0.5. Chest x-ray showed nasogastric
tube in place; small left pleural effusion.
CT of the abdomen revealed marked thickening of the colonic
wall. Distal transverse to descending. No perforation. No
obstruction. Likely ischemic.
HOSPITAL COURSE: On admission, the patient complained of
chest pain. She was on nasogastric tube drops for blood
pressure control, beta blocker, aspirin. A line. Cardiology
to follow-up. She was placed on four liters nasal cannula.
She was made n.p.o. Intravenous gastrointestinal
prophylaxis. At this time, the patient was considered a non
surgical abdomen as per surgery. The patient was placed on
Vancomycin, Flagyl and Levofloxacin for prophylaxis.
Hydration. Clostridium difficile scan was run.
Cardiology consult recommended continuing tele monitoring in
Intensive Care Unit. Blood pressure was good at 150 mm of
mercury systolic. Tele monitoring until the a.m. and to
check enzymes. Echo impression was hyperdynamic left
ventricle with moderate dynamic left ventricular outflow
tract obstruction. Clostridium difficile was negative as
well as Salmonella, Shigella, Campylobacter and E. coli.
The patient continued to improve. Gastrointestinal consult
was obtained and recommended continuing supportive management
as the surgery team was doing. Stated that no need for
colonoscopy at this time. Would recommend endoscopy in the
future for colon cancer screening if the patient and the
patient's family wished to pursue.
By [**2118-3-12**], the patient was tolerating clears with no nausea,
vomiting or pain. On [**2118-3-13**], the current jaw pain
continued minimally with a negative electrocardiogram. The
patient remained afebrile. Colitis was improving. Diet was
advanced to solids and her antibiotics were switched to p.o.
Levofloxacin and Flagyl. Cardiology suggested that the
patient follow-up within six weeks with Dr. [**Last Name (STitle) **] in
cardiology for further evaluation of LV02 obstruction and
titration of antihypertensive.
DISPOSITION: The patient was discharged to rehabilitation
center.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Colitis.
2. Diverticulosis.
3. Gastroesophageal reflux disease.
4. Cerebrovascular accident with residuals.
5. Cholangitis.
6. Hypertension.
7. Osteoporosis.
DISCHARGE MEDICATIONS:
1. Levofloxacin for seven days.
2. Metronidazole for seven days.
3. Remainder of home medications.
FOLLOW-UP PLANS:
1. Patient is to call and schedule an appiontment with
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 1989**] for evaluation
of possible unstable angina, resultant electrocardiogram
changes and jaw pain.
2. The patient has an appointment with the gastrointestinal
room, [**2118-5-31**] at 3 o'clock.
3. The patient also has an appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in the stoma building, endoscopy suite. Phone number
[**Telephone/Fax (1) 463**] at 3 o'clock p.m. on [**2118-5-31**].
critchlaw,jonatham 02.205
Dictated By:[**Last Name (NamePattern1) 52643**]
MEDQUIST36
D: [**2118-3-14**] 10:46
T: [**2118-3-14**] 10:56
JOB#: [**Job Number 103711**]
|
[
"557.9",
"401.9",
"562.10",
"413.9",
"424.1",
"530.81",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3768, 3937
|
3960, 4063
|
1892, 3725
|
661, 999
|
1022, 1874
|
3740, 3747
|
4080, 4881
|
134, 460
|
482, 638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,547
| 124,062
|
3541
|
Discharge summary
|
report
|
Admission Date: [**2158-1-4**] Discharge Date: [**2158-1-9**]
Date of Birth: [**2074-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
OPERATION:
1. Coronary artery bypass graft x 3, left internal mammary
artery to the left anterior descending artery and
saphenous vein graft to the diagonal and the posterior
descending artery.
2. Endoscopic harvesting of the long saphenous vein both
from the left and the right thigh.
History of Present Illness:
This is an 83-year-old gentleman who
had had an MI [**77**] years ago and has hypertension, congestive
heart failure and hypercholesterolemia. The patient had an
abnormal stress test, following which he had a cardiac
catheterization which revealed severe triple vessel disease.
The cardiac catheterization revealed disease in the LAD,
diagonal and right pulmonary artery. The patient was,
therefore, referred for us for elective coronary artery
bypass grafting. His preoperative echocardiogram showed an
ejection fraction between 30-35%.
Past Medical History:
CAD-s/p MI [**2144**],hypercholesterolemia,HTN,Crohn's disease,CHF
(newly diagnosed),GERD,spinal stenosis,Rt venous stasis ankle
ulcer (healed)followed by Dr. [**Last Name (STitle) **],neuropathy,Kyphosis,Basal
cell CA,childhood asthma,anxiety/depression,osteoarthritis of
bilateral knees and hips,Tonsillectomy,Bilateral Inguinal Hernia
repair
otitis media,Colonic Polyps,cellulitis ([**9-7**])left leg (treated
with docloaxzcillin/ woundcare dressing changes with
VNA),fatigue,Rt thigh pain
Social History:
lives alone, widower
has 2 sons
ambulates with cane
has lifeline
does not drive
sedentary lifestyle
retired [**Hospital1 **] state educator
denies tobacco and etoh
Family History:
NC
Physical Exam:
VS: pulse 57 resp 16 sat 99% bp 127/58
ht 61in wt 148lb
gen: nad
skin dry, intact
heent: perrla eomi
neck supple w full rom
chest: lungs CTAB
heart irregular
abd: soft, NT, ND, +BS
ext: warm, well-perfused, 1+ pedal edema
neuro: grossly intact
Pertinent Results:
[**2158-1-9**] 07:35AM BLOOD WBC-5.1 RBC-2.64* Hgb-8.4* Hct-25.4*
MCV-96 MCH-31.6 MCHC-32.8 RDW-19.7* Plt Ct-233
[**2158-1-9**] 07:35AM BLOOD Glucose-120* UreaN-41* Creat-0.9 Na-144
K-3.8 Cl-103 HCO3-31 AnGap-14
PRE-BYPASS:
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler.
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
Mild TR , Physiological PI
There is no pericardial effusion.
Post_Bypass:
LVEF 35%.
Normal RV systolic function.
Mild TR, MR, AI.
Intact thoracic aorta.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2158-1-5**] where he underwent cabgx3 with Dr.
[**First Name (STitle) **].
Please see op report for further details. Overall the patient
tolerated the procedure well and post-operatively was
transferred in stable condition to the CVICU for further
observation and invasive monitoring. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable on no
vasoactive support. He was found suitable for
transfer to telemetry on POD 2. Beta
blockade and diuresis were initiated. Chest tubes and pacing
wires were
discontinued without complication. The patient went into a rate
controlled atrial fibrillation. Beta blocker was titrated
accordingly. He will not be anti-coagulated due to his fall
risk and co-morbidities which include Crohn's disease.
Physical therapy was
consulted for assistance with post-operative strength and
mobility. The patient progressed as planned through the cardiac
surgery pathway. By POD 4 the wound
was healing and pain was controlled with oral analgesics. He
was discharged to rehab on POD 5.
Medications on Admission:
Amitriptyline 10',Betamethasone Dipropionate 0.05% ointment, prn
Coreg 3.125",Lasix 20',Lisinopril 2.5',Lovastatin 20',Canasa
1000mg PR',Prilosec 20', Potassium Chloride 20',ASA 81'
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
40mg/day x 2 weeks, then 20mg/day until further instructed.
Tablet(s)
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg 2x/day for 2 weeks, then 200mg/day until further
instructed.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal DAILY (Daily).
12. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 665**] [**Telephone/Fax (1) 250**] in [**12-31**] weeks
Cardiologist Dr. [**Last Name (STitle) 73**] in [**12-31**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-1-9**]
|
[
"356.9",
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"285.9",
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"511.9",
"715.89",
"459.81",
"276.2",
"412",
"555.9",
"428.32",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5693, 5765
|
3090, 4280
|
338, 642
|
5833, 5929
|
2212, 3067
|
6553, 7065
|
1926, 1930
|
4512, 5670
|
5786, 5812
|
4306, 4489
|
5953, 6530
|
1945, 2193
|
279, 300
|
670, 1212
|
1234, 1729
|
1745, 1910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,779
| 111,977
|
35358
|
Discharge summary
|
report
|
Admission Date: [**2160-5-22**] Discharge Date: [**2160-6-10**]
Date of Birth: [**2114-3-20**] Sex: F
Service: MEDICINE
Allergies:
Methotrexate
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
acute acetaminophen toxicity
Major Surgical or Invasive Procedure:
1. EGD
2. Intubation, extubation
3. Colonoscopy
History of Present Illness:
Pt is a 46F w/hx of prior Tylenol OD requiring intubation
w/ICP monitoring & ARF requiring CVVH ([**10-13**]), severe chronic
pain secondary to Crohns and ankylosing spondylitis treated with
prednisone daily, as well as DVT treated with coumadin who has
been transfered from [**Hospital6 6640**] after significant
opiate/acetaminophen ingestion over 48 hrs greater than 4hrs
prior to presentation. Per report, pt presented to the OSH with
RUQ [**Hospital6 1676**] pain and tachycardia and reported taking 72
vicodin
within 48hrs. Initial labs revealed an acetaminophen level of
176.9, AST/ALT over 12K, INR 16.9, TBili 2.4 & Cr 1.9. She was
loaded with acetylcysteine, given 2U FFP, Vit K 10 IM and 1500
in
IVF and was transfered to [**Hospital1 18**] for further management. In the
ED
she is hypotensive to the 70's-80's and requiring pressor
support
with 2 pressors after 5L IVF, 3U FFP and 3U PRBCs. A R femoral
a-line was placed with ultrasound guidance. She is very anxious,
slurring her speech and appears confused. However, she is A&Ox3
and providing some history with redirection. She states that
she
has been trying to wean herself from long-acting opiates, having
transitioned from Oxycontin to dilaudid. She was recently
prescribed Vicodin and given 120 tablets. She states she did not
know that Vicodin contained acetaminophen and did not intend to
hurt herself. She denies suicidality or depression. She reports
[**10-13**] generalized pain with acute worsening in the RUQ and
epigastrium.
Past Medical History:
Past Medical History: h/o Tylenol OD [**10/2159**] c/b ARF, hepatic
failure, VAP, foot necrosis [**2-6**] pressors; Bilateral DVT [**1-/2160**];
8mm clean ulcer at prepyloric antrum seen on EGD [**2160-4-15**]
(H.Pylori neg); Psychiatric disorder (anxiety vs bipolar);
chronic pain; h/o domestic abuse; Crohn's disease; anklyosing
spondylitis; Long term alcoholism; h/o Hep A; iron-deficiency
anemia
Past Surgical History: Distal ileum resection [**2-/2160**], CCY [**2156**],
R
hip replacement [**2153**] c/b multiple infections, L hip replacement
[**2156**] also c/b infections, back/knee surgeries per past notes
Social History:
Pt denies EtOH abuse or use of illicits, denies depression or
suicidality
Family History:
Father - colitis? (frequent stomach pain)
Mother - RA, ankylosing spondylitis
Grandmother - ankylosing spondylitis
Physical Exam:
ADMISSION PHYSICAL:
V/S: T 98.1, P 103-115, BP 96-121/60-79, RR 18-27, Pox 98-100%
Gen: Intubated and sedated
Skin: Warm and dry; mild jaundice
Head/Neck: Sclera anicteric, Pupils 3 mm reactive, ETT/OGT in
place
CV: Tachycardic, +S1S2, no m/r/g
Lungs: CTAB
Abd: Soft, non-distender, +tenderness RUQ, hyperactive BS
Ext: 2+ pulses, no c/c/e
Neuro: Sedated but arousable to verbal stimuli, follows
commands, no clonus/hyperreflexia
DISCHARGE PHYSICAL:
afebrile, normotensive
Gen: Pleasant female, sitting up in bed, awake, Mildly icteric.
NAD.
HEENT: Mild jaundice, mildly icteric sclera, MMM. erythematous
rash on malar region
PULM: no use of access mm, CTA B/L
CVS: RRR. Nl S1/S2. [**2-10**] murmur most prominent at apex.
ABD: +BS, distended, midline scar c/w prior resection,
non-tender, no rebound or guarding, +hepatomegaly
Extremities: gauze over left ankle, right ankle with
erythematous clearing rash on ankle, similar over left wrist
(improved), and back
Neuro: Aox3. moving all extremities, no gross deficits, No
asterixis.
Pertinent Results:
ADMISSION LABS:
[**2160-5-22**] 07:05PM BLOOD WBC-11.5*# RBC-2.69* Hgb-7.8* Hct-24.1*
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.9 Plt Ct-116*#
[**2160-5-22**] 10:38PM BLOOD WBC-24.0*# RBC-4.55# Hgb-13.3# Hct-40.0#
MCV-88 MCH-29.3 MCHC-33.4 RDW-14.9 Plt Ct-142*
[**2160-5-22**] 07:05PM BLOOD Neuts-94.2* Lymphs-4.9* Monos-0.7*
Eos-0.1 Baso-0.1
[**2160-5-22**] 07:05PM BLOOD PT-60.4* PTT-53.7* INR(PT)-6.6*
[**2160-5-22**] 10:38PM BLOOD Fibrino-212
[**2160-5-22**] 07:05PM BLOOD Glucose-100 UreaN-31* Creat-1.4* Na-142
K-3.0* Cl-116* HCO3-11* AnGap-18
[**2160-5-22**] 10:38PM BLOOD Glucose-70 UreaN-37* Creat-1.8* Na-142
K-4.0 Cl-112* HCO3-12* AnGap-22*
[**2160-5-22**] 07:05PM BLOOD ALT-8730* AST-[**Numeric Identifier 5161**]* AlkPhos-108*
TotBili-1.5
[**2160-5-23**] 02:00AM BLOOD ALT-7060* AST-9040* CK(CPK)-166
AlkPhos-160* TotBili-3.9*
[**2160-5-23**] 05:39AM BLOOD ALT-6330* AST-7790* CK(CPK)-123
AlkPhos-234* TotBili-4.8*
[**2160-5-23**] 10:26AM BLOOD ALT-5920* AST-6130* AlkPhos-241*
TotBili-5.5*
[**2160-5-23**] 02:10PM BLOOD ALT-1870* AST-4420* AlkPhos-152*
TotBili-5.3*
[**2160-5-23**] 08:05PM BLOOD ALT-4730* AST-3200* AlkPhos-134*
TotBili-5.4*
[**2160-5-24**] 12:17AM BLOOD ALT-4348* AST-1308* CK(CPK)-44
AlkPhos-119* TotBili-4.7*
[**2160-5-24**] 05:00AM BLOOD ALT-3791* AST-[**2067**]* CK(CPK)-34
AlkPhos-116* TotBili-4.7*
[**2160-5-24**] 12:55PM BLOOD ALT-3726* AST-1263* LD(LDH)-265*
AlkPhos-116* TotBili-4.5*
[**2160-5-24**] 09:05PM BLOOD ALT-3188* AST-842* LD(LDH)-303*
AlkPhos-131* TotBili-4.8*
[**2160-5-25**] 01:56AM BLOOD ALT-2968* AST-649* LD(LDH)-282*
AlkPhos-139* TotBili-5.0*
[**2160-5-22**] 07:05PM BLOOD Lipase-70*
[**2160-5-22**] 07:05PM BLOOD Albumin-2.8* Calcium-6.4* Phos-4.2 Mg-1.6
[**2160-5-22**] 07:05PM BLOOD Ammonia-28
[**2160-5-22**] 07:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-110*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2160-5-22**] 07:24PM BLOOD Type-[**Last Name (un) **] pO2-71* pCO2-25* pH-7.22*
calTCO2-11* Base XS--15 Comment-GREEN TOP
[**2160-5-22**] 07:24PM BLOOD Glucose-75 Lactate-2.2* K-2.4*
DISCHARGE LABS:
[**2160-5-30**] 05:25AM BLOOD calTIBC-248* Hapto-51 Ferritn-328*
TRF-191*
[**2160-6-3**] 06:38AM BLOOD WBC-4.9 RBC-3.06* Hgb-9.3* Hct-27.5*
MCV-90 MCH-30.2 MCHC-33.7 RDW-18.4* Plt Ct-244
[**2160-6-3**] 06:38AM BLOOD PT-13.6* PTT-28.8 INR(PT)-1.2*
[**2160-6-3**] 06:38AM BLOOD Glucose-74 UreaN-7 Creat-0.5 Na-140 K-4.1
Cl-106 HCO3-30 AnGap-8
[**2160-6-3**] 06:38AM BLOOD ALT-214* AST-38 AlkPhos-218* TotBili-2.5*
[**2160-6-3**] 06:38AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6
[**2160-6-5**]:
Na 142 K 4.1 Cl 106 HCO3 28 BUN 11 Cr 0.6 BG 76
Ca 9.0 Mg 1.7 P 4.1
ALT 133 AST 29 AP 187 Tbili 1.4
WBC 3.8 Hct 28.5 Hgb 9.7 Plt 292
INR 1.2
MICRO:
Blood Culture, Routine (Final [**2160-5-28**]): NO GROWTH.
Urine culture [**2160-5-22**]:
[**2160-5-22**] 11:19 pm URINE Source: Catheter.
**FINAL REPORT [**2160-5-25**]**
URINE CULTURE (Final [**2160-5-25**]):
THIS IS A CORRECTED REPORT [**2160-5-25**].
Reported to and read back by DR [**Last Name (NamePattern4) 80602**] [**2160-5-25**] 1125AM.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PREVIOUSLY REPORTED AS ESCHERICHIA COLI PRESUMTIVE
IDENTIFICATION([**2160-5-24**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
STUDIES:
CXR [**2160-5-22**]:
IMPRESSION: Low lung volumes with probable bibasilar
atelectasis.
LIVER U/S [**2160-5-22**]: IMPRESSION: Limited duplex ultrasound with
hepatic vasculature appearing grossly patent.
PATHOLOGY [**2160-5-29**]: DIAGNOSIS:
Proximal rectal mucosal biopsy:
Colonic mucosa with focal surface erosion and lamina propria
acute inflammation; no significant architectural distortion or
features of chronic injury. Five levels examined.
Note: The most likely etiology is a localized vascular or
drug-related ischemic injury. Clinical correlation is
recommended.
COLONOSCOPY [**2160-6-3**]:
Findings:
Mucosa: Normal mucosa was noted. Cold forceps biopsies were
performed for histology throughout the whole colon.
Excavated Lesions A few non-bleeding diverticula were seen in
the whole colon. Diverticulosis appeared to be of mild severity.
The single shallow circular non-bleeding 1 cm ulcer was found in
the distal rectum.
Impression: Normal mucosa in the colon (biopsy)
Ulcer in the colon
Diverticulosis of the whole colon
Otherwise normal colonoscopy to terminal ileum
Recommendations: Single shallow circular non-bleeding 1 cm ulcer
was found in the distal rectum. This was not bleeding. Normal
mucosa to terminal ileum without gross evidence of colitis.
Random biopsies performed. Please await biopsy results.Given
patients narcotic requirement will require MAC anesthesia for
future colonoscopy. Please return to [**Hospital1 **].
COLONIC BIOPSIES:
[**2160-5-29**]:
Colonic mucosa with focal surface erosion and lamina propria
acute inflammation; no significant architectural distortion or
features of chronic injury. Five levels examined.
[**2160-6-3**]:
Colonic mucosa with no diagnostic abnormality.
No granulomas or dysplasia are identified.
Brief Hospital Course:
Pt is a 46yo F with PMH of Crohn's disease, past chronic pain,
presenting as a transfer from [**Hospital6 6640**] with
acute liver failure status post vicodin overdose and attempted
suicide. She was admitted to the surgical intensive care unit on
[**2160-5-22**] with acute acetaminophen toxicity. Her mental status
declined over the next 24 hours as her liver and kidney function
declined, and she was intubated electively on [**2160-5-23**] for
worsening mental status / airway protection. At the time of
admission she was given a bolus of N-acetylcysteine (NAC) and
started on a maintenance drip. She was volume resuscitated in
the ED and initially required norepinephrine for blood pressure
support however this was weaned off on hospital day #2.
Starting on hospital day #[**2-7**] she began to show signs of
improvement in terms of her liver and kidney function. She was
extubated on [**5-26**] without difficulty. LFTs and creatinine at
that point were improving daily. She was started on clears and
advanced to a regular diet. Her mental status was back to
baseline alert, oriented and conversant. Given Ms. [**Known lastname 80603**]
complex social issues and history of narcotic abuse, she was
deemed not a candidate for liver transplantation and transferred
to medicine. She had a lower GI bleed, requiring transfusions in
the ICU. A sigmoidoscopy showed a rectal ulcer. She subsequently
had a colonoscopy with again evidence of rectal ulcer, but no
active bleeding. Hepatic function continued to improve and
psychiatry was consulted for assistance in management of suicide
attempt. She was transferred the medical floors where she
continued to improve.
***PT IS MEDICALLY CLEARED AND STABLE FOR TRANSFER TO PSYCH
FACILITY***
# Acetaminophen overdose: Pt was treated with NAC and monitored
in the ICU. She slowly improved and was extubated. LFT's were
trended, initially with transaminases >10,000 that slowly
improved over time. Her LFT's had almost completely normalized
at the time of transfer. Psychiatry was consulted and
recommended inpatient treatment once pt medically cleared. Once
pt was stable, she was transferred to inpatient psychiatric
admission.
** Labs for chem-7, AST/ALT, AP, Tbili 1x weekly **
# ESBL K. Pneumoniae UTI: Found on urine culture during
admission to ICU, which grew resistant Klebsiella for which she
was treated with meropenem.
# Crohn's Disease: Patient currently on prednisone as an
outpatient as poor response to methotrexate. Initially started
on steroid bursts for concern of adrenal insufficiency while in
the ICU. Eventually tapered to 10 mg prednisone po daily (home
dose is 5 mg daily), with plans to continue the same dose. She
had intermittent [**Known lastname 1676**] pain associated with her Crohn's. Her
pain was controlled with Morphine IR. She will follow-up with GI
on discharge for further management.
# Lower GI bleed: Pt had bleed during MICU course. Flex
sigmoidoscopy showed rectal ulcer that was presumable source of
bleeding. Transfused 4 units of PRBC's with maintenace of
hemodynamic stability. Coumadin for previous DVT's held (see
below). Biopsies from the sigmoidoscopy showed focal surface
erosion and lamina propria acute inflammation. On the medicine
floors she had one more episode of bloody stools during her prep
for colonoscopy. Follow up colonoscopy showed diverticulosis
throughout with 1cm rectal ulcer and biopsies taken, with no
active bleeding. She had no recurrent bleeding for >72hours
prior to transfer. Her hematocrit was stable, at her baseline
(Hct 27-29) on the day of discharge. Biopsies showed colonic
mucosa with no diagnostic abnormality, no granulomas.
Pt will follow-up with GI on discharge.
# Gastric ulcer: seen on EGD from OSH. Pt was placed on
Famotidine during this admission. Her coumadin was discontinued.
She should have repeat EGD as an outpatient with GI.
# Thrombocytopenia with history of hypercoagulation: Baseline
platelet level from [**Month (only) 956**] was 200 thousands. Admission
platelet 116 which drifted to 60's. Similar drop in [**Month (only) 359**]
[**2159**] on prior admission for APAP overdose. No evidence of
splenomegaly/sequestration or DIC as fibrinogen >400. Initial
concern for HIT but HIT Ab's negative. Platelets eventually
began to increase with resolution of hepatic decompensation.
Platelets remained stable and were within normal limits on
discharge.
# History of DVT's, upper extremities from [**1-/2160**]: pt had been
anti-coagulated previously on Coumadin, with INR
supratherapeutic on admission (INR 6.6). Coumadin was held given
GIB. Additionally, pt is not a good Coumadin candidate given
past suicide attempts.
# Tinea corporis: Treated with topical terbinazole. Oral
medications not preferred given recent hepatic failure.
Dermatology was consulted and scrapings were sent, with KOH
showing septate hyphae. She was switched to Ketoconazole cream,
to be applied twice daily to extremities. Pt was aware to keep
extremities covered and to avoid direct contact with others to
avoid spread.
# Lower extremity wounds:
Wound assessment:
Type: r/t pressors
Location:left medial ankle
Size: approx. 5 x 4 cm
Wound bed: red, friable with yellow biofilm
Exudate: moderate-large (pt did not have absorptive dressing
in
place-Adaptic was in place instead and the dressing had not been
changed for 3 days)
Odor: none
Wound edges: irregular
Periwound tissue: scar, intact, dry
Wound Pain: 0 /10
Recommendations:
Elevate LE's while sitting.
Moisturize B/L LE's, periwound tissue and feet [**Hospital1 **] with Aloe
Vesta Moisture Barrier Ointment.
Left medial ankle ulcer:
Commercial wound cleanser to irrigate/cleanse.
Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue with
each drg change.
Apply Aquacel AG (cut 4 x 4" in half) over the wound bed and
barely dampen with normal saline
Cover with dry gauze, ABD, Kling wrap
Change dressing daily.
Spiral Ace Wraps to B/L LE's from just above the toes to just
below knees. (you will need two 4" aces for each leg)
Elevate B/L LE's for 30 minutes prior to application.
Remove ace wraps at bedtime.
Pt will follow-up with plastic surgery on discharge for further
management.
TRANSITIONAL CARE:
1. CODE: FULL
2. CONTACT:
CASE WORKER [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1968**] - [**Telephone/Fax (1) 80604**]
Daughter [**First Name4 (NamePattern1) 80605**] [**Last Name (NamePattern1) 80606**] [**Telephone/Fax (1) 80607**] (HCP); cell [**Telephone/Fax (1) 80608**]
Son [**Name (NI) **] [**Name (NI) 80606**] (Alternate HCP if unable to reach [**Name (NI) 80605**])
[**Telephone/Fax (1) 80609**]
[Sister, info from prior admission: [**Name (NI) **] [**Known lastname 40984**]. Home:
[**Telephone/Fax (1) 80610**], Cell: [**Telephone/Fax (1) 80611**]]
3. FOLLOW-UP:
- PCP after psychiatric admission
- GI with repeat EGD
- Plastics
4. MEDICAL MANAGEMENT:
- START Famotidine, Prednisone 10mg, Calcium, Vitamin D,
Morphine for pain control, Ondansetron prn nausea, Trazodone prn
insomnia, Continue colace
- STOP Coumadin, NO Vicodin or any acetaminophen products
5. RISKS TO REHOSPITALIZATION:
- Past suicide attempts, depression
6. OUTSTANDING TASKS:
- scrapings from skin taken [**2160-6-6**] pending
Medications on Admission:
Coumadin
Oxycontin
Doxepin
Prednisone
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: This medication can cause sedation
and should not be taken while driving or doing heavy activity.
DO NOT take more than the prescribed amount.
.
6. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
**MEDICALLY CLEARED AND STABLE FOR DISCHARGE TO INPATIENT
PSYCHIATRIC TREATMENT**
Primary Diagnoses:
1. Fulminant hepatic failure [**2-6**] Tylenol overdose
2. Suicide attempt
3. GI bleeding
4. Thrombocytopenia
5. Tinea corporis
Secondary Diagnoses:
1. Crohn's disease
2. Chronic pain
3. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 40984**],
It was a pleasure taking care of you during this admission. You
were admitted after a toxic level of Vicodin ingestion. You had
acute liver failure from this amount of Tylenol, which required
a stay in the ICU for close monitoring. Your liver function
slowly improved.
You also had bleeding from the rectum and colonoscopy showed
a rectal ulcer. You were transfused blood for this. Your blood
levels thereafter remained stable.
The psychiatrists saw you for the suicide attempt, and
recommended inpatient treatment which you will continue when you
leave here.
During this hospitalization, you were found to have a urinary
tract infection which was treated with intravenous antibiotics.
You had a fungal infection in your skin, for which the
dermatologists saw you and recommended cream. You will need to
continue to apply this cream twice daily and keep your arms and
legs covered to avoid direct contact with others.
The following medications were changed during this admission:
- STOP Vicodin, Oxycontin, or any other pain medications you
were taking or had prescriptions for prior to this admission
- STOP Coumadin
- STOP Doxepin
- Increase the dose of Prednisone from 5mg daily 10mg by mouth
daily
- START Calcium 500mg by mouth twice daily
- START Vitamin D 1000mg by mouth daily
- START Famotidine 20mg by mouth twice daily
- START Trazodone 25mg by mouth at night as needed for insomnia
- START Ondansetron 4mg tablet by mouth every 8 hours as needed
for nausea
- START Ketoconazole cream apply to right leg, back and left
wrist twice daily until further advised by the dermatologists.
- START Morphine IR 15mg by mouth every 4 hours as needed for
pain
** This medication can cause sedation and should not be taken
while driving or doing heavy activity. DO NOT take more than the
prescribed amount.
- CONTINUE Colace 100mg by mouth twice daily to prevent
constipation
**IT IS VERY IMPORTANT THAT YOU DO NOT EVER OVERDOSE ON TYLENOL
OR ANY OTHER MEDICATION AGAIN, AS THIS IS LIFE-THREATENING**
It was a pleasure taking care of you during this admission!
Followup Instructions:
Please follow-up with the following appointments:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2160-6-18**] at 1:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], 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
** Your GI doctors recommended a repeat endoscopy to assess for
the gastric ulcer seen previously. Please discuss this with them
at your next appointment. They will help to arrange this.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] DIVISION OF PLASTIC SURGERY
Address: [**Doctor First Name **], STE 5A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 6331**]
Appointment: Friday [**2160-6-27**] 9:15am
Department: DERMATOLOGY
When: TUESDAY [**2160-7-8**] at 1 PM
With: [**Name6 (MD) 6821**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please follow-up with the psychiatrists. You will need to
schedule an appointment with your primary care doctor when you
leave the inpatient psychiatric hospital.
Please call your primary care doctor, Dr. [**Last Name (STitle) 51466**], after you are
discharged to schedule a follow-up appointment. His office can
be reached at [**Telephone/Fax (1) 53977**].
Completed by:[**2160-6-10**]
|
[
"599.0",
"531.40",
"555.9",
"570",
"V58.61",
"287.5",
"280.9",
"276.2",
"V12.51",
"110.5",
"569.41",
"782.1",
"041.3",
"303.90",
"276.8",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"96.04",
"31.42",
"38.93",
"96.71",
"48.24"
] |
icd9pcs
|
[
[
[]
]
] |
18376, 18446
|
9941, 17258
|
303, 353
|
18789, 18789
|
3822, 3822
|
21079, 22716
|
2636, 2752
|
17347, 18353
|
18467, 18696
|
17284, 17324
|
18940, 21056
|
5870, 9918
|
2334, 2528
|
2767, 3803
|
18717, 18768
|
235, 265
|
381, 1887
|
3838, 5854
|
18804, 18916
|
1931, 2311
|
2544, 2620
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,269
| 102,920
|
54226
|
Discharge summary
|
report
|
Admission Date: [**2129-7-19**] Discharge Date: [**2129-7-23**]
Date of Birth: [**2095-7-22**] Sex: F
Service: SURGERY
Allergies:
Corn
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
34 year old female admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass
History of Present Illness:
[**Known firstname 29778**] has class III extreme morbid obesity with weight of
403.9
lbs as of [**2129-5-24**] (initial screen weight on [**2129-5-20**] was 405.9
lbs), height of 65 inches and BMI of 67.2. Her previous weight
loss efforts have included Weight Watchers 4 attempts in 10
years
losing about 20 lbs each time most recently in [**2128**], 6-[**Street Address(1) 111118**] counseling in [**2126**] losing 30+ lbs as well as PCP guidance
and 2-3 months of Slim-Fast in the [**2111**] losing [**2-8**] lbs. She has
not taken prescription weight loss medications or taken
over-the-counter ephedra-containing appetite suppressants/herbal
supplements. In all her efforts she was unable to maintain
whatever weight she had lost for any significant length of time.
Past Medical History:
She has history of depression/PTSD with panic attacks and
suicidal ideation [**2119**] to [**2123**] but not now and has been in
behavioral and psychotherapy for 5 years [**2122**]-[**2127**] on medication
(Celexa).
Her medical history is noted for obstructive sleep apnea since
[**2126**] on CPAP (setting [**12-19**]) but does not use often, polycystic
ovary syndrome since age 16, hyperlipidemia on no medications,
thyroid disorder (Graves' disease) [**2120**] had been on PTU now off,
occasional heartburn secondary to stress, iron deficiency 3
years
ago, weight-related constant back pain and left hip pain
secondary to bursitis. She had past h/o seizures (tonic-clonic)
that stopped by age 16. She has h/o rectal bleeding (had
colonoscopy in [**2126**] and 2/[**2129**]).
Social History:
She denied tobacco, recreational drugs or
alcohol usage, drinks 5 per week iced coffee and 5 per week soda
in summer once per week in winter. She is a
special needs teacher in the [**Location (un) 1294**] Public Schools. She is
single with no children.
Family History:
She denied tobacco, recreational drugs or
alcohol usage, drinks 5 per week iced coffee and 5 per week soda
in summer once per week in winter. Family history is noted for
father deceased age 63 with diabetes and obesity; mother living
60's with thyroid disease; maternal grandfather deceased age 80
of cancer; maternal grandmother deceased age 78 of cancer,
hyperlipidemia and arthritis; paternal grandfather deceased age
around 68 with heart disease; paternal aunts alive with obesity;
paternal uncle/cousins alive with thyroid disease. She is a
special needs teacher in the [**Location (un) 1294**] Public Schools. She is
single with no children. She denied tobacco, recreational drugs
or
alcohol usage, drinks 5 per week iced coffee and 5 per week soda
in summer once per week in winter. Family history is noted for
father deceased age 63 with diabetes and obesity; mother living
60's with thyroid disease; maternal grandfather deceased age 80
of cancer; maternal grandmother deceased age 78 of cancer,
hyperlipidemia and arthritis; paternal grandfather deceased age
around 68 with heart disease; paternal aunts alive with obesity;
paternal uncle/cousins alive with thyroid disease.
Physical Exam:
Her blood pressure was 140/97, pulse 71 and O2 saturation 97%
room air. On physical examination [**Last Name (un) **] was casually dressed,
outgoing, pleasant and in no distress. Her skin was warm, quite
dry with acne, no rashes. Sclerae were anicteric, conjunctiva
clear, pupils were equal round and reactive to light, fundi were
normal, mucous membranes were moist, tongue was pink and the
oropharynx was without exudates or hyperemia. Trachea was in the
midline and the neck was supple with good range of motion, no
adenopathy, thyromegaly or carotid bruits. Chest was symmetric
and the lungs were clear to auscultation bilaterally with good
air movement. Cardiac exam was regular rate and rhythm, normal
S1
and S2, no murmurs, rubs or gallops. The abdomen is very obese
but soft, non-tender, non-distended with bowel sound activity,
moderate pannus, no incision scars, no hernias. Spinal curvature
was normal with no spinal tenderness or flank pain. Lower
extremities were without edema, venous insufficiency or
clubbing.
There was no joint swelling or inflammation of the joints. There
were no focal neurological deficits and her gait was normal.
Pertinent Results:
[**2129-7-20**] 09:05AM BLOOD WBC-11.7* RBC-4.05* Hgb-10.8* Hct-31.6*
MCV-78* MCH-26.8* MCHC-34.2 RDW-14.3 Plt Ct-432
[**2129-7-21**] 03:09AM BLOOD WBC-10.6 RBC-3.92* Hgb-10.2* Hct-31.7*
MCV-81* MCH-26.0* MCHC-32.2 RDW-13.9 Plt Ct-379
[**2129-7-20**] 09:05AM BLOOD Glucose-112* UreaN-8 Creat-0.6 Na-141
K-4.2 Cl-106 HCO3-30 AnGap-9
[**2129-7-22**] 06:20AM BLOOD Glucose-80 UreaN-7 Creat-0.6 Na-142 K-3.9
Cl-105 HCO3-27 AnGap-14
[**2129-7-20**] 09:05AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.1
[**2129-7-21**] 03:09AM BLOOD Calcium-8.5 Phos-1.9* Mg-2.0
[**2129-7-20**] 05:37PM BLOOD Type-ART pO2-140* pCO2-49* pH-7.38
calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2129-7-20**] UGI - No leak or obstruction.
[**2129-7-20**] CXR - IMPRESSION: No evidence for pneumonia or fluid
overload. Mild bibasilar
atelectasis.
Brief Hospital Course:
Patient underwent a laparoscopic gastric bypass without
complications. She was kept in the post anesthesia recovery room
the first night postoperatively. She was transferred to the
floor on postoperative day one. Throughout day she had trouble
with pain control and oxygenation. Several methods of cpap and
bipap tried on floor. Her dilaudid PCA was increased. To provide
her with alternative methods of oxygenation and pain control she
was transfered to the surgical intensive care unit. There she
was seen by pulmonary and the pain service. For the next 24
hours her pain receded and her pain improved. Late in the day on
her second postoperative day she was transferred back to the
regular floor. She was progressed from a stage one to a stage 3
diet without nausea or vomiting. She was taken off the dilaudid
pca and changed to oral roxicet for pain. Incentive spiromenter
use and ambulation were encouraged. Patient will follow up with
Dr. [**Last Name (STitle) **] in 3 weeks and needs to follow up with her primary
care in one to two weeks.
Medications on Admission:
Spironolactone 50 mg", systemic acne (had been on Zovia); Celexa
60 mg'; Tylenol and Advil
Discharge Medications:
1. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take for 6 months.
Disp:*60 Capsule(s)* Refills:*5*
2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: Please
take for one month.
Disp:*600 ml* Refills:*0*
3. Roxicet 5-325 mg/5 mL Solution Sig: 5-10 cc PO every [**4-10**]
hours as needed for pain.
Disp:*600 ml* Refills:*0*
4. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation.
Disp:*600 ml* Refills:*0*
5. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. medication
Please do not take any nonsteroidal medication (motrin, alleve)
as this can cause ulcers and bleeding.
Discharge Disposition:
Home
Discharge Diagnosis:
Spironolactone 50 mg", systemic acne (had been on Zovia); Celexa
60 mg'; Tylenol and Advil
Discharge Condition:
Stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**10-19**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2129-8-10**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2129-8-10**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2129-10-26**] 6:00
Completed by:[**2129-7-25**]
|
[
"300.01",
"530.81",
"V85.4",
"327.23",
"345.90",
"242.00",
"278.01",
"256.4",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.39",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7389, 7395
|
5456, 6505
|
321, 363
|
7529, 7538
|
4626, 5433
|
9520, 10061
|
2252, 3439
|
6646, 7366
|
7416, 7508
|
6531, 6623
|
7586, 8152
|
3454, 4607
|
224, 283
|
9162, 9497
|
391, 1163
|
8177, 9150
|
1185, 1965
|
1981, 2236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,887
| 150,268
|
15096
|
Discharge summary
|
report
|
Admission Date: [**2139-9-30**] Discharge Date: [**2139-10-26**]
Date of Birth: [**2077-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Bleeding at blood draw site, INR>19.2
Major Surgical or Invasive Procedure:
Blood transfusion
History of Present Illness:
Patient is a 61 year-old male with a history of cerebal palsy,
mild mental retardation, atrial flutter s/p cardioversion, PEs
in [**2134**], [**2138**] on coumadin who presented with a supratherpauetic
INR. Patient states that his visiting nurse came to draw his INR
yesterday, and afterwards, he had persistent bleeding from the
site on his hand all day. By the afternoon, he was called by his
PCP's office, was told his INR was 10 and that he should hold
his coumadin. He went to bed last night and woke up with blood
on the sheets from his hand. He thus dialed 911 and was [**Last Name (un) 4662**]
in by EMS. Patient otherwise completely asymptomatic and has
been taking his coumadin dose as directed, no changes in diet,
no recent nausea/vomiting/diarrhea or decreased PO intake. He
does state that he recently started a new anti-depressant two
weeks ago, but does not recall the name.
.
On arrival to the ED, initial vitals were 97 86 130/70 15 97%.
INR was found to be > 19.2, ALT 45, K+ 2.2. CT head showed no
acute process. Patient was given 10 mg PO Vitamin K, 40 mEq K+
in 1 L NS at 250cc/hr. He is being admitted for reversal of
supratherpauetic INR.
.
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, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Cerebral palsy, wheelchair bound as of ~[**2130**]
- History of PEs (bilateral in [**12/2134**], right subsegmental in
[**8-/2138**]) on anticoagulation
- A-flutter s/p cardioversion [**10-2**], on amiodarone and
anticoagulated
- HTN
- Right heart failure with moderate Pulmonary hypertension, 2+
TR on TTE (but done in the setting of PE [**8-/2138**])
- Hypothyroidism
- h/o recurrent MRSA cellulitis
- Incontinence
- Cervical spondylosis
- Chronic back pain
- Obesity
- Hyperlipidemia
- Chronic venous insufficiency
- Depression
- Open heart surgery at age 12, unknown type of repair (patent
foramen ovale or ventricular septal defect?)
- Hematuria w/ atypical cells [**8-/2138**]
Social History:
Apparently lives by himself with a "caretaker;" per d/c summary
in [**2138**], could not perform ADLs. Had been at [**Hospital3 2558**]
following that admission. He had prior admission for abuse from
previous caregiver. [**Name (NI) **] uses an electric wheel chair to move
about. He smomked 1 ppd for 10 years, quit in [**2128**]. He drinks
alcohol occasionally and denies illicit drugs. He denies having
any living family.
Family History:
Mother died at 48 from brain tumor. Sister died at 42 from
breast cancer. No premature CAD of sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 96.4 112/58 86 18 95% RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
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, no focal deficits noted.
Pertinent Results:
ADMISSION LABS
==============
[**2139-9-30**] 12:47AM BLOOD WBC-8.1 RBC-5.43# Hgb-16.6# Hct-45.4#
MCV-84 MCH-30.5 MCHC-36.6* RDW-13.6 Plt Ct-273
[**2139-9-30**] 12:47AM BLOOD Neuts-71.3* Lymphs-18.9 Monos-6.6 Eos-2.0
Baso-1.2
[**2139-9-30**] 12:47AM BLOOD PT-150* PTT-54.4* INR(PT)-GREATER TH
[**2139-9-30**] 09:30AM BLOOD PT-124.5* PTT-57.4* INR(PT)-15.4*
[**2139-9-30**] 12:47AM BLOOD Glucose-180* UreaN-18 Creat-0.6 Na-137
K-2.2* Cl-90* HCO3-29 AnGap-20
[**2139-9-30**] 12:47AM BLOOD ALT-45* AST-35 AlkPhos-76 TotBili-0.5
[**2139-9-30**] 09:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.7
INR TREND
===========
[**2139-9-30**] 12:55PM BLOOD PT-110.4* INR(PT)-13.4*
[**2139-10-1**] 06:25AM BLOOD PT-40.7* PTT-37.8* INR(PT)-4.2*
[**2139-10-2**] 07:05AM BLOOD PT-26.2* PTT-31.8 INR(PT)-2.5*
[**2139-10-3**] 06:45AM BLOOD PT-21.0* PTT-37.2* INR(PT)-1.9*
[**2139-10-4**] 06:15AM BLOOD PT-18.0* PTT-34.6 INR(PT)-1.6*
[**2139-10-19**] 06:05AM BLOOD PT-15.4* PTT-25.7 INR(PT)-1.3*
[**2139-10-20**] 07:00AM BLOOD PT-16.6* PTT-27.3 INR(PT)-1.5*
[**2139-10-21**] 06:55AM BLOOD PT-18.8* INR(PT)-1.7*
[**2139-10-22**] 06:02AM BLOOD PT-25.7* PTT-29.5 INR(PT)-2.4*
[**2139-10-23**] 08:15AM BLOOD PT-28.7* PTT-32.0 INR(PT)-2.8*
[**2139-10-24**] 05:55AM BLOOD PT-29.1* PTT-33.9 INR(PT)-2.8*
[**2139-10-25**] 05:33AM BLOOD PT-29.2* INR(PT)-2.8*
[**2139-10-26**] 06:15AM BLOOD PT-30.6* INR(PT)-3.0*
CARDIAC ENZYMES
===============
[**2139-9-30**] 12:55PM BLOOD CK-MB-2 cTropnT-<0.01
[**2139-10-1**] 12:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**2139-10-1**] 06:25AM BLOOD CK-MB-3 cTropnT-<0.01
DISCHARGE LABS
==============
[**2139-10-24**] 05:55AM BLOOD WBC-6.5 RBC-3.98* Hgb-12.0* Hct-37.3*
MCV-94 MCH-30.1 MCHC-32.1 RDW-15.7* Plt Ct-506*
[**2139-10-21**] 06:55AM BLOOD Glucose-124* UreaN-16 Creat-0.5 Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
MICROBIOLOGY
==============
SPUTUM
**FINAL REPORT [**2139-10-4**]**
GRAM STAIN (Final [**2139-10-2**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2139-10-4**]):
MODERATE GROWTH Commensal Respiratory Flora.
IMAGING
==============
HEAD CT [**2139-9-30**]
IMPRESSION:
1. No acute intracranial pathologic process. No intracranial
hemorrhage.
2. Similar marked global atrophy, with moderate chronic
microvascular
ischemic disease.
CT OF THE ABDOMEN: [**2139-10-10**]
There are mild bibasilar atelectasis. There are no focal hepatic
lesions. The gallbladder is slightly distended but there is no
evidence of cholecystitis. The pancreas and spleen are normal.
Multiple bilateral nonobstructive up to 14 mm (in the right mid
pole) renal stones are seen, similar to [**2138**]. No hydronephrosis.
The adrenal glands are prominent bilaterally but no evidence of
focal lesions. There are scattered, non-pathologically enlarged
retroperitoneal lymph nodes.
There are mild atherosclerotic calcifications of the abdominal
aorta.
There is no free intraperitoneal fluid.
The esophagus, stomach, small and large bowel are normal.
There is a large left rectus sheath hematoma which extends into
the left
extraperitoneal pelvic space. The hematoma has a fluid-fluid
level consistent with an acute on chronic component. The rectus
sheath component measures about 14 x 7 x 12 cm, the
extraperitoneal pelvic component measures about 17 x 11 x 17 cm.
The urinary bladder is displaced posteriorly. The rectum is
normal.
Additionally, there is subcutaneous stranding at the left flank
overlying the left iliac crest, also representing a small amount
of hematoma.
There is no evidence of active extravasation within the
hematoma.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
Large left rectus sheath and left extraperitoneal acute on
chronic hematoma as described above.
Brief Hospital Course:
61 year-old male with a history of cerebal palsey, mild mental
retardation, atrial flutter s/p cardioversion, Pulmonary
embolisms in [**2134**], [**2138**] on coumadin admitted with bleeding from
a peripheral blood draw site with INR 19. He was treated with
vitamin K and given lovenox bridge when INR <2.0, his course was
complicated by pneumonia, and rectus sheath hematoma.
ACTIVE ISSUES
==============
#. Supertherapeutic INR: After discussion with care givers and
pharmacy, it is likely that this was an accidental overdose by
caregivers. [**Name (NI) **] was admitted with bleeding from peripheral IV
site which was treated with compression. Hematocrit remained
stable. Head CT was negative for acute hemorrhagic stroke. He
was treated with lovenox 100mg [**Hospital1 **] and remained in hospital
until INR stabilized. After patient suffered rectus sheath
hematoma, anticoagulation was discontinued. Patient underwent
ablation of inferior epigastric arteries, though no active
rectus sheath bleeding was noted on IR. Patient was transfused a
total of 4 units of pRBCs (last transfusion on [**10-11**] for SBPs in
the 90s). Subsequent serial HCTs were stable and increasing to
37.3 on discharge.
.
#. Pneumonia: On hospital day 2, patient complained of cough
productive of green sputum and later had fever to 100.9. He was
treated with levofloxacin for community acquired pneumonia and
metronidazole for anaerobic coverage given aspiration risk.
Sputum sample was unable to be islated as patient was unable to
produce forceful cough. Coverage for health care associated
pneumonia was considered unnecessary and patient improved after
8 days of the above regimen. He developed muscle strain related
to coughing and was treated with acetaminophen, oxycodone and
lidocaine patch. Standing oxycodone was discontinued prior to
discharge, but he required occasional oxycodone 5mg doses for
breakthrough pain.
.
#. Ileus: On [**2139-10-8**] he had abdominal distention and worsening
abdominal pain, plain film showed ileus. He was treated with
suppositories and bowel rest with improvment in abdominal pain
and distention.
.
#. Rectus sheath hematoma: while coughing, patient developed
abdominal pain related to muscle strain. He was treated with
oxycodone for pain with improvement. On the evening of [**2139-10-9**]
patient became hypotensive after a large bowel movement. Hct was
checked and noted to be down 32->24, but the stool was guaiac
negative. INR was 3.0. He was treated with intervenous fluids,
given FFP, 2 Units PRBC. CT scan showed a large rectus sheath
hematoma without evidence of active bleeding. Because repeat Hct
did not appropriately increase after transfusion, he was given
an additional 1 unit PRBC and transferred to the MICU for closer
monitoring. Interventional radiology was consulted to perform
angioembolization. The hematoma resolved over the course of the
rest of his stay.
.
# Recurrent pulmonary embolism: Patient has suffered two
pulmonary emobli in [**2136**] and [**2138**] and had been on life long
anticoagulation. After he developed rectus sheath hematoma,
coumadin was discontinued. Lower extremitity ultrasound for DVT
was performed and was very limited. Hematology was consulted and
recommended restarting warfarin without a LMWH bridge. This was
performed and once patient's INR was therapeutic ([**2-5**]) he was
discharged.
.
#. Hypokalemia: On admission, potassium was 2.2 believed to be
related to torsemide. EKG did not reveal U waves. He was treated
with intravenous and oral potassium and serum potassium level
normalized. Torsemide was resumed.
.
# EKG changes: admission EKG was remarkable for ST Depressions
in V4-5 which appeared more prominent in comparison to EKG from
[**2138-11-21**]. He complained of mild lower back pain which was
considered unlikely to represent angina. He was given ASA 325
and placed on telemetry. He ruled out for myocardial infarction
by three sets of negative cardiac enzymes. Serial EKGS showed
persistence of ST Depressions in V4-5. Changes are likely a
normal variant which appeared more prominent based on lead
placement.
#. Atrial Flutter/Fibrillation: On admission, patient was rhythm
controlled in normal sinus rhythm. Amiodarone and metoprolol
were continued.
CHRONIC ISSUES
==============
#. Hypertension: Continued metoprolol, spironolactone.
.
#. Hyperlipidemia: Continued statin.
.
#. Cerebral Palsy: continued baclofen.
TRANSITIONAL ISSUES
==============
# Prediabetic state: During this admission, the patient was
noted to have consistently impaired fasting glucose (AM glucose
between 100 and 125), and on several occasions his AM glucose
was >125. The patient is thus most likely in a pre-diabetic
state. Given his obesity, cerebral palsy, and other
co-morbidities, lifestyle modifications may be difficult or
impossible, and his primary care physician may consider
[**Name9 (PRE) 44072**] him on a metformin regimen.
.
# Anticoagulation: The patient was noted to have a stable INR
2.8->2.8->3.0 when taking 2mg warfarin daily.
.
# CODE: FULL
# CONTACT: [**Name (NI) 44073**] (caretaker) [**Telephone/Fax (1) 44074**]
Medications on Admission:
AMIODARONE HCL 200 MG TABS (AMIODARONE HCL) 1 tab po daily
LOVASTATIN 40 MG TABS (LOVASTATIN) 1 tab po daily
METOPROLOL TARTRATE 50 MG TABS (METOPROLOL TARTRATE) 1 tab PO
BID, hold for SBP <100 and HR <60
TORSEMIDE 20 MG TABS (TORSEMIDE) 1 tab po in the morning
SPIRONOLACTONE 25 MG TABS (SPIRONOLACTONE) 1 tab po in the
morning
LEVOTHYROXINE SODIUM 75 MCG TABS (LEVOTHYROXINE SODIUM) 1 tab po
daily
BACLOFEN TAB 20MG (BACLOFEN) 1 po TID
EUCERIN CREA (SKIN PROTECTANTS, MISC.) Apply as directed
COUMADIN 1 MG TABS (WARFARIN SODIUM) ON HOLD
COUMADIN 2 MG TABS (WARFARIN SODIUM) 1 po daily
COUMADIN 5 MG TABS (WARFARIN SODIUM) ON HOLD
HYDROXYZINE HCL 25 MG TABS (HYDROXYZINE HCL) prn use
ASPIRIN EC 81 MG TBEC (ASPIRIN) 1 tab PO daily
DAILY MULTI VITAMIN/MINERALS TABS (MULTIPLE VITAMINS-MINERALS) 1
tab PO daily
DIAZEPAM 5 MG TABS (DIAZEPAM) 1 tablet once a day as needed for
anxiety
WELLBUTRIN SR 200 MG XR12H-TAB (BUPROPION HCL) 1 tablet in the
morning
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every [**4-8**]
hours as needed for itching.
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for anxiety.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
8. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
9. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
11. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<10 or HR<60.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
16. Eucerin Cream Sig: One (1) Topical twice a day as
needed for dry skin.
17. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE take according to coumadin clinic instructions.
Disp:*30 Tablet(s)* Refills:*0*
18. Wellbutrin SR 200 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
19. Outpatient Lab Work
Please check INR on Monday [**2139-11-2**].
Discharge Disposition:
Home With Service
Facility:
Physician's Health Care
Discharge Diagnosis:
Primary
- Coumadin overdose
- Rectus Sheath Hematoma
- Pneumonia
Secondary
- Cerebral palsy
- History of PEs (bilateral in [**12/2134**], right subsegmental in
[**8-/2138**]) on anticoagulation
- A-flutter
- hypertension
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. [**Known lastname 44065**],
As you know, you were admitted to [**Hospital1 18**] for high coumadin level
and bleeding from the site of a blood draw. We checked your
blood level and found that you had not lost a significant amount
of blood. We treated you with vitamin K to counteract the
coumadin and your coumadin level improved.
While in the hospital, you complained of cough and developed a
fever. We treated you with antibiotics and your symptoms
improved. You developed abdominal pain and were found to have
bleeding into the muscles of your abdomen. We stopped your
coumadin, gave you a blood transfusion, and your blood level
stabilized. We then re-started you on the coumadin, and when it
reached a medically-appropriate level, you were discharged from
the hospital to your home.
Because you had been bleeding, we have adjusted your coumadin
dose. Please follow the instructions of your coumadin clinic
regarding the dose you should take daily.
Please remember to take your medications exactly as you were
instructed. Please weigh yourself every morning, and call the
doctor if your weight goes up more than 3 lbs.
The following changes were made to your medications:
- Your NEW coumadin dose is 2 mg daily. Please do not exceed
this dose. Adjust dose according to the instructions of the
coumadin clinic.
- Added docusate, biscodyl and senna to be take as needed for
constipation
Followup Instructions:
Please keep the following appointments:
Monday [**2139-11-2**] at 12 pm
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
Fax: [**Telephone/Fax (1) 34420**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
|
[
"278.00",
"401.9",
"799.02",
"V12.55",
"311",
"564.09",
"459.81",
"E858.2",
"272.4",
"288.60",
"244.9",
"428.0",
"416.8",
"428.22",
"560.1",
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"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
15423, 15477
|
7603, 12726
|
344, 364
|
15743, 15858
|
3665, 7580
|
17346, 17833
|
2976, 3092
|
13730, 15400
|
15498, 15722
|
12752, 13707
|
15919, 17323
|
3132, 3646
|
267, 306
|
392, 1809
|
15873, 15895
|
1831, 2517
|
2533, 2959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,163
| 147,392
|
43480
|
Discharge summary
|
report
|
Admission Date: [**2161-4-3**] Discharge Date: [**2161-4-9**]
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
TIA
Major Surgical or Invasive Procedure:
carotid stent
History of Present Illness:
82 y.o. pt of Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], admitted to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1281**] Hospital on
[**4-1**] with TIA symptoms, U/S performed that day showed stenosis of
the R carotid with an intimal flap concerning for dissection. Pt
originally presented with multiple episodes of transient loss of
vision in the right eye c/w amaurosis fugax. Pt has had BL
carotid endarterectomies performed at [**Hospital6 13185**]--R in [**2148**], L in [**2152**]. Pt transferred here for further
workup. Pt c/o constipation and some abdominal distension.
Past Medical History:
1. HTN,
2. Cerebrovascular dz s/p bilat carotid endardarectomy (as
above)
3. DM
4. CAD, s/p CABG [**2146**]--LIMA to LAD, SVG to PD, SVG to OM;
multiple revascularizations afterwards with known total
occlusion of LAD following LIMA anastomosis, as well as proximal
RCA occlusion and PL occlusion. SVG to OM was occluded and SVG
to PDA showed stenosis of 40% by cardiac cath in 11/99. Pt had
an MI in [**2155**], with no change seen on cath.
5. CHF--likely [**2-25**] ischemic CM--EF 25-30% by Echo in [**10-27**].
6. Mod pulmonary hypertension
7. Mod MR [**First Name (Titles) **] [**Last Name (Titles) **]
8. Chronic anemia requiring epo administration
9. CRI--Cr 2.3 at OSH
10. Glaucoma
11. PVD
12. Afib--placed on amiodarone
13. GERD
14. Intractable hiccups
15. Thrombocytopenia--unexplained
Social History:
Pt is married and lives with his wife. [**Name (NI) 595**] speaking only.
Nonsmoker.
Family History:
NC
Physical Exam:
Vitals: T 96.0 BP 154/84 HR 69 R 16 Sat 99% RA
*
PE: G: Pt is [**Name (NI) **] but [**Name (NI) 595**] speaking, does understand a little
English.
HEENT: MMM, anicteric sclerae
Neck: Bruits auscultated BL. No JVD
Lungs: CTA BL BS, No W/R/C
CV: RRR, S1, Loud S2, 2/6 Systolic crescendo/decrescendo
murmur loudest at RUSB
Abd: Soft, NT, BS+
Ext: No E/C/C, DP pulses faint but palpable
Nails: Absent lunulae, no [**Doctor First Name **] nails.
Neuro: CN 2-12 intact. 5/5 strength throughout. No clonus.
Pertinent Results:
cath report [**2160-4-7**]:
RCCA normal, ICA serial 90% lesions in hte prior CEA site. The
ICA fills the ipsilateral MCA/ACA without cross filling from the
contralateral ICA. The LCCA and ICA are normal without lesions
to the ipsilateral ACA and MCA.
Stented RCCA.
Admit Labs:
[**2161-4-3**] 07:13PM BLOOD WBC-3.6* RBC-4.19*# Hgb-12.3*# Hct-38.3*#
MCV-91 MCH-29.4 MCHC-32.2 RDW-17.6* Plt Ct-110*
[**2161-4-3**] 07:13PM BLOOD Plt Ct-110*
[**2161-4-3**] 07:13PM BLOOD PT-13.5 PTT-29.4 INR(PT)-1.1
[**2161-4-3**] 07:13PM BLOOD Glucose-167* UreaN-78* Creat-2.1* Na-140
K-4.5 Cl-109* HCO3-21* AnGap-15
[**2161-4-3**] 07:13PM BLOOD ALT-18 AST-15 AlkPhos-69 TotBili-0.5
[**2161-4-3**] 07:13PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.8*# Mg-2.1
Discharge Labs:
[**2161-4-9**] 06:30AM BLOOD WBC-3.3* RBC-3.86* Hgb-11.4* Hct-33.5*
MCV-87 MCH-29.4 MCHC-34.0 RDW-16.5* Plt Ct-63*
[**2161-4-8**] 04:48AM BLOOD Neuts-58.8 Lymphs-30.1 Monos-10.1 Eos-0.8
Baso-0
[**2161-4-8**] 04:48AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Microcy-1+
[**2161-4-9**] 06:30AM BLOOD Plt Ct-63*
[**2161-4-9**] 06:30AM BLOOD Glucose-117* UreaN-61* Creat-2.2* Na-140
K-4.0 Cl-107 HCO3-24 AnGap-13
[**2161-4-8**] 04:48AM BLOOD CK(CPK)-27*
[**2161-4-9**] 06:30AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
[**2161-4-8**] 04:48AM BLOOD Triglyc-77 HDL-59 CHOL/HD-2.3 LDLcalc-61
Echo [**2161-4-6**]:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
is mildly dilated. Overall left ventricular systolic function is
severely
depressed. Resting regional wall motion abnormalities include
dyskinesis of
the vbase of the inferior and inferolateral walls with akinesis
of the septum,
mid and apical inferior andmid and apical inferolateral walls.
The lateral and
anterior walls are not well seen but probably hypokinetic.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated. The ascending aorta is
mildly
dilated.
5.The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation
is seen.
6. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-25**]+)
mitral regurgitation is seen.
7.The estimated pulmonary artery systolic pressure is normal.
There is no
pericardial effusion.
Compared with the findings of the prior report (tape unavailable
for review)
of [**2160-9-30**], the inferior and inferolateral walls are now
dyskinetic. The
inferior and inferoalteral walls are akinetic almost right down
to the very
apex, involveing more terrritory ( by report) than previous.
Brief Hospital Course:
82yo [**Date Range 595**] speaking gentleman with PMH of hypertension, CAD,
CABG, bilateral CEA, CHF, anemia, CRI, AF.
1. R carotid stenosis: MRI/MRA demonstrated R carotid [**Last Name (un) 93591**]
stenosis and high grade CCA/ICA stenosis on R (more likely
atherosclerosis rather than dissection). Pt was taken to the
cath lab and stented. He spent 1 night in the CCU for intensive
blood pressure control, including a nitroprusside drip. He was
then transferred to the floor, where his blood pressure was kept
between 100-140 systolic and he had unchanged neuro exam.
During the hospitalization he had no focal neuro findings, and
is discharged back to rehab.
*
2. Abd pain: Pt c/o of some mild abd pain initially, with good
response to aggressive bowel regimen and simethicone.
*
3. CAD: All cardiac meds were continued.
*
4. +UA: Positive WBC on UA. Pt started on Levo, which he should
take for total 7 days.
*
5. CHF: EF 25-30% according to Echo (see report). Discharged on
listed CHF meds.
*
6. Thrombocytopenia: Pt appears to have Plt between 87 - 123,
with values as low as 13-22 in [**2-27**]. His Plt count was stably
depressed throughout, and workup for myelodysplastic syndrome or
myelodysplasia could be considered as an outpatient as the
patient was also noted to have low WBC.
Medications on Admission:
Timolol
Lasix
Glyburide
Plavix
Lipitor
Senekot
lopressor
IMdur
kdur
nifedipine
ASA
Protonix
Discharge Medications:
1. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
13. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
14. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab-Swamscott
Discharge Diagnosis:
Carotid Stenosis
Discharge Condition:
Stable
Discharge Instructions:
Minimize heavy activity and exertion for 1 month.
If you experience any new weakness, headaches, numbness, or
facial drooping, call primary care physician [**Name Initial (PRE) **]/or go to the
Emergency dept.
Please call [**Telephone/Fax (1) 327**] to arrange for ultrasound of carotids
in 2 1/2 months, and follow up the results with Dr. [**First Name (STitle) **] in 3
months.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks for blood pressure check.
Follow up with Dr. [**First Name (STitle) **] in 3 months.
Follow up with Primary care physician [**Last Name (NamePattern4) **] 1 month.
|
[
"397.0",
"E934.2",
"414.8",
"287.4",
"424.0",
"401.9",
"599.0",
"V45.81",
"250.00",
"427.31",
"428.0",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"88.41",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
8111, 8169
|
5123, 6421
|
226, 241
|
8230, 8238
|
2475, 3213
|
8668, 8891
|
1896, 1901
|
6564, 8088
|
8190, 8209
|
6447, 6541
|
8262, 8645
|
3230, 5100
|
1916, 2456
|
183, 188
|
269, 896
|
918, 1778
|
1794, 1880
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,303
| 185,638
|
20990
|
Discharge summary
|
report
|
Admission Date: [**2170-7-19**] Discharge Date: [**2170-7-30**]
Date of Birth: [**2117-4-25**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
Bronchoscopy, Endotrachial intubation
History of Present Illness:
53 y/o M with COPD on continuous home O2, OSA on bipap at
night, CAD, right diaphragmatic paralysis presents with one week
of worsening productive cough with green/beige sputum. Patient
reports sputum has turned pink over the past 2-3 days. In
addition, patient has become increasing short of breath, with
increased sinus pressure and congestion, and rhinorhea. Patient
has also experienced some intermittent chest tightness, most
recently for 30 min the day of admission. The morning of
admission the patient had nausea, and an episode of emesis with
coughing. The patient was taken to the [**Hospital1 **] [**Location (un) 620**] where he was
noted to have fever, and hypotension to sbp 90 and received 4L
IVF, CTX and Vanco. He was transferred to [**Hospital1 18**] for further
evaluation.
In ED noted 62 72/41 18 88%4L. ? STE on EKG. Trop 0.7 at OSH.
Seen by Cards, likely demand ischemia. RIJ placed on Levophed.
Lactate normal. Receiving K, Zosyn. Admitted to MICU.
Upon arrival temp 101.3, bp 100/48, hr 74, rr 19, 86% 6LNC.
Past Medical History:
1. Obstructive Sleep apnea with hypoventilation
-Followed by Dr. [**Last Name (STitle) **] in sleep medicine
-Chronic CO2 retainer in the 60s, Bicarb in the 30s
-Requires supplemental O2 during the day, and BiPAP at night
2. Coronary Artery Disease
-s/p STEMI [**2168-9-6**] with RCA blockage and spontaneous dissection
of the LAD with placement of 6 DES and fluorotime >100 min and
radiation burn to the right.
-PMIBI [**10-3**] with Normal perfusion; Dilated LV cavity with LVEF
of 48%.
-Managed by [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
3. HTN
4. Hyperlipidemia
5. GERD
6. Depression
7. Diaphragmatic Hemiparesis
8. Asthma
9. Obesity
10. BPH
11. Osteoporosis
12. DJD
Social History:
No Tobacco or Alcohol use, quit both 20yrs ago, prior 24py
tobacco, prior alcohol heavy x 12yrs.
Pt works with disabled adults. He lives with his brother and his
brother's partner. They have 3 dogs and 1 cat.
Tobacco: 12 years x 2PPD
EtOH: no alcohol
Drugs: Marijuana in college
Family History:
No family history of premature coronary artery disease
or sudden death. His mother had a AAA in her 50s and his father
had a CABG in his 50s and a cerebral aneurysm.
Physical Exam:
General Appearance: Well nourished, Overweight / Obese, RIJ
oozing blood
Eyes / Conjunctiva: PERRL, sinus ttp
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Distant),
(Murmur: Systolic), holosystolic at base
JVP: 8cm
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present), chronic venous stasis skin changes around ankles,
calves
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : , Diminished: throughout, very tight, Rhonchorous:
left base)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, date/time,
Movement: Purposeful, Tone: Normal
Pertinent Results:
Labs on Admission: [**2170-7-19**]
WBC-17.9*# RBC-2.62*# Hgb-8.5*# Hct-25.5*# MCV-97 RDW-13.6 Plt
Ct-175
Neuts-84* Bands-4 Lymphs-6* Monos-6 Eos-0
PT-17.4* PTT-27.5 INR(PT)-1.6*
Glucose-165* UreaN-17 Creat-1.0 Na-136 K-3.0* Cl-87* HCO3-42*
AnGap-10
ALT-15 AST-36 CK(CPK)-253* AlkPhos-46 TotBili-1.1
Lactate-1.2
VitB12-521 Folate-19.4 Hapto-294*
.
Other Labs:
[**2170-7-19**] 10:15AM BLOOD cTropnT-0.90*
[**2170-7-19**] 03:15PM BLOOD CK-MB-14* MB Indx-5.5 cTropnT-0.66*
[**2170-7-19**] 10:21PM BLOOD CK-MB-17* MB Indx-5.0 cTropnT-0.47*
[**2170-7-20**] 05:00AM BLOOD CK-MB-20* MB Indx-6.8* cTropnT-0.34*
[**2170-7-20**] 11:19AM BLOOD CK-MB-16* MB Indx-7.4* cTropnT-0.26*
[**2170-7-20**] 04:04PM BLOOD CK-MB-12* MB Indx-6.3* cTropnT-0.26*
[**2170-7-22**] 05:25PM BLOOD CK-MB-4 cTropnT-0.13*
[**2170-7-26**] 03:56AM BLOOD WBC-12.6* RBC-3.57* Hgb-11.0* Hct-34.2*
MCV-96 MCH-30.8 MCHC-32.1 RDW-13.8 Plt Ct-312
[**2170-7-26**] 03:56AM BLOOD Glucose-113* UreaN-18 Na-143 K-3.7 Cl-100
HCO3-37* AnGap-10
[**2170-7-26**] 12:33PM BLOOD Type-ART Temp-37.0 pO2-46* pCO2-58*
pH-7.42 calTCO2-39* Base XS-10 Intubat-NOT INTUBA
.
Micro:
[**2170-7-19**] Urine culture: no growth
[**2170-7-19**] Blood culture: no growth
[**2170-7-22**] Broncheoalveolar lavage: 3+ (5-10 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2170-7-24**]): NO GROWTH, <1000 CFU/ml.
.
Other Studes:
[**2170-7-19**] EKG: Sinus rhythm. Poor R wave progression. Non-specific
ST-T wave changes. Non-specific intraventricular conduction
delay. Compared to the previous tracing of [**2170-2-3**] QRS complex is
slightly wider, bradycardia is absent.
[**2170-7-19**] CXR: Sinus rhythm. Poor R wave progression. Non-specific
ST-T wave changes. Non-specific intraventricular conduction
delay. Compared to the previous tracing of [**2170-2-3**] QRS complex is
slightly wider, bradycardia is absent.
[**2170-7-26**] CXR: The nasogastric tube and the endotracheal tube have
been removed, the right-sided central venous access line is
unchanged. Moderate increase in extent of the pre-existing
retrocardiac opacity. The elevation of the right hemidiaphragm
and the subsequent right basal atelectasis are unchanged. No
newly appeared focal parenchymal opacity suggesting pneumonia.
No signs of overt overhydration. The left sinus is not included
on today's image. On the right, there is no evidence of pleural
effusion.
Brief Hospital Course:
1. Sepsis due to Severe multilobar CAP: The patient was
initially treated with vancomycin, zosyn, and azithromycin.
Sputum cultures done [**7-19**] showed orapharyngeal flora.
Bronchoalveolar lavage done while the patient was being treated
with antibiotics showed no growth. Given that he likely has a
community-acquired pneumonia, his antibiotics were switched to
just levofloxacin, on [**7-24**], which he should continue for a total
of 14 days ending on [**2170-8-1**]. He was given final po doses to
take at home upon discharge.
.
2. Respiratory Failure: The patient had to be intubated for poor
oxygenation. Besides the antibiotics, he was diuresed with
Lasix. He tolerated extubation well. His blood gasses have been
stable and show stable hypercarbia. He is on BiPAP 12L at night
(up from 8L at home) and nasal canula oxygen during the day. He
completed a prednisone taper on [**2170-7-27**]. He has also been
treated with [**Date Range 4010**], albuterol/ipratroprium nebs, and
montelukast.
.
3 Cardiac Demand Ischemia: The patient's troponins were elevated
but trended down during his hospital stay. By EKG and enzymes,
this likely resulted from demand ischemia. His Aspirin, plavis,
and lisinopril were continued. His beta-blocker was held
secondary to hypotenion.
.
4. Hypotension: The patient's blood pressures were 100/60 when
measured manually. His beta blocker and metolazone were held and
he was given a reduced dose of his home lasix. The patient was
diuresed with Lasix and was net negative for several days.
.
5. Coagulopathy: The patient had an elevated INR. This was
thought to be secondary to poor nutrition and sepsis. The
patient was given one dose of vitamin K on [**2170-7-27**].
.
6. Hyperglycemia: The patient has no history of DM, but has
elevated blood sugars in setting of infection/stress and
steroids. The patient's blood sugars were managed with sliding
scale insulin.
.
7. Hyperlipidemia: The patient was given atorvastatin.
.
8. Chronic diastolic CHF and CAD: The patient continued aspirin,
plavix, lisinopril, and lasix (at a lower dose). Metolozone and
metoprolol were held in the setting of hypotension.
.
9. Seasonal Allergies: Stable. The patient was treated with
montelukast.
.
10. Depression: Stable. The patient continued Lexapro.
.
11. Dry Eyes: The patient was given the formulary equivalent one
his home Patanol, then was permitted to use patanol from home.
.
12. Insomnia: In the intensive care unit, the patient was given
Benadryl at night to help him sleep. This was discontinued once
the patient was transferred to the medical floor.
.
13. Anemia: The patient was found to be anemic, with a baseline
of 32-35. He was started on ferrous sulfate for a low iron
level. Transferrin and TIBC were not checked. The patient may
need a colonoscopy as an outpatient to evaluate this further.
.
14. Osteoporosis: The patient was treated with alendronate,
calcium, and vitamin D.
.
15. Hypokalemia: This was thought to be due to furosemide. The
patient received potassium supplements as needed.
Medications on Admission:
Alendronate [Fosamax]70 mg daily
Atorvastatin [Lipitor] 80 mg daily
Clopidogrel 75 mg Tablet daily
Escitalopram [Lexapro] 20 mg QHS
Fexofenadine [[**Doctor First Name **]] 60 mg [**Hospital1 **]
Fluticasone-Salmeterol250 mcg-50 mcg/Dose INH [**Hospital1 **]
Furosemide [Lasix] 80 mg, 2 tabs daily
Lisinopril 2.5 mg daily
Metolazone
Metoprolol Tartrate 25 mg [**Hospital1 **]
25 mg Tablet
Montelukast [Singulair] 10 mg QHS
Nitroglycerin 0.3 mg Tablet, Sublingual PRN
Olopatadine [Patanol] 0.1 % Drops OU TID
Ranitidine HCl [Zantac]
Acetaminophen [Tylenol] 325 mg Tablet PRN
Aspirin 81 mg daily
81 mg Tablet, Chewable
Ergocalciferol (Vitamin D2) [Vitamin D]
Potassium
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
7. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever, pain.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: Take 3 tablets a day (750mg) for two more
days through [**8-1**].
Disp:*6 Tablet(s)* Refills:*0*
14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
Disp:*2 inhalers* Refills:*2*
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
Disp:*2 inhalers* Refills:*3*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
20. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
21. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
22. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual 5 minutes: Take one tablet every 5 minutes for a
maximum of 3 tablets as needed for chest pain.
23. oxygen
Home oxygen; 3-4 liters nasal cannula as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. pneumonia
2. severe sepsis
3. respiratory failure, requiring mechanical ventillation
4. asthma
5. COPD
6. diastolic heart failure
7. obstructive sleep apnea
.
Secondary:
1. hypertension
2. hyperlipidemia
3. depression
4. gastroesophageal reflex disease
5. osteoporosis
Discharge Condition:
Stable.
Discharge Instructions:
You came to the hospital with severe pneumonia, requiring
admission to the intensive care unit and placement of a
breathing tube. You were treated with antibiotics, steroids,
and nebulizers. With treatment, you lungs improved, the
breathing tube was removed, and you were transferred to the
medical floor. You completed the course of steroids. You
should continue your antibiotics until [**2170-8-1**].
.
We have arranged follow-up appointments, as explained below.
.
You should return to the emergency room if you have difficulty
breathing, worsening cough, wheezing, fever, chills, chest pain,
vomiting, or any other symptoms that are concerning to you.
During this admission you were started on Spiriva (an inhaled
medication to help with breathing), albuterol inhaler (to help
with wheezing and shortness of breath), and antibiotics (to
treat your pneumonia). We stopped your metolazone for now; you
can discuss this change with your PCP during your next
appointment.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] to make a follow-up
appointment as soon as possible: [**Telephone/Fax (1) 5294**]. At this time you
can discuss restarting your metolazone.
Please call [**Telephone/Fax (1) 327**] in order to [**Telephone/Fax (1) **] a high resolution
CT scan of your chest. The pulmonologists would like to better
evaluate your lung disease.
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2170-9-11**] 9:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2170-11-15**] 3:20
Pulmonary clinic will contact you about a follow-up appointment
to evaluate your COPD and obstructive sleep apnea. At this time
you will also do [**Month/Day/Year 11149**] (pulmonary function tests).
|
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75,315
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12725
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Discharge summary
|
report
|
Admission Date: [**2132-11-26**] Discharge Date: [**2132-12-3**]
Date of Birth: [**2061-11-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Neck swelling.
Major Surgical or Invasive Procedure:
[**12-1**] SVC venogram with initiation of TPA therapy
[**12-2**] PICC line placed in IR
[**12-2**] TPA cath check
History of Present Illness:
Mr. [**Known lastname 1683**] is a 71-year-old man with adenocarcinoma of the rectum
(diagnosed in [**6-/2131**]) who underwent neoadjuvant chemoradiation
followed by proctosigmoidectomy and a left lower lobe resection
for pathologically confirmed lung metastases. Following two
cycles of FOLFOX chemotherapy, he underwent resection of a 1.7
cm solitary liver metastasis in [**2132-6-29**]. He then began
further adjuvant therapy with 5FU/LV at 500 mg/m2. Oxaliplatin
was eliminated due to neuropathy. He started cycle 2 of 4
planned cycles of 5FU/LV on [**11-19**] (one week prior to this
admission).
.
He was admitted to OMED for prehydration and CTPA following
discovery of non-occlusive thrombus around his port and finding
of hypoxia with tachycardia in clinic on day of admission.
.
He was seen at oncology clinic (day 8 of 5FU/LV) with neck
swelling. He had been seen by his primary care physican two days
prior and noted to have neck swelling, at which time a CT was
done that showed non-occlusive clot around his port. The plan
had been to start lovenox with IR clot stripping. However, when
at clinic he was noted to be dyspneic with minimal exertion. His
O2 sat dropped to 90% and HR up to 110 with ambulation. With
rest HR down to 90's and O2 back up to 97%RA. Decision was made
to admit to hospital for further monitoring and work-up of
pulmonary embolus.
.
On further review of systems, patient notes that he has been
increasingly dyspneic with normal activities (lawn-moving,
walking around house, to and from mailbox, etc) at home. He had
attributed this to the chemotherapy he is recieving, as he has
experienced these symptoms in the past in conjunction with
chemotx. He denies symptoms of CHF, including orthopnea, PND,
lower extremity swelling. He notes that he has had an MI in the
past; also he has significant smoking history, history of
hypertension, hyperlipid, and diabetes (diet-controlled?). He
denies h/o palps, dizziness, cough, or fever, though does
endorse intermittent lightheadedness that is neither exertional
nor postional.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. ASCVD, status post MI in [**2111**] status post PTCA.
4. Status post appendectomy.
5. Diabetes.
.
Past Oncological History
Metastatic adenocarcinoma of the rectum
- [**6-/2131**]: The patient presented with a change in bowel habits
and was noted to have an abnormal rectal exam by his primary
care physician, [**Name10 (NameIs) 39262**] [**Name Initial (NameIs) **] gastrointestinal evaluation.
- [**2131-7-23**] colonoscopy: Exophytic cancer of the rectum 8-12 cm
above the anal margin. Polyp noted at the anorectal junction.
Biopsy: Invasive, moderately differentiated adenocarcinoma
arising in association with adenoma. Polyp: Adenoma with
high-grade dysplasia.
- [**2131-7-25**] rectal ultrasound: T3 posterior midline tumor with
luminal narrowing of the rectum.
- [**2131-8-2**] CT scan of the torso: Irregular, polypoid lesion
seen within the rectum, with multiple subcentimeter presacral
and pericolic lymph nodes identified. Two pulmonary nodules seen
in the left lower lobe, the largest measuring 2.9 x 2.2 cm.
Multiple low-attenuation lesions seen within the liver, the
largest of which may represent cyst, smaller lesions are not
fully characterized. Low-attenuation lesions seen within the
left kidney, possibly a cyst, although too small to
characterize. Per report, a CT PET performed elsewhere
demonstrated uptake in the left base of the lung.
- [**2131-8-14**] to [**2131-9-25**]: Neoadjuvant chemoradiation with
continuous 5-FU at 225 mg/m2/day and radiation therapy five days
weekly.
- [**2131-12-10**]: Proctosigmoidectomy with stapled coloanal
anastomosis and diverting loop ileostomy. Pathology revealed
adenocarcinoma of the rectum, low-grade, with invasion into the
perirectal adipose tissue and metastasis to 7 of 13 regional
lymph nodes (T3N2). The resection margins were uninvolved.
- [**2132-1-28**] PET SCan: Interval progression of disease with an
increase in the size of the previously identified lung
metastasis. There is a new FDG-avid focus in segment 4A of the
liver which most likely represents metastasis.
- [**2132-2-13**]: Ileostomy takedown with simultaneous flexible
bronchoscopy and VATS with left lower lobe resection. Pathology
from the ileostomy stoma demonstrated findings consistent with
ileostomy stoma with no evidence of malignancy. The left lower
lobe wedge resection demonstrated an adenocarcinoma, 4.1 cm,
consistent with metastasis of rectal origin. The pleural and
apparent stapled margins were free of malignancy.
- [**2132-2-14**]: Evaluation by the hepatobiliary surgery consult
team due to the finding on his recent PET scan of a likely liver
metastasis. It was felt that the lesion was amenable to surgical
resection, and it was planned that the patient would undergo two
cycles of chemotherapy prior to proceeding with hepatic
resection.
- [**2132-4-9**]: FOLFOX chemotherapy initiated. The patient completed
two cycles of therapy on [**2132-6-3**].
- [**2132-7-11**]: Hepatic resection of a 1.7cm segment 4a metastatic
lesion by Dr. [**Last Name (STitle) **].
- [**2132-10-22**]: Cycle 1 Day 1 5FU/LV for further adjuvant
chemotherapy. Oxaliplatin eliminated due to neuropathy.
- [**2132-11-19**]: Presented to clinic to begin cycle 2 of 5FU/LV for
his resected colon cancer.
Social History:
The patient is divorced and has three sons in their 40s. He is a
construction inspector. He denies alcohol and uses no illicit
drugs. He smoked one pack of cigarettes daily for approximately
30 years before quitting in [**2111**].
Family History:
The patient's maternal uncle had an abdominal cancer, details
unclear. His father died of an MI. His mother died of
[**Name (NI) 2481**] disease. He has two brothers who are well.
Physical Exam:
Physical Exam at Admission
Vitals: BP 133/63, HR 90, RR 14, sat 95%
gen-well appearing man, NAD, appears stated age, ruddy
complexion
HEENT-nc/at, perrla, EOMI, +plethoric face/ruddy complexion,
anicteric, MMM
neck-swelling without obvious JVD, no LAD, supple
chest-b/l ae no w/c/r
heart-s1s2 rrr no m/r/g
abd-+well healed abdominal surgical scars, +bs, soft, NT, ND
ext-no c/c/e, L.arm-with instrumentation 1+edema, 2+pulses
neuro-aaox3, CN2-12 intact, non-focal
.
Physical Exam at Discharge
GEN awake, alert and oriented; NAD; breathing and speaking
comfortably in bed
HEENT decreased facial swelling/redness from admission
LUNGS CTA bilaterally
[**Last Name (un) **] obese, non-tender
NEURO CN II-XII grossly intact, strength 5/5 and symmetric
upper and lower extremities
Pertinent Results:
Labs on Admission
[**2132-11-26**] 11:10AM WBC-7.2 RBC-3.96* HGB-12.5* HCT-34.3* MCV-87
MCH-31.6 MCHC-36.5* RDW-17.9*
[**2132-11-26**] 11:10AM PLT COUNT-226
[**2132-11-26**] 11:10AM PT-13.2 INR(PT)-1.1
[**2132-11-26**] 11:10AM GRAN CT-4860
.
Labs on Transfer out of ICU
[**2132-12-2**] 04:30AM BLOOD WBC-7.6 RBC-3.54* Hgb-11.2* Hct-31.0*
MCV-88 MCH-31.6 MCHC-36.1* RDW-19.6* Plt Ct-134*
[**2132-12-2**] 08:07AM BLOOD PT-14.2* PTT-34.8 INR(PT)-1.2*
[**2132-12-2**] 04:30AM BLOOD Glucose-146* UreaN-21* Creat-1.2 Na-137
K-4.3 Cl-104 HCO3-25 AnGap-12
[**2132-12-2**] 04:30AM BLOOD ALT-27 AST-31 AlkPhos-121* TotBili-1.1
[**2132-12-2**] 04:30AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.4 Mg-2.2
.
[**11-27**] CTA Chest: IMPRESSION:
1. No gross pulmonary embolism, subject to suboptimal pulmonary
arterial opacification. that if evaluation of PE is needed in
the future, it should be evaluated by IVC rather than upper
extremity injection.
2. SVC thrombosis with extension in right and left
brachiocephalic veins. Left inferior pulmonary vein thrombosis.
3. New and enlarging lung nodules, worrisome for metastasis.
4. Unchanged unevenly distributed subpleural fibrosis, could be
drug related.
5. Prior left lower lobe wedge resection and partial liver
resection with no signs of local recurrence.
6. Unchanged T4 lesion since [**2131**] of indeterminate clinical
significance.
.
[**11-28**] TTE:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is moderate regional left ventricular systolic
dysfunction with severe hypokinesis/akinesis of the inferior,
inferolateral and basal inferoseptal segments (proximal RCA
lesion). The remaining segments contract normally (LVEF =
35-40%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
There is no aortic regurgitation .The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Mild mitral regurgitation.
.
[**12-1**] CT head: Normal non-contrast head CT with no evidence of
metastasis. If metastasis is of clinical concern, MR is a more
sensitive modality for the evaluation of intracranial
metastasis.
.
[**12-2**] PTA Venous
IMPRESSION:
1. Repeat SVC venogram demonstrated flow improvement in the SVC
with no collateral veins across the midline.
2. Venous angioplasty with balloon dilation with further
improvement of the flow in the SVC.
PLAN: Heparin infusion to further declot the residue clots in
the SVC and may switch to Coumadin in the near future to prevent
the development of clots in the SVC.
Brief Hospital Course:
In summary, this is a 71 year-old man with history of metastatic
colon cancer s/p multiple surgeries, including
proctosigmoidectomy, lung and liver resections, now on cycle 2
of 5 FU/LV presenting from clinic with hypoxia, tachycardia and
dyspnea with mild exertion.
.
DYSPNEA ON EXERTION / HYPOXIA
Differential diagnosis at admission included pulmonary embolism,
pulmonary infectious process, SVC syndrome, and CHF (given
cardiac risk factors). After prehydration, CTPA was done that
showed SVC thrombosis with extension into the right and left
brachiocephalic veins. There was no pulmonary arterial embolism.
Patient was started on heparin drip. Pulmonary service was
consulted and agreed that given imaging findings and history of
facial swelling and redness, SVC syndrome was a very likely
explanation for his symptoms. IR was then consulted and planned
for intravenous thrombolysis to break-up clot. Prior to
procedure, CT head was done that showed no intracranial
metastases.
.
On [**12-1**], patient underwent local thrombolytic tx to the SVC clot
and was transferred to the ICU for overnight monitoring. He
returned to the floor the following day with significant
improvement in symptoms. His facial swelling had improved also.
He was seen by physical therapy on day prior to discharge and
cleared for discharge to home.
.
He is discharged on Lovenox injections 1 mg/kg [**Hospital1 **], which he
will likely need to continue for 6 months. He will follow-up
with his outpatient oncologists, Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **].
.
LOW PLATELETS
Platelets were downtrending at time of discharge. There is
concern of HIT given that he was on heparin throughout
hospitalization, although his platelet count is still high at
117 (and there were several fluctuations in platelet levels from
day to day). We have asked that VNA visit him two days after
discharge. His CBC will be faxed to his primary oncologist. If
his platelet count continues to fall, he may need readmission
and bridging to coumadin with DTI like argatroban.
.
METASTATIC COLORECTAL ADENOCARCINOMA
On cycle 2 of 5FU/LV; further plan for chemotherapy is per Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) **].
.
HYPERTENSION
We continued his outpatient beta-blocker while hospitalized.
ACEI was held for concern of worsening renal failure in setting
of multiple contrast loads for CTPA and intravenous
thrombolysis.
.
CHRONIC CONGESTIVE HEART FAILURE
Full echocardiogram report is above. Findings are consistent
with CAD and sytolic dysfunction. He is on a BB, statin, and
ACEI. Aspirin is being held in the setting of receiving
chemotherapy. This can be restarted per his oncologist's recs.
.
HYPERLIPID
We continued his outpatient statin.
.
DIABETES MELLITUS (?DIET-CONTROLLED?)
His blood sugars were persistently elevated during hospital
course. He required 12 units of glargine HS and was placed on
humalog sliding scale. Hemoglobin A1c came back at 7.7. I
spoke with him regarding follow-up with his primary physcian and
told him there are medications that could help with blood sugar
control. He knows to address this issue at his next outpatient
visit.
.
PERIPHERAL NEUROPATHY
We continued his outpatient vitamin B6.
.
He was kept on a cardiac diet. Heparin drip was given for SVC
thrombus with switch to Lovenox at discharge. His code status
remained full code throughout hospital course.
Medications on Admission:
# ATORVASTATIN [LIPITOR] - 20 mgTablet - 1 Tablet(s) by mouth
daily
# LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
# METOPROLOL SUCCINATE [TOPROL XL] - 100 mg SR
# VITAMIN B12 50 mg [**Hospital1 **]
Discharge Medications:
1. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a
day.
Disp:*60 syringes* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril Oral
6. Outpatient Lab Work
Patient needs CBC on Friday [**12-5**] and faxed to Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] at
[**Hospital1 18**] ([**Telephone/Fax (1) 28907**].
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Superior vena cava syndrome
Non-occlusive thrombus in the superior vena cava
.
Hypertension
Hyperlipidemia
Diabetes, diet-controlled
Discharge Condition:
Vitals signs stable. Satting fine on room air.
Discharge Instructions:
You were hospitalized for treatment of a blood clot in a vein
leading into your heart. You underwent a procedure to help
dissolve the clot. We have started you on a medicine called
Lovenox to help prevent any clots from forming again. You will
likely need to take this medicine for 6 months but should
follow-up with your oncologist, Dr. [**First Name (STitle) **], to determine exactly
how long. You have been instructed on how to administer this
medicine by injection.
.
You will need to have your blood drawn on Friday by the visiting
nurses. The results will be faxed to Dr. [**First Name (STitle) **], and she will
call you with any concerns.
.
We noticed during this hospitalization that your blood sugars
were high. You should discuss this with your primary care
physician, [**Name10 (NameIs) **] discuss whether there is any need to begin
medical treatment for diabetes.
.
Your follow-up appointments at [**Hospital1 18**] are below.
.
Please return to the emergency room or call your doctor if you
have any fever, any worsening shortness of breath
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8950**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2132-12-17**] 9:00
[**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2132-12-17**] 10:00
Completed by:[**2132-12-4**]
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22,432
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672
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Discharge summary
|
report
|
Admission Date: [**2159-8-1**] Discharge Date: [**2159-8-7**]
Date of Birth: [**2074-12-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84M h/o COPD, dCHF, AF, AS valve area 0.7, s/p superior
segmentectomy of right lower lobe [**12/2158**], c/o dyspnea and cough.
.
He was seen initially at [**Hospital 4628**] hospital where sats noted as
high 80s-low 90s on 3L with borderline trop (0.08 which is
[**Hospital1 5075**] reference cutoff). BNP there 734 by report. CXR
there also showed pna, but he was not treated there. Given trop,
cards at OSH was called however defferred cath since INR 3.5.
Patient was given aspirin, steroids, and Lasix 40mg (approx 5
hours PTA here). Also had CT head/cspine (both negative) for
fall 1 week ago.
.
On arrival to the ED at [**Hospital1 18**], VS were: 98.6, 76, 107/57, 16,
hypoxic in the mid 80s on 3 L, but mentating very well and says
he feels relatively well. Lungs had minimal crackles at
bilateral bases.
.
Creatinine 1.2 (baseline 0.9-1.0). CBC 8.5 95% N/37.8/312. UA
was negative. ABG was 7.38/33/132 on NRB 100%. Lactate 1.5.
INR 3.6. Trop was 0.07. CXR consistent with pneumonia. ED
resident thinks no ST changes on EKG. Blood cultures were sent.
Patient was discussed with Dr. [**Last Name (STitle) 5076**] who agrees that this may be
pneumonia and demand and recommends diuresis and that he may
need cath if does not improve medically. He was given
Levofloxacin 750mg before transfer to ICU.
.
VS on transfer: afebrile (99), 71, 117/70s, mid 20s, 98% on NRB.
BP low to mid 90s when arrived per ED resident. Access is 2
18G IV. Tried titrating down on oxygen a couple of hours ago and
did not tolerate it.
.
On the floor, history is obtained from the patient and his son.
They state that since his wife's passing on [**7-14**] he has not been
doing well but denies dyspnea or CP during that time. His
daughter moved from [**Name (NI) 108**] and has been living with him and
helping with his medications. He has not missed any medications
nor had any changes except an antidepressant. Patient did have a
fall [**7-21**] when he had been drinking wine and fell over a dining
room chair after he tripped. He was evaluated in the ED the next
day and had neg CT scans. Day prior to admission he was doing
well, did yard work and then took 3 cans of prune juice because
of constipation. (Children report he takes a lot of OTC stool
meds.) He then had multiple unknown number of episodes of
diarrhea yesterday and last night. No fevers or chills, no
cough. His son states that the patient told him that he awoke at
4am with pain up and down his epigastrum which resolved. No back
pain. He then went back to bed and his son found him this
morning at 8:30am sitting in a chair and pale. He was unsteady
and not very responsive. No history of stroke or CVA.
Currently, he states that he feels much improved though has been
dyspneic for the past day since doing the yardwork. No chest
pain at all. No swelling. + Cough, no sputum. Home sat is
90-91% without home oxygen need.
Past Medical History:
Right lung nodule s/p R VATS superior segmentectomy of right
lower lobe. [**2158-12-12**], 3.0 x 2.5 x 2.0 cm poorly differentiated
pleomorphic carcinoma T2aN0, Stage 1B
COPD (last PFTs [**2148**] FEV1/FVC 98%, FEV1 55)
Coronary artery disease
CHF (last echo [**2158**] showed preserved EF >70%, diastolic
dysfunction)
BPH
Osteoarthritis bilateral hips s/p right total hip replacement
Hypercholesterolemia
atopic dermatitis
cervical spondylosis
s/p tonsillectomy
Social History:
Lives with his daughter, wife recently passed away [**2159-7-14**],
retired plumbing/heating
Tob: smoked x60yrs, quit [**2147**]
EtOH: less than daily
Family History:
Mother d. 69, father d. 72, 3 brothers and 1 sister, all passed
away.
Physical Exam:
Vitals: 99, 62, 113/60, 91/5l
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, ecchymoses b/l
eyes and chin
Neck: supple, JVP to mandible
Lungs: no ronchi, occassional end expiratory wheeze with minimal
decrease at bases b/l
CV: Regular rate and rhythm, normal S1 + S2, 4/6 SEM best at
RUSB and radiating to carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, decreased hair growth, no
edema
Pertinent Results:
At admission:
[**2159-8-1**] 01:50PM BLOOD WBC-8.5 RBC-4.34* Hgb-12.5* Hct-37.8*
MCV-87 MCH-28.8 MCHC-33.1 RDW-14.6 Plt Ct-312
[**2159-8-1**] 01:50PM BLOOD Neuts-94.7* Lymphs-3.9* Monos-0.9*
Eos-0.3 Baso-0.2
[**2159-8-1**] 01:50PM BLOOD PT-35.4* PTT-41.5* INR(PT)-3.6*
[**2159-8-1**] 01:50PM BLOOD Glucose-191* UreaN-35* Creat-1.2 Na-137
K-4.7 Cl-97 HCO3-30 AnGap-15
[**2159-8-1**] 07:48PM BLOOD ALT-24 AST-37 CK(CPK)-273 AlkPhos-67
TotBili-0.4
[**2159-8-1**] 01:50PM BLOOD proBNP-4829*
[**2159-8-1**] 01:50PM BLOOD cTropnT-0.07*
[**2159-8-1**] 07:48PM BLOOD CK-MB-8 cTropnT-0.04*
[**2159-8-1**] 02:52PM BLOOD Type-ART FiO2-100 O2 Flow-15 pO2-132*
pCO2-53* pH-7.38 calTCO2-33* Base XS-5 AADO2-529 REQ O2-88
Intubat-NOT INTUBA Comment-NON REBREA
[**2159-8-1**] 01:58PM BLOOD Lactate-1.5
[**2159-8-1**] 03:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2159-8-1**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-8-1**] URINE Legionella Urinary Antigen -PENDING
INPATIENT
[**2159-8-1**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2159-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2159-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Final Report
CHEST RADIOGRAPH PERFORMED ON [**2159-8-1**]
Comparison with a CT chest from [**2159-5-11**] as well as a chest
radiograph from
[**2159-2-8**].
CLINICAL HISTORY: Hypoxia, question acute process in the chest.
FINDINGS: Portable AP upright chest radiograph is obtained.
Slight increase
in vague opacities involving the mid-to-lower lungs are
increased from the
prior radiograph and could reflect underpenetration and poor
technique, though
the possibility of pneumonia is difficult to exclude. Suture
material in the
right perihilar region is unchanged. No large pleural effusion
is seen.
Cardiomediastinal silhouette is stable. No pneumothorax. Bony
structures are
grossly intact.
IMPRESSION: Limited study with subtle increased opacity
involving the
mid-to-lower lungs bilaterally, may reflect pneumonia. Consider
more
optimized technique with dedicated PA and lateral views to more
clearly and
thoroughly assess.
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: WED [**2159-8-1**] 2:27 PM
TTE [**8-2**]
The left atrium is dilated. The estimated right atrial pressure
is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%) with possible mild inferolateral hypokinesis.
Cannot exclude other focal wall motion abnormality due to
suboptimal views. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are severely
thickened/deformed. There is probably severe aortic valve
stenosis (valve area 0.8-1.0cm2); estimation limited by
suboptimal left ventricular outflow tract Doppler recordings and
uncertainty in measurement of the left ventricular outflow tract
diameter. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen but may be
underestimated. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-12-15**],
the aortic valve gradient is similar.
Brief Hospital Course:
Mr. [**Known lastname 5066**] is an 84 year old man with history of COPD, dCHF,
AF, Aortic Stenosis valve area 0.7, s/p superior segmentectomy
of right lower lobe [**12/2158**], transfered from OSH with very mild
troponin elevation, transfered to [**Hospital1 18**] for cardiac evaluation,
admitted to the MICU with pneumonia and heart failure.
# Community Acquired Pneumonia
Patient was noted to have RML and retrocardiac opacities on CXR.
He was started on levofloxacin for pneumonia, transitioned to
ceftriaxone and azithromycin in the ED, then transitioned back
to levofloxacin on the floor for treatment course of 7 days
total antibiotics, finished during hospitalization. Legionella
urinary antigen negative. On discharge, satting 89% on room air
and 95% on 3L nasal cannula. Ambulatory sats were 85% on RA,
improved with 2L nasal canula. Pt was discharged on home
oxygen.
# Acute on Chronic dCHF:
Baseline weight of 214 lbs per son. [**Name (NI) **] was felt to be in acute
on chronic heart failure in the MICU where he was given IV lasix
as needed for diuresis. He takes furosemide 40mg [**Hospital1 **] at
baseline. Patient was discharged on furosemide 40mg every Other
day in setting of elevated bicarbonate and limited fluid buildup
after two days of holding diuretics, felt to have contraction
alkalosis. Pt's daughter was advised to call if weight
increasing by 3 lbs. Followup appointment with PCP next week.
# COPD Exacerbation
Patient was treated 5 day predisone burst. Given nebulizers.
# Troponin elevation:
Very mild troponin elevation to 0.08 at OSH, normalized on
admission, likely secondary to demand ischemia. No EKG changes
to suggest active ischemia. Most likely became hypovolemic,
possible with poor foward flow in setting of AS, and had demand
episode. He was changed back to ASA 81 (from 325 initiatially)
and Atorvastatin 10mg (from 80mg initially).
# Diarrhea:
Resolved on admission. Most likely due to prune juice/oral
medications including miralax per daughter.
# Delirium:
Patient with episodes of delirium overnight during
hospitalization, likely in setting of infection and ICU stay,
improved by time of discharge.
# Acute grieving/depression:
Patient recovering from recent loss of wife ([**2159-7-14**]). Spent
time with pastoral care and social work and recommend follow-up
with [**Female First Name (un) **] psych as outpatient.
# Hypothyroidism
TSH elevated to 21 with low Free T4 0.04. This level of
elevation unlikely to only be secondary to acute illness, so low
dose levothyroxine started at 25mcg daily. Pt will require
repeat TSH in 6wks as outpatient. Hypothyroidism may contribute
to functional decline over last couple of months and depressive
symptoms.
# Acute renal insufficiency
Discharged with creatinine of 1.2. Decreased furosemide dose to
40mg every other day from 40mg [**Hospital1 **], until followup by PCP.
# Atrial fibrillation
Currently in NSR. Initially held coumadin because of elevated
INR, then restarted. Warfarin should be continued at 2.5mg
daily for 2 more days then decreased to half tab (1.25mg), then
back to home dosing of alternating 2.5mg and 1.25mg. Patient's
primary care physician office was notified. INR on discharge
was 1.8. INR will be redrawn by PCP's office on Friday [**8-10**].
Continued amiodarone.
# BPH:
Continued finasteride, held terazosin given BP effects.
Terazosin may be restarted and uptitrated back to home dose by
PCP.
# Communication: Patient, son/daughter HCP
[**Name (NI) **] [**Telephone/Fax (1) 5077**]; [**Telephone/Fax (1) 5078**]; [**Doctor First Name 553**] [**Telephone/Fax (1) 5079**]
# Code: Full
==============================
TRANSITIONAL ISSUES:
- TSH will need to be rechecked in 6 weeks as an outpatient
(started on 25 mcg of levothyroxine because of elevated TSH and
low Free T4)
- [**Month (only) 116**] need [**Female First Name (un) **] psych consult
- INR to be drawn [**8-10**], followed up by PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] will follow daily weights
- PCP to recheck lytes at next visit and uptitrate the
furosemide as necessary
- PCP to consider restarting terazosin
Medications on Admission:
(confirmed with family)
mirtazapine 7.5 mg Tab
1 Tablet(s) by mouth at bedtime
.
Lipitor 10 mg Tab
1 Tablet(s) by mouth daily
.
Centrum Silver Tab
1 tab Tablet(s) by mouth once daily
.
Advair Diskus 500 mcg-50 mcg/dose for Inhalation
1 puff by mouth twice a day
.
Spiriva with HandiHaler 18 mcg & inhalation Caps
1 Puff by mouth once daily
.
triamcinolone acetonide 0.5 % Topical Cream
Apply as needed twice a day
.
aspirin 81 mg Tab, Delayed Release
1 Tablet(s) by mouth daily
.
albuterol sulfate HFA 90 mcg/Actuation Aerosol Inhaler
2 Puffs by mouth every 4-6 hours as needed
.
furosemide 40 mg Tab
1 Tablet(s) by mouth twice a day
.
finasteride 5 mg Tab
5 mg Tablet(s) by mouth once daily
.
amiodarone 200 mg Tab
one Tablet(s) by mouth once a day
.
spironolactone 25 mg Tab
1 Tablet(s) by mouth once a day
.
warfarin 2.5 mg Tab
[**12-3**] tab M, W,F; 1 tablet Tues, Th Sat, Sun
.
terazosin 5 mg Cap
2 Capsule(s) by mouth at bed time
.
Allergies: NKDA
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. triamcinolone acetonide 0.5 % Cream Sig: One (1) Topical
twice a day: Apply as needed twice a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Home Oxygen
2L continuous oxygen via nasal cannula.
Note: Patient desatted to less than 84% when ambulating.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day: Until you see your PCP and he adjusts the dose. Tablet(s)
14. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO every other
day: Please take for 2 more days [**2159-8-8**] and [**2159-8-9**] and then take
1.25mg ([**12-3**] tab) on Friday [**2159-8-10**] and return to regular dose of
2.5mg (1 tab) every other day and a half pill on the other days.
15. warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO every other day:
Please start this dose on Friday [**2159-8-10**] and continue every other
day (alternating with 2.5mg tab) unless otherwise specified by
your primary care doctor.
16. Outpatient Lab Work
Please have INR (coumadin level) drawn at primary care doctor's
office Friday [**2159-8-10**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Community Acquired Pneumonia
Acute on Chronic Diastolic Congestive Heart Failure
Severe Aortic Stenosis
Secondary Diagnoses:
Atrial Fibrillation
Delirium
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr. [**Known lastname 5066**],
You were admitted to the hospital because you were found to have
a pneumonia, COPD exacerbation, and had extra fluid.
You first came to [**Hospital3 2783**], which transferred you to
[**Hospital3 **], where you stayed in the intensive care unit for one
night and then moved to the medical floor. Here, you continued
to receive antibiotics and steroids and your breathing improved.
The following changes were made to your medications:
- Please STOP your spironolactone for now.
- Please DECREASE your furosemide to 40 mg once EVERY OTHER day
until you see your primary care doctor. In the meantime, please
check your weight daily at home and call your doctor if your
weight increased by more than 3 lbs.
- Please START Levothyroxine 25mcg daily
- Please STOP your terazosin for now. This medication may be
slowly restarted by your primary care doctor.
- Continue your warfarin at 2.5 mg for 2 more days (Wednesday
[**8-8**] and Thursday [**8-9**]) and then return to your normal dose of
2.5mg (1 tab) every other day and 1.25 ([**12-3**] tab) on the other
days. You should take 1.25mg ([**12-3**] tab) on Friday [**2159-8-10**] unless
otherwise specified by your primary care doctor.
Please have your INR (coumadin level) checked on Friday [**2159-8-10**]
at your primary care doctor's office.
Please use your oxygen at home, particularly while walking,
until you follow up with your primary care doctor.
Please have your electrolytes drawn at your primary care doctor
visit next Thursday.
Your thyroid function will need to be rechecked in [**3-7**] wks after
starting the levothyroxine.
Because of your heart failure, please weigh yourself every
morning and call the doctor if your weight goes up more than 3
lbs and please do not eat more than 2grams of total daily salt
per day.
Followup Instructions:
Please follow up with your primary care doctor and keep your
other appointments as follows:
Department: BIDHC [**Location (un) **]
When: THURSDAY [**2159-8-16**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5080**], MD [**Telephone/Fax (1) 3329**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: MONDAY [**2159-11-12**] at 10:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2159-11-13**] at 11:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2159-8-8**]
|
[
"428.33",
"162.5",
"244.9",
"272.0",
"780.09",
"491.21",
"486",
"424.1",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
] |
15062, 15120
|
8004, 11675
|
310, 316
|
15338, 15460
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4585, 7981
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344, 3242
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15475, 15499
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3264, 3729
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3745, 3898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,697
| 128,775
|
38373
|
Discharge summary
|
report
|
Admission Date: [**2136-5-30**] Discharge Date: [**2136-6-8**]
Date of Birth: [**2079-9-5**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ischemic Pain.
Major Surgical or Invasive Procedure:
OPERATION PERFORMED: Left below-the-knee amputation.
History of Present Illness:
This is a 56yo M with a long history of
failed interventions to the LLE. Eight months ago, he underwent
an endarterectomy of the femoral bifurcation and SFA stenting.
He then underwent a L [**Name (NI) 85459**] PTFE graft. This occluded, and he
had TPA in [**4-14**]. He embolized to his distal vessels and had
incomplete clearance after balloon angioplasty of the distal PT.
The patient underwent an angiogram last week, which showed
continued occlusion. He is returning now for a left
femoral-plantar bypass.
Past Medical History:
PMH: CAD s/p MI and cardiac stent, DM2 (IDDM), HIT
PSH: cardiac stent, LN biopsy in neck, unknown LE vascular
procedures
Social History:
mechanic, lives with wife, + tobacco, + etoh
Family History:
nc
Physical Exam:
On Admission:
PHYSICAL EXAM
Vital Signs: Temp: 100.1 RR: 20 Pulse: 87 BP: 132/71
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No right carotid bruit, No left carotid bruit.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, abnormal: Obese.
Rectal: Not Examined.
Extremities: Abnormal: LLE rubor to mid-shin, BLE 1+ edema L>R.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: D. DP: N. PT: N.
DESCRIPTION OF WOUND: left great toe erythematous with black
eschars at tip
well-healed L groin incision
On Discharge:
AFVSS
Gen: NAD, AOx3
Pulm: No resp distress
Abd: S/NT/ND
Ext: LLE s/p BKA staples intact no erythema or drainage from
wound. staples R and L LE intact no erythema or wound drainage
Pertinent Results:
Date: [**2136-5-29**]
Signed by [**First Name11 (Name Pattern1) 1141**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], NP on [**2136-5-29**] at 3:37 pm Affiliation:
[**Hospital1 18**]
Cosigned by [**Name (NI) **] [**Last Name (NamePattern1) **], MD on [**2136-5-30**] at 10:13 am
Lab called to report that patient is HIT + based on labs drawn
during the [**Hospital 228**] hospital stay.
[**2136-5-29**] 06:30AM BLOOD Hct-37.6*
[**2136-5-30**] 08:30PM BLOOD WBC-9.5 RBC-4.98 Hgb-12.3* Hct-37.3*
MCV-75* MCH-24.6* MCHC-32.9 RDW-17.4* Plt Ct-248
[**2136-5-31**] 06:50AM BLOOD WBC-8.2 RBC-4.74 Hgb-11.3* Hct-35.7*
MCV-75* MCH-23.8* MCHC-31.5 RDW-17.3* Plt Ct-247
[**2136-5-31**] 11:50PM BLOOD WBC-8.8 RBC-3.85* Hgb-9.3* Hct-28.7*
MCV-75* MCH-24.2* MCHC-32.4 RDW-17.3* Plt Ct-245
[**2136-6-1**] 06:03AM BLOOD Hct-27.7*
[**2136-6-2**] 02:05AM BLOOD WBC-10.9 RBC-3.37* Hgb-8.5* Hct-25.7*
MCV-76* MCH-25.3* MCHC-33.3 RDW-17.8* Plt Ct-202
[**2136-6-3**] 05:00AM BLOOD WBC-9.1 RBC-3.29* Hgb-8.3* Hct-25.1*
MCV-77* MCH-25.4* MCHC-33.2 RDW-17.5* Plt Ct-199
[**2136-6-4**] 05:23AM BLOOD WBC-9.6 RBC-3.63* Hgb-9.3* Hct-27.7*
MCV-76* MCH-25.5* MCHC-33.5 RDW-17.6* Plt Ct-254
[**2136-6-5**] 04:57AM BLOOD WBC-8.3 RBC-3.98* Hgb-10.2* Hct-30.1*
MCV-76* MCH-25.6* MCHC-33.8 RDW-17.6* Plt Ct-306
[**2136-6-5**] 03:27PM BLOOD WBC-8.3 RBC-3.97* Hgb-10.1* Hct-30.4*
MCV-77* MCH-25.5* MCHC-33.3 RDW-18.3* Plt Ct-312
[**2136-6-6**] 03:54AM BLOOD WBC-8.4 RBC-3.73* Hgb-9.5* Hct-29.0*
MCV-78* MCH-25.6* MCHC-32.9 RDW-17.9* Plt Ct-327
[**2136-6-7**] 05:08AM BLOOD WBC-10.5 RBC-3.68* Hgb-9.0* Hct-28.4*
MCV-77* MCH-24.5* MCHC-31.8 RDW-17.6* Plt Ct-430
[**2136-6-8**] 06:20AM BLOOD WBC-12.3* RBC-3.85* Hgb-9.6* Hct-29.1*
MCV-76* MCH-24.9* MCHC-32.9 RDW-17.7* Plt Ct-477*
[**2136-5-31**] 11:50PM BLOOD Neuts-80.9* Lymphs-13.4* Monos-4.6
Eos-0.8 Baso-0.3
[**2136-5-30**] 08:30PM BLOOD PT-12.7 PTT-25.7 INR(PT)-1.1
[**2136-5-31**] 05:53PM BLOOD PT-16.6* PTT-40.0* INR(PT)-1.5*
[**2136-5-31**] 08:45PM BLOOD PT-18.2* PTT-45.1* INR(PT)-1.7*
[**2136-6-1**] 06:03AM BLOOD PT-20.2* PTT-49.7* INR(PT)-1.9*
[**2136-6-2**] 02:05AM BLOOD PT-22.7* PTT-52.6* INR(PT)-2.1*
[**2136-6-2**] 09:07AM BLOOD PT-23.6* PTT-62.0* INR(PT)-2.2*
[**2136-6-3**] 05:00AM BLOOD PT-26.0* PTT-72.4* INR(PT)-2.5*
[**2136-6-4**] 05:23AM BLOOD PT-23.5* PTT-65.3* INR(PT)-2.2*
[**2136-6-5**] 04:57AM BLOOD PT-28.2* PTT-79.3* INR(PT)-2.8*
[**2136-6-5**] 04:57AM BLOOD Plt Ct-306
[**2136-6-5**] 03:27PM BLOOD Plt Ct-312
[**2136-6-6**] 03:54AM BLOOD Plt Ct-327
[**2136-6-7**] 05:08AM BLOOD Plt Ct-430
[**2136-6-8**] 06:20AM BLOOD Plt Ct-477*
[**2136-5-29**] 06:30AM BLOOD UreaN-11 Creat-0.7 K-4.5
[**2136-5-30**] 08:30PM BLOOD Glucose-182* UreaN-11 Creat-0.7 Na-135
K-4.1 Cl-97 HCO3-26 AnGap-16
[**2136-5-31**] 06:50AM BLOOD Glucose-115* UreaN-10 Creat-0.6 Na-139
K-3.8 Cl-105 HCO3-27 AnGap-11
[**2136-5-31**] 11:50PM BLOOD Glucose-103* UreaN-6 Creat-0.4* Na-140
K-3.9 Cl-107 HCO3-25 AnGap-12
[**2136-6-2**] 02:05AM BLOOD Glucose-131* UreaN-8 Creat-0.5 Na-135
K-4.0 Cl-101 HCO3-27 AnGap-11
[**2136-6-3**] 05:00AM BLOOD Glucose-166* UreaN-7 Creat-0.5 Na-137
K-4.0 Cl-102 HCO3-28 AnGap-11
[**2136-6-4**] 05:23AM BLOOD Glucose-124* UreaN-5* Creat-0.5 Na-136
K-3.8 Cl-98 HCO3-28 AnGap-14
[**2136-6-5**] 03:27PM BLOOD Glucose-142* UreaN-7 Creat-0.5 Na-136
K-3.9 Cl-102 HCO3-23 AnGap-15
[**2136-6-6**] 03:54AM BLOOD Glucose-152* UreaN-6 Creat-0.5 Na-133
K-4.0 Cl-98 HCO3-27 AnGap-12
[**2136-6-8**] 06:20AM BLOOD Glucose-160* UreaN-6 Creat-0.4* Na-134
K-4.1 Cl-98 HCO3-25 AnGap-15
[**2136-6-1**] 10:29AM BLOOD CK-MB-3 cTropnT-<0.01
[**2136-6-5**] 03:27PM BLOOD cTropnT-<0.01
[**2136-6-6**] 03:54AM BLOOD cTropnT-<0.01
[**2136-5-30**] 08:30PM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
[**2136-6-6**] 03:54AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9
[**2136-5-31**] 01:15PM BLOOD Type-ART Rates-/10 Tidal V-700 FiO2-60
pO2-276* pCO2-46* pH-7.33* calTCO2-25 Base XS--1
Intubat-INTUBATED Vent-CONTROLLED Comment-ETT
[**2136-5-31**] 02:26PM BLOOD Type-ART Rates-/12 Tidal V-700 FiO2-38
pO2-152* pCO2-40 pH-7.40 calTCO2-26 Base XS-0 Intubat-INTUBATED
Vent-CONTROLLED Comment-ETT
[**2136-5-31**] 03:46PM BLOOD Type-ART pO2-151* pCO2-40 pH-7.42
calTCO2-27 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED
[**2136-5-31**] 06:01PM BLOOD Type-ART Rates-12/ Tidal V-700 FiO2-33
pO2-111* pCO2-42 pH-7.40 calTCO2-27 Base XS-0 Intubat-INTUBATED
Vent-CONTROLLED
[**2136-5-31**] 08:55PM BLOOD Type-ART Rates-12/ Tidal V-700 O2 Flow-2
pO2-177* pCO2-40 pH-7.42 calTCO2-27 Base XS-1 Intubat-INTUBATED
Vent-CONTROLLED
[**2136-5-31**] 10:08PM BLOOD Type-ART pO2-177* pCO2-45 pH-7.37
calTCO2-27 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2136-5-31**] 11:56PM BLOOD Type-ART pO2-223* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
[**2136-5-31**] 01:15PM BLOOD Glucose-84 Lactate-1.4 Na-136 K-3.7
Cl-102
[**2136-5-31**] 10:08PM BLOOD Glucose-93 Lactate-0.9 Na-136 K-4.0
Cl-103
[**2136-5-31**] 01:15PM BLOOD freeCa-1.13
[**2136-5-31**] 11:56PM BLOOD freeCa-1.07*
Brief Hospital Course:
[**Known lastname **],[**Known firstname 1575**] was admitted on [**5-30**] with Ischemic Pain. Agreed
to have an elective surgery. Pre-operatively, she was consented.
A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all
other preparations were made.
Previously pt had LLE CFA to PT with PTFE. This was a known
occlussion.
Pt had known HIT, Argatroban started for goal PTT 60-80
It was decided that he would undergo:
Left common femoral artery to plantar artery on bypass graft
using left greater saphenous vein, right greater saphenous vein
with venovenostomy, angioscopy vein
inspection, valve lysis.
Prepped, and brought down to the endo OR for surgery.
Intra-operatively, was closely monitored and remained
hemodynamically stable. Tolerated the procedure well without any
difficulty or complications. He was extubated in the OR
Post-operatively, transferred to the CVICU for further
stabilization and monitoring.
He was then transferd to the VICU in stable condition. Pt graft
went down POD # 1. Family and patient aware. He was put on his
home meds. While in the VICU, received monitored care. When
stable was delined. Diet was advanced.
C/w argatroban.
Pain consult for Pain control.
Recieved blood products. HCT stable.
He has had progressive ischemia of the left foot, leading to
gangrene of the left toes. Given these findings and the non
salvageability of the foot, the patient was consented for left
below-knee amputation.
It was then decided to perform a Left below-the-knee amputation.
Prepped, and brought down to the endo OR for surgery.
Intra-operatively, was closely monitored and remained
hemodynamically stable. Tolerated the procedure well without any
difficulty or complications. He was extubated in the OR.
Pt then recieved fundoperinox. Coumadin started for the
treatmetn of HIT.
He was then transferd to the VICU in stable condition. While in
the VICU, received monitored care. When stable was delined.
Diet was advanced.
When stabilized from the acute setting of post operative care,
was then transferred to floor status.
On the floor, remained hemodynamically stable with pain
controlled. Continues to make steady progress without any
incidents. Discharged to Rehab in stable condition.
Pain did see the patient. ON DC his pain is well controlled.
Medications on Admission:
metformin 1000', metoprolol 25'', pravastatin 20', lisinopril
30', insulin, gabapentin 300'', cymbalta EC 30', nitroglycerin,
oxycontin 30''', oxycodone 30''' per pain contract
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR goal is [**2-8**]. .
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heart
burn.
11. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Please wean off.
12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
13. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily): DC when INR greater then 2.
15. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
17. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
18. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
19. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO four times a day:
prn for breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
POSTOPERATIVE DIAGNOSIS: Left lower extremity ischemia with
gangrene.
Heparin Induced Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE INSTRUCTIONS BELOW KNEE AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing for 4-6 weeks. You should
keep this amputation site elevated when ever possible.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 14 days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-6-22**] 11:30
Completed by:[**2136-6-8**]
|
[
"289.84",
"440.24",
"V45.82",
"305.1",
"996.74",
"V58.67",
"414.01",
"E878.2",
"401.9",
"412",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"84.15",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
11300, 11347
|
6959, 9268
|
287, 343
|
11495, 11495
|
1977, 6936
|
16815, 16998
|
1113, 1117
|
9495, 11277
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|
9294, 9472
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1132, 1132
|
1774, 1958
|
233, 249
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13226, 16119
|
16143, 16792
|
371, 889
|
1146, 1760
|
11510, 11622
|
911, 1034
|
1050, 1097
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,531
| 128,483
|
10577+10578+10579
|
Discharge summary
|
report+report+report
|
Admission Date: [**2157-6-28**] Discharge Date: [**2157-8-6**]
Date of Birth: [**2130-12-18**] Sex: F
Service: MED-ICU
HISTORY OF PRESENT ILLNESS: The patient is a 26 year old
woman with a past medical history significant for
long-standing poorly controlled diabetes mellitus, a three
year history of a poorly defined neuropathy and chronic
diarrhea, also of uncertain etiology. The patient had been
worked up extensively for these problems without definitive
diagnosis but had been treated with multiple anti-motility
agents and pancreatic enzymes for her diarrhea with little
relief.
For several weeks prior to admission, the patient had
complained of increasing weakness of her lower extremities
and increasing fatigue. In addition, approximately one week
prior to admission, the patient fractured her left toe and
experienced erythema and edema of her distal left foot. On
[**6-28**], the patient was admitted to [**Hospital1 190**] for work-up of progressive weakness and
diarrhea, and control of labile blood sugars. On admission,
the patient was started on Oxacillin for presumed cellulitis
of her left foot.
On the Medical Floor after admission, the patient's course
was notable for labile blood sugars for which the [**Last Name (un) **]
Service was consulted as well as diarrhea which was treated
with Octreotide, Imodium and Paregoric. She also was treated
with Diflucan and Ciprofloxacin for funguria and bacteruria.
On these regimens, the patient was stable on the Medical
Floor but with little apparent improvement in her symptoms.
However, on the night of [**7-3**], the patient became
febrile to 101.3 F., and complained of increased bloating.
During the morning of [**7-4**], the patient complained of
abrupt onset of shortness of breath accompanied by poorly
characterized chest pain and blood sugars of 29. The patient
was given an ampule of D50 which increased her blood sugar
to 248, but her shortness of breath worsened and the patient
was found to have oxygen saturations in the 50s on room air,
which increased only to the mid-70s on 100% non-rebreather.
The patient was then intubated but failed to increase her
oxygen saturation and her systolic blood pressure dropped to
the 80s. The patient was found to have an endotracheal tube
in the right main stem bronchus, in other words, out of the
left lung. The endotracheal tube was pulled back to 2.5
centimeters above the carina but the patient's PaO2 remained
at 79 in 100% non-rebreather. A subsequent chest x-ray
showed bilateral diffuse infiltrates consistent with adult
respiratory distress syndrome. Her blood pressure continued
to drop to systolic blood pressures of 60s and she was
started on Neo-Synephrine and the CSRU following by boluses
of two liters intravenous fluids with little increase in her
blood pressure.
Differential diagnoses for acute respiratory failure were at
this point was aspiration pneumonitis with adult respiratory
distress syndrome versus pulmonary embolism.
Electrocardiogram, lower extremity ultrasound and
transthoracic echocardiogram were done all without signs of
pulmonary embolus, however, given the abrupt onset and
inability to complete a CT angiogram due to the patient's
unstable status, empiric heparin was started according to the
pulmonary embolism protocol. In addition, given the
patient's fever the night prior to this incident,
hypertension and antibiotics were changed to Zosyn,
Ciprofloxacin, Vancomycin, Flagyl and Fluconazole for broad
anti-microbial coverage for sepsis.
Based on an abdominal radiograph that showed a massively
distended dilated stomach filled with fluids, and given the
patient's history of gastroparesis, it was felt that the
gastric distention and chest x-ray were consistent with an
aspiration process. The patient was admitted to the Medical
Intensive Care Unit with a course described below.
PAST MEDICAL HISTORY:
1. Type 1 diabetes mellitus, poorly controlled.
2. Chronic inflammatory demyelinating polyneuropathy (CIDP),
poorly and not fully defined.
3. Autonomic insufficiency with orthostatic hypotension.
4. Atonic bladder with history of recurrent urinary tract
infections.
5. Iron deficiency anemia and anemia of chronic disease.
6. Migraines.
7. History of major depressive disorder and general anxiety
disorder.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Insulin NPH 15 mg q. a.m./q. p.m.; Regular 10 mg q.
a.m./q. p.m.
2. Glargine 50 mg q. h.s.
3. Creon 10, 33.2-10-38, six capsules three times a day with
meals.
4. Sandostatin 50 mg twice a day.
5. Paregoric two tablets twice a day.
6. Klonopin 0.5 mg twice a day.
7. Oxycontin 20 mg twice a day.
8. Naprosyn 500 mg twice a day.
9. Ativan 0.5 mg q. h.s.
10. Imodium p.r.n. diarrhea.
11. Kaopectate p.r.n. diarrhea.
12. Fioricet [**Medical Record Number 3668**], one to two q. four to six hours
p.r.n. migraines.
SOCIAL HISTORY: The patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
Appears to have good social support. Used to work as a
phlebotomist but currently on disability. Has an eleven pack
year history of smoking with occasional marijuana that helps
with her diarrhea. She drinks alcohol socially.
FAMILY HISTORY: Significant for a father with coronary
artery disease with rheumatoid arthritis and a mother with
coronary artery disease and diabetes mellitus.
PHYSICAL EXAMINATION: On admission to the Medical Intensive
Care Unit, temperature 93.8 F., orally, heart rate of 113
with a blood pressure of 128/74. Respiratory: The patient
was on a ventilator on SIMV plus pressure support setting
breathing at a respiratory rate of 14 with an oxygen
saturation of 88% on 100% FIO2 with control pressures of 45.
On general examination, she was a woman intubated and
paralyzed with an OG tube in place. HEENT examination: Her
right pupil was found to be oval and sluggishly reactive.
Her left pupil round and more reactive (of note, she has had
a dart injury to her right eye as a child which leaves her
eye and pupil less reactive). Her neck was supple with no
jugular venous distention. Trachea was midline. Her heart
examination was tachycardic with normal S1 and S2. No
murmurs, rubs or gallops were heard. Her lungs had decreased
breath sounds bilaterally, left worse than right to the
mid-lung fields. She had diffuse rhonchi throughout. Her
abdomen was distended and tense and tympanitic with no
masses. Extremities had one plus pitting edema with erythema
in the left foot 2 to 3 centimeters above the ankle. No
crepitus or warmth. Her skin was cool and dry with no
cyanosis. On neurologic examination, she was sedated.
ADMISSION LABORATORY: Her admission labs included a CBC of
white blood cell count of 12.5, hematocrit of 30.8, platelets
of 353. Sodium of 137, potassium 4.4, chloride 101,
bicarbonate 28, BUN 19, creatinine 0.8 and glucose of 289
with a calcium of 7.5, phosphate of 6.3 and magnesium of 1.5.
Her AST was 37, ALT 37, alkaline phosphatase of 134,
bilirubin of 0.1, amylase 58, lipase 26.
Her lactate was 2.9. A serum toxicology screen was negative.
Blood cultures and fungal cultures were sent. A urine
culture showed greater than 100,000 yeast. A urinalysis
showed 11 to 20 white blood cells, few bacteria and many
yeast.
Initial chest x-ray showed a endotracheal tube in the right
main stem bronchus and later after repositioning of the
endotracheal tube diffuse bilateral patchy air space disease
and marked gastric distention.
SUMMARY OF INTENSIVE CARE UNIT COURSE BY ISSUES:
1. PULMONARY: As stated above, the patient was intubated on
[**7-4**] secondary to hypoxia. The etiology of the
patient's symptoms were considered to be aspiration versus
pulmonary embolus. She was started on broad-spectrum
anti-microbials. On [**7-5**], the patient suffered a left
pneumothorax in the setting of attempted central line
placement with hypoxemia and hypotension. A left chest tube
was placed at this time which improved her oxygen
saturations.
The patient required multiple adjustments to her ventilator
settings from assist control to pressure control over the
next few weeks largely due to repeated episodes of hypoxemia
of unclear etiology. A CT angiogram on [**7-8**] showed no
evidence of pulmonary embolus. The patient continued to have
patchy adult respiratory distress syndrome disease greater on
the right than on the left side. Overall, the patient
continued to have a stuttering course in her recovery from
adult respiratory distress syndrome particularly sensitive to
both agitation and sedation, leading to decreased oxygen
saturation, tachycardia and tachypnea.
She required occasionally Lasix as well to maintain her
oxygen saturations as during the initial few weeks; she had a
tendency to develop pulmonary edema secondary to intravenous
fluids. Her left pneumothorax continued to improve and the
chest tube was removed on [**2157-7-20**]. The remaining
small pneumothorax resolved over the next few days.
Given that it was felt that the patient would be a slow wean
off the endotracheal tube the patient had a tracheostomy
placed on [**2157-7-21**]. She had a chest CT scan on
[**2157-7-22**], which showed a right pleural effusion as
well as diffuse air space disease in both lungs,
predominantly in a parabroncho-vascular distribution. A
thoracocentesis on [**7-23**] showed pleural fluid with 250
white blood cells, 29% polys, a pH of 7.48, negative Gram
stains. Pleural fluid LDH was 176. This was suggestive of
an exudative process concerning for a parapneumonic effusion.
Given a finding of Gram positive cocci in sputum and a
concern for parapneumonic effusion, the patient was started
on Vancomycin empirically, however, the cultures remained
negative and the Vancomycin was discontinued on [**7-26**].
Following the thoracocentesis, the patient was begun to be
weaned off her sedation and continued to improve her
respiratory status and by [**8-4**], requiring only
pressure support. On [**8-6**], she was stable on a
pressure support of [**3-20**] and considered for a trial of trache
mask in anticipation of further pulmonary rehabilitation at
an outside hospital.
2. INFECTIOUS DISEASE: Given the patient's initial fever
and white blood cell count of 12.9, she was started on broad
spectrum anti-microbials with Zosyn, Gentamycin, Flagyl,
Vancomycin and Fluconazole. She continued to have yeast in
her urine and she was started on amphotericin bladder washes.
Over the next six weeks, the patient continued to have
intermittent fevers and white blood cell count as high as
25,000. On [**7-14**], she had a blood culture from an A-line
that was positive for coagulase negative Staphylococcus. The
A-line was changed.
A blood culture on [**7-6**] was positive for [**First Name5 (NamePattern1) 564**]
[**Last Name (NamePattern1) 563**]. Given this blood culture and the fact that she
also had yeast in her sputum and her urine, she was started
on amphotericin-B as well as continued on Gentamycin and
Zosyn for Gram negative rods in her sputum. The
amphotericin-B dose was 0.5 mg per kg intravenously q. day.
On [**7-15**], the patient was switched to AmBisome 3 mg per
kg for a total of 270 mg q. day, given that her creatinine
had begun to increase from 0.7 to 1.1 over the prior few
days.
As noted before, the patient was continued on AmBisome until
[**7-31**], for a total of a 23 day course of amphotericin
and AmBisome. At this point, given a concern for drug
related fevers and given that repeat fungal cultures had
remained negative, the AmBisome was stopped at this point.
The patient also had a positive urine culture on [**7-23**]
for Klebsiella pneumonia which was resistant to all
penicillin and cephalosporins. The patient was placed on
contact precautions; the Foley was changed and repeat
cultures remained negative. Given the patient's diarrhea and
continued increased white blood cell counts, the patient had
repeated tests for Clostridium difficile toxins which were
negative. A C. difficile cytoculture is still pending.
Work-up for any other source of infection remained negative.
Of note, on [**7-16**], the patient's alkaline phosphatase was
noted to 1,199, which was increased from 73 on [**7-6**].
Gastrointestinal was consulted and there was a concern for an
infiltrative liver process, particularly Candidiasis versus
biliary disease. Total parenteral nutrition was also
considered as a potential etiology.
The patient had a liver and gallbladder ultrasound on [**7-16**], which showed no intrahepatic biliary ductal dilatation
but a thickened gallbladder wall measuring 5 to 6 millimeters
and a small rim of pericholecystic fluid. No gallstones were
identified and the liver parenchyma was homogenous.
Acalculous cholecystitis was considered as a diagnosis but a
lack of gallbladder distention as well as acute dilatation of
the common duct made this less probable. The patient's
alkaline phosphatase remained stable over that weekend and a
repeat ultrasound on [**7-20**] showed resolution of these
findings; however, the patient's alkaline phosphatase
remained elevated and given the concern for an interstitial
liver process, the patient had an abdominal CT scan which
showed no evidence of liver disease or other intra-abdominal
abscesses.
At the same time, the patient also had a chest CT scan which
has been described above in the Pulmonary Section and a sinus
CT scan which was negative for sinus disease.
The alkaline phosphatase began to slowly improve, but given
the patient's continued fevers and persistent concern, a HIDA
scan was obtained on [**7-27**] which was negative. By
[**8-6**], the alkaline phosphatase had dropped back to
257, had been decreasing every day.
On [**7-28**], the patient underwent an Indium-[**11-26**] white
blood cell scan to assess for any other foci of infection.
This scan was completely negative. The patient's white blood
cell count continued to improve and she was afebrile on
[**8-1**] and 17, however, at that point her white blood
cell count started to rise again and she developed a new
fever to 102.0 F. She was started on Vancomycin and Cefepime
empirically for pneumonia and/or line infection.
Blood cultures were drawn from her left subclavian line and
her right arterial line. Three out of the four bottles of
the right arterial line returned Gram positive cocci. The
Cefepime was discontinued. The patient received a new right
subclavian line and will be discharged on a seven day course
of Vancomycin in light of the positive A-line cultures.
The patient also will be discharged on p.o. Flagyl 500 mg
three times a day given her diarrhea, for a seven day course
past the last day of Vancomycin.
3. CARDIOVASCULAR: Following intubation, the patient was
hypotensive, requiring a Neo-Synephrine drip. She had an
echocardiogram on [**7-5**] and again on [**7-25**], to
evaluate for cardiac dysfunction and valvular diseases. The
echocardiogram demonstrated normal heart function and an
ejection fraction of 65%. No vegetations were seen. The
etiology of her hypertension was felt to be a combination of
sepsis, chronic autonomic dysfunction and sedation. Once the
patient was weaned off of her sedation and was improving
clinically, her blood pressures remained stable, only
requiring occasionally fluid boluses in the setting of
Oxycodone or Haldol when given p.r.n.
She did not require Neo-Synephrine to maintain her blood
pressure after [**2157-7-25**].
4. GASTROINTESTINAL: The patient has a long history of work
up for three year chronic diarrhea. She has been followed by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10689**] and the work-up is detailed in the [**Hospital 16730**]
medical record. The GI Service was initially consulted given
the evidence of potential mass in the patient's stomach on
KUB and the additional abdominal CT scan. The patient had
been taking large amounts of Imodium prior to the admission,
apparently as much as 36 tablets a day. The GI Service was
interested in performing an esophagogastroduodenoscopy but
given the patient's initial inability to wean off the
Neo-Synephrine, this had to be deferred.
The CT scan of the abdomen on [**7-22**], showed no
evidence of collections within the stomach. Given this, an
esophagogastroduodenoscopy and any further work-up for the
diarrhea was deferred until the patient has completed her
rehabilitation.
In regards to her diarrhea, the patient initially had absent
bowel sounds and no sounds and no bowel movements but
following administration of Reglan and Lactulose, developed
green foul smelling diarrhea felt to be consistent with
Clostridium difficile. She was treated with Flagyl p.o. 500
mg p.o. three times a day and her stool output decreased and
she began to have watery brown stools.
At the date of discharge, she still had about 200 to 400 cc.
of watery brown stool. On [**8-5**], the patient was also
restarted on her Creon in addition to her tube fees.
For further work-up of her underlying gastrointestinal
illness, she will have to follow-up with the Gastrointestinal
Service as an outpatient once her acute medical issues have
resolved. As noted above, the Gastrointestinal Service had
also been consulted regarding the increase in alkaline
phosphatase and the possibility of liver involvement of her
Candidiasis. Given that she was being treated with AmBisome,
at that time no further work-up was recommended by the
Gastrointestinal Service.
5. RENAL: The patient's baseline creatinine is 0.6 to 0.7.
In the initial stages of her adult respiratory distress
syndrome she had a tendency to go into pulmonary edema in the
setting of receiving large amounts of fluid from total
parenteral nutrition as well as her amphotericin-B requiring
lasix. In the setting of amphotericin-B, Lasix and CT scans
with contrast, her creatinine increased to 1.1, which
prompted the change to AmBisome. Following this switch, the
creatinine decreased back to the patient's baseline of 0.6 to
0.7, where it has been stable since.
6. HEMATOLOGY: The patient's hematocrit largely remained
stable in the mid-20s range throughout the admission. She
did, however, require two transfusions of single units of
packed red blood cells in the setting of repeated blood draws
for blood cultures and laboratory studies. Given this
chronic anemia, her iron studies were repeated on [**7-25**], and showed an iron of 10, ferritin of 731 and a TIBC of
80, consistent with anemia of chronic disease.
During the admission, there was also noted that whenever a
line was attempted to be placed, the needle or catheter had a
tendency to clot. Given this finding and persistent fevers,
a hypercoagulability work-up was initiated. The patient was
negative for lupus anticoagulant, cardiolipin antibodies, IgG
and IgM, Factor V lidin. The anti-thrombin 3 was normal at
85; homocysteine was normal at 10.3. The patient's protein C
was low at 62 (normal larger than 67). Factor protein S was
41% (normal 51 to 133%). A prothrombin mutation is pending.
Protein C can be lowered in adult respiratory distress
syndrome and Protein S can be lowered in chronic diseases.
The Hematology Service was curb-sided and did not feel that
therapy was warranted at this point. The patient had normal
D-Dimer and high fibrinogen and showed no signs of active
clot formation.
7. PSYCHIATRY: The patient, as an outpatient, was on
Klonopin for anxiety and depression. The Psychiatric Service
had been consulted during the initial admission and had
recommended the initiation of Remeron. Following the
intubation, the patient was sedated and on an Ativan drip as
well as a Fentanyl drip for her chronic pain. Both of these
drips were weaned as the patient's respiratory status
improved and she was put on a Fentanyl patch, initially 75
micrograms per hour and later 50 micrograms per hour for pain
control.
The Psychiatric Service was consulted regarding the
initiation of new anti-depressant therapy. Their
recommendations were to place the patient on 0.5 mg
intravenous Haldol twice a day as well as p.r.n. Haldol;
Remeron 7.5 mg q. h.s. was started on [**8-3**]. The plan
will be to discontinue the patient's Haldol as she becomes
more awake and she will need outpatient psychiatric follow-up
for further adjustment of her medications.
8. NEUROLOGY: The Neurology Service had been consulted
during the beginning stages of the admission regarding the
patient's progressive weakness. The consideration was that
the patient had mitochondrial neuro-gastrointestinal and
cephalomyopathy, however, mitochondrial mutation analysis
revealed that this was not the case. The Neurology Service
did not have any further recommendations at this point.
Given the question of the patient's chronic inflammatory
demyelinization disease for which the etiology has not been
identified, the patient might benefit from a future neurology
work-up once the stages of rehabilitation are completed.
9. NUTRITION: Following intubation, the patient was started
on total parenteral nutrition and as she became more stable,
a nasogastric tube was placed, however, given the patient's
history of gastroparesis the tube feeds through the
nasogastric tube did not succeed. The patient had a
post-pyloric NJ-tube placed on [**7-25**], and cuticular
tube feeds were started at this point. However, on [**7-31**], the patient pulled out the NJ-tube. She was placed back
on total parenteral nutrition and a PEG-J tube was placed on
[**8-3**] and she was started on tube feeds with Peptamen
supplemented by Creon three times a day. She has been
tolerating these tube feeds well.
Once she has been weaned off the vent, the issue of p.o.
intake can be revisited.
Of note, a PEG-J tube cannot be used for bolus feeds, but
only for continuous tube feeds.
Please see Discharge Addendum to be discharged separately for
[**Hospital 228**] hospital course following [**8-6**], including
Condition on Discharge, Discharge Service, Discharge
Medications and Discharge Diagnoses.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 423**]
MEDQUIST36
D: [**2157-8-6**] 16:18
T: [**2157-8-6**] 17:40
JOB#: [**Job Number 34805**]
Admission Date: Discharge Date: [**2157-8-9**]
Date of Birth: Sex:
Service: MICU/GREEN
ADDENDUM: The patient continued to be afebrile for a few
days. She received a trach collar and was saturating 100% on
35% FIO2.
CONDITION ON DISCHARGE: Good.
DISCHARGE SERVICE: MICU Green.
DISCHARGE MEDICATIONS: Insulin sliding scale and fixed doses
per flow sheet. Creon 10 mg two caps po t.i.d. Wednesdays
and Mondays. Fentanyl patch 15 micrograms per hour
transcutaneous patch q 72 hours, Remeron 15 mg po q.h.s.,
Vancomycin 1 gram intravenous q 12 last dose to be given on
[**2157-8-10**], Ativan 0.5 to 2 mg po/iv q two hours prn,
Haldol 0.5 to 1 mg intravenous t.i.d. prn and Bacitracin
ointment one application t.p.b.i.d. Nystatin oral suspension
5 milliliters po t.i.d., Miconazole powder 2% application
t.p.b.i.d., Albuterol two puffs inhaler q 2 to 4 hours,
Pantoprazole 40 mg po q 24 hours and heparin 5000 units
subcutaneous week q 12 hours to be discontinued when the
patient is ambulating.
DIET: Tube feeding Peptamen VHP full strength 55 cc per
hour, flushes 15 cc of water q 12 hours.
FOLLOW UP APPOINTMENTS: Scheduled by the patient.
DISCHARGE STATUS: The patient was discharged on [**8-9**]
to [**Hospital3 **]. The follow up appointments to be
scheduled by rehab staff by Dr. [**First Name (STitle) **] [**Name (STitle) **] from GI and
psychiatry.
DISCHARGE DIAGNOSES:
1. Adult respiratory distress syndrome secondary to
aspiration pneumonia.
2. Insulin dependent diabetes mellitus.
3. Chronic inflammatory demyelinating polyneuropathy.
4. Anemia.
5. Gastroparesis.
6. Multi drug resistant Klebsiella infection of urinary
tract.
Dictated By:[**Last Name (STitle) 34806**]
MEDQUIST36
D: [**2157-8-9**] 07:38
T: [**2157-8-9**] 08:02
JOB#: [**Job Number 34807**]
Admission Date: Discharge Date: [**2157-8-9**]
Date of Birth: Sex:
Service: MICU/GREEN
ADDENDUM: The patient continued to be afebrile for a few
days. She received a trach collar and was saturating 100% on
35% FIO2.
CONDITION ON DISCHARGE: Good.
DISCHARGE SERVICE: MICU Green.
DISCHARGE MEDICATIONS: Insulin sliding scale and fixed doses
per flow sheet. Creon 10 mg two caps po t.i.d. Wednesdays
and Mondays. Fentanyl patch 15 micrograms per hour
transcutaneous patch q 72 hours, Remeron 15 mg po q.h.s.,
Vancomycin 1 gram intravenous q 12 last dose to be given on
[**2157-8-10**], Ativan 0.5 to 2 mg po/iv q two hours prn,
Haldol 0.5 to 1 mg intravenous t.i.d. prn and Bacitracin
ointment one application t.p.b.i.d. Nystatin oral suspension
5 milliliters po t.i.d., Miconazole powder 2% application
t.p.b.i.d., Albuterol two puffs inhaler q 2 to 4 hours,
Pantoprazole 40 mg po q 24 hours and heparin 5000 units
subcutaneous week q 12 hours to be discontinued when the
patient is ambulating.
DIET: Tube feeding Peptamen VHP full strength 55 cc per
hour, flushes 15 cc of water q 12 hours.
FOLLOW UP APPOINTMENTS: Scheduled by the patient.
DISCHARGE STATUS: The patient was discharged on [**8-9**]
to [**Hospital3 **]. The follow up appointments to be
scheduled by rehab staff by Dr. [**First Name (STitle) **] [**Name (STitle) **] from GI and
psychiatry.
DISCHARGE DIAGNOSES:
1. Adult respiratory distress syndrome secondary to
aspiration pneumonia.
2. Insulin dependent diabetes mellitus.
3. Chronic inflammatory demyelinating polyneuropathy.
4. Anemia.
5. Gastroparesis.
6. Multi drug resistant Klebsiella infection of urinary
tract.
Dictated By:[**Last Name (STitle) 34806**]
MEDQUIST36
D: [**2157-8-9**] 07:38
T: [**2157-8-9**] 08:02
JOB#: [**Job Number 34807**]
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2,445
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51740
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Discharge summary
|
report
|
Admission Date: [**2144-6-24**] Discharge Date: [**2144-7-7**]
Date of Birth: [**2087-3-31**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
trauma to chest
Major Surgical or Invasive Procedure:
Chest tube placement and removal
NG tube placement and removal
Intubation and successful extubation
Central line placement and removal
History of Present Illness:
Pt is a 57 yo man with h/o alcohol abuse, COPD, schizoaffective
d/o, remote h/o seizures, who was transferred from [**Hospital 1562**]
hospital s/p fall on [**2144-6-20**] with 3 rib fractures, and
hemopneumothorax requiring chest tube. Pt fell on his left side
while on a 5 foot wall, hitting his left chest. There was no
LOC. His wife called 911 as he was having trouble. At [**Hospital1 1562**],
he was found to have the broken ribs and hemopneumothorax, and
the chest tube was inserted. There were continued problems
oxygenating the patient; CT PE protocol was negative and
bronchoscopy was done which did not reveal any bronchial
obstructing lesions, and only a small amount of mucous. He was
then intubated at [**Hospital1 1562**] for respiratory failure. His course
was also complicated by hypotension (briefly on levophed),
evidence of RV strain (resolved after chest tube), and HCT drop
to 29 (s/p 3 units of PRBCs). Sputum micro at OSH showed GP and
pt was started on Linezolid and levaquin (d/cd at [**Hospital1 18**]).
Pt was then transferred to [**Hospital1 18**] for further management. He was
noted to have a large Aa gradient while vented. Pt was initially
started on heparin gtt for a question of ischemic stroke. Head
CT and MRI were negative and this was then d/cd. There was
question one night of seizure like activity but the story was
unclear and EEG was not consistent with seizure activity. Pt was
extubated on [**2144-6-27**]. After extubation, pt was answering
questions unintelligibly, moaning, or looking away. The SICU
team has been trying to avoid sedating medications, but he does
require morphine for pain. Per psychiatry, risperdone and
mirtazapine (which the patient is on at home) were discontinued
(abilify and effexor had been stopped earlier). Chest tube was
d/cd on [**2144-6-29**]. Early am [**2144-6-30**] pt had a.fib ~150. He was
given diltiazem and metoprolol with little effect. He was loaded
with amiodarone and cardioverted. Pt continues to be delirious
and is transferred to medicine for further work-up.
Past Medical History:
EtOH abuse in past- sober 10 years
Hypercholesterolemia
COPD
Bipolar vs. schizoaffective d/o-depression and two major
overdoses,
with previous hospitalizations at the [**Hospital3 **] Hospital,
[**Hospital 882**] Hospital, and the VA
H/O seizure disorder-[**2-20**] seizures in life, last one was 4 years
ago.
Social History:
PCP- [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 11556**] [**Last Name (NamePattern1) **] in [**Hospital1 1562**], MA; Neurologist: Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital1 1562**] ([**Telephone/Fax (1) 107182**])
Pt is married. He is a former paramedic but has been on
disability for 20 years [**2-19**] bipolar. 1.5 ppd tobacco x 40 years.
+marijuana use. EtOH as above.
Family History:
Non-contributory.
Physical Exam:
On transfer to medicine:
T: 98/100.2 BP: 101/53 P: 73 RR: 21 O2: 94%RA; I/O 1760/2256
Gen: Sitting in bed, NAD
HEENT: PERRL, EOMI. Sclera anicteric. OP no exudate.
CV: RRR S1S2. No M/R/G
Lungs: +air movement bilaterally. Crackles at bases.
Abd: Soft, ND/NT, +BS.
Ext: No edema. DP 2+.
Neuro: alert, oriented to "hospital" and "[**2144**]" able to do DOWF
but not MOYB. Perseverative. Called pen a pencil, able to
correctly name stethoscope. Occasionally will talk in a
nonsensical manner, but redirectable. CN 2-12 intact. Strength
[**5-21**] in all extremities. Non focal exam.
Pertinent Results:
Chemistries on admission to [**Hospital1 18**]
[**2144-6-24**] 09:49PM GLUCOSE-116* UREA N-19 CREAT-0.7 SODIUM-147*
POTASSIUM-3.9 CHLORIDE-117* TOTAL CO2-24 ANION GAP-10
[**2144-6-24**] 09:49PM ALBUMIN-1.9* CALCIUM-7.7* PHOSPHATE-3.1
MAGNESIUM-2.0
LFTs
[**2144-6-24**] 09:49PM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-46
AMYLASE-150* TOT BILI-0.5
[**2144-6-24**] 09:49PM LIPASE-31
TFTs
[**2144-6-24**] 09:49PM TSH-3.7
CBC
[**2144-6-24**] 09:49PM WBC-8.7 RBC-3.28* HGB-10.3* HCT-30.4* MCV-93
MCH-31.3 MCHC-33.8 RDW-15.1
[**2144-6-24**] 09:49PM PLT COUNT-144*
Coags
[**2144-6-24**] 09:49PM PT-13.7* PTT-28.8 INR(PT)-1.3
Radiology:
[**2144-6-24**]- CT head without contrast
IMPRESSION: No evidence of intracranial hemorrhage. Fluid and
opacification of the sinuses and mastoid air cells. There are
two small equivocal hypodensities in the medial right temporal
lobe, vaguely defined, of unclear significance.
[**2144-6-24**]- CTA chest, abdomen, pelvis
1) Rib fractures.
2) Bilateral lower lobe collapse with small surrounding
effusions.
3) Chest tube in left hemithorax.
4) Small amount of ascites.
5) Some thickening and stranding in the left pararenal fascia of
unclear significance, also about the left kidney and pancreas.
6) Small abdominal aortic aneurysm.
[**2144-6-25**] Echo-
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. There is no aortic valve stenosis. The
mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is an anterior space which most likely represents a fat
pad.
[**2144-6-26**] MR [**Name13 (STitle) 430**]-
No evidence of acute ischemia/infarction,intracranial mass
effect, or hemorrhage.
[**2144-7-2**]- CXR (AP)-1) Right sided diffuse patchy and ground glass
opacities that likely represent lung contusion but could also be
asymmetric fluid overload vs. infection.
2) NG tube in stomach.
[**2144-6-30**]-EEG- Consistent with diffuse, mild encephalopathy.
Brief Hospital Course:
Impression: 57 yo male with history of EtOH abuse (sober), COPD,
bipolar disorder, transferred from OSH with hemopneumothorax s/p
chest tube, respiratory distress s/p intubation.
Chest Trauma
The patient had a mechanical fall of off a 5 foot ladder landing
on his left side. He was taken to [**Hospital 1562**] Hospital where he
was noted to have three rib fractures and left sided
hemopneumothorax. He was also in respiratory distress. His
cervical spine was stabilized, he was intubated and a left-sided
chest tube was placed. He was transferred to [**Hospital1 18**] for further
management. The patient was admitted to the SICU, and did well
from a trauma standpoint: he was extubated, the chest tube was
removed, and his pain was well controlled. His cervical, lumbar
and thoracic spine was cleared clinically and his collar was
then removed. Radiographs of his full spine did not show any
evidence of fracture of dislocation. He was then transferred to
the medicine service on [**2144-7-2**] for further management of
delirium.
Delirium
After extubation the patient was confused and disoriented,
though his neurological exam was non focal. The differential
included infection, a toxic-metabolic cause, stroke, or seizure.
He had been febrile at [**Hospital 1562**] hospital and had been started
on broad spectrum coverage (linezolid and levaquin), but these
was stopped on transfer to [**Hospital1 18**]. CXR did not show a clear
pneumonia. Urine was positive for a pan sensitive enterococcus,
and he was started on a 7 day course of antibiotics (initially
levofloxacin and then vanco given the reinitiation of
amiodarone). His MRI and CT scans were negative for stroke. An
EEG was done and was not consistent with seizure. The patient
had been receiving ativan and morphine, and had become
hypernatremic since admission to 152, all of which could have
contributed to his delirium. Neurology and psychiatry consults
were obtained, and medications that could be contrubuting to his
change in mental status were discontinued. He was found to have
a free water deficit of ~2 liters and was given D5W boluses with
improvement in his sodium. He was given haldol prn for
agitation with QT interval monitoring by EKG, and briefly
required a 1:1 sitter and restraints to prevent him from pulling
out tubes/lines. His outpatient psychiatric medications
(effexor, mirtazapine, and risperidol) were initially held. (Of
note, risperdal was later added back). His mental status
improved slowly with these interventions and he became
increasingly less agitated and more oriented. By discharge he
was attentive and oriented x3. His serum sodium on discharge
was 142. He should follow up with psychiatry regarding
reinitiation of effexor and mirtazapine.
Bipolar
He was continued on depakote and lamictal. On investigation, it
appears that the patient was on these for his bipolar disorder,
likely not for his seizures. Psychiatry recommended some dosage
changes in the setting of his delirium. He was discharged on
Depakote 250 [**Hospital1 **] and lamictal 25 [**Hospital1 **].
Hypoxia
The patient was intubated for hypoxia in the setting of a
hemopneumothorax. He was weaned off of the ventilator without
difficulty. The patient had CXR evidence of a left sided lung
contusion. His pain was controlled and he used an incentive
spirometer to prevent atelectatic changes. By discharge, the
patient was breathing room air with adequate oxygen saturations.
CV
a. Ischemia: The patient had no known history of CAD. Hre was
formally ruled out with enzymes and was continued on ASA.
b. Pump: The patient also had no known history of CHF. He did
get some lasix doses while intubated. Serial CXRs did not
demonstrate gross volume overload. I/Os and daily weights were
obtained.
c. Rhythm: The patient had evidence of a conduction system
disorder. While in the SICU he went into atrial fibrillation
with RVR to the 150s (no history of AF prior to this). His rate
was immediately controlled and he underwent amiodarone loading
and successful cardioversion (<24 hours after onset of AF). He
was continued on amiodarone and oral metoprolol. Subsequently,
he was monitored on telemetry and was noted to have episodes of
asymptomatic sinus bradycardia to the 20-30s during sleep as
well as an 8 second pause. The amiodarone and metoprolol were
held. EP was consulted and the patient had a pacemaker placed.
The amiodarone taper was restarted. He will follow up in device
clinic next week, and with Dr. [**Last Name (STitle) 73**] in follow up.
EtOH abuse
The patient does have a history of ETOH abuse, but had been
sober for many years. He was briefly on benzos for a question of
delirium [**2-19**] withdrawl but these were discontinued, and his
delirium improved. He was given MVI, thiamine, and folate
supplementation.
COPD
The patient had a history of smoking. He received nebulizer
treatments as needed.
F/E/N
After extubation the patient was seen by speech and swallow,
initially while he was still in a c-collar. He was found to
have overt aspiration of thin liquids but tolerated purees. His
NG tube was initially kept in place to augment his oral intake,
but he self-dc'd this on [**2144-7-2**]. Once his c-collar was removed
and his mental status cleared, he was re-evaluated by s/s who
still felt that the patient was aspirating thin liquids. This
can be re-evaluated at rehab.
Access
The patient had a right internal jugular central line but this
was removed without complications prior to transfer out of the
SICU. On discharge, he had a midline in place for 4 days of
vancomycin.
PPx
The patient was kept on a ppi and SQ heparin for DVT
prophylaxis. He was evaluated by PT and OT prior to discharge.
He was able to ambulate with assist, but would benefit from
rehab.
Medications on Admission:
Outpatient medications:
Lipitor 10',
EffexorXR 150',
Depakote 1000",
Risperidal 0.5",
Abilify 10',
mirtaxone 30',
Lamictal 150",
ASA 81',
MVi
Medications on transfer to medicine:
Lansoprazole Oral Suspension 30 mg NG DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Lamotrigine 75 mg PO BID
Amiodarone HCl 200 mg PO TID Duration: 7 Days Start: [**7-1**]
Aspirin 325 mg PO DAILY
Metoprolol 25 mg PO BID
Bisacodyl 10 mg PR HS:PRN
Folic Acid 1 mg IV DAILY
Miconazole Powder 2% 1 Appl TP QID
Haloperidol 2.5-5 mg IV Q2H agitation
Morphine Sulfate 2-4 mg IV Q4H:PRN
Heparin 5000 UNIT SC TID
Thiamine HCl 100 mg PO DAILY
Insulin Sliding Scale
Valproic Acid 500 mg PO Q12H
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO Q12H
(every 12 hours).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) per
sliding scale Subcutaneous four times a day: QID fingersticks.
14. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times
a day: 200mg po tid x1 week; then 200mg po bid x 2 weeks; then
200mg po daily ongoing.
16. Vancomycin HCl 1000 mg IV Q 12H Duration: 4 Days
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 10 days.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Traumatic hemopneumothorax s/p chest tube placement
Delirium, likely toxic-metabolic in nature
Tachy-brady syndrome s/p pacemaker placement
Schizoaffective disorder vs. bipolar disorder
History of seizure disorder
COPD
Hypercholesterolemia
History of ETOH abuse >10 years ago
Discharge Condition:
Stable, ambulatory, mental status improving (alert and oriented
x3 on discharge), afebrile, breathing room air.
Discharge Instructions:
You were treated for rib fractures and trauma to your lung, and
for a urinary tract infection. You also had a pacemaker placed.
1. Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**1-19**]
weeks of discharge, in the "device clinic" to check on the
pacemaker and with Dr. [**Last Name (STitle) 73**] as scheduled.
2. Please continue to take medications as prescribed. Finish a
course of antibiotics for your urinary tract infection.
3. Call your doctor or return to the emergency department if you
notice fevers, chills, confusion, dizzyness, lightheadedness,
chest pain, difficulty breathing, or any other concerning
symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 107183**] ([**Telephone/Fax (1) 107184**]) within 1-2 weeks of
discharge.
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-7-14**] 1:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2144-8-10**] 11:00
Please see a psychiatrist at rehab regarding restarting effexor
and mirtazapine.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
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8,986
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22296
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Discharge summary
|
report
|
Admission Date: [**2173-6-16**] Discharge Date: [**2173-6-23**]
Date of Birth: [**2095-7-26**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Retroperitoneal bleed, cellulitis
Major Surgical or Invasive Procedure:
IVC filter placed [**2173-6-16**]
History of Present Illness:
77 y/o female w/ hx of [**Hospital 2754**] transferred to [**Hospital Unit Name 153**] from [**Hospital3 26615**]
hospital after having a retroperitoneal bleed while undergoing
anticoagulation for a right LE DVT. On [**2173-6-9**] the Pt was
driving with husband from [**Name (NI) 622**] to [**State 350**] when she
experienced right leg swelling, erythema, pain. She went to AJH
and was determined to have a small common femoral non-occlusive
thrombus. She was anticoagulated with heparin and coumadin, and
treated with oxacillin to cover possible cellulitis which was
switched to levofloxacin and clindamycin. Her Hct dropped from
39.5 to 23. She was transfused with 2 units of PBRCs, 1 unit
FFP, and protamine (INR 3.5). Transferred to [**Hospital1 18**] where she
received 1 mg vitamine K, 2 units FFP, 2 unit PRBC and had a
[**Location (un) 260**] filter placed. Hct 31.6 on [**2173-6-19**]. Coags have
corrected. Pt still has difficulty ambulating secondary to pain
in right leg and lower abdomen as well as compressive
neuropathy. Transferred now to floor.
Past Medical History:
HTN
hypothyroid
hyperlipidemia
osteoporosis
right abdominal hernia repair
Social History:
Lives in [**State 622**] with husband. Retired housewife. occasional
ETOH, no Tobacco, no drugs. Daughter lives in [**Location 86**]--will
return to [**State 622**] on discharge, only here because of acute
process while enroute to [**Location (un) 86**].
Family History:
Pt states that her parents died of "old age".
Physical Exam:
Tm99.3, Tc:98.8, P89, BP134/52, O2sat 98% 2L
GEN: Pt lying in bed in NAD
HEENT: EOMI, PERRL, MMM, cleft palate
NECK: no lad, no JVD, no carotid bruits
CHEST: CTAB
CV: RRR, NL S1/S2
ABD: BS+, distended, tender to palpation in RLQ, no guarding no
rebound
EXT: warm, 1+ edema R>L, no erythema, no C/C
NEURO: no sensation from right inguinal area to knee. normal
strength 5+ throughout. normal reflexes throughout. deviated
right toe.
Pertinent Results:
[**2173-6-16**]: CT of abdomen from [**Hospital3 26615**] Hospital: large right
retroperitoneal hemorrhage. Full report in chart.
Admit labs:
[**2173-6-16**] 09:53PM PT-17.3* PTT-29.4 INR(PT)-2.0
[**2173-6-16**] 09:53PM PLT COUNT-252
[**2173-6-16**] 09:53PM WBC-11.3* RBC-3.10* HGB-9.7* HCT-26.8* MCV-86
MCH-31.4 MCHC-36.3* RDW-14.3
[**2173-6-16**] 09:53PM CALCIUM-7.8* PHOSPHATE-3.1 MAGNESIUM-2.2
[**2173-6-16**] 09:53PM ALT(SGPT)-88* AST(SGOT)-77* LD(LDH)-225 ALK
PHOS-58 TOT BILI-1.0
[**2173-6-16**] 09:53PM GLUCOSE-111* UREA N-21* CREAT-1.1 SODIUM-127*
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-26 ANION GAP-13
[**2173-6-16**] BLOOD CULTURE: AEROBIC BOTTLE and ANAEROBIC BOTTLE --no
growth.
[**2173-6-17**] CXR--The heart is normal in size. The pulmonary
vasculature is normal. Linear atelectasis is seen in the lung
bases. No pleural effusion or pneumothorax
[**2173-6-18**]: Hct 28.1,
[**2173-6-19**]: WBC 13.8, Hct 31.6, ALT 66, AST 58
[**2173-6-19**] 06:15AM BLOOD PT-12.8 PTT-25.5 INR(PT)-1.1
[**2173-6-20**] repeat CT abd/pelvis:
IMPRESSION:
1. Large right retroperitoneal hematoma anterior to and
extending along the
entire aspect of the right psoas muscle as well as involving and
expanding the
right psoas muscle.
2. Small bilateral pleural effusions, right greater than left
with bibasilar
atelectasis.
3. Tiny hypodensities within both kidneys, too small to fully
characterize
Discharge labs:
[**2173-6-23**] 07:15AM BLOOD WBC-8.9 RBC-3.40* Hgb-10.5* Hct-31.6*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.6 Plt Ct-426
[**2173-6-23**] 07:15AM BLOOD Glucose-102 UreaN-19 Creat-1.0 Na-135
K-4.6 Cl-99 HCO3-29 AnGap-12
Brief Hospital Course:
This is a pleasant 77 y/o woman transferred from [**Hospital3 26615**]
hospital to the [**Hospital Ward Name 332**] ICU on [**2173-6-16**] after having a
retroperitoneal bleed in the context of anticoagulation for
right LE DVT. Patient also transferred with cellulitis. She
was transferred to medical floor on [**2173-6-19**] and discharged on
[**2173-6-23**].
On [**2173-6-9**] Ms. [**Known lastname 58088**] was driving with husband from [**Name (NI) 622**]
to [**State 350**] when she experienced right leg swelling,
erythema, pain. She went to AJH and was determined to have a
small common femoral non-occlusive thrombus. She was
anticoagulated with heparin and coumadin, and treated with
oxacillin to cover possible cellulitis which was switched to
levofloxacin and clindamycin. Her hematocrit dropped from 39.5
to 23. She was transfused with 2 units of PBRCs, 1 unit FFP,
and protamine (INR 3.5). She was then transferred to [**Hospital1 18**] [**Hospital Unit Name 153**]
where she received 1 mg vitamin K, 2 units FFP, 2 unit PRBC and
had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter placed. Hct 31.6 on [**2173-6-19**]. The
patient was then transferred to floor at [**Hospital1 18**] after INR/PTT had
normalized and given that hematocrit had stabilized.
Her INR/PTT and hematocrit all remained stable during her stay
on the floor and there was no evidence of new bleeding.
Additionally, there was no evidence of development of PE
secondary to her known DVT.
Patient continued to have difficulty ambulating after transfer
to the floor secondary to pain in right leg and lower abdomen
and a compressive neuropathy with decreased sensation in her
right lower extremity and some weakness in her right leg. The
neuropathy was attributed to the retroperitoneal bleed and
subsequent hematoma formation. Repeat CT on [**6-20**] showed
hematoma extending along right psoas and involving right psoas.
Extensive literature research and consultation with surgery and
neurology culminated in a decision not to attempt evacuation of
hematoma given risks of infection, further bleeding, as well as
the fact that significant time had passed during the patient's
stabilization, and thus the hematoma was unlikely to be amenable
to evacuation. Furthermore, there was no clear evidence that
intervention would favorably impact neuropathy. On discharge,
the patient's right leg strength had improved and she was able
to ambulate with minimal assistance. She was cleared by
physical therapy. She continued to experience decreased
sensation over her right lower extremity below her inguinal
area. She was discharged with Tylenol and oxycodone for pain
control. SAD.
On discharge, the patient was intent on returning to [**State 622**] to
see family. Although she was advised against taking another
long car trip, which precipated her DVT and subsequent events,
she was determined to undertake this trip. She was advised to
drink copious fluids, stop routinely to walk about, continually
exercise calf muscles and to go to ER immediately if she becomes
symptomatic including leg pain, SOB, chest pain.
Long-term determination of her need for anti-coagulation in
setting of retro-peritoneal bleed will be under purvue of PCP as
she is not currently a candidate for anti-coagulation given
recent bleed. She has [**Location (un) 260**]. Patient advised to follow-up
immediately with her PCP in [**Name9 (PRE) 622**].
Concerning the patient's cellulitis: it improved throughout her
stay at [**Hospital1 18**]. She was treated with a 7 day course of
clindamycin/levoquin. She had no fevers, chills and her
erythema, tenderness and warmth all improved on course of
antibiotics. She continues to have area of resolving cellulitis
on discharge. Given her complicated
course, with increased stasis given limited mobility, and
significant DVT, will continue levoquin/clindamycin for
additional 7 days PO as an outpatient. SAD and patient informed
of importance of continuing these meds.
Concerning the patient's hypertension: It has been
well-controlled on this admission, with no acute issues. She
can continue outpatient meds in consultation with her PCP in
[**Name9 (PRE) 622**].
Concerning her h/o hyperlipidemia: No acute issues, can continue
lipitor as an outpatient.
Concerning her h/o osteoporosis: No acute issues, can restart
Fosomax as an outpatient. Vitamin D and calcium.
H/O Hypothyroidism: No acute issues, levothyroxine was
continued-can continue as an outpatient.
The patient's code status if full code.
The patient was discharged in stable condition on meds. SAD.
Patient was advised to return/ go to ER if she experienced
SOB/CP, light-headedness, abdominal pain, increased leg pain,
sensory of motor symptoms. She is advised to call her PCP
immediately upon return to [**State 622**]. She is intent on taking
car trip back at this time against our advice. (Please see
above.)
Medications on Admission:
Lisinopril 10 mg QD
Levothyroxine Sodium 0.025 mg QD
Lipitor 20 mg QD
ASA 81 mg QD
Fosamax 70 mg Qwk
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*0*
3. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 7 days.
Disp:*42 Capsule(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QTUES
(every Tuesday).
Disp:*12 Tablet(s)* Refills:*2*
6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*61 Tablet(s)* Refills:*0*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
retroperitoneal bleed, cellulitis
Discharge Condition:
stable Hct, ambulating
Discharge Instructions:
If Pt experiences lightheadedness, CP, SOB, palpitations, leg
edema/redness/swelling, or marked abdominal pain she should
seeks immediate medical attention.
Followup Instructions:
F/U with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58089**] in [**State 622**] w/i 2 weeks.
[**Hospital 58090**] [**Hospital 58091**] Community hospital
[**Location (un) 58091**] Community Medical Group
Greenspring Physicians
[**2168**] East Court
[**Location (un) 58091**], [**Numeric Identifier 58092**]
phone: [**Telephone/Fax (1) 58093**]
fax: [**Telephone/Fax (1) 58094**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,297
| 129,528
|
49903
|
Discharge summary
|
report
|
Admission Date: [**2120-7-18**] Discharge Date: [**2120-7-24**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p fall, found down by niece
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yr/o F with Hx HTN, DM, osteoporosis, and breast CA (post
[**Doctor First Name **]/chemo) who still lives alone despite dementia and baseline
mental status that is A & O x 1 who was found stuck between her
bed and a desk at home today by niece (presumably there up to
24hrs). She was conscious with no obvious trauma and had
absolutely no complaints. Her niece brought her to ED for
evaluation where head CT and cervical CT showed no acute
findings on prelim read. Initial EKG showed ST elevations
anteriouly and inferiorly and troponin was 1.34 with CK of 7711
despite lack of sx. Pt was given ASA and started on a heparin
gtt. Cards consult was obtained and after discussions with
family decided not to pursue intervention but proceed with
medical management. Pt was admitted to CCU for monitoring.
.
Of note, has recent history of progressive cognitive decline on
top of chronic dementia and is roughly A&O x 1 at baseline.
Family has been trying to keep her at home because another
elderly family member did poorly when placed in a facility and
because Ms [**Known lastname 9907**] herself gets very confused and disoriented
when not at home.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: 12 yrs ago with stent to
the circ, cath done [**12-27**] anginal symptoms
3. OTHER PAST MEDICAL HISTORY:
- osteoporosis
- L infiltrating lobular breast carcinoma with breast-conserving
surgery followed by postoperative radiation therapy in [**2114**]
-70% stenosis of the R carotid
Social History:
- Tobacco history: smoked for several years in the past but quit
in [**2073**]
- ETOH: social
- Illicit drugs: done
- Lives alone despite dementia/altered baseline Mental status
Family History:
- No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
- Mother: parkinson's
- Father: died of pneumonia
Physical Exam:
Admission physical exam:
VS: T=96.5 BP=139/64 HR=68 RR=20 O2 sat= 97% RA
GENERAL: NAD. Oriented tp self and place. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mucous membranes
dry. No xanthalesma.
NECK: Supple with non elevated JVP, R carotid bruit
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**11-30**] holosystolic murmur heard best at
the apex. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness.
MSK: Ecchymosis over the L shoulder, moving extremity well, no
pain to palpation
EXTREMITIES: No c/c/e. L leg cool
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+
Left: Carotid 2+ DP 1+
Discharge physical exam:
VS: 97.8 BP 160s/70s - 110s/50s HR 60s-80s 98% RA
MSK: Ecchymosis of L shoulder continuing to improve from
admission
Rest of exam unchanged from admission
Pertinent Results:
Admission labs/studies:
.
142 104 38
-------------< 208
3.8 23 1.2
.
CK: 7711 / Trop-T: 1.34
.
Ca: 9.9 Mg: 2.0 P: 4.0
.
WBC 15.6 / Hgb 14.1 / Hct 41.1 / Plts 178 / Mcv 92
N:88 Band:2 L:8 M:2 E:0 Bas:0
.
PT: 12.3 PTT: 21.0 INR: 1.0
U/A: Color Yellow Appear Clear SpecGr 1.011 pH 5.5 Urobil
Neg Bili Neg Leuk Neg Bld Lg Nitr Neg Prot 100 Glu Tr Ket
10 RBC 1 WBC 1 Bact Few Yeast None Epi 0
Other Urine Counts
CastHy: 7 Mucous: Occ
Urine culture ([**2120-7-18**]): no growth
CT C-Spine ([**7-18**]): Moderate multi-level DJD. No acute fracture
or mal-alignment. Right apical lung scarring.
CT Head ([**7-18**]): Left parieto-occipital subgaleal hematoma. No
acute intracranial injury.
CXR ([**7-18**]): COPD. Biapical pleural thickening. No acute
cardiopulmonary
process.
TTE ([**2120-7-18**]): Mild symmetric left ventricle with normal cavity
size and regional left ventricular dysfunction with
hypokinesis/near-akinesis and ballooning of the apical segments
consistent with left ventricular apical aneurysm. No left
ventricular mass/thrombus appreciated. Above findings consistent
with possible Takotsubo cardiomyopathy vs. mid to distal
occlusion of a wrap-around left anterior descending coronary
artery.
CXR ([**2120-7-22**]): Lungs are hyperinflated suggestive of COPD
changes. Since
[**2120-7-18**], bilateral mild pleural effusions are new. Diffuse
interstitial
thickening seen in prior radiographs is no different. Note is
made of
bilateral apical pleural thickening. There is no lung
consolidation.
Cardiomegaly is mild.
Discharge Labs:
[**2120-7-23**] 07:50AM BLOOD WBC-9.7 RBC-3.69* Hgb-11.6* Hct-34.8*
MCV-94 MCH-31.5 MCHC-33.4 RDW-14.0 Plt Ct-179
[**2120-7-23**] 07:50AM BLOOD Glucose-159* UreaN-26* Creat-1.0 Na-142
K-4.2 Cl-107 HCO3-23 AnGap-16
[**2120-7-22**] 06:05AM BLOOD ALT-53* AST-34 LD(LDH)-592* AlkPhos-57
TotBili-0.5
[**2120-7-17**] 11:50PM BLOOD ALT-66* AST-182* LD(LDH)-930*
CK(CPK)-7711* AlkPhos-55 TotBili-0.9
[**2120-7-18**] 03:43AM BLOOD ALT-62* AST-161* LD(LDH)-763*
CK(CPK)-5866* AlkPhos-51 TotBili-0.8
[**2120-7-18**] 04:05PM BLOOD CK(CPK)-3024*
[**2120-7-19**] 12:58AM BLOOD CK(CPK)-2657*
[**2120-7-17**] 11:50PM BLOOD cTropnT-1.34*
[**2120-7-18**] 03:43AM BLOOD CK-MB-42* MB Indx-0.7 cTropnT-1.14*
[**2120-7-23**] 07:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
Brief Hospital Course:
Primary Reason for Hospitalization:
[**Age over 90 **]yoF with h/o dementia presents after being found down for up
to 24hrs, and incidentally found to have ST-elevations in
anterior leads with elevated cardiac enzymes.
.
Active Issues:
# ST elevations: Admission EKG showed ST elevations in leads II,
AVF, V2-V6. Initially concerning for possible STEMI
(wrap-around LAD), however history more c/w Takotsubo
cardiomyopathy given setting of acute stress. Family opted for
medical management instead of cardiac cath given her age,
cognitive decline, and goals of care. She remained asymptomatic.
TTE showed apical akinesis with low-normal EF (40-45%). She
received heparin gtt for 48 hours. Her ASA dose was increased
to 162 mg daily. Atorvastatin was initially held due to c/f
rhabdomyolysis but was restarted on HD#3. Her home atenolol was
switched to metoprolol in the setting of renal failure. After
her renal function improved, she was started lisinopril 10mg
daily.
.
# Rhabdomyolysis: Pt's history of fall with prolonged down time,
disproportionate CK elevation compared to CKMB, and urine
dipstick with large blood but few RBCs all suggestive of
rhabdomyolysis [**12-27**] fall. She was given continuous IVFs for
renal protection, and her creatinine improved to 0.9 (mildly
elevated at 1.2 on admission). Her atorvastatin was initially
held but restarted on HD#3.
.
# UTI: UA on HD#3 c/f UTI. She was empirically started on IV
ceftriaxone and her culture sensitivies showed that ceftriaxone
was a good antibiotic choice for this e.coli infection. She was
treated with a 3 day course of ceftriaxone. She remained
afebrile with a normal WBC count following antibiotic therapy.
.
# Dementia: patient was found to be aggitated during the
evening on hospital day 4. In speaking to the family the
patient was not normally aggitated, but had some baseline
cognitive impairment at home. She was given 5 mg Zyprexa PO x2
and 0.5 mg Haldol IM in addition to her nightly 12.5 mg of
seroquel. She had improvement in her aggitation without further
interention. A geriatrics consult was requested and they
suggested that we increase her night time dose of Seroquel to
25mg. This was continued during this hosptial course.
.
# Transaminitis: Mild LFT elevation on admission, likely
secondary to a skeletal muscular source rather than hepatic.
Enzymes were trended and had improved by time of discharge.
.
# Leukocytosis: WBC 15 on admission but resolved by HD#3, likely
[**12-27**] acute inflammation in the setting of MI and rhabdomyolysis.
Patient did show e/o UTI on UA on HD#3 (described above), but
this occured after resolution of leukocytosis.
.
Stable Issues:
.
# HTN: Patient's home amlodipine was discontinued during this
admission. Her home atenolol was switched to metoprolol in the
setting of renal failure. After her renal function improved,
she was started on lisinopril due to decreased EF (40-45% on
TTE).
.
# HLD: Simvastatin 80mg was switched to Atorvastatin 40mg.
Statin therapy was initially held in setting of rhabdomyolysis
as above, then restarted on HD#3.
.
Transitional issues:
- Patient maintained DNR/DNI code status throughout
hospitalization.
- She was transitioned to an ECF after discharge.
- She should follow up with her primary care doctor and
cardiology within two weeks time.
Medications on Admission:
atenolol 25 mg daily
amlodipine 2.5 mg daily
ASA 81 mg daily
glipizide 2.5 mg daily
simvastain 80 mg q hs
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
7. trazodone 50 mg Tablet Sig: [**11-28**] Tablet PO qHS: PRN as needed
for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**]
Discharge Diagnosis:
Takotsubo cardiomyopathy
Diabetes
High blood pressure
osteoporosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms [**Known lastname **] it was a pleasure participating in your care. As you
know you fell at home and were brought to the hospital. There
was concern that you had a heart attack but it was determined
that most likely your heart was not working well due to the
stress of the fall. You were also found to have a urinary tract
infection for which you were given antibiotics and no longer
require further antibiotic therapy.
.
The following changes were made to your medications:
.
Atenolol, Amlodipin and Simvastatin were stopped. Please STOP
taking these medications.
.
The following medications were started:
1. Tab Metoprolol 25 mg was started. Please take 1 tab twice
daily.
2. Tab Aspirin 81 mg, was increased from one to two tablets once
daily.
3. Atorvastatin 40mg Tablet was started. Please take one tablet
once daily.
4. Lisinopril 10 mg tablet was started. Please take one tablet
once daily for your blood pressure.
5. Seroquel 25mg tablet was started, please take one tablet by
mouth at bedtime.
6. trazodone 12.5 tablet was started. Please take one tablet by
mouth at bedtime as needed for insomnia
.
You should continue to take your glipizide without change.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2120-8-12**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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icd9cm
|
[
[
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[
[
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4,096
| 161,677
|
52683
|
Discharge summary
|
report
|
Admission Date: [**2170-6-5**] Discharge Date: [**2170-6-22**]
Date of Birth: [**2091-9-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
perirectal abscess
Major Surgical or Invasive Procedure:
I+D perirectal abscess (6/23+[**6-10**]), left open
History of Present Illness:
78 yo male with multiple medical problems admitted on [**6-5**] for
fever, perirectal abscess, ARF. He lives alone and had
apparently been experiencing pain in rectum due to
"folliculitis" for several weeks. He is diabetic and had very
poor PO intake prior to admission. He was dehydrated, confused,
febrile and in pain when he was admitted to the medicine service
from the emergency department.
Past Medical History:
* diabetes type 2
* hypercholesterolemia
* hypertension
* GERD
* PVD
* degenerative joint disease
* LLE atherectomy
* CCY
* pancreatitis
Social History:
lives at home alone. cooks for himself. quit smoking for 48
years in [**2154**]. used to drink alcohol but has not for several
years.
Family History:
non-contributory
Physical Exam:
VITALS (on discharge)97.8 135/42 60 18 97%3L
GEN: pleasant, NAD,well-nourished
HEENT: PERRL, EOMI, sclera anicteric, no conjuctival injection,
mucous membranes dry, no lymphadenopathy, neck supple, full ROM,
neg JVD, no carotid bruits
[**Last Name (un) **]: very poor air movement bl, exp wheeze.
COR: RRR, S1 and S2 wnl, no murmurs/rubs/gallops
ABD: non-distended with positive bowel sounds, non-tender,no
guarding, no rebound or masses
Rectum: Wound is open, clean and dry. Minimal skin induration,
minimal tenderness. No discharge or odor.
EXT: no cyanosis, clubbing, edema
Pertinent Results:
Cardiac enzymes negative several times
Albumin low (2.5)
[**6-22**]: WBC 9.5, HCT 31.1
[**2170-6-22**] UreaN-9 Creat-0.9 Na-139 K-4.2 Cl-108 HCO3-24 AnGap-11
[**2170-6-20**] ALT-16 AST-26 LD(LDH)-222 AlkPhos-111 Amylase-48
TotBili-0.3
[**2170-6-20**] Calcium-8.6 Phos-3.0 Mg-2.1
GRAM STAIN (or rectal wound) (Final [**2170-6-20**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
YEAST. SPARSE GROWTH.
BACTERIA. SPARSE GROWTH. ? OF THREE COLONIAL
MORPHOLOGIES.
BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.
ANAEROBIC CULTURE (Pending):
Brief Hospital Course:
Patient was treated on medical service with IVF for ARF, to
which he responded well with BUN/Creatinine dropping. Several
days after admission he became increasingly febrile and acutely
uncomfortable in the rectal area (WBC increased to 20). Surgery
was consulted and patient was transferred to the surgery service
for incision and drainage of a perirectal abscess (6/23+[**6-10**]).
Cultures from the wound initially grew out enterococcus and
anaerobes, and the wound was negative for MRSA. Several sets of
blood cultures were negative. The patient was treated with 10
days of antibiotics, initially levo/vanco and metronidazole,
although treatment was tailored based on repeat cultures. He is
no longer on antibiotics, has been afebrile and wound looks
good. Since drainage, the wound is open, and has been packed
several times/day. THe patient also [**First Name9 (NamePattern2) 60594**] [**Last Name (un) **] baths tid.
This care will need to continue until the would granulates,
heals over and closes on its own- something we anticipate will
take time. When he stools the wound needs to be cleaned
(irrigated with NS and repacked with clean gauze).
While the abscess was the main reason for the patient's
admission, several other issues required management while he was
in the hospital. He is IDDM, and [**Last Name (un) **] was consulted for better
glucose control. Their recommendations will be included in the
discharge instructions and medication lists.
In addition, the patient experienced several episodes of chest
pain, sob. Cardiology was consulted and he was cleared. He ruled
out for MI several times and EKGs showed no acute change. He
remained on telemetry due to his cardiac history the entire
admission, and is known to experience PVCs, sometimes as many as
[**10-4**], while being asymptomatic. This was felt to be
unconcerning to cardiology, unless they occurr in runs similar
to Vtac, at which point (or at any point the patient is
symptomatic) cardiac enzymes should be sent. He has a history of
CHF and his sob was felt to be mostly due to fluid overload
while in the hosptital. At discharge he is felt to be nearly
back to baseline fluid-wise,although he still has significant
atelectasis and an unclear h/o asthma/COPD for which he requires
frequent nebulizer treatment. He needs aggressive chest PT and
to be up and out of bed often as well as a clear eye on making
sure that he does not become fluid overloaded.
In general, He is eating a regular diet and tolerating it well,
and has not needed IVF for over a week. He is usually alert and
oriented, however can become confused at night. We have found
that trazodone qhs is very helpful rather than haldol or some
other sort of sedative. He is an endearing man who unfortunately
will require considerable help keeping his abscess area clean
and un-infected, and we hope that you will be able to help him
as best you can. Thank you.
Medications on Admission:
* insulin NPH 32 units qam + 20 units qpm
* atenolol 25 mg daily
* lipitor 20 mg daily
* monopril 20
* protonix 40 mg daily
* plavix 75 mg daily
* aspirin 325 mg daily
* HCTZ 25 mg daily
* neurontin 100 mg twice daily
* pletal 50 mg daily
Discharge Medications:
albuterol nebulizer q 2h prn
ipratropium bromide nebs q4h prn
aspirin 325mg po qd
atorvastatin 20 mg po qd
atenolol 25 mg po bid
plavix 75mg po qd
gabapentin 100mg po bid
hydrochlorothiazide 25mg po qd
insulin sliding scale plus fixed dose of NPH (30 units in am, 18
in pm)
lisinopril 20mg po qd
nitroglycerin SL 0.3mg SL prn
tylenol 3, q4-6hr prn
pantoprazole 40mg po qd
trazodone 25mg po qhs
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute Renal Failure, insulin-dependent diabetes mellitus,
congenstive heart failure, Rectal Abscess
Discharge Condition:
Good
Discharge Instructions:
Wound Care: Please re-pack the rectal wound with clean, dry
curlex [**Hospital1 **]. Every time the patient stools the wound needs to be
re-packed (with clean curlex), and if there is stool
contamination, the wound needs to be irrigated with normal
saline as well. He also needs [**Last Name (un) **] baths tid.
Finger sticks qid for DM.
Oxygen as needed, prn nebs, and the rest of medications as
listed.
Followup Instructions:
PLease follow-up with the surgeon, Dr. [**Last Name (STitle) 6633**] in 2 weeks for
the rectal abscess. Please follow-up with Dr. [**Last Name (STitle) 1538**] in [**12-17**]
weeks (his internist), and with Dr. [**Last Name (STitle) **] (cardiologist) in a
week or two as well. In-house cardiology recommended TTE be done
on an outpatient basis, and this will need following up on with
Dr. [**Last Name (STitle) **].
Completed by:[**2170-6-22**]
|
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icd9cm
|
[
[
[]
]
] |
[
"48.23",
"48.81"
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icd9pcs
|
[
[
[]
]
] |
6328, 6407
|
2710, 5621
|
332, 385
|
6550, 6556
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1775, 2209
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|
986, 1124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,996
| 136,635
|
17328
|
Discharge summary
|
report
|
Admission Date: [**2161-12-7**] Discharge Date: [**2161-12-19**]
Date of Birth: [**2130-8-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Hypoxic respiratory failure, intubated in ED.
Major Surgical or Invasive Procedure:
intubation, central line, art line, dialysis
History of Present Illness:
31 year old male with ESRD secondary to membranous
glomerulonephritis, recent admission from [**8-30**] - [**2161-10-7**] for
aortic valve MSSA endocarditis/abscess presumed secondary to HD
line infection, course complicated by post-operative aortic root
abscess requiring homograft/redo AVR, and bilateral subclavian
DVTs for which he is on coumadin, who presented to the ED this
a.m. complaining of 3 days of shortness of breath, and 1 day of
severe chest pain with inspiration.
.
Initial history was obtained through discussions with ED
physician and via the chart, as the patient has been intubated.
Per their report, the patient denied recent fevers, chills, or
cough. He has had shortness of breath over the last 3 days, as
well as severe pleuritic left sided chest pain since yesterday.
He reports non-bloody diarrhea over the last few days. Of note,
he had a low grade fever at HD 2 days prior to admission at
which time blood cultures were sent. [**1-18**] bottle is growing
coagulase positive staph.
.
On arrival to the ED, vitals were 99.6, 135/101, HR 100, RR 40,
87% on RA. He was placed on a NRB with O2 sat in the low 90s,
however he continued to be tachypneic, with severe pleuritic
chest pain. He was started on BIPAP, which he did not tolerate,
despite a trial of ativan to help relax him. He pulled off the
BIPAP, with O2 sats falling to the mid-80s, with persistent
tachypnea, therefore he was intubated. Of note, his O2 sat was
around 20% for a couple of minutes peri-intubation. After
intubation, he seemed to be quite dysynchronous with the
ventilator, requiring fentanyl, versed, and propofol to achieve
synchrony. He was hemodynamically stable throughout.
Post-intubation ABG on 100% FiO2 was 7.35/35/77.
.
CXR revealed bilateral infiltrates. He was given vancomycin 1
gram, ceftriaxone 1 gram, and azithromycin 500 mg all x 1.
.
Labs were notable for hyperkalemia (6.2) for which he was given
kayexalate, HCO3, insulin, and D50. He was seen by renal who
plan to do hemodialysis urgently.
Past Medical History:
# ESRD: Secondary to membranous glomerulonephritis diagnosed on
renal biopsy in [**2158**]. Has been on HD x 5 yrs, awaiting renal
transplant. AVF placed in LUE in [**2161-10-30**].
# Hypertension
# Hyperlipidemia
# Chronic fatigue syndrome
# Aortic endocarditis/abscess with MSSA, presumed secondary to
HD line infection, status post aortic valve replacement in [**9-23**]
(23 mm [**Doctor Last Name **] Magna aortic valve bioprosthesis. Model number
3000 TFX, serial number [**Female First Name (un) 47962**]). Post-op course complicated
by aortic root abscess requiring re-do AVR/homograft on [**2161-9-29**].
Completed 6 week course of nafcillin on [**2161-11-12**].
# Bilateral subclavian vein thromboses on US in [**9-23**]
# PFO, with left to right shunt across interatrial septum at
rest, seen on TTE [**2161-9-29**].
# Pyloric stenosis in childhood, surgically repaired
Social History:
Originally from [**Male First Name (un) 1056**]. Now lives by himself in Mission
[**Doctor Last Name **] (though not sure if this is current). Drinks 2-3
drinks/month. Smokes 1/2ppd x10 years. Denies IVDU. Works in the
electrical engineering dept. at [**Hospital1 112**].
Family History:
mother - breast ca at 45, survivor, aunt - died of MI at 50, no
other family hx of renal disease, no DM or other CA in the
family
Physical Exam:
101.3, 113, 114/62, on AC 650x16 (spont 32), FiO2 100%, PEEP
10. Pip 18, compliance 81.
GENERAL: Slim male appearing slightly dysynchronous with the
ventilator.
NECK: JVP not visible.
COR: RR, normal rate, sharp S2, no murmurs, rubs, gallops.
CHEST: Rhonchi diffusely. Left subclavian HD line with small
amount of purulent drainage around the opening, overlying skin
erythematous.
ABDOMEN: Normoactive bowel sounds, soft, non-distended,
paradoxical movements.
EXTR: Left radial AVF without thrill, mildly erythematous, no
mass. No edema, no palpable cords on lower extremities.
Pertinent Results:
[**2161-12-7**] 12:30PM PT-21.9* PTT-32.7 INR(PT)-2.1*
[**2161-12-7**] 12:30PM PLT COUNT-147*
[**2161-12-7**] 12:30PM NEUTS-91.1* BANDS-0 LYMPHS-6.8* MONOS-1.5*
EOS-0 BASOS-0.6
[**2161-12-7**] 12:30PM WBC-9.9# RBC-4.05* HGB-13.9* HCT-42.3
MCV-105* MCH-34.3* MCHC-32.8 RDW-16.2*
[**2161-12-7**] 12:30PM CALCIUM-9.5 PHOSPHATE-4.4# MAGNESIUM-1.8
[**2161-12-7**] 12:30PM CK-MB-5 cTropnT-0.13*
[**2161-12-7**] 12:30PM LIPASE-9
[**2161-12-7**] 12:30PM ALT(SGPT)-18 AST(SGOT)-23 CK(CPK)-216* ALK
PHOS-75 AMYLASE-50 TOT BILI-0.3
[**2161-12-7**] 12:30PM UREA N-74* CREAT-13.2*# SODIUM-131*
POTASSIUM-6.2* CHLORIDE-91* TOTAL CO2-18* ANION GAP-28*
[**2161-12-7**] 12:45PM LACTATE-2.3*
[**2161-12-7**] 03:44PM LACTATE-2.3*
Brief Hospital Course:
***PLEASE NOTE PATIENT LEFT AMA PRIOR TO INR BEING IN GOAL RANGE
OF [**2-20**]***
.
31 year old male with ESRD secondary to membranous
glomerulonephritis, recent aortic valve MSSA
endocarditis/abscess presumed secondary to HD line infection,
course complicated by post-operative aortic root abscess
requiring homograft, and bilateral subclavian DVTs for which he
is on coumadin, who presented to the ED this a.m. with dyspnea,
pleuritic chest pain, found to have hypoxic respiratory failure
secondary to bilateral lobar pneumonia, and sepsis in the
setting of recently positive blood culture at dialysis.
.
1) Hypoxic respiratory failure/Pneumonia/ARDS: Likely secondary
to pneumonia but also may have element of alveolar hemorrhage.
The patient was managed with vent settings to minimize lung
injury according to the ARDSnet protocol. After self extubation,
he was maintained on supplemental O2 by NC, and over the rest of
his hospital course, he had stable and improving lung function.
He did experience transient desaturation and tachypnea during
his stay on the floor but this was secondary to volume overload
due to receiving several units of blood prior to undergoing
dialysis.
.
# MSSA Septicemia: [**6-23**] blood culture bottles from [**12-5**], [**12-7**]
positive, with HD catheter tip positive as well. Surveillance
cultures from [**12-8**], [**12-8**], [**12-10**] NGTD. Staph aureus bacteremia
concerning for seeding of prosthetic AVR but TEE showed no
evidence of endocarditis and no abscesses seen on CT torso. ID
followed him throughout his stay and will see him as an
outpatient in clinic when he finishes his 6 week course of
nafcillin.
- On nafcillin 2gm IV Q4h since [**12-9**] (planned for 6 week
course) and completed gentamicin 35 mg IV Q48H through [**12-12**].
- has picc line in place for IV nafcillin as outpatient.
.
# Anemia: The patient had an acute anemia to 25 secondary to a
left thigh hematoma and adductor/obturator bleed after placement
of a L groin HD catheter. He received several units of blood and
the hct stabilized after 2 days. He is also on epogen with HD
chronically for a chronic anemia.
.
# ESRD: The patient has a LUE AVF, but it has apparently clotted
off. Renal placed left femoral HD line, but complicated by left
leg hematoma, now resolved. Femoral cath was pulled [**2161-12-15**]
after tunnelled cath was placed in the RSC. He will be on
T/Th/Sat schedule upon discharge via tunnelled cath placed in
RSC. We continued renagel, nephrocaps, epogen with HD.
.
# Anticoagulation: Currently on a heparin gtt bridge to coumadin
with INR goal of [**2-20**] for bioprosthetic AVR and subclavian clots.
The patient's INR was only at 1.8 when he left AMA. He was urged
to follow up as an outpatient with his primary care physician to
have his INR checked and his coumadin adjusted accordingly.
.
# Pancreatitis: Mr. [**Known lastname 11041**] began having abdominal pain on HD 2
and was noted to have an amylase of 308, lipase of 250. He was
made NPO and his pain has subsided with morphine. Abd US
revealed a pancreatic duct at upperlimit of normal w/o evidence
of obstruction/stones. He has had a recent abd CT which also
commented on a duct at the upper limit of normal. As for the
cause of his pancreatitis, he did briefly get propofol which can
precipitate pancreatitis, but the cause is currently unknown.
His amylase is stable and his lipase is now normal. The patient
no longer has any abdominal complaints and was tolerating a PO
diet well at time of discharge.
.
# Subclavian DVTs: heparin gtt to coumadin as above.
.
# anion gap acidosis: the patient had an anion gap acidosis
likely secondary to uremia which closed after receiving HD.
.
# Hypertension: The patient was gradually restarted on home
antihypertensives. Lisinopril was titrated up to 20mg, and
titrated up labetalol to 350mg tid with eventual good control of
SBP.
.
# Diarrhea: C diff negative x 2, no Shigella or Campy on stool
culture. Resolved at time of discharge.
Medications on Admission:
Atorvastatin 20 mg daily
Epo 4000 units M,W,F
Renagel 800 mg TID
Labetalol 200 mg TID
Warfarin 3 mg ?
Lisinopril 10 mg daily
Nephrocaps daily
Amlodipine 10 mg daily
Discharge Medications:
1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1)
2gm/100mL Intravenous Q4H (every 4 hours).
Disp:*180 2gm/100mL* Refills:*2*
2. Outpatient Lab Work
Please check CBC/Differential, LFT's every week.
3. Heparin Flush 100 unit/mL Kit Sig: One (1) 3ml Intravenous
once a day: Please flush each lumen via sash daily.
Disp:*30 1* Refills:*2*
4. Normal Saline Flush 0.9 % Syringe Sig: One (1) 5ml Injection
once a day: Please flush each lumen via sash daily.
Disp:*30 1* Refills:*2*
5. Outpatient Lab Work
Please have your INR checked within 3 days of discharge
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Labetalol 100 mg Tablet Sig: 3.5 Tablets PO TID (3 times a
day).
Disp:*315 Tablet(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO three times
a day as needed.
Disp:*90 Tablet(s)* Refills:*0*
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Start by taking 2 tablets daily, then f/u with your PCP on
[**Name9 (PRE) 766**] for INR check and adjust dose.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Primary:
MSSA Sepsis
.
Secondary:
ESRD on HD
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for sepsis with respiratory failure requiring
endotracheal intubation secondary to an infection from your
dialysis catheter.
.
You will restart all outpatient medications as prior to
admission. Please note that we increased your Labetalol to 350mg
three times daily, as well as your Lisinopril to 20mg daily. You
will also resume your regular dialysis schedule upon discharge.
.
You will be taking the IV antibiotic, nafcillin, for a total of
6 weeks.
.
If you experience shortness of breath, chest pain, headache,
fever or chills or swelling/redness or pain at the site of your
dialysis catheter, please seek medical attention.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of discharge.
.
You will need to have your INR checked on Monday after discharge
so your coumadin dose can be readjusted.
.
Please follow up in the Infectious Disease Clinic with [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2162-1-15**] 9:30am
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
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[]
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244, 291
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3337, 3610
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,637
| 192,325
|
45278
|
Discharge summary
|
report
|
Admission Date: [**2184-6-9**] Discharge Date: [**2184-6-24**]
Date of Birth: [**2120-7-28**] Sex: F
Service: MEDICINE
Allergies:
Valium / Darvon / Scopolamine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Pt is a 63 year old female p/t of Dr. [**Last Name (STitle) 3060**] of oncology with hx
of factor 8 defficeny [**2-2**] to factor 8 inhibitor now presenting
from rehab with fever and neutropenia. She had a recent
prolonged hospital course at [**Hospital1 **] due to her coagulopathy and
since then has been at the [**Hospital 38**] rehab. Her hosptial course
was complicated by significant bleeding into her arms with line
placement and spontanous bleeding, overall requiring 20 units of
blood. Also was treated for a MSSA bacteremia. She was
discharged with a PICC, which fell out appx 10 days prior to
this hospitalization. She has been continued on steriods and
daily cytoxan for her factor 8 inhibitor, and is s/p 2
treatements with Rituximab. Now over the last 4 days she states
she has noticed a slight cough without sputum. This AM she was
noted to have chills and rigors and a temperature of 102 per
records. She denies any GI sx, dysuria, other resp sx, sore
throat, of rash. She last had a dose of pentamidine one month
prior. Also has been having left leg swelling starting today.
She was noted at the rehab to have a postive UA. Urine cx was
pending. CXR was clear.
In the ER VS were T- 101.1, BP- 125/61, HR- 107, RR-22, O2
100%RA. She was given a dose of cefepime 2gIV. Blood cx were
sent. Lactate was elevated at 4.7. PIV was started in left
thumb. Also given 2L IVF NS, tylenol of 650mg, and humalog 35
units. Found to have neutropenia. Admitted to [**Hospital Unit Name 153**] due to
difficult access. Discusses with heme/onc.
Past Medical History:
- Acquired Factor VIII Inhibitor, on steriods, cytoxan, and
rituximab
- DM type 2, on high dose insulin, followed by [**Last Name (un) **]
- Anemia, baseline Hct 24-26, as per HPI - Has been on Aranesp,
Procrit for this in the past
- Hypertension
- Hyperlipidemia
- Has had multiple surgeries on right knee; first was in [**2140**]
- Recent h/o MSSA bacteremia [**5-8**]
Social History:
Recently residing at [**Hospital 38**] Rehab. Previously lived with
daughter, previously independent, 10 year tobacco history but
not smoking currently, no etoh or IVDU. She is a nurse and works
as a case manager for a health insurance company.
Family History:
non-contributory
Physical Exam:
T 99 BP 161/63 HR 104 RR 27 O2 sat 100% 2L NC
Gen - NAD, obese pleasant female, awake and alert
HEENT - Clear OP, moist MM
CV - tachy, slight systolic murmur at 2ICS
Lungs - CTA B but difficult to assess due to body habitus
Abd - soft, NT, ND, +BS, echymosis present on abd
Ext - no c/c, +erythema on both lower extremities, edema 2+,
warm
Skin - multiple echymosis, warm
Neuro - A&O x3, moving all extremities, except decreased
mobility in right index fingers and thumb
Pertinent Results:
LABS ON ADMISSION:
[**2184-6-9**] 10:55AM BLOOD WBC-0.3*# RBC-2.09* Hgb-7.5* Hct-22.1*
MCV-106* MCH-36.0* MCHC-33.9 RDW-18.1* Plt Ct-159
[**2184-6-9**] 10:55AM BLOOD Neuts-63 Bands-3 Lymphs-15* Monos-9
Eos-10* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2184-6-9**] 10:55AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2184-6-9**] 10:55AM BLOOD PT-14.0* PTT-65.2* INR(PT)-1.2*
[**2184-6-9**] 10:55AM BLOOD ESR-110*
[**2184-6-9**] 10:55AM BLOOD Glucose-199* UreaN-36* Creat-1.6* Na-138
K-3.1* Cl-99 HCO3-25 AnGap-17
[**2184-6-9**] 10:55AM BLOOD ALT-5 AST-0 LD(LDH)-514* CK(CPK)-41
AlkPhos-54 TotBili-0.6
[**2184-6-9**] 10:55AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.8
[**2184-6-9**] 09:15PM BLOOD Type-[**Last Name (un) **] Temp-39.2 pO2-37* pCO2-41
pH-7.48* calTCO2-31* Base XS-6 Intubat-NOT INTUBA
[**2184-6-9**] 11:10AM BLOOD Glucose-198* Lactate-4.7*
[**2184-6-9**] 06:52PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2184-6-9**] 06:52PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2184-6-9**] 06:52PM URINE RBC-0 WBC-135* Bacteri-FEW Yeast-NONE
Epi-4
**FINAL REPORT [**2184-6-15**]**
Blood Culture, Routine (Final [**2184-6-15**]):
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.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2184-6-10**]):
REPORTED BY PHONE TO [**Location (un) **] [**Doctor Last Name 2601**] @ 11:25 AM ON [**2184-6-10**].
GRAM POSITIVE COCCI IN CLUSTERS.
MRSA SCREEN (Final [**2184-6-12**]): No MRSA isolated.
LABS ON DISCHARGE:
OTHER PERTINENT LABS:
IMAGES:
CHEST (PORTABLE AP) Study Date of [**2184-6-9**] 11:48 AM
UPRIGHT AP VIEW OF THE CHEST: The lungs are clear. There is no
appreciable
pleural effusion or pneumothorax. Mild cardiomegaly and
elevation of the
right hemidiaphragm are unchanged from [**2184-4-27**]. The mediastinal
silhouette,
hilar contours and pulmonary vasculature are unremarkable.
ECHO, [**6-14**]:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Increased PCWP.
Brief Hospital Course:
Pt is a 63 year old female with acquired factor 8 inhibitor who
presented on [**6-9**] from rehab with fever and neutropenia. She was
admitted to the intensive care unit, was pan cultured, PICC line
was placed, and started on cefepime and vancomycin. Her fevers
resolved and transferred to medical floor. Her [**6-9**] blood
culture grew staph aureus and her initial broad spectrum abx
were eventually narrowed to nafcillin. She was then taken off
tylenol to monitor for fevers which she spiked for 4 days. A
work-up for infectious source was completed including surface
echocardiogram, CT scan, and numerous blood and urine cultures
followed. Evidence for PCP pneumonia arose from ground-glass
opacity on CT, positive beta-glucan, and recent steroid taper.
We were not able to collect sputum for definate diagnosis of PCP
pneumonia but the suspicion was high enough for emperic
treatment. Infectious Disease followed her and she was started
on bactrim with a defined course and nafcillin continued for a
defined course for possible endocarditis. Upon discharge she
was afebrile and hemodynamically stable. Detailed information
with guidelines by problem:
FACTOR 8 INHIBITOR: pt was followed by heme/onc throughout her
course and cytoxan and rituximab were held with steroid dose
continued; no bleeding complications were noted and PTT remained
elevated but stable. GUIDELINE: if pt bleeds significantly at
rehabilitation facility she will need activated factor VII at
[**Doctor First Name **]-[**Country **] so immediate transfer should occur, on the way to
[**Doctor First Name **]-[**Country **] please begin blood transfusion and isotonic fluid
repletion to maintain hemodynamics until arrival. If DDAVP is
available it can also be given in the case of mild-moderate
bleed while waiting for a transfer.
ACUTE RENAL FAILURE: the pt experienced contrast induced
nephropathy from CT scan which showed downtrend (Cr 1.8 -> 1.3).
Her lisinopril and torsemide are currently being held due to
this issue and future medications should be renally dosed.
GUIDELINE: a component of intrinsic renal dysfuction may be due
to interstitial nephritis from bactrim and/or nafcillin.
Therefore, her creatinine needs to be monitored and if it
continues to rise please call her Infectious Disease doctor
([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 457**]) before considering changing
these antibiotics.
ELEVATED AST/ALT: this may be due to her PCP pneumonia and/or
nafcillin. A typical nafcillin hepatotoxicity presentation is
one of cholestatic injury with elevation of alkaline phosphatase
and total bilirubin which is not her current picture. Her liver
function tests should be monitored and in the event of increase
please call her Infectious Disease doctor ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 457**]) before considering changing antibiotics. An
increase in AST and/or ALT of 2x the upper normal limit can be
tolerated with her current antibiotic regimen. She has history
of Hep B vaccination with positive HBsAb and negative HBsAg. Her
elevated LFT's were noted during the first hospitalization and
she had negative testing for autoimmune hepatitis including [**Doctor First Name **],
AMA, and IgG level. On CT, the gallbladder was distended and
contained multiple layering gallstones, but there was no
evidence of abnormal gallbladder wall thickening or
pericholecystic fluid. There was no intra- or extra-hepatic
biliary ductal dilation. She had no clinical cholecystitis. We
recommend that her LFT's be monitored frequently, Nafcillin be
stopped if she developed a picture consistant with nafcillin
toxicity (usually cholestatic hepatitis), and get U/S if she
develop symptoms or signs consistant with cholecystitis.
T2DM: her morning and afternoon blood sugars were in the 70's
near her time of discharge and her insulin SC bedtime doses were
decreased.
Total discharge time 89 minutes
Medications on Admission:
Prednisone 60 mg daily
Multivitamin 1 tab daily
Vitamin D3 400 unit daily
Simvastatin 40 mg daily
Omeprazole 20mg before breakfast
Acetaminophen 1g Q12H PO
Clonidine 0.2mg Q8H PO
Colace 100mg [**Hospital1 **]
Cyclophosphamide 225mg daily
Toprol XL 100 mg daily
Torsemide 20 mg daily
Trazodone 25 mg qhs prn
Calcium Carbonate 500 mg tid
Senna 2 tabs daily PO
Sorbitol 70% 30ml PO PRN constipation
Bisacodyl 10mg PR PRN constipation
Amlodipine 10 mg daily
Bacitracin oint Daily to skin tear on left arm
Zofran 4 mg IV q8h prn
Lantus 36 units qam
Eucerin cream daily
Insulin Aspart SSI (see order)
Lantus 34 units at breakfast
Zofran 8 mg tab prior to cyclophosphamide
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
14. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily): hold for loose stools.
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection every eight (8) hours as needed for nausea.
16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) for 16 days: Last day [**7-9**], then
switch to 1 single strength tab daily.
17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 5 days: for vulvovaginitis.
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. Nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous
every four (4) hours for 5 weeks: Last day [**7-21**].
21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for candidiasis.
22. Insulin Glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous QAM.
23. Insulin Lispro 100 unit/mL Solution Sig: Per attached
sliding scale units Subcutaneous QACHS.
24. Outpatient Lab Work
Please check weekly labs each Monday with: CBC and
differential, AST, ALT, T. bili, Alk Phos, BUN, Creatinine, ESR
and CRP. Fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Infectious
diseases clinic at [**Telephone/Fax (1) 432**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Final diagnoses:
Bacteremia
febrile neutropenia
PCP pneumonia
acute renal failure
vulvovaginitis
acquired factor VIII inhibitor
acute blood loss anemia
Secondary diagnoses:
Type 2 Diabetes Mellitus
Hypertension
Osteoarthritis
Discharge Condition:
Vital signs stable. Afebrile x >3 days. Ambulating only with
assistance from physical therapy. Tolerating PO.
Discharge Instructions:
You were admitted with fever in the setting of neutropenia. You
were found to have bacteria in your blood and were treated with
antibiotics. You experienced fever during your course and were
found to have Pneumocystis carinii pneumonia and put on
appropriate antibiotics.
You had a CT of your pelvis which revealed an incidental finding
of a pelvic cyst, we recommend that you pursue a non-urgent
pelvic ultrasound as an outpatient to further characterize this
finding.
The following changes were made to your medications:
- You were discharged on Nafcillin 2 g IV Q4H. This should be
taken for 6 weeks (start [**6-9**], end: [**7-21**])
- You were discharged on Ondansetron 4 mg IV Q8H: as needed for
nausea while you are taking Bactrim
- You were discharged on Sulfameth/Trimethoprim DS 2 TAB PO Q6H
to be taken for 21 days (start: [**6-19**], end: [**7-3**]). Once this is
completed you should transition to 1 single strength (SS) tablet
daily while on steroids, please discuss this with your doctor.
- You were discharged on Ferrous Sulfate 325 mg PO DAILY
- Your torsemide has been held while your kidney function has
been impaired, discuss restarting this with your doctor when
your kidney function returns to normal.
- Your cyclophosphamide is on hold indefinitely, discuss
restarting this with Dr. [**Last Name (STitle) 3060**].
-Your insulin sliding scale was slightly adjusted as your blood
sugars were on the low side.
Please follow up with your hematologist Dr. [**Last Name (STitle) 3060**] and your
infectious disease doctor Dr. [**Last Name (STitle) **] as indicated below. Call
your doctor or return to the emergency room if you experience
brisk bleeding, fever >100.4 degrees, chest pain, shortness of
breath, or for any other concerning symptoms.
Followup Instructions:
You have the following appointment scheduled:
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2184-7-21**] 11:00
Please follow up with your hematologist Dr. [**Last Name (STitle) 3060**] within 2 weeks
of hospital discharge [**Telephone/Fax (1) 96736**].
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
within 1 month [**Telephone/Fax (1) 14751**].
|
[
"278.00",
"715.90",
"250.90",
"038.11",
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"272.4",
"780.61",
"585.3",
"584.9",
"136.3",
"997.5",
"286.0",
"285.1",
"288.00",
"403.90",
"V58.67",
"112.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14292, 14389
|
7077, 11060
|
295, 316
|
14660, 14774
|
3088, 3093
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16592, 17095
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2563, 2581
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11777, 14269
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14410, 14410
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11086, 11754
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14798, 16569
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2596, 3069
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14584, 14639
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14427, 14563
|
250, 257
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5601, 5601
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344, 1890
|
5624, 7054
|
3108, 5581
|
1912, 2285
|
2301, 2547
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
797
| 100,863
|
1154
|
Discharge summary
|
report
|
Admission Date: [**2139-8-24**] Discharge Date: [**2139-8-29**]
Date of Birth: [**2096-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever and HA
Major Surgical or Invasive Procedure:
IJ catheter placement
History of Present Illness:
42M with h/o HIV/AIDS, last CD4 312 [**2139-8-20**] and h/o bacterial
and crytopcoccal meningitis presents to ED with complaint of
fever to 101-102 and HA over the last seven days. HA is new,
gradual in onset, steady and unremitting in intensity. He rates
pain at worst between [**2144-8-3**]. States he had taken taken tylenol
initially for relief but has since been ineffective. Evaluated
by PCP 3 days PTA, no intervention at that time except
recommendation to return to ED if HA persisted. Pt endorses mild
photophobia nad neck stiffness, no other symptoms. No chills, no
n/v, no CP or SOB, no urinary changes except "dark urine." In
ED, CT negative, LP also essentially negative (Protein and
glucose normal, tube 4 with 2 WBC and no RBC, 88% lymphocytes).
Transient hypotension in ED, predominantly 90/50s, eventual
response to fluid. Received 2g CTX and 1g Vanco in ED, as well
as 6 liters NS. Admitted to MICU under MUST protocol, initial
lactate 5.0.
Past Medical History:
1. HIV/AIDS, last CD4 312, nadir 135 in [**2136**]
2. hepatitis B
3. hepatitis C
4. pancytopenia [**1-28**] HIV, baseline hct 35 and baseline plt 80
5. distant h/o cryptococcal menigitis
6. distant h/o bacterial menigitis
7. distant h/o e.coli sepsis
8. h/o STI including chlamydia, molluscum, herpes
9. h/o PSA
10. h/o oral candidiasis
11. s/p L herniorrhaphy
Social History:
Uses tobacco, approximately 1 pack weekly, denies alcohol or
IVDU currently. Pt is currently unemployed but was a former
airline analyst. Lives with roommate.
Family History:
NC
Physical Exam:
T 101.5 in ED, 96.5 in MICU BP 120/66 HR 92 RR 15 Sats 100%
RA
Gen: Pt lethargic but appears ok, NAD
HEENT: ncat, perrla, eomi, conjunctiva non-injected, sclerae
with mild icterus
CV: rrr s mrg, flat neck veins
Lungs: CTAB, good air movement
Abd: sntnd, +bs, no hsm appreciated.
ext: 2+ ble pulses, no peripheral edema. 1-2 cm purplish
blanching lesions on BLE that are chronic, appear c/w chronic
venous stasis change
Neuro: AO x 3, MAE, neuro grossly intact
Pertinent Results:
[**2139-8-24**] 11:04PM LACTATE-2.7*
[**2139-8-24**] 10:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-25
GLUCOSE-56
[**2139-8-24**] 10:30PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-0
LYMPHS-88 MONOS-6 MACROPHAG-6
[**2139-8-24**] 10:10PM LACTATE-3.4*
[**2139-8-24**] 09:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2139-8-24**] 09:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-MOD
[**2139-8-24**] 09:30PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2139-8-24**] 05:39PM LACTATE-5.0*
[**2139-8-24**] 05:32PM GLUCOSE-125* UREA N-50* CREAT-3.7*#
SODIUM-120* POTASSIUM-5.0 CHLORIDE-85* TOTAL CO2-22 ANION GAP-18
[**2139-8-24**] 05:32PM ALBUMIN-2.5* CALCIUM-8.3* PHOSPHATE-2.0*
MAGNESIUM-1.6
Brief Hospital Course:
A/P 42M with h/o HIV/AIDS, hep b and c, distant h/o cryptococcal
and bacterial meningitis with UTI, septic shock, likely
secondary to urinary source. Also with resolving hyponatremia,
ARF, metabolic acidosis, anemia, concerning mental status
changes, new abdominal distension.
.
1. Septic Shock:
Patient with SIRS plus suspected source of infection given UA,
hypotension and evidence of inadequate end-organ perfusion.
Initial WBC in ED 24.0, lactate 5.0. Blood/urine cx growing
E.coli, pansensitive to antibiotics. LP in the ED was negative
for infxn. Pt was admitted to ICU, administered aggressive NS
IVF hydration, given Vanco/CTX for empiric Abx coverage until
E.Coli was isolated, and vanco was discontinued. Pt was
discharged on a course of cefpodoxime to complete a 14 day
course for E.Coli bacteremia.
.
2. Hyponatremia:
Due to infxn and hypovolemia, corrected with IVF hydration.
.
3. Mental status changes:
Initially seen in MICU in setting of infection, long-term HIV
and rapid sodium correction and liver disease. LP was negative
for infxn. Resolved with treatment of infection.
.
3. ARF:
Pre-renal in etiology given patient's hypovolemic and
distributive picture, but differential includes HRS. FeNa 0.9%,
which does not help in differenting prerenal vs. HRS. Creatinine
trended down during admission from 3.7 ---> 1.8 on discharge to
be followed up as an outpatient. His previous baseline had been
0.9-1.2.
.
4. Anemia:
Hct stable 27.4 today (27.1 yest). Slow to return to baseline
36-37.
.
5. HIV:
Pt with h/o HIV, hepatitis. Initially HAART held due to
metabolic acidosis in setting of ARF and sepsis. HAART was
restarted prior to discharge once patient was stable and
infection was under treatment. Pt with elevated
.
6. Hepatitis
Pt with Hx of Hep B/C, during this admission found to have
elevated AFP, but patient declined further w/u at this time. Pt
to consider MRI as outpatient to r/o HCC. No mass seen on abd
u/s.
.
DISPO
- Full Code. Pt to f/u with Dr. [**Last Name (STitle) 4844**] as an outpatient.
Medications on Admission:
1. ABACAVIR SULFATE 300MG [**Hospital1 **]
2. BACTROBAN 2%--Apply to open sore twice a day
3. EFAVIRENZ 600MG QHS
4. LAMIVUDINE 300MG q day
5. NADOLOL 30 MG daily
6. PROTONIX 40 mg po BID
7. TEMAZEPAM 15MG prn QHS
8. TENOFOVIR 300MG po daily
9. TOBRADEX 0.3-0.1%--Two gtts each eye twice a day
10. ZOLOFT 50 mg po daily
Discharge Medications:
1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Tobramycin Sulfate 0.3 % Drops Sig: Two (2) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*0*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO every other day.
Disp:*15 Tablet(s)* Refills:*0*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
11. Nadolol 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: E.coli bacteremia/sepsis from urinary source
Secondary: HIV, hepatitis B, hepatitis C
Discharge Condition:
Stable, afebrile >48 hours. Ambulating without difficulty.
Discharge Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 4844**] in 1 week. Please call
([**Telephone/Fax (1) 1300**] to schedule a follow up.
.
2. Take the medications as directed below.
.
3. If develop urinary pain or burning, fevers or chills,
temperature >101, lightheadedness, or any symptoms, please call
Dr. [**Last Name (STitle) 4844**] or proceed to the nearest ER.
Followup Instructions:
1) Primary Care
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-10-19**] 6:40
- your blood pressure has been high during your hospital course.
This should be monitored closely as an outpatient.
2) Renal
Please call to schedule an appointment with Dr. [**Last Name (STitle) 4090**] at [**Last Name (un) **]
([**Telephone/Fax (1) 7403**]) to be seen within 2 weeks following discharge
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2140-5-4**]
|
[
"599.0",
"785.52",
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"584.9",
"276.2",
"287.5",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6944, 6950
|
3245, 5283
|
328, 352
|
7089, 7151
|
2424, 3222
|
7569, 8210
|
1921, 1925
|
5654, 6921
|
6971, 7068
|
5309, 5631
|
7175, 7546
|
1940, 2405
|
276, 290
|
380, 1342
|
1364, 1727
|
1743, 1905
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,088
| 168,233
|
47162
|
Discharge summary
|
report
|
Admission Date: [**2107-1-29**] Discharge Date: [**2107-2-10**]
Date of Birth: [**2029-7-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
77 year old male,recently discharged from [**Hospital1 18**] for CHF
exacerbation,thought to be due to to urosepsis(e.coli). His stay
was complicated by GI bleed, resulting in demand ischemia. He
was discharged to a nursing home on ceftriaxone. This time, the
patient presented to [**Hospital 4068**] Hospital on [**1-28**] with dyspnea,
diaphoresis, hypoxia, telemetry showed supraventricular
tachycardia (aflutter vs fib. He was intubated for airway
protection and transferred to [**Hospital1 18**] CCU for further care. He was
noted to have a both an elevated WBC >16 and a metabolic
acidosis, though in the setting of acute renal failure.
In the CCU pt recieved Azithromycin and Ceftriaxone for presumed
community aquired pneumonia and was extubated in [**5-10**] hours after
intubation. He was on heparin for ~24 hours as he ruled in for
an MI by enzymes. He was monitored in the unit for 24 hours and
transferred to medical floor on [**2107-1-30**].
Past Medical History:
1.CAD: S/p 3V CABG '[**96**], PCI to RCA '[**02**], PCA instent stenois seen
on cath [**8-8**], patent grafts
2. HTN
3. Hyperlipidemia
4. CHF EF 40%, [**2-6**]+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**] [**8-8**]
5. PVD: S/p L aorto-fem bypass
6. Hx of TB with LLL resection in [**2062**]
7. Lymphoma s/p XRT
8. Parkinsons Disease
9. Vascular Dementia
10.Depression
11.Diverticulosis
12.BPH
Social History:
SH: [**Location (un) 1036**] NH resident. Divorced, estranged from children,
sister is contact person.
Family History:
NC
Physical Exam:
PE: Tc: 98.9; Tm: 99.0; BP: 122/53 (84-140/40-60); P: 102
(80-112)
RR:15; O2: 94% RA; I/O 671/585
Gen: Elderly male laying in bed in NAD. Answers simple yes/no
questions
HEENT: Mucuous membranes slightly dry
Neck: No JVD.
CV: RRR S1S1. Distant. +S3. ?I/VI systolic LUSB
Lungs: right base: bronchial sounds. Left [**Last Name (un) **] bronchial sounds
throughout. No crackles.
Abd: +BS. Soft, NT, ND.
Rectal: No masses seen. Grossly enlarged prostatate. TRace guaic
positive stool.
Ext: No edema. DP 2+ b/l.
Neuro: Knows he is in [**Location (un) **]. Not sure where he is. does not
know date. Knows his name. Strength 5/5 upper extremities.
Brachioradialis and biceps reflex [**3-9**] b/l.
Pertinent Results:
LABS ON DISCHARGE:
Hct 30 (baseline)
WBC = 9
INR 1
Glucose-79 UreaN-11 Creat-0.9 Na-143 K-3.9 Cl-109* HCO3-28
AnGap-10
Vanc trough 17.4 (goal >10) ([**2107-2-7**])
lactate 1.5
Cardiac Labs:
CK 185, 587, 257, 80, 67
TnT 0.67, 2.25
CKMB 22, 82, 21, 5
[**Month/Day/Year **]
LA 4x3cm
LV septum 1.5cm
LVEF 45% with mild global HK
E/A ratio 0.57
E wave decel 260ms
TR gradient = 31mmHg (<25) - indicating pulmonary hypertension
Radiology
CXR [**2107-1-29**]- AP FINDINGS: The patient has been intubated in the
interval, with endotracheal tube 2.5 cm above the carina. Median
sternotomy sutures are again seen, with mediastinal clips.
Allowing for rotation, the lungs are probably minimally changed
in appearance. Prominent lung markings are on the left, which
may be chronic vs representing edema/infection. There appears to
be a layering left- sided pleural effusion, most prominent at
the left apex, possibly combined with pleural thickening. There
has been some volume loss on the left. No evidence of
pneumothorax.
[**Month/Day/Year **] [**2107-2-1**]-Conclusions:
The left atrium is mildly dilated. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed. Resting regional wall motion abnormalities include
inferior and inferoseptal hypokinesis. Right ventricular chamber
size is normal. Right ventricular systolic function is normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-6**]+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
No vegetation seen (cannot exclude).
Compared with the prior study (tape reviewed) of [**2106-8-23**], left
ventricular systolic function the anterior wall motion now
appears improved and the inferior wall appears similar.
Chest PA/Lat [**2107-1-31**]-IMPRESSION:
1. Apparent diffuse opacification of the left hemithorax, likely
secondary to rotation and technique. However, a layering
effusion or other acute process is difficult to exclude.
Followup radiographs could help clarify this. No evidence of
focal pneumonia.
2. Stable left-sided volume loss and pleural thickening.
Brief Hospital Course:
1. Shortness of breath- Pt was intubated for SOB at OSH and
transferred to the CCU. His attending cardiologist felt that
his primary cause of SOB and tachycardia was not cardiac in
origin but more related to an infectious etiology. There he was
diuresed with an improvement in his SOB and started on Levaquin
and vancomycin. He was quickly extubated and transfered to the
floor. His SOB was likely secondary to worsening heart failure
related to his underlying infection (tracheo bronchitis) as well
as his acute MI in the setting of demand ischemia. On physical
exam initially, there were no signs of CHF, though he did
receive lasix at the OSH with some improvement.
Pneumonia was unlikely. On CXR initially, a stable left lower
opacity was seen, thought to be related to an old resection for
TB. CT edmonstrated no consolidation. Sputum grew out MRSA with
oral flora. This may be the etiologic agents or may represent
colonization as pt lives in nursing home. Aspiration as a cause
for his tracheobronchitis is very possible. He has severe
Parkinson's Disease and becomes extreemly rigid when missing his
Sinemet giving him a profound aspiration risk. He remained
afebrile throughout his hospital course and his white count on
admission was decreased from previous measurements at the OSH.
He was treated with a 14 day course of vancomycin and levaquin
to cover the organisms. He has a PICC line and will only need
an additional 5 days of vanc after leaving the hospital. This
will need to be removed once he has completed his treatement
course and sent for cultures.
2. Coronary Artery Disease and [**Name (NI) **] Pt with LBBB on EKG that is
old. He is S/p CABG with 3 VD. He ruled in for an MI with a peak
CK of 560. His hsopital course was not comlicated by arrythmias
and he was aggresively treated with beta blockers, plavix, asa,
ACE inhibitor, and statin. His MI occured in the setting of
demand ischemia due to his infection and atrial tachycardia.
There is a questionably history of atrial fibrillation though
this was never demonstarted on ECG.
Pt was rate controlled with beta blocker. He was initially on IV
lopressor and once NGT was placed, metoprolol was titrated up to
***
We continued ASA, statin, beta blocker, and plavix.
3. Acute renal failure/hypernatremia-
Creatinine was 1.4 on admission and improved to *** with
hydration. Pt was hypernatremic on admission to the medicine
floor to 147. He was repleted with free water as hypernatremia
improved.
4.History of GIB
Pt has a history of LGIB on last admission. It may be from from
diverticulosis, though pt did not have his Outpt colonoscopy as
of yet. Hematocrit was stable throughout the hospital course.
T&S was active and rectal guaic was trace positive. Pt was kept
on a PPI.
5. Tachycardia
Pt tachycardic previously now in 80-100s. Likely atrial
tachycardia vs. flutter. Mr. [**Known lastname 99933**] was rate controlled with
metoprolol which was titrated up.
6. F/E/[**Name (NI) **] Pt was seen to be a great aspiration risk. NGT was
placed on transfer to the medicine floor but pt pulled it.
Several attempts were made the next day but placement was
difficult as twice it went to the lungs and other times it was
difficult to place secondary to nasal anatomy. Pt had NGT placed
under fluoroscopy on HD#4. He was started on tube feeds and
nutrition saw pt. Near discharge, he passed his vdeo swallow
with the following recommendations:
**Pureed solids, thin liquid diet . MUST HAVE 1:1 assistance
throughout the full meal per S&S recommendations. Also,
aspiration precautions including chin tuck to chest, take sip
from straw and swallow 2 times take a bite, tuck chin to chest
and swallow. alternate between bites and sips.
**Tube Feeds: ultracal Cycle at 120cc/hr for 16hrs (4pm to 8am
or whatever is convenient). Keep head of bed up at 35 degrees
during tube feeds. Give free water boluses 150cc every QID.
.
7. Hypertension
BP was well controlled on beta blocker.
8. Parkinsons Disease
Continued Carbidopa-Levodopa (25-250) 1 tab tid.
9. Accessright picc line.
Medications on Admission:
sinemet dose ?
plavix
imdur 30
lasix ? 40mg
lipitor 40
metoptolol 50mg [**Hospital1 **]
lisinopril 5mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*90 * Refills:*2*
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO DAILY (Daily).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
7. Lansoprazole 30 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*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO twice a day: for total dose of
150 mg [**Hospital1 **].
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO twice a day: for total dose of
150mg [**Hospital1 **].
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Vancomycin HCl 500 mg Recon Soln Sig: 1.5 500 mg recon soln
for total dose of 750mg Intravenous once a day for 5 days: last
dose to be given [**2107-2-13**].
Disp:*8 500 mg recon soln* Refills:*0*
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: per PICC flush
protocol.
Disp:*qs ML(s)* Refills:*3*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary:
NSTEMI
SVT
MRSA tracheobronchitis
Parkinson's Disease
Discharge Condition:
good to rehab for IV Abx therapy
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters daily
Note new medications - see med sheet
Followup Instructions:
contact your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10145**], phone
[**Telephone/Fax (1) 10573**] within 1-2 weeks of your hospital discharge. He
will need to arrange for your PICC line to be removed and the
tip cultured.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"427.89",
"202.80",
"V12.01",
"V45.81",
"041.11",
"V45.82",
"440.31",
"507.0",
"276.0",
"428.0",
"562.10",
"290.40",
"437.0",
"490",
"410.71",
"V09.0",
"311",
"584.9",
"518.82",
"332.0",
"401.9",
"272.4",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10974, 11051
|
5008, 9079
|
333, 345
|
11158, 11192
|
2629, 2629
|
11414, 11810
|
1900, 1904
|
9235, 10951
|
11072, 11137
|
9105, 9212
|
11216, 11391
|
1919, 2610
|
274, 295
|
2648, 4985
|
373, 1333
|
1355, 1764
|
1780, 1884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,537
| 143,560
|
38953
|
Discharge summary
|
report
|
Admission Date: [**2199-4-24**] Discharge Date: [**2199-5-31**]
Date of Birth: [**2153-10-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
Bone marrow biopsy
Central line placement
History of Present Illness:
45 F with no PMH presented with 2 wks fatigue and malaise. Over
past week got bruising on legs so went to go see PCP. [**Name10 (NameIs) 34887**] was
grossly abnormal with leukocytosis, anemia, and
thrombocytopenia.
She was sent emergently to the ER.
.
REVIEW OF SYSTEMS:
She denies headaches, blurred vision, confusion, drowsiness,
ankle edema, chest pain, palpitations, subjective fevers,
chills,
or rigors. She did note an episode of dyspnea while getting out
of the shower the other day. She has had increasing petechiae
and ecchymoses over the past week. She has also had some
gingival bleeding when brushing her teeth as well as some light
vaginal spotting over the past few days (last menstrual period
was over 6 months ago); she denies epistaxis. Otherwise, a
complete review of systems was obtained and is negative except
as
noted above.
Past Medical History:
None
Social History:
She lives with her parents. She was born in
[**Location (un) 6847**] but grew up in the [**Location (un) 86**] area. She is a lifelong
non-smoker and denies heavy alcohol use. She works in
information technology.
Family History:
She has a brother and a sister, both of whom are
healthy. She does not have children. She denies any known
history of malignancy or hematologic disorders in her family.
Physical Exam:
T 98.6 BP 102/66 HR 83 RR 18 Sat 96% on room air
GENERAL: anxious young woman in no acute distress
HEENT: no scleral icterus; (+) conjunctival pallor; no oral
ulcers, plaques, or thrush; pupils equal, round, and reactive to
light; extraocular movements intact
NECK/LYMPH: supple; no lymphadenopathy appreciated in
anterior/posterior cervical, supra-/infraclavicular, or
preauricular regions
CV: regular rate/rhythm, normal s1 and s2, no murmurs
CHEST: clear to auscultation throughout; no wheezes, rales, or
ronchi
ABDOMEN: soft, nontender, nondistended, normal bowel sounds, no
hepato-/splenomegaly
EXTR: warm, no edema, 2+ DP pulses
SKIN: scattered petechiae over her back and all four
extremities;
small ecchymoses on both legs; no jaundice
NEURO: alert and oriented x3, CN 2-12 intact, 5/5 strength
throughout all four extremities
ECOG: 1
Pertinent Results:
Labs on Admission:
[**2199-4-25**] 12:00AM BLOOD WBC-92.2* RBC-1.95* Hgb-6.6* Hct-19.7*#
MCV-101* MCH-34.0* MCHC-33.7 RDW-18.1* Plt Ct-119*#
[**2199-4-24**] 04:00PM BLOOD Neuts-4* Bands-0 Lymphs-8* Monos-1* Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0 Other-86*
[**2199-4-24**] 04:00PM BLOOD PT-13.7* PTT-25.8 INR(PT)-1.2*
[**2199-4-24**] 04:00PM BLOOD Fibrino-574*
[**2199-4-29**] 03:28AM BLOOD Gran Ct-2706
[**2199-4-24**] 04:00PM BLOOD Glucose-139* UreaN-18 Creat-1.3* Na-138
K-3.8 Cl-98 HCO3-25 AnGap-19
[**2199-4-24**] 04:00PM BLOOD ALT-72* AST-106* LD(LDH)-3280* AlkPhos-81
TotBili-0.8
[**2199-4-24**] 04:00PM BLOOD Lipase-40
[**2199-4-24**] 04:00PM BLOOD Albumin-4.7 Calcium-9.2 Phos-4.4 Mg-2.1
UricAcd-9.3*
[**2199-4-25**] 05:56PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2199-4-25**] 05:56PM BLOOD HCG-LESS THAN
[**2199-4-24**]
Bone marrow Biopsy:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
Involvement by ACUTE MYELOID LEUKEMIA, see note.
Note:
By morphology this would be best classified as AML with minimal
maturation (FAB-AML subclass M2). Background dysplasia is noted,
and correlation with clinical and cytogenetic findings is
recommended to assess for an antecedent myelodysplastic process.
Correlation with clinical, cytogenetics and molecular findings
is necessary for exact WHO subclassification.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are decreased
in number, normochromic, and exhibit anisopoikilocytosis
including ovalocytes, microcytes are rare dacryocyte. Numerous
(8 per 100 WBCs) nucleated red cells, including some with
asymmetric nuclear budding are noted. Polychromatophils and
cells with coarse basophilic stippling are also seen. The white
blood cell count appears increased. Pelgeroid hypogranular
neutrophils are seen. Platelet count appears decreased; large
forms are seen; giant forms are not present.
Differential count shows 1% neutrophils, 2% monocytes, 15%
lymphocytes, 80% blast, 2% myelocytes. Blasts have scant amount
of cytoplasm, high nuclear-to-cytoplasmic ratio, large
round-to-oval nuclei with prominent nucleoli. Occasional cells
with cytoplasmic granules and occasional vacuoles are seen.
Aspirate Smear:
The aspirate material is adequate for evaluation and consists of
abundant cellular spicules. The M:E ratio is 0.6:1. Erythroid
precursors are decreased with dyspoietic maturation; forms with
irregular nuclear contour and asymmetric nuclear budding are
seen. Myeloid precursors appear markedly increased in number
and consists predominantly of blasts. Megakaryocytes are not
seen.
Differential shows: 60% Blasts, 1% Promyelocytes, 3% Myelocytes,
6% Bands/Neutrophils, 1% Plasma cells, 12% Lymphocytes, 17%
Erythroid.
Blasts are morphologically similar to those seen in the
peripheral smear. Occasional clusters of plasma cells are seen.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. It is a 1.5 cm
core biopsy consisting of trabecular bone and marrow material.
The cellularity is greater than 90% and consists predominantly
of a population of immature cells with a moderate amount of
eosinophilic cytoplasm, round to oval nuclei, high nuclear to
cytoplasmic ratio and prominent nucleoli. The immature cells
occupy greater than 80% of marrow cellularity.
Erythroid precursors are markedly decreased and show atypical
forms with irregular nuclear membrane and asymmetric nuclear
budding. Maturing myeloid precursors are markedly decreased.
Megakaryocytes are markedly decreased.
A small non-paratrabecular lymphoid aggregate comprised of small
lymphocytes is present and accounts for less than 5% of the
marrow cellularity.
Marrow clot section is similar to the biopsy.
Touch prep is similar to the aspirate.
Special Stains:
Iron stain is adequate for evaluation. Storage iron is
decreased. Sideroblasts are present many with increased
siderotic granules. Ringed sideroblasts are absent.
[**2199-4-24**]
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR,
Glycophorin A, Kappa, lambda; and CD antigens 2, 3, 4, 5, 7, 8,
10, 11c, 13, 14, 15, 19, 20, 33, 34, 41, 45, 56, 64, 71, 117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield.
Cell marker analysis demonstrates that the majority of the cells
isolated from this bone marrow are in the CD45-dim, low
side-scatter 'blast' region. They express immature antigens
CD34, HLA-DR (subset; 56%) along with myeloid associated
antigens CD33, CD117, CD11c (subset, dim) and CD71. They
additionally co-express CD7 (dim). A minor subset (17%) dimly
co-express CD19. They lack other B and T cell associated
antigens, are CD10 (cALLa) negative and are negative for CD13,
CD14, CD15, CD56, CD64, and Glycophorin A. Blast cells
comprise 65% of total events.
Lymphoid cells comprise 4% of total gated events. B cells
comprise 10% of lymphoid-gated events, are polyclonal, and do
not express aberrant antigens. T cells comprise 65% of
lymphoid gated events and express mature lineage antigens, and
have a helper-cytotoxic ratio of 102 (usual range in 0.7-30).
INTERPRETATION
Immunophenotypic findings consistent with involvement by an
acute myeloid leukemia.
CYTOGENETICS
KARYOTYPE: 46,XX[15]
INTERPRETATION:
This karyotype is characteristic of a chromosomally
normal female.
No clonal cytogenetic aberrations were identified
in metaphases analyzed from this unstimulated
specimen. This normal result does not exclude a
neoplastic proliferation.
Small chromosome anomalies may not be detectable
using the standard methods employed.
CT CHEST [**2199-5-24**]
There is airspace consolidation seen within the left lower lobe,
is concerning
for newly developed pneumonia. The remainder of the lungs remain
well
aerated. No pleural effusions or evidence of pneumothorax. No
discrete
pulmonary nodules. The tracheobronchial tree is patent to the
subsegmental levels.
The patient is noted to be status post bilateral central venous
catheter
placement with tips terminating within the cavoatrial junction.
The heart and great vessels are otherwise unremarkable on this
non-contrast examination.
Multiple scattered mediastinal and axillary lymph nodes without
pathological enlargement.
This examination is not tailored for subdiaphragmatic
evaluation. The
visualized portions of the abdomen are unremarkable.
BONE WINDOWS: The visualized osseous structures are unremarkable
with no
suspicious lytic or sclerotic foci.
IMPRESSION: Patchy left lower lobe airspace consolidation,
consistent with pneumonia.
MR right ankle [**2199-5-7**]:
IMPRESSION:
1. No evidence of right ankle hemarthrosis.
2. Moderately severe subcutaneous edema diffusely throughout the
right ankle,
extending proximally beyond the field of view, and into [**Last Name (un) 22044**]
fat pad.
3. Slight edema at the central/medial talar dome is compatible
with small
area of osteochondral injury.
4. Minimal tibialis posterior tenosynovitis.
[**2199-5-24**]: Bone Marrow Biopsy:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
HYPOCELLULAR ERYTHROID DOMINANT MARROW FOR AGE WITH LEFT SHIFTED
MYELOPOIESIS. NO MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY ACUTE
LEUKEMIA SEEN. SEE NOTE.
Note: By immunohistochemistry with CD34 blasts account for less
than 5% of the cellularity. CD68 highlights large collections
of maturing neutrophils and monocytes. A large subset of these
cells is immunoreactive for myeloperoxidase. CD3 and CD20 stains
scattered small T and B lymphocytes, respectively. The
immunophenotypic findings support the morphological impression
of regenerating bone marrow.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased in number and are overall normocytic and normochromic
with occasional elliptocytes present. The white blood cell
count appears markedly decreased. Platelets are markedly
decreased. Large forms are not seen. Giant forms are not
present. Differential count shows 4% monocytes, 96%
lymphocytes.
Aspirate Smear:
The aspirate material is adequate for evaluation. The M:E ratio
is 0.6:1. Erythroid precursors are increased and show
megaloblastoid maturation. Myeloid precursors appear decreased
and show left-shifted maturation. Megakaryocytes are present
in decreased numbers; abnormal forms are not seen. Differential
(300 cells) shows: 1% Blasts, 2% Promyelocytes, 15%
Myelocytes, 7% Metamyelocytes, 2% Bands/Neutrophils, 5% Plasma
cells, 8% Lymphocytes, 56% Erythroid.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation and consists of a
1.3 cm core biopsy of trabecular bone with a variable
cellularity ranging from 5-20%, overall 10%. There is bony
remodelling with focal marrow fibrosis. The M:E ratio estimate
is decreased. Erythroid precursors are increased and exhibit
megaloblastic maturation. Myeloid elements are decreased and
exhibit left-shifted maturation. Megakaryocytes are present in
normal number and seen in focal loose clusters. A small
paratrabecular lymphoid infiltrates comprised of small
lymphocytes is present and account for <5% of the marrow
cellularity. There is interstitial infiltrate of plasma cells
occurring in small clusters occupying <5% of marrow cellularity.
Marrow clot section contain to few spicules for evaluation.
Brief Hospital Course:
45 year old woman with acute myelogenous leukemia presents for
initiation of chemotherapy.
# AML: Patient with low grade fever, ecchymoses, petichiae, and
a marked leukocytosis >160K on presentation. Bone marrow biopsy
was consistent with an acute myeloid leukemia with normal
cytogenetics so she was treated initially with Hydroxyurea and
then with [**Doctor First Name **]/Ara-C 7+3. She tolerated the regimen well without
evidence of tumor lysis. She was initially placed on
Allopurinol, but this was discontinued after her chemotherapy
was complete as she had no evidence of high or rapidly changing
urate levels. A bone marrow biopsy on day 14 and day 28
demonstrated a clean bone marrow. She will follow-up with her
oncologist Dr. [**Last Name (STitle) 410**] upon discharge.
# Bilateral LL PNA: On admission, the patient was febrile and a
CXR demonstrated a left lower lobe pneumonia, so she was placed
on Cefepime & Vancomycin. She was sat'ing well on RA until
hospital day 2 when she was noted to asymptomatically desaturate
to the low 90's on room air. Overnight, after beginning IVF's
with chemotherapy, she developed an oxygen requirement that
progressed to a NRB and she required a brief transfer to the
[**Hospital Unit Name 153**] for hypoxia. Imaging at that time demonstrated evidence of
a bilateral lower lobe pneumonia with pulmonary edema. She
responded immediately to IV Lasix therapy and returned to
sat'ing well on RA. She returned to the BMT floor without
additional hypoxia.
# Ankle pain: On admission, the patient noted some right ankle
discomfort with difficulty with plantar and dorsiflexion. Plain
films were negative. Rheumatology was consulted and attempted
arthrocentesis of her ankle that did not yield joint aspirate
and resulted in an ecchymoses. The ankle continued to be tender
so an MRI was obtained that demonstrated no hemoarthrosis, only
edema and some mild tenosynovitis. Orthopaedic surgery was
consulted and recommended only supportive care. With elevation
and multipodus boots, the ankle improved and the patient
regained full range of motion and ability to ambulate.
# Rash: Patient developed acral erythema on day 8 of therapy
with a few isolated blisters on her heels. Her Vancomycin
infusion rate was decreased, but on day 9, the erythema
progressed and she also developed a new pink papular rash along
her thighs, neck, chest, behind her ears, and along her
hairline. Dermatology was consulted and they felt her
presentation was consistent with a chemotherapy induced acral
erythema with id response. Per their recommendations, she was
placed on Clobetasol & Triamcinolone ointment and her
antibiotics were switched to Vancomycin, Aztreonam, &
Micafungin. Her rash resolved and her acral erythema faded and
began to peel.
# Hyperphosphatemia: Patient was noted to have an isolated
rising serum Phosphate that peaked at 6.2 on day 22. She also
had a mildly elevated Alk Phos level, but other electrolytes and
LFT's were normal. A work-up demonstrated a normal GGT,
suggesting a bony source of Alkaline Phosphatase, but a serum
Calcium was normal and the patient had a normal PTH level. A
review of medications did not demonstrate a source of ingested
Phosphate, but the patient's Caphosol was held out of concern
that it may have been inadvertantly ingested. As the patient's
Ca x Ph product was greater than 55, she was also started on
Sevelamer on day 22 with an improvement in her serum phosphate.
She was discharged home on Sevelamer.
Medications on Admission:
calcium with vitamin D
multivitamin
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
3. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: with meals.
Disp:*90 Tablet(s)* Refills:*2*
5. Hair Prosthesis
Hair Prosthesis
Acute Myelogenous Leukemia for Chemotherapy
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Myelogenous Leukemia status post chemotherapy
with Ara-C and Idarubicin
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 because you developed fatigue
and leg bruising and were found to have acute myelogenous
leukemia. You underwent a course of induction chemotherapy. At
this time, your counts have recovered and you are ready to go
home with follow-up with your primary oncologist.
We made the following changes to your medications:
We STARTED you on Pantoprazole 40mg twice a day
We STARTED you on Sevelamer 800mg three times a day with meals
Please avoid crowded public areas.
Please measure your temperatures twice a day and call for any
temperatures over 100.4.
Please call [**Telephone/Fax (1) 8717**] and ask to page BMT fellow on call or
return to the hospital right away if you develop cough,
shortness of breath, fevers, chills, nightsweats, diarrhea,
nausea, vomiting, or any other concerning symptoms.
Followup Instructions:
You need to follow up with your oncologist Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] as
follows:
Wednesday, [**2199-6-5**] at 2:00 pm
Completed by:[**2199-7-15**]
|
[
"205.00",
"E933.1",
"285.22",
"486",
"692.9",
"518.81",
"700",
"274.01",
"288.03",
"287.5",
"054.9",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"38.93",
"99.25",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
16175, 16181
|
12037, 15535
|
328, 371
|
16312, 16312
|
2577, 2582
|
17323, 17523
|
1525, 1696
|
15622, 16152
|
16202, 16291
|
15561, 15599
|
16463, 16785
|
1711, 2558
|
16815, 17300
|
671, 1250
|
276, 290
|
399, 652
|
2597, 12014
|
16327, 16439
|
1272, 1278
|
1294, 1509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,748
| 111,200
|
18714
|
Discharge summary
|
report
|
Admission Date: [**2180-3-10**] Discharge Date: [**2180-3-18**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
swan ganz catheter placement
History of Present Illness:
Mr. [**Known lastname 51298**] is a 84 year old male with a history of type A
aortic dissection repair in [**7-26**] complicated by embolic stroke
that was admitted from an OSH on [**3-10**] with w/ type B aortic
dissection for medical management.
The patient is a caregiver for his blind and disabled wife with
diabetes, and has not been taking medications for 1 month due to
being too busy with his wife and possibly not comprehending
importance. He presented to an outside hospital complaining of
low back pain. A CT scan obtained at the outside showed: type B
dissection to L external iliac a. Patent celiac/SMA/[**Female First Name (un) 899**]/renals,
4 cm ascending AAA. Pt started on esmolol+nipride, transferred
to [**Hospital1 18**].
During CCU stay, patient cardioverted from Aflutter/Afib. Team
had some difficulty with controlling labile blood pressures in
setting of post cardioversion sinus bradycardia- has been
controlled with Hydralazine and Labetalol IV and is now being
switched to PO meds. Also found to have newly decreased EF (see
echo report) and new ARF.
On ROS: the patient denies chest pain, shortness of breath,
abdominal pain, dysuria, fever/chills.
Past Medical History:
1.Type A aortic dissection-repair [**7-26**]
2. HTN noncompliant w/ meds
3. Depression
Social History:
Lives in [**Location 4310**] with his wife - blind and disabled from [**Name (NI) 1568**]
patient is her primary caregiver. [**Name (NI) **] also lives with him- ? if
helpful. No tobacco, no EtOH, no recreatinoal drugs
Family History:
non-contributory
Physical Exam:
98.7, 60, 114/58, 20, 94%RA, 100/70 i/o since mdn, 73.7kg
NAD, AAOx3, resting comfortably, no concerns
MMM, OP-clear
RRR
bibasilar crackles
Soft, NT/ND, +BS
trace LE edema, warm, radial 2+ bilat, DP- not palpable at
marked area.
Pertinent Results:
Echo: The left atrium is elongated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is moderate global left ventricular
hypokinesis. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
are mildly thickened but no aortic stenosis is present. Mild
(1+) aortic regurgitation is seen. Mild to moderate ([**12-26**]+)
mitral regurgitation is seen. There is moderate [2+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
Global biventricular hypokinesis c/w diffuse process
(toxin,metabolic, multivessel CAD, etc.). Mild-moderate mitral
regurgitation. Mild arotic regurgitation.
Abdominal MRI:
1) Aortic dissection extending at least as high as the
descending thoracic aorta, its proximal extent is not included
on this study, which extends distally at least as far as the
left common iliac artery. Mural thrombus at the level of the
diaphragmatic hiatus within the abdominal aorta.
2) Single widely patent renal arteries on each side. Extrinsic
compression of the left renal artery by the false lumen during
the cardiac cycle is not excluded on the basis of this study.
Cine imaging of the renal artery can be performed to assess for
that possibility. The patient shall be brought back for these
additional images at no additional cost. Both kidneys however
perfuse symmetrically with contrast.
3) Bibasilar atelectasis.
[**2180-3-10**] 05:23PM GLUCOSE-186* UREA N-18 CREAT-1.7* SODIUM-139
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-16* ANION GAP-17
[**2180-3-10**] 05:23PM CK-MB-4 cTropnT-0.02*
[**2180-3-10**] 05:23PM FERRITIN-94
[**2180-3-10**] 05:23PM TSH-1.6
[**2180-3-10**] 05:23PM CRP-5.45*
[**2180-3-10**] 05:23PM WBC-9.8 RBC-4.95 HGB-14.9 HCT-43.4 MCV-88
MCH-30.2 MCHC-34.4 RDW-14.5
[**2180-3-10**] 06:00AM ALT(SGPT)-72* AST(SGOT)-30 CK(CPK)-106 ALK
PHOS-146* TOT BILI-1.7*
[**2180-3-10**] 06:00AM GGT-60
[**2180-3-10**] 06:00AM TRIGLYCER-83 HDL CHOL-46 CHOL/HDL-3.0
LDL(CALC)-76
Brief Hospital Course:
Mr. [**Known lastname 51298**] was admitted with an Aortic Dissection Type B, from
thoracic aorta to level of external iliacs. There was mural
thrombus in the new dissecting Type B aorta but he was not
anticoagulated with heparin secondary to dissection per vascular
surgery recomendations. His blood pressure control goal was SBP
100-120 and to facilitate this he was switched from PO
medications to labetalol, hydralazine, and isosorbide
mononitrate. This controled him well, although he had been
labile in the CCU and with sinus bradycardia.
Mr. [**Known lastname 51298**] had irregularities with his rhythm. He was DC
cardioverted from atrial flutter/atrial fibrillation to
borderline sinus bradycardia. He was also loaded with amiodarone
400 QD however he was not anticoagulated because of dissection.
Following conversion to NSR, Mr. [**Known lastname 51300**] pressure dropped,
requiring use of pressors. He was eventually weaned off without
further complications. Once stable, he was restarted on oral
agents.
From the standpoint of his pump function, the echo showed EF of
35 % and Mr. [**Known lastname 51300**] old EF was normal. The etiology for this
change was unclear as it could be from either hypertension or
from CAD or from both. Since the creatinine bumped from a
previous contrast [**Last Name (LF) 1868**], [**First Name3 (LF) **] outpatient catheterization was
suggested once the creatnine goes back to baseline. His aspirin
and plavix were continued. He was initially not on a statin but
it was not clear as his total cholesterol was 130 and LDL 78.
Even so, it was started since antiinflammatory effects may help
with the ulcerating plaques in the aortic intima.
Mr. [**Name14 (STitle) 51301**] was found to have acute renal failure with stable Cr
at 2.1. This was not thought to be secondary to extension of the
dissection because the MR showed that the renal arteries come
off the true lumen. Instead, it was thought likely from
contrast [**Name14 (STitle) 1868**]. His renal function and cardiac catheterization
should be followed as an outpatient. He was transferred to the
floor for further management once his acute issues were stable.
Patient had an unremarkable floor course and discharged home on
[**2180-3-18**] for cardiology followup as an outpatient.
Medications on Admission:
patient noncompliant
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. 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*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): will need to increase dose as tolerated as oupatient in
3weeks by discussing with Dr. [**First Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
9. Labetalol HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Hydralazine HCl 10 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All CAre
Discharge Diagnosis:
aortic dissection
hypertension
congestive heart failure
Discharge Condition:
fair- able to walk and carry out ADLs.
Discharge Instructions:
-avoid vigorous activity
-take all medications as prescribed, they are ESSENTIAL to your
health and life with this aortic dissection.
-heart healthy diet
-call your doctor or return to the emergency department with any
chest pain, shortness of breath, back pain, high blood pressure,
or any other concerns
Followup Instructions:
Followup with your primary care doctor in [**12-26**] weeks for followup
on your blood pressure (VERY IMPORTANT WITH THIS DISSECTION) and
your renal function. Call for an appointment.
Followup with Dr [**First Name (STitle) **] your cardiologist in [**12-26**] months, first
available appointment, to follow this aortic dissection and to
discuss need for futher cardiac catheterization because of your
decreased heart function.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"427.32",
"V12.59",
"425.4",
"584.9",
"441.02",
"287.5",
"285.9",
"276.3",
"V15.81",
"401.9",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"38.91",
"88.72",
"00.17",
"99.62",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8299, 8338
|
4258, 6552
|
250, 280
|
8438, 8479
|
2134, 4235
|
8834, 9392
|
1852, 1870
|
6623, 8276
|
8359, 8417
|
6578, 6600
|
8503, 8811
|
1885, 2115
|
201, 212
|
308, 1490
|
1512, 1600
|
1616, 1836
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,030
| 191,274
|
591
|
Discharge summary
|
report
|
Admission Date: [**2136-9-11**] Discharge Date: [**2136-9-15**]
Date of Birth: [**2065-8-18**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Mental status change, abdominal pain
Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
Right IJ intravenous catheter placement
History of Present Illness:
Ms. [**Known lastname 4636**] is a 71 yo wheel-chair bound woman with
paraplegia, hypertension, and question of COPD who was admitted
on [**9-11**] with altered mental status. Per the patient, she had
been experiencing constipation for 5-6 days prior to admission.
She did have a small BM on the morning of admission. On the day
of admission, the patient reported feeling sweaty and dizzy, and
dropped a cup of tea onto her lap. Her neighbor who was
visiting noticed she was weak and dysarthric, and called
lifeline who then brought the patient to the ED.
.
In the ED, her initial vitals were temp 99.5, bp 113/44, HR 96,
RR 16, SaO2 96% on NRB. Her bp decreased to 81/38 in the ED and
she became unable to respond to commands, so she was given 4 L
NS. Her bp slightly improved to 91/45. She also had a large
loose BM in ED. A right IJ was placed. UA was nitrite positive
with moderate bacteria. CXR was concerning for left lower lobe
pneumonia. The patient was thought to have sepsis [**1-6**] to PNA
vs. UTI, and she was given Vancomycin 1 mg IV x1, Levaquin 750
mg IV x1, and Tylenol PR 1 gm x1 and transferred to the MICU.
.
In the MICU the patient was started on Levophed for pressure
support. WBC 19.6 with a left shift, Lactate 3.4 -> 2.2. She
was initially drowsy and lethargic. She then complained of
being constipated, despite having repeated episodes of loose
stool since arrival to the MICU. She complained of low back
pain & LLQ. No CP/SOB or cough. Other ROS negative. The
patient's family reports that she often develops similar MS
changes when she has an infection.
.
Currently, the patient reports a 2 day history of servere
([**9-12**]) constant burning lower midline abdominal pain that
radiates down to her rectum. She says this is similar pain to
what she experienced when she was admitted [**12-11**]. No back pain
though she is unsure if she would sense back pain. She also
notes severe diarrhea and loose stools since admission. She
reports a cough occasionally productive of light brown mucous.
Denies HA, fevers/chills.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Paraplegia (From Anterior Spinal Infarct sustained during a
thoracic aneurysm repair)
4. Suprapubic Catheter in place, recurrent UTIs ? on Ppx Bactrim
5. Fecal Incontinence
6. ? COPD: Per PCP note, patient is CO2 retainer. PFTs on [**3-/2129**]
showed FVC 3.59 (104% pred) and FEV1 2.66 (105% pred). On 2L
home O2 at night.
7. s/p Thoracic Aneurysm Repair ([**2128**])
8. LLL Collapse/PNA s/p mucous plug removal via bronchoscopy
9. GERD
10. Depression
Social History:
The patient lives alone in [**Hospital3 4634**]. Wheelchair bound.
She has a health aid for assistance in the morning and evening,
for help with dressing and bathing. Her son usually prepares
her food. Has son, [**Name (NI) **], & dtr in-law, [**Name (NI) 1439**], are her HCPs.
They see pt ~wkly. The patient has a 2-3ppd x 40+ years, but has
smoked +/- (3 cigarettes/day) for the past 5 yrs. No EtOH or
illicit drug use.
Family History:
Son: DM.
Physical Exam:
Vitals: temp 97.7, bp 130/70, HR 80, RR 20, SaO2 96% on 2L
Gen: Obese female in no distress. Alert and oriented to person,
place, and time.
HEENT: Slera anicteric. NCAT. EOMI. MMM. No pharyngeal erythema.
No nuchal rigidity.
CV: Regular rate. Nl S1, S2, No murmur, rub, gallop.
Pulm: CTA anteriorly and laterally. No wheezes/rhonchi.
Abd: Positive bowel sounds. Soft and obese abdomen. Tender
diffusely, but especially in periumbilical area. Has decreased
senstaion of lateral abdominal wall. No guarding, positive
rebound in the midline. Tympanitic to percussion. No masses.
Suprapubic catheter in place and the surrounding area is not
erythematous. Rectal tube in place.
Ext: Trace lower extremity edema, stockings on.
Neuro: Sensory level on abdomen at approx T6. Full [**4-7**] UE
strength, 0/0 LE strength. PERRL. CN II-XII intact.
Pertinent Results:
LABS:
[**2136-9-11**] 08:25PM BLOOD WBC-19.6*# RBC-5.60* Hgb-17.1* Hct-50.5*
MCV-90 MCH-30.4 MCHC-33.7 RDW-16.0* Plt Ct-322
[**2136-9-15**] 06:45AM BLOOD WBC-8.5 RBC-4.06* Hgb-12.3 Hct-36.5
MCV-90 MCH-30.4 MCHC-33.8 RDW-15.7* Plt Ct-198
[**2136-9-11**] 08:25PM BLOOD Neuts-87.7* Lymphs-9.1* Monos-2.4 Eos-0.4
Baso-0.3
[**2136-9-12**] 05:47AM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.1
[**2136-9-11**] 08:25PM BLOOD Glucose-270* UreaN-16 Creat-0.7 Na-136
K-4.5 Cl-94* HCO3-27 AnGap-20
[**2136-9-15**] 06:45AM BLOOD Glucose-150* UreaN-2* Creat-0.4 Na-144
K-3.0* Cl-108 HCO3-25 AnGap-14
[**2136-9-12**] 02:12AM BLOOD ALT-45* AST-53* LD(LDH)-203 CK(CPK)-50
AlkPhos-134* Amylase-63 TotBili-0.4
[**2136-9-12**] 12:46PM BLOOD CK(CPK)-55
[**2136-9-12**] 07:40PM BLOOD CK(CPK)-42
[**2136-9-13**] 07:15AM BLOOD CK(CPK)-37
[**2136-9-14**] 07:15AM BLOOD ALT-36 AST-30 LD(LDH)-200 AlkPhos-101
Amylase-29 TotBili-0.2
[**2136-9-12**] 02:12AM BLOOD Lipase-18
[**2136-9-14**] 07:15AM BLOOD Lipase-21
[**2136-9-12**] 02:12AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2136-9-12**] 12:46PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2136-9-12**] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2136-9-13**] 07:15AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2136-9-12**] 02:12AM BLOOD Albumin-3.5 Calcium-7.6* Phos-3.2 Mg-2.5
[**2136-9-14**] 07:15AM BLOOD Albumin-3.0* Cholest-160
[**2136-9-14**] 07:15AM BLOOD Triglyc-182* HDL-36 CHOL/HD-4.4
LDLcalc-88 LDLmeas-98
[**2136-9-13**] 01:02PM BLOOD %HbA1c-5.9
[**2136-9-12**] 03:30AM BLOOD Type-ART Temp-35.6 O2 Flow-4 pO2-92
pCO2-45 pH-7.32* calTCO2-24 Base XS--3 Intubat-NOT INTUBA
[**2136-9-11**] 08:33PM BLOOD Lactate-3.4*
[**2136-9-11**] 11:02PM BLOOD Lactate-2.2*
[**2136-9-13**] 10:59AM BLOOD Lactate-1.0
[**2136-9-11**] 09:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2136-9-11**] 09:25PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
[**2136-9-11**] 09:25PM URINE RBC-0-2 WBC-[**2-6**] Bacteri-MOD Yeast-NONE
Epi-0-2 TransE-0-2
[**2136-9-11**] 09:25PM URINE CastHy-[**5-13**]*
[**2136-9-13**] 08:23PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2136-9-13**] 08:23PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
MICRO:
Blood Cx ([**9-11**]): No growth x4
.
Urine Cx ([**9-11**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
.
Stool Cx ([**9-12**]):
FECAL CULTURE (Final [**2136-9-14**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2136-9-14**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2136-9-13**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2136-9-13**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2136-9-13**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
OVA + PARASITES (Final [**2136-9-13**]):
NO OVA AND PARASITES SEEN.
.
Urine Cx ([**9-12**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
Stool Cx ([**9-13**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Urine Cx ([**9-13**]): YEAST. ~1000/ML.
.
IMAGING:
CXR Portable ([**9-11**]): IMPRESSION: Findings concerning for left
lower lobe pneumonia.
.
CXR Portable ([**9-11**]): FINDINGS: There has been interval placement
of a right IJ intravenous catheter with its tip projecting over
the expected location of the lower SVC. The upper vascular
redistribution as well as interstitial edema is more prominent
in the supine view. Again seen is an area of increased opacity
projecting over the left mid lung. There is no supine evidence
of pneumothorax.
IMPRESSION:
1. No pneumothorax.
2. Findings concerning for left lower lobe pneumonia.
3. Pulmonary vascular redistribution and interstitial edema.
.
ECG ([**9-12**]): Sinus rhythm at a rate of 62 with prolonged P-R
interval to 224. Left axis deviation. Poor R wave progression.
Consider anterior myocardial infarction, age undetermined. Since
prior tracing of [**2135-12-12**] left atrial abnormality is not seen on
the current tracing.
.
CT Head ([**9-12**]): There is no acute intracranial hemorrhage.
There is no mass, edema or shift of normally midline structures.
Extensive periventricular white matter hypodensities are present
again. There is an area of new and more conspicuous and
extensive hypodensity in the left frontal lobe, extending to the
cortex and subcortical white matter.
Surrounding soft tissues and osseous structures are
unremarkable.
Imaged mastoid air cells are well aerated. There is mucosal
thickening in the maxillary sinuses, bilaterally, as well as
ethmoid and sphenoid sinuses.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. New and more conspicuous area of left frontal hypodensity,
which may represent acute infarction. Evaluation with MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted sequence is recommended.
.
TTE ([**9-12**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF=60-65%). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Mild
pulmonary artery systolic hypertension.
.
CT Abdomen/Pelvis ([**9-12**]):
Left basilar atelectasis is again noted.
Diffuse fatty infiltration of the liver is incidentally seen.
Adrenal glands, pancreas, and spleen appear grossly
unremarkable. Numerous gallstones are identified. Simple right
renal cyst is seen. Also, several small hypoattenuating foci are
seen within the kidneys bilaterally, which are too small to
characterize but likely represent simple cysts.
Evaluation of the bowel reveals mural thickening involving the
sigmoid colon as well as a portion of the rectum. Surrounding
fat stranding is noted consistent with inflammation. This is a
nonspecific imaging finding. Differential considerations do
include inflammatory and infectious etiologies as well as
ischemia. In retrospect on the prior exam dated [**2134-9-12**], there
is suggestion of distal sigmoid and rectal wall thickening to
suggest chronicity _____ recurrence of this disease process.
Pelvic structures are grossly unremarkable. A rectal tube and
Foley catheter are noted.
No lytic or blastic bony lesions are identified. Multiple
Tarlov's cysts are again seen within the region of the sacrum.
IMPRESSION:
1. Sigmoid and rectal thickening as detailed above. This is a
nonspecific finding and may represent an infectious or
inflammatory etiologies as well as ischemia. Of note, this
similar though less diffuse findings were identified on a prior
CT scan dated [**2134-9-12**].
.
MR [**Name13 (STitle) 430**]/MRA Brain ([**9-13**]): IMPRESSION:
1. No acute infarct.
2. FLAIR hyperintense foci consistent with chronic microvascular
infarcts in the white matter of both cerebral hemispheres.
3. Maxillary sinus disease.
Brief Hospital Course:
# Abdominal pain/Diarrhea: The patient reported constipation for
the 5-6 days prior to admission. In the MICU, she complained of
being constipated, despite having repeated episodes of loose
stool since arrival to the MICU. She was empirically started on
Flagyl. Once she was on the medicine floor, she reported a 2 day
history of servere ([**9-12**]) constant burning lower midline
abdominal pain that radiated down to her rectum. She also
complained of severe diarrhea and loose stools since admission.
CT abdomen/pelvis showed sigmoid and rectal thickening which is
a nonspecific finding and may represent infectious or
inflammatory etiologies as well as ischemia. Serial exams showed
a soft abdomen. Stools were guaiac positive. Stools were
negative for C. difficile x2 and O&P x2. Of note, her admission
in [**12-11**] noted "that the patient developed burning rectal pain
during course of admission" which was felt to be secondary to
referred neuropathic pain. GI was consulted as there was concern
for ischemic colitis given the patient's recent hypotension and
lactate of 3.4 on admission. She went for flexible sigmoidoscopy
on [**9-14**] which showed erythema and edema in the mid-sigmoid
colon and distal sigmoid colon compatible with colitis, and a
polyp in the mid-descending colon which was not removed since
the patient was on heparin SQ. These findings were compatible
with a resolving colitis including ischemic or infectious
etiologies. The patient was scheduled for a screening
colonoscopy on [**11-6**] at which point the very small polyp, and any
others can be removed. She was discharged on Flagyl PO.
.
# Hypotension: On admission, the patient's blood pressure was
113/44, then decreased to 81/38 in the ED. She became unable to
respond to commands and was given 4 L NS with only slight
improvement to 91/45. A right IJ was placed, and the patient was
transferred to the MICU with concern for pneumonia or UTI
sepsis. She received Levophed, but it remains unclear if the
patient was truly hypotensive. The MICU team reported that
non-invasive BPs were 20 points below the arterial values. TTE
showed mild symmetric LVH, LVEF 60-65%, and mild pulmonary
artery systolic hypertension. Cardiac enzymes were negative x4.
Her Lasix was held upon discharge until the patient follows up
with Dr. [**Last Name (STitle) 1266**] as an outpatient.
.
# Mental status change: On the day of admission, the patient
reported feeling sweaty and dizzy, and dropped a cup of tea onto
her lap. Her neighbor who was visiting noticed she was weak and
dysarthric, and called lifeline who then brought the patient to
the ED. She continued to have waxing and [**Doctor Last Name 688**] mental status,
which was likely due to delirium in the setting of acute
illness. Head CT showed no acute intracranial hemorrhage but did
show a new and more conspicuous area of left frontal
hypodensity, which may represent acute infarction. Neurology was
consulted, and they did not believe that the head CT findings
were consistent with her presentation with bilateral upper
extremity weakness. MRI head/MRA brain showed no acute infarct,
and FLAIR hyperintense foci were consistent with chronic
microvascular infarcts in the white matter of both cerebral
hemispheres. HgA1c was 5.9%. She was started on ASA 81 mg daily.
.
# Pneumonia: On admission to the ED, the patient was afebrile,
but SaO2 was 96% on NRB and she had a WBC of 19.6 with 88%
neutrophils. Lactate was 3.4. CXR was concerning for left lower
lobe pneumonia. She became hypotensive in the ED, and there was
concern she had a pneumonia or UTI sepsis, so she was started on
Vancomycin and Ceftriaxone and transferred to the MICU (she also
got Levofloxacin in the ED). Blood cultures were negative, and
urine legionella antigen was negative. On day 3 of admission,
the Vancomycin was discontinued, and Azithromycin was started.
She was discharged on Levofloxacin daily to complete a 10 day
course.
.
# UTI: The patient has a suprapubic catheter, and is likely
chronically colonized. UA showed positive nitrite, trace
leukocytosis, [**2-6**] WBC, and moderate bacteria. Urine culture
showed fecal contamination, and the patient has a history of
fecal incontinence. She was initially started on Ceftriaxone
which was changed to Levofloxacin.
.
# GERD: She was started on Protonix 40 mg daily.
.
# Hyperlipidemia: Lipid panel during this admission showed Chol
160, TG 182, HDL 36, and LDL 88. She is not on any medications
for hyperlipidemia.
.
# Paraplegia: The patient is paraplegic from an Anterior Spinal
Infarct sustained during a thoracic aneurysm repair. She was
continued on Gabepentin 900 mg tid and Baclofen 40 mg tid.
.
# COPD: She is on 2 L home O2 at night. She was continued on
Advair and Duonebs.
.
# Depression: She was continued on Nortriptyline 50 mg qhs and
Bupropion SR 100 mg [**Hospital1 **].
.
# Code status: DNR/DNI - confirmed with [**Name (NI) 1439**] [**Name (NI) 4640**] (pt's
dtr-in-law & HCP)
.
# Contact: [**Name (NI) 2759**] [**Name (NI) **] [**Name (NI) 4636**] (son) & [**Name (NI) 1439**] [**Name (NI) 4640**]
(daughter-in-law) [**Telephone/Fax (1) 4635**]/ c [**Telephone/Fax (1) 4641**]
Medications on Admission:
MEDICATIONS (confirmed w/ [**Location (un) 1226**] pharmacy [**Telephone/Fax (1) 4642**]):
1. Baclofen 40 mg TID
2. Gabapentin 900 mg PO TID (3 times a day).
3. Nortriptyline 50 mg qhs
4. Lactulose 1 tablespoon [**Hospital1 **]
5. Bupropion SR 100 mg [**Hospital1 **]
6. Furosemide alternating 40 mg and 80 mg every other day.
7. Advair 250/50 one puff [**Hospital1 **]
8. Duonebs one amp QID prn
9. Nystatin powder
.
ALLERGIES: NKDA
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
3. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Nystatin 100,000 unit/g Powder Topical
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for GERD.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) amp Inhalation
four times a day as needed for shortness of breath or wheezing.
10. medication
Nystatin powder
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
VNA carenetwork
Discharge Diagnosis:
PRIMARY
1. Abdominal Pain, Diarrhea
2. Chronic Microvascular Brain Infarcts
3. Hypotension
SECONDARY
1. Hypertension
2. Hyperlipidemia
3. Paraplegia (From Anterior Spinal Infarct sustained during a
thoracic aneurysm repair)
4. Suprapubic Catheter
5. Fecal Incontinence
6. COPD on 2L Home O2 at night
7. s/p Thoracic Aneurysm Repair ([**2128**])
8. GERD
9. Depression
Discharge Condition:
afebrile, tolerating oral diet, abdominal pain improved
Discharge Instructions:
You came to the hospital with confusion. You experienced low
blood pressure and required a stay in the intensive care unit.
You then underwent a CAT scan of your abdomen and a flex sig of
your intestines. It showed that you had some colitis. Please
have a repeat colonoscopy in several months/years as an
outpatient.
.
1. Take all medications as prescribed
2. Make all follow-up appointments
3. If you develop fevers >101.5, chills, nausea, vomiting,
severe abdominal pain, weakness, or any other concerning
symptoms, contact your provider or report to the Emergency
Department
4. Please continue your levoflox and flagyl for another 5 days.
5. Please hold your lasix until you meet with Dr. [**Last Name (STitle) 1266**] to
discuss.
6. We started you on aspirin daily
7. We started you on protonix daily.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] [**Telephone/Fax (1) 608**] in [**12-6**]
weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
|
[
"V12.54",
"V46.2",
"344.1",
"V44.6",
"211.3",
"496",
"557.9",
"530.81",
"787.91",
"311",
"486",
"787.6",
"458.8",
"599.0",
"564.09",
"288.60",
"272.4",
"747.81",
"V12.59",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
18809, 18855
|
11872, 17040
|
311, 376
|
19266, 19324
|
4333, 11849
|
20185, 20453
|
3442, 3452
|
17524, 18786
|
18876, 19245
|
17066, 17501
|
19348, 20162
|
3467, 4314
|
235, 273
|
404, 2470
|
2492, 2984
|
3000, 3426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,912
| 100,053
|
28897
|
Discharge summary
|
report
|
Admission Date: [**2124-7-14**] Discharge Date: [**2124-7-19**]
Date of Birth: [**2067-12-2**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 year old with alcoholic cirrhosis and end-stage liver disease
who has been "in and out" of the [**Location 24355**] over
the past few months for repeated episodes of LE cellulitis
including ? nec fascitis on one occasion. He had been in a
rehab hospital today (was sent there from the VA) and was
feeling well per his report, wanting to be D/C'd when they got
labs that were concerning (hct, cr) and sent him to [**Hospital 6451**] Hospital. There he was found to have a Hct of 27, SBP
in the 60's, Melena. He was started on levophed and NS "wide
open" through one 20 Ga IV. He was transferred here. On
arrival in the ED here, he was afebrile, HR 91, BP 72/36 RR 20
Sat 96% on 2L. He was given 2 18 Ga PIV, a Rt. femoral TLC,
Vitamin K, a litre of NS, FFP (3 U), 1 U PRBC and IV protonix.
GI and renal were consulted. His Cr. was 3.6, his K was 5.8,
but he was not noted to have any ECG changes on 12-lead; he was
given kayexelate.
.
MICU admission requested.
Past Medical History:
Alcoholic cirrhosis with end-stage liver disease - not on
transplant list anywhere per pt. (was to be evaluated for this).
CRI (? baseline Cr.)
Mult. recent episodes cellulitis
DM2
Social History:
etoh, last drink per pt. over 10 yy ago; no IVDU, was in Army,
also worked as a delivery man
Family History:
DM - mother, denies hx. CHD in family
Physical Exam:
VS: BP 60's over 40's HR 115, AF, R 25, 96% NC
HEENT EOMI, sclerae are icteric
COR: Tachy, regular, [**12-27**] hsm
PULM: CTA ant
ABD: Distended and tense ascites
EXT: 4+ LE edema
NEURO: Alert, oriented to place, time, event
Brief Hospital Course:
Patient was admitted to the MICU. His condition continued to
deteriorate despite all measures and he was made DNR/DNI in
consensus with his family on [**2124-7-18**]. He continued to decline
and in the morning of [**2124-7-19**], after verbal discussion with
his three children, patient was made COMFORT MEASURES ONLY. He
was treated with morphine for respiratory distress and pressors
were withdrawn. Patient passed away shortly thereafter and was
pronounced deceased on [**7-19**] at 00:20 by [**First Name8 (NamePattern2) 11556**] [**Last Name (NamePattern1) 18721**] MD
and [**First Name8 (NamePattern2) 2894**] [**Last Name (NamePattern1) **] MD.
.
.
.
IMP:56 y/o with ETOH cirrosis and end-stage liver disease who
presented to OSH from rehab with hypotension, melena
.
#Hypotension: Likely cause is GIB/hypovolemia.
Place A line, cont. to bolus for Map less than 65. Add
vasopressin if not responding to levophed and IVF. Monitor UOP.
Serial Hct. Transfuse for hct less than 25. FFP to correct
coagulopathy. Discuss with GI.
.
#Melena - as above, call GI. [**Month (only) 116**] need NGL. Serial Hct. PPI IV
BID. Octreotide gtt.
.
#Cirrhosis/liver disease: obstructive picture. Patient had
pericentesis x 2 in order to relieve his abdominal ascites. The
first removed 4.5 liters of clear yellow ascites fluid and the
second removed about 2 liters.
Consult liver. Continue lactulose. Follow INR. Check albumin.
Hold diuretics while hypotense.
.
#Renal failure: ? baseline Cr. Possible HRS vs. pre-renal from
volume depletion [**12-23**] GIB. Consult liver and renal, continue
volume repletion, maintain SBP as above. Consider albumin post
tap, Consider adding midodrine. Patient was started on CVVH.
.
#Hyperkalemia: Resolved.
.
# FEN: IVF as above, lytes prn, NPO given GIB.
.
# PPX: PPI [**Hospital1 **], coagulopathic.
.
# Access: 2 PIV, TLC lt. groin.
.
# Code: COMFORT MEASURES ONLY
.
# Communication: Daughter - [**Name (NI) **], [**First Name3 (LF) **], and daughter [**Name (NI) **]
.
# Disposition: MICU
Medications on Admission:
Aldactone
Calcium
Lasix
Insulin
Lactulose
Nepro
Ocycodone
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"303.03",
"571.2",
"572.4",
"427.31",
"584.5",
"287.5",
"276.7",
"403.91",
"532.00",
"250.00",
"572.2",
"286.7",
"570",
"707.10",
"112.84",
"585.9",
"276.52",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"38.95",
"99.07",
"39.95",
"38.93",
"45.13",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
4121, 4130
|
1938, 3980
|
298, 304
|
4182, 4192
|
4249, 4260
|
1634, 1673
|
4088, 4098
|
4151, 4161
|
4006, 4065
|
4216, 4226
|
1688, 1915
|
247, 260
|
332, 1304
|
1326, 1508
|
1524, 1618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,203
| 157,723
|
37389
|
Discharge summary
|
report
|
Admission Date: [**2198-1-9**] Discharge Date: [**2198-1-11**]
Date of Birth: [**2160-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
pericardial effusion, chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement
History of Present Illness:
Mr. [**Known lastname 6515**] is a 37yo male with PMH s/f recent porcine AVR for
congenital bicuspid valve who is now being tranferred from and
OSH ED for evaluation for pericardial tamponade. Patient reports
having had a congenital bicuspid aortic valve repaired on
[**2197-11-21**]. There were no immediate complications of the surgery
although patient was noted to have two small PE's around time of
the surgery. Following the procedure he was maintained on
coumadin and aspirin with a goal INR of 2.5-3.5 (despite aortic
porcine valve). Patient had been in good health, although
tending to run high by INR since the surgery until this weekend
when he developed bilateral shoulder pain. He describes the pain
as very similar to a muscle aches, and that it radiates down
into his chest. Occasionally has radiated to the back as well.
Is pleuritic, but not exertional. This morning patient noted
marked exertional dyspnea with an exercise limitation of 20-30
yards which prompted him to present to the [**Hospital1 2436**] ED.
Patient initially seen at [**Hospital3 2783**] where VS were T98,
Bp 100/77, HR 136, RR 24, O2 sat 99%RA. Labs notable for anemia,
and INR 6.8. Bedside USD at that time showed no RV collapse and
ECG interpreted as nml (although shows electrical alternans). CT
chest showed no dissection but large pericardial effusion.
Impression was for pericarditis. Patient was given IVF bolus to
prevent progression to tamponade and transferred to [**Hospital1 18**] for
further evaluation
In the ED, initial vitals were: T98.2, HR 112, BP 121/83, RR 16,
O2 sat 100%RA. Exam notable for clear lungs, tachycardia. Labs
notable for Hct 28. CT A/P showed no RP bleed, but large
pericardial effusion. Bedside Echo showed some RV collapse.
Cards consulted as well as Cardiac Surgery. In the ED was given
4mg morphine IV, 10 units vitamin K, 2 units FFP and admitted to
[**Hospital Unit Name 196**] for management.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors, sick
contacts, muscle aches, or other complaints. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Hypertension
2. CARDIAC HISTORY:
-Bicuspid Aortic Valve Repair [**11/2197**]
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
Additional PMH
-Pulmonary Emboli x 2 at time of surgery
Social History:
Moved from [**State 33977**] to [**Location (un) 86**] 1 year ago for work, he works for
Cintas uniform company.
-Tobacco history: chews 2 pack per day equivalent
-ETOH: social
-Illicit drugs: denies
Family History:
Father with CABG in his late 50's
Paternal GF and PGM w/ CABG in 60's. Mother died last month of
breast cancer. No h/o valvular disease. 3 healthy brothers
Physical Exam:
VS: T97.8, 134/83, HR 103, 20, 100%2L, Pulsus 16-18mmHg
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of [**1-22**] cm.
CARDIAC: RR, normal S1, S2. No m/g. No thrills, lifts. No S3 or
S4. Rub noted w/ausculatation, more prominent along left border.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM. Mild TTP in epigastrum/RUQ. Abd
aorta not enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2198-1-8**] 08:40PM WBC-6.2 Hgb-8.9* Hct-28.2* Plt Ct-384
[**2198-1-8**] 08:40PM Neuts-59.6 Lymphs-33.0 Monos-5.7 Eos-1.4
Baso-0.3
[**2198-1-8**] 08:40PM PT-56.4* PTT-37.5* INR(PT)-6.3*
[**2198-1-8**] 08:40PM Glucose-91 UreaN-22* Creat-1.1 Na-138 K-4.2
Cl-103 HCO3-25 AnGap-14
[**2198-1-8**] 08:40PM CK(CPK)-72
[**2198-1-8**] 08:40PM CK-MB-NotDone
[**2198-1-8**] 08:40PM cTropnT-<0.01
OTHER PERTINENT LABS
[**2198-1-9**] 06:46AM Iron-15*
[**2198-1-9**] 06:46AM calTIBC-335 Ferritn-38 TRF-258
[**2198-1-8**] 08:40PM CK(CPK)-72
[**2198-1-9**] 06:46AM CK(CPK)-66
[**2198-1-8**] 08:40PM CK-MB-NotDone cTropnT-<0.01
[**2198-1-9**] 06:46AM CK-MB-NotDone cTropnT-<0.01
[**2198-1-9**] 06:13PM BLOOD ESR-20*
[**2198-1-8**] 08:40PM INR(PT)-6.3*
[**2198-1-9**] 07:42AM INR(PT)-1.8*
[**2198-1-9**] 06:13PM INR(PT)-1.4*
[**2198-1-10**] 03:07AM INR(PT)-1.4*
[**2198-1-11**] 06:10AM INR(PT)-1.4*
MICROBIOLOGY:
[**2198-1-9**] Pericardial effusion Cx: prelim negative
STUDIES:
[**2198-1-8**] ECHO:
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Global left ventricular systolic function is good
(LVEF >40%). The right ventricular cavity is small. There is
dysnchronous septal motion (post-op). A a well-seated
bioprosthetic aortic valve prosthesis is present with mobile
leaflets. No aortic regurgitation is seen. The mitral valve
leaflets are grossly normal without mitral regurgitation. There
is a large circumferential pericardial effusion most prominent
inferior (4.0 cm) and lateral (3.2cm) to the left ventricle, but
also extending anteriorly around the right ventricle and right
atrium. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology.
IMPRESSION: Suboptimal image quality. Large circumferential
pericardial effusion with echocardiographic evidence c/w
tamponade physiology. Grossly normal aortic valve bioprosthesis.
[**2198-1-8**] CT abdomen/pelvis:
1. No evidence of retroperitoneal hematoma. Fluid in the abdomen
is of
intermediate attenuation and may represent hemoperitoneum. In
addition,
circumferential gallbladder mural thickening may represent mural
hemorrhage.
2. Large pericardial effusion, unchanged from the recent
comparison.
3. Calcified nodule in the right lower lobe.
[**2198-1-9**] Cardiac cath:
COMMENTS:
1. Hemodynamics revealed elevated pericardial pressure at 25
mmHg.
1050cc of bloody fluid was removed with resolution of effusion
and
tamponade by echocardiogram and normalization of pericardial
pressure.
The pericardial fluid was sent for laboratory studies.
FINAL DIAGNOSIS:
1. Severe pericardial tamponade.
[**2198-1-9**] ECHO:
There is symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). Right ventricular chamber size and free wall motion are
normal. A bioprosthetic aortic valve prosthesis is present which
was not fully assessed. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is a
residual moderate sized pericardial effusion (2 cm) after
drainage of 250 cc of fluid. After removal of 1050 cc of
additional pericardial fluid, there is a residual small
pericardial effusion (0.7 cm). The effusion appears
circumferential. There is brief right atrial diastolic collapse.
Compared with the report of the prior study (images unavailable
for review) of [**2198-1-8**], the pericardial effusion is smaller.
[**2198-1-10**] ECHO:
There is mild symmetric left ventricular hypertrophy. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= XX %). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2198-1-9**],
left ventricular systolic function appears slightly more
vigorous. The pericardial effusion is now slightly larger.
[**2198-1-11**] ECHO:
The estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is mild global left ventricular
hypokinesis (LVEF = 45 %). 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. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The estimated
pulmonary artery systolic pressure is normal. There is a very
small pericardial effusion.
Compared with the prior study (images reviewed) of [**2198-1-10**],
the size of the pericardial effusion remains very small. The
other findings are similar.
DISCHARGE LABS:
[**2198-1-11**] 06:10AM WBC-3.8* Hgb-8.6* Hct-26.2* Plt Ct-378
[**2198-1-11**] 06:10AM PT-15.6* PTT-25.4 INR(PT)-1.4*
[**2198-1-11**] 06:10AM Glucose-76 UreaN-12 Creat-0.8 Na-143 K-4.7
Cl-109* HCO3-28 AnGap-11
[**2198-1-11**] 06:10AM Calcium-8.7 Phos-3.5 Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 6515**] is a 37yo male with PMH s/p recent porcine AVR for
congenital bicuspid valve on [**11-21**] who was tranferred from OSH
ED for evaluation for pericardial tamponade. S/p 1050cc drainage
of bloody effusion and drain placement.
#. Pericardial Effusion s/p drain placement: Pt with tamponade
physiology seen on ECHO. He underwent removal of 1050cc of
bloody fluid and drain placement. There was resolution of the
effusion after drain placement. The patient had a
super-therapeutic INR of 6.8. Appears patient was on 3 months
of anti-coagulation for following valve vs PE. No history of URI
or infection to indicate viral pericarditis. Likely spontaneous
bleed from anti-coagulation. Repeat ECHOs showed a small amount
of residual effusion. AC was held as there is no clear
indication for it at this time, in addition to the patient's h/o
difficulty controlling INR. The patient should have a repeat
ECHO in [**2-10**] weeks to assess for resolution of pericardial
effusion.
#. s/p AVR with porcine valve: Pt with replacement of valve on
[**11-21**] and placed on anti-coagulation for 3 months. AC with
Coumadin was discontinued. The patient is on ASA 81mg PO daily.
#. Anemia: Hct 26. CT abdomen/pelvis did not show evidence of RP
bleed. Likely spontaneous bleeding from elevated INR. Pt with
>1000cc of bloody fluid removed from pericardium. Iron studies
show iron deficiency. The patient was started on an iron
supplement prior to discharge.
#H/o PEs: 2 PEs seen incidentally on CT chest 2-3 days after his
AVR surgery in [**State 33977**] on [**2197-11-21**]. No evidence of PE seen on
OSH CTA. Pt has been on coumadin since surgery. Coumadin has
been held, as above.
Medications on Admission:
Metoprolol XL 50mg daily
Aspirin 81mg daily
Coumadin 5mg daily
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Use daily for 6 weeks, then decrease
to 14mg/day patch for 2 weeks. .
Disp:*30 Patch 24 hr(s)* Refills:*1*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain: Take if the Ibuprofen does not take
away the pain. .
Disp:*20 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please check CBC on [**1-18**] and call results to Dr. [**Last Name (STitle) 12167**] at
[**Telephone/Fax (1) 56234**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion
Aortic Valve Disease s/p porcine AVR
Pulmonary Embolus
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a large collection of blood around your heart that was
likely because your blood was too thin. Your Warfarin has been
stopped and a drain was placed in the space around your heart
that drained the blood. You had another echocardiogram that
showed that the blood has not reaccumulated. You will need
another Echocardiogram in about 2 weeks to check again. This can
be done by Dr. [**Last Name (STitle) 12167**]. You are quite anemic becaues of the
blood loss.
new medicines:
1. Aspirin 81 mg daily: this is for the valve replacement
2. Ferrous sulfate: to help your body make more red blood cells.
3. STOP taking Metoprolol and Warfain
4. Nicotine patch: take 21 mg for 6 weeks, then 14 mg for 2
weeks, then 7 mg for 2 weeks, then stop.
5. Ibuprofen: take as needed for the chest discomfort.
6. Vicodin: take as needed for chest discomfort if the ibuprofen
doesn't work.
.
You should not go back to work until after you see Dr. [**Last Name (STitle) 12167**].
Followup Instructions:
Cardiology:
Dr. [**Last Name (STitle) 12167**] Phone: [**Telephone/Fax (1) 56234**] Date/Time: [**1-26**] at 9:00am.
You will have an echocardiogram on that same date.
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 84060**] Date/time: Please
keep any regular scheduled appts.
|
[
"423.0",
"423.3",
"V42.2",
"V58.61",
"V12.51",
"E934.2",
"285.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
12517, 12523
|
9875, 11581
|
346, 388
|
12643, 12643
|
4425, 4425
|
13780, 14125
|
3363, 3521
|
11694, 12494
|
12544, 12622
|
11607, 11671
|
7032, 9573
|
12788, 13757
|
9589, 9852
|
3536, 4406
|
2951, 3129
|
274, 308
|
416, 2868
|
4441, 7015
|
12657, 12764
|
2890, 2931
|
3145, 3347
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,295
| 161,394
|
39955
|
Discharge summary
|
report
|
Admission Date: [**2107-2-2**] Discharge Date: [**2107-2-15**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Ampullary Tumor
Major Surgical or Invasive Procedure:
1. Pylorus preserving Whipple's resection.
2. Open cholecystectomy.
3. J-tube placement.
History of Present Illness:
The patient is an 88-year-old woman who is pretty rigorous and
robust and generally healthy. She presented with biliary
obstruction and workup of this revealed an ampullary tumor.
This was biopsy proven to be adenocarcinoma. She had a stent
placed followed by a indwelling metal stent by Dr. [**Last Name (STitle) **]. The
patient was referred to Dr. [**Last Name (STitle) **] for resection. The details
of the whipple procedure including all the risks and benefits
were discussed with the patient and she agreed to proceed with
the operation. The patient was also seen by the geratology group
and was seen to have elevated blood pressure. It was found that
she was supposedly treated for this by her primary care
physician, [**Name10 (NameIs) **] had not been following this proposed regimen. A
lot of her super high blood pressure was due to anxiety issues
she vacillated with her visits. For this reason we elected to
place an epidural catheter to help manage any postoperative
delirium issues with the use of possible opiate narcotics.
Past Medical History:
HTN
PSH:
Her surgical history includes nasal procedures in the past. Her
GI procedures include an ERCP performed on [**11-26**], which
showed ampullary lesion and this was stented. The pathology
from
that showed adenocarcinoma in the setting of high-grade
dysplasia.
Social History:
Denies any smoking or EToH. Lives at home with husband.
Family History:
No h/o colon, pancreatic or other GI tumors.
Physical Exam:
On Discharge:
V/S: 96.9 P 70 BP 146/80 RR 20 O2 98%RA
GEN: NAD, AAx3
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND. Jtube in place and patent. Wound is clean,
dry, intact.
Pertinent Results:
[**2107-2-2**] 05:41PM BLOOD WBC-9.9 RBC-3.56* Hgb-11.8* Hct-33.6*
MCV-94 MCH-33.3* MCHC-35.2* RDW-13.4 Plt Ct-206
[**2107-2-14**] 07:15AM BLOOD WBC-11.6* RBC-3.27* Hgb-10.6* Hct-31.8*
MCV-97 MCH-32.6* MCHC-33.5 RDW-14.2 Plt Ct-387
[**2107-2-2**] 05:41PM BLOOD Glucose-167* UreaN-10 Creat-0.6 Na-139
K-3.6 Cl-105 HCO3-24 AnGap-14
[**2107-2-14**] 07:15AM BLOOD Glucose-116* UreaN-7 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-29 AnGap-10
[**2107-2-14**] 07:15AM BLOOD ALT-9 AST-11 AlkPhos-73 Amylase-25
TotBili-0.3
[**2107-2-8**] 05:33PM ASCITES Amylase-7980
[**2107-2-12**] 10:35AM ASCITES Amylase-[**Numeric Identifier **]
CT A/P - [**2107-2-9**]
IMPRESSION:
1. Several dilated loops of small bowel with air-fluid levels;
however, there is no transition point and contrast passes into
the transverse colon. Findings are suggestive of an ileus.
2. Expected postoperative appearance status post Whipple.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2107-2-2**] for treatment of ampullary cancer. On [**2107-2-2**], the
patient underwent pylorus-preserving pancreaticoduodenectomy
(Whipple) and open cholecystectomy, and Jtube placement, which
went well without complication. Please refer to the operative
note for further details. The patient was extubated in the
operating room and was initially sent to the unit for blood
pressure control with a strict goal of SBP 140-160s. This was
managed with IV labetolol prn. On POD1, the patient was
transferred to the floor. She was NPO with NGT, on IV fluids
with a foley catheter and JP drain in place. She was receiving
epidural with good pain control. The patient was hemodynamically
stable. Her CVL was d/c'd on POD1.
Post-operative pain was initially well controlled with epidural,
which was converted to oral pain medication when tolerating
clear liquids. The NG tube was self discontinued on POD 2, and
the epidural/foley catheter were both discontinued on POD#4. The
patient subsequently voided without problem, but [**Name (NI) **] was low, so
foley was replaced on POD5 and bolus was given, which patient
responded to accordingly. Foley was again d/c'd on POD6, and
patient voided without problem for the remainder of her stay.
The patient was started on sips of clears on POD#3, which was
progressively advanced as tolerated to a regular diet. The
patient did not take much by mouth during her stay, so tube
feeds were started to supplement her nutrition. These feeds
were via the j-tube and were advanced slowly to goal rate. The
patient had a bout of nausea/emesis on POD6 and patient was made
NPO, and tube feeds were held. JP amylase was sent in the
evening of POD#6 and was elevated to 7980. CT scan on POD7
showed ileus pattern, but no obvious fluid collections, and the
JP drain was in good position. On POD9, trophic tube feeds were
restarted and patient was given sips, which were tolerated well.
Her diet was re-advanced to regular at discharge, and tube feeds
were readvanced to goal. On POD10, JP amylase was rechecked and
was elevated to [**Numeric Identifier 87873**], but patient was eating well with no
complaints. On POD11, patient's J-tube became blocked, and was
unable to be fixed with bedside viokase and guide-wire. The
patient was sent to IR and had her j-tube replaced. The JP
output was decreasing at time of discharge, and JP drain was
left in place. The JP fluid was sent for culture and initially
grew out GNRs, mixed flora, and budding yeast. The patient was
started on cipro, flagyl, and fluconazole. The cipro was
transitioned to keflex, when speciation showed ancef sensitive
EColi.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. The patient was started on
lisinopril, and metoprolol XR to assist with blood pressure.
During here hospital stay, her BP ranged from 140-160s systolic,
and occasionally higher to the 180s. She remained completely
asymptomatic from her HTN during her stay.
At the time of discharge on [**2107-2-15**] 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. Staples were removed, and steri-strips
placed. The patient was discharged to rehab. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
lisinopril (not taking), cod liver oil (not currently taking)
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Stop on [**2107-2-23**].
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day: Stop on [**2107-2-23**].
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): stop on [**2107-2-23**].
9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Ampullary Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**6-14**] 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
JP Drain Care: To bulb suction. Cleanse insertion site with mild
soap and water or sterile saline, pat dry, and place a drain
sponge daily and PRN. Monitor and record quality and quantity of
output. Empty bulb frequently. Ensure that the JP is secured to
the patient.
Monitor for s/s infection or dislocation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2107-3-4**] 9:45
Please call your Primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
in One week to have your blood pressure medications adjusted as
necessary.
Completed by:[**2107-2-15**]
|
[
"575.11",
"285.9",
"294.8",
"560.1",
"401.9",
"530.81",
"562.10",
"293.1",
"569.62",
"156.2",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7",
"96.6",
"51.22",
"46.39",
"97.03"
] |
icd9pcs
|
[
[
[]
]
] |
7932, 7999
|
2988, 6778
|
264, 355
|
8060, 8060
|
2067, 2965
|
11375, 11738
|
1813, 1859
|
6890, 7909
|
8020, 8039
|
6804, 6867
|
8211, 9192
|
9818, 11352
|
1874, 1874
|
1888, 2048
|
9224, 9803
|
209, 226
|
383, 1431
|
8075, 8187
|
1453, 1724
|
1740, 1797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,842
| 102,152
|
21756
|
Discharge summary
|
report
|
Admission Date: [**2110-12-5**] Discharge Date: [**2110-12-20**]
Date of Birth: [**2041-1-14**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a postoperative
admission, admitted directly to the operating room for an
aortic valve and aortic root replacement. This is a 69 year
old woman with a known dilated aortic root to 4.9 centimeters
and critical aortic stenosis. She had a recent admission
with planned surgery which was delayed secondary to a white
blood cell count of 3.0. She had a hematology evaluation and
she was cleared for surgery. Readmitted on [**2110-11-21**], for
scheduled surgery again and was found to have a left
cellulitis secondary to a Pneumovax vaccine that she had
several days prior to admission. The case was again
postponed and she was admitted on the day of surgery for a
scheduled aortic valve replacement along with a root
replacement. She had a cardiac catheterization done
[**2110-10-9**], that showed normal coronaries and aortic root of
4.9 centimeters, one plus mitral regurgitation and one plus
tricuspid regurgitation, ejection fraction of 65 percent with
critical aortic stenosis and the aortic valve area 0.5
centimeter square and a gradient of 113 with one plus aortic
regurgitation.
PAST MEDICAL HISTORY: Aortic stenosis.
Hypertension.
PAST SURGICAL HISTORY: Partial oophorectomy.
Bilateral vein stripping.
ALLERGIES: She states an allergy to Penicillin which causes
a rash.
MEDICATIONS ON ADMISSION:
1. Lisinopril 40 mg daily.
2. Hydrochlorothiazide 25 mg daily.
3. Multivitamin.
4. Benadryl.
5. P.r.n. Albuterol.
SOCIAL HISTORY: She lives with husband in [**Name (NI) 11333**],
[**State 350**]. She works part-time as a bank teller. She
denies tobacco use. Alcohol use two glasses of wine per day.
FAMILY HISTORY: Significant only for an aunt who had
coronary artery disease.
PHYSICAL EXAMINATION: Height five feet seven inches, weight
160 pounds. General sitting comfortably in chair in no acute
distress. Neurologically, alert and oriented times three,
moves all extremities, follows commands, nonfocal
examination. Respiratory clear to auscultation bilaterally.
Cardiovascular regular rate and rhythm, S1 and S2, with a
III/VI holosystolic murmur. The abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with no edema. Pulses - radial two
plus on the right and one plus on the left. Dorsalis pedis
two plus bilaterally. Posterior tibial two plus bilaterally.
HOSPITAL COURSE: As stated, the patient was admitted
directly to the operating room for a planned aortic valve
replacement, aortic root repair. Please see the operating
room report for full details. In summary, she had an aortic
valve replacement with a number 27 millimeter [**Last Name (un) 3843**]-
[**Doctor Last Name **] pericardial valve and replacement of the ascending
and hemi-arch aorta with 28 millimeter Gelweave graft. Her
bypass time was 120 minutes with a cross clamp time of 76
minutes and a circulatory arrest of 9 minutes. She tolerated
the operation well and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit. At the time
of transfer, the patient was AV paced at 80 beats per minute
with a mean arterial pressure of 65 and a CVP of 6. She had
Neo-Synephrine at 1.0 mcg/kg/minute, Propofol at 10
mcg/kg/minute and Amiodarone at 1 mg per minute. The patient
did well in the immediate postoperative period. Her
anesthesia was reversed. She was weaned from the ventilator
and successfully extubated. On postoperative day number one,
the patient continued to be hemodynamically stable requiring
only Neo-Synephrine to maintain an adequate blood pressure.
She also continued on her Amiodarone drip which was initially
started for ventricular tachycardia in the operating room of
which she had no further episodes during her immediate
postoperative period, a postoperative day number one. The
patient remained in the Cardiothoracic Intensive Care Unit
for close hemodynamic monitoring. On postoperative day
number two, the patient again was doing well. Her Neo-
Synephrine infusion was weaned. Her Swan-Ganz catheter was
removed and she was begun on diuretics. Additionally, the
patient's Amiodarone drip was converted to oral dosing. She
remained in the Intensive Care Unit for continued requirement
of Neo-Synephrine to maintain an adequate blood pressure. By
postoperative day number three, the patient had weaned off
her Neo-Synephrine drip and was transferred from the
Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continued
postoperative care and cardiac rehabilitation. Over the next
several days, the patient's activity level was increased with
the assistance of the nursing staff and the physical therapy
staff. It was noted on postoperative day number five that
the patient did have an intermittent sternal click
accompanied by a complaint of pain, however, the wound looked
clean with no erythema and no drainage. However, by the
following day, the patient did begin to drain serosanguineous
fluid from the base of her sternal incision site. Over the
next several days, the patient continued to have sternal
drainage. She remained hemodynamically stable without a
white blood count during this entire period, however, because
of the continued drainage on [**2110-12-15**], the patient returned
to the operating room where she underwent sternal debridement
and rewiring. Cultures from that debridement came back
negative. She tolerated the operation well and was
transferred again from the operating room to the
Cardiothoracic Intensive Care Unit. She remained
hemodynamically stable and extubated immediately after
surgery. She remained in the Intensive Care Unit only on the
day of surgery and then was transferred back to the floor the
following morning for continued postoperative care. On
postoperative day number two from her sternal rewiring, her
chest tubes were put to water seal following which the
patient was noted to have a 20 percent right-sided
pneumothorax. The tubes were again returned to suction with
the lung fully reexpanding. On the following morning, the
patient's chest tubes were again placed to water seal and a
follow-up chest x-ray showed minimal apical pneumothorax.
The tubes were left on water seal for 24 hours. A repeat
chest x-ray showed no change in the apical pneumothorax and
on postoperative day number four from the rewiring, her chest
tubes were removed. On postoperative day number five from
the rewiring, it was deemed that the patient was stable and
ready to be transferred to rehabilitation for continuing
care.
At the time of this dictation, the patient's physical
examination is as follows: Temperature 97.3, heart rate 87,
sinus rhythm, blood pressure 114/69, respiratory rate 20,
oxygen saturation 95 percent in room air. Laboratory data
reveals white blood cell count 8.3, hematocrit 32.8. Sodium
137, potassium 3.9, chloride 99, CO2 29, blood urea nitrogen
9, creatinine 0.8. Glucose 98. On physical examination, the
patient is alert and oriented times three, moves all
extremities, follows commands. Pulmonary clear to
auscultation bilaterally. Cardiac regular rate and rhythm,
S1 and S2 with no murmurs. The sternum is stable and incision
with staples. No erythema or drainage. The abdomen is soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities are warm and well perfused with no edema. Follow-
up chest x-ray after chest tubes were removed shows a small
residual right apical pneumothorax unchanged from the two
prior days, both before and after chest tubes were removed.
CONDITION ON DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325 one to two tablets q4-6hours p.r.n.
2. Acetaminophen 325/650 q4hours p.r.n.
3. Aspirin 81 mg p.o. daily.
4. Colace 100 mg p.o. twice a day.
5. Metoprolol 100 mg twice a day.
6. Multivitamin one tablet daily.
7. Zinc Sulfate 220 mg daily.
8. Ascorbic Acid 500 mg twice a day.
9. Niferex 150 mg daily.
10. Thiamine 100 mg daily.
11. Potassium Chloride 40 mEq daily for two weeks.
12. Lasix 40 mg daily for two weeks and then 20 mg daily
times one week.
DISCHARGE STATUS: The patient is to be discharged to [**Location (un) 37268**].
FO[**Last Name (STitle) 996**]P: She is to have follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5263**] in two to three weeks and follow-up with Dr. [**Last Name (Prefixes) 411**] in four weeks.
DISCHARGE DIAGNOSES: Aortic stenosis, status post aortic
valve replacement with a number 27 [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial valve.
Aortic root enlargement, status post replacement of the
ascending and hemi-arch aorta with a number 28 Gelweave
graft.
Status post sternal rewiring.
Hypertension.
Status post oophorectomy.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2110-12-20**] 11:44:43
T: [**2110-12-20**] 12:33:46
Job#: [**Job Number 57167**]
|
[
"441.7",
"427.41",
"414.01",
"427.1",
"250.00",
"401.9",
"276.2",
"682.3",
"E878.1",
"424.1",
"V45.81",
"E879.8",
"512.1",
"998.31",
"999.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"35.21",
"89.64",
"39.61",
"34.04",
"34.79",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
1821, 1884
|
8594, 9186
|
7771, 8572
|
1498, 1614
|
2557, 7713
|
1352, 1472
|
1907, 2539
|
166, 1272
|
1295, 1328
|
1631, 1804
|
7738, 7745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,060
| 191,307
|
38416
|
Discharge summary
|
report
|
Admission Date: [**2161-7-28**] Discharge Date: [**2161-8-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain, DOE
Major Surgical or Invasive Procedure:
Percutaneous aortic valvuloplasty
Bare metal stent placed in SVG-D1
History of Present Illness:
Patient is an 87 y/o male with PMHx CAD s/p CABG, iCM (EF 35%),
AS who presented to the ED with chest pain, DOE, and a near
syncopal episode prior to presentation.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
In the ED, initial vitals were Afeb, 68, 134/38, 18, 100%RA. The
patient recieved ASA 325mg x 1.
On the floors, the patient was kept on his home medications. He
underwent a cardiac cath which showed 3 vessel disease as well
as severe aortic stenosis. He was evaluated by Thoracic surgery
for an AVR, however it was decided he would be a better patient
for a valvuloplasty. He underwent valvuloplasty with Dr. [**Last Name (STitle) **]
on [**8-3**] where his gradient improved from 65 to 41 mmHg and
increased of CO from 4.39 to 4.8. He also underwent BMS to
SVG-D1. During the procedure he felt abdominal cramps such as if
he were to move his bowels as well as nausea and vomited x1 a
black material that he reports looked like blood. His blood
pressure decreased from 150/46 to 118/46 mmHg. At some point
during procedure, nurse was concerned for a "seizure", but
patient was awake and with normal exam when physicians evaluated
him. He was transferred to the CCU for monitoring post
procedure.
Past Medical History:
Acute myocardial infarction [**2126**] and [**8-/2154**]
- Aortic valve stenosis (peak gradient 83mm, Mean gradient
48mmHg, 0.8cm)
- Moderate AI
- LVEF 35-40% with inferior and basilar septal HK.
- Paroxysmal Atrial Fibrillation
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: -Coronary Artery Bypass Graft x 4 [**2136**] [**Hospital1 336**] (LIMA-LAD,
SVG to rPRA, DM,OM)
-PERCUTANEOUS CORONARY INTERVENTIONS: -Angiojet extraction of
thrombus/PTCA with stenting of saphenous
vein graft->Obtuse marginal artery [**2153**] [**Hospital1 2025**]
3. OTHER PAST MEDICAL:
Gastroesophageal reflux disease
Low grade dementia with memory loss and emotional lability
Hiatal hernia
Hematuria
-Hernia repair
-Appendectomy
Social History:
Tobacco history:70 pk yr smoking history, Quit 2 months ago.
-ETOH: No excessive ETOH intake.
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T= 97.8 BP=131/56 mmHg HR=53 RR=12 O2 sat=99% 2 L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. SEM harsh, in RUSB louder, but audible
in all sites, radiating towards both carotid arteries. He also
has a [**12-29**] diastolic murmur best heard in LLSB. No r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2161-7-28**] 07:15PM BLOOD WBC-7.7 RBC-3.99* Hgb-12.0* Hct-35.4*
MCV-89 MCH-30.1 MCHC-33.9 RDW-13.1 Plt Ct-147*
[**2161-7-29**] 06:35AM BLOOD WBC-6.9 RBC-3.68* Hgb-11.1* Hct-32.7*
MCV-89 MCH-30.2 MCHC-34.0 RDW-13.2 Plt Ct-141*
[**2161-7-30**] 06:35AM BLOOD WBC-8.4 RBC-3.75* Hgb-11.5* Hct-33.1*
MCV-88 MCH-30.5 MCHC-34.6 RDW-13.1 Plt Ct-148*
[**2161-7-31**] 06:40AM BLOOD WBC-8.1 RBC-3.53* Hgb-10.6* Hct-31.5*
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.4 Plt Ct-142*
[**2161-8-1**] 04:40AM BLOOD WBC-8.2 RBC-3.58* Hgb-10.8* Hct-32.1*
MCV-90 MCH-30.1 MCHC-33.6 RDW-13.6 Plt Ct-135*
[**2161-8-2**] 05:45AM BLOOD WBC-7.5 RBC-3.56* Hgb-11.1* Hct-31.8*
MCV-89 MCH-31.1 MCHC-34.8 RDW-13.4 Plt Ct-153
[**2161-8-4**] 05:15AM BLOOD WBC-8.4 RBC-3.20* Hgb-9.8* Hct-28.0*
MCV-87 MCH-30.7 MCHC-35.1* RDW-13.6 Plt Ct-144*
.
[**2161-7-28**] 07:15PM BLOOD PT-11.7 PTT-28.0 INR(PT)-1.0
[**2161-8-2**] 05:45AM BLOOD PT-12.2 INR(PT)-1.0
[**2161-8-4**] 05:15AM BLOOD PT-11.5 PTT-24.0 INR(PT)-1.0
.
[**2161-7-28**] 07:15PM BLOOD Glucose-158* UreaN-36* Creat-1.6* Na-141
K-4.7 Cl-105 HCO3-27 AnGap-14
[**2161-7-29**] 06:35AM BLOOD Glucose-105* UreaN-34* Creat-1.5* Na-144
K-4.3 Cl-108 HCO3-28 AnGap-12
[**2161-7-30**] 06:35AM BLOOD Glucose-109* UreaN-29* Creat-1.4* Na-142
K-4.1 Cl-107 HCO3-28 AnGap-11
[**2161-7-31**] 06:40AM BLOOD Glucose-106* UreaN-32* Creat-1.5* Na-141
K-4.3 Cl-105 HCO3-25 AnGap-15
[**2161-8-1**] 04:40AM BLOOD Glucose-107* UreaN-33* Creat-1.5* Na-138
K-4.1 Cl-105 HCO3-26 AnGap-11
[**2161-8-2**] 05:45AM BLOOD Glucose-106* UreaN-32* Creat-1.4* Na-142
K-4.3 Cl-107 HCO3-27 AnGap-12
[**2161-8-3**] 06:50AM BLOOD Glucose-101* UreaN-34* Creat-1.4* Na-141
K-4.1 Cl-106 HCO3-27 AnGap-12
[**2161-8-3**] 05:44PM BLOOD Na-139 K-4.4 Cl-106
[**2161-8-4**] 05:15AM BLOOD Glucose-119* UreaN-30* Creat-1.5* Na-138
K-3.9 Cl-104 HCO3-24 AnGap-14
.
[**2161-7-29**] 06:35AM BLOOD CK(CPK)-58
[**2161-7-29**] 01:25PM BLOOD ALT-11 AST-17 AlkPhos-50 TotBili-0.4
[**2161-8-3**] 05:44PM BLOOD CK(CPK)-93
[**2161-8-4**] 05:15AM BLOOD CK(CPK)-71
[**2161-7-28**] 07:15PM BLOOD cTropnT-0.02*
[**2161-7-29**] 06:35AM BLOOD CK-MB-3 cTropnT-0.02*
[**2161-8-3**] 05:44PM BLOOD CK-MB-8
[**2161-8-4**] 05:15AM BLOOD CK-MB-5
.
[**2161-7-29**] 06:35AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.5
[**2161-7-30**] 06:35AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.4
[**2161-7-31**] 06:40AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.2
[**2161-8-1**] 04:40AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.3
[**2161-8-2**] 05:45AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
[**2161-8-3**] 06:50AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.4
[**2161-8-4**] 05:15AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.3
.
[**2161-8-3**] 05:44PM BLOOD Iron-20*
[**2161-8-3**] 05:44PM BLOOD calTIBC-244 Ferritn-342 TRF-188*
.
[**2161-7-30**] 06:35AM BLOOD %HbA1c-6.5* eAG-140*
.
REPORTS
CARDIAC CATH [**7-29**]
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel disease. The LMCA has no
angiographically
apparent disease. The LAD had a total occlusion in the proximal
portion
of the vessel and a diagonal with an 80% mid vessel stenosis.
The Cx had
a total proximal occlusion. The RCA had a total proximal
occlusion.
2. Limited resting hemodynamics revealed elevated right and left
sided
filling pressures with an RVEDP of 14mmHg and an LVEDP of
21mmHg. The
Pulmonary pressures were moderately elevated with a PASP of
44mmHg. The
cardiac index was preserved at 2.2 l/min/m2. There was a 60mmHg
gradient
from the LV to the aorta on pullback of the catheter. The
central aortic
pressure was noted to be 143/44 mmHg.
3. Limited arterial conduit arteriography revealed an SVG to OMB
that
had a 40-50% ostial stenosis. The SVG to PDA had a 60-70%
stenosis in
the mid portion of the SVG. The RPDA was a very large vessel and
provided collaterals to the Cx distribution. The SVG to Diagonal
had a
90% ostial stenosis with slow flow into the diagonal branch. The
diagonal branch had collateral from the LAD. The LIMA to the LAD
was
widely patent and the LAD was a small vessel in caliber.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe aortic stenosis.
3. Moderate diastolic ventricular dysfunction.
4. Moderate pulmonary hypertension.
.
CT Chest w/o contrast [**7-29**]
FINDINGS:
The patient is after median sternotomy and CABG. The appearance
of the
sternum is unremarkable with no evidence of dehiscence. There
are several
bypass grafts noted, at least two originating from the ascending
aorta.
Descending aorta is normal in diameter, not exceeding 3 cm.
Calcifications
involve the entire ascending aorta and starts approximately 7 cm
above the
aortic valve. The extent of calcification is more pronounced at
the anterior circumference of the aorta than at the posterior
part. There is a small gap between the superior end of the
calcifications and the first bypass graft, approximately 1.5 cm
in diameter. The aortic arch and descending aorta are calcified
as well. The aortic valve is heavily calcified. The diameter of
the pulmonary arteries is unremarkable. Native coronary arteries
are extremely calcified. Heart size is normal. There is a
relative bulging of the cardiac apex that potentially may
represent a prior myocardial infarct of the apex of the left
ventricle. The imaged portion of the upper abdomen demonstrates
calcified abdominal aorta, atrophic changes in the pancreas.
Several mediastinal lymph nodes are
not pathologically enlarged. The airways are patent to the level
of subsegmental bronchi bilaterally. Diffuse bronchial wall
thickening is noted, bilaterally, mostly in the upper lungs.
Those findings in conjunction with multiple centrilobular
nodules might be consistent with respiratory bronchiolitis/viral
infection. Superior segment of right lower lobe subpleural
lesion, 4:90, is 10 x 7 mm in diameter and most likely
represents atelectasis, but would require further followup to
exclude the possibility of neoplasm. A right hilar calcified
lymph nodes as well as right lower lobe calcified granuloma are
consistent with prior ranulomatous exposure. Bibasilar linear
opacities most likely representing
areas of atelectasis. Left upper lobe posterior nodule, is 2.5
cm in
diameter, 4:75, a lingular nodule is calcified, 4:113. There is
no pleural or pericardial effusion demonstrated. Extensive
degenerative changes are present in the thoracic spine. There
are no bone lesions worrisome for infection or neoplasm.
IMPRESSION:
1. Extensive calcifications of the ascending aorta as described
in detail in the body of the report.
2. Status post CABG with at least two bypasses originating from
the ascending aorta.
3. Extensive calcifications of native coronary arteries and
aortic valve.
Questionable prior myocardial infarct involving the left
ventricular apex.
4. Suspected respiratory bronchiolitis/infectious process in the
upper lungs, correlate if history of smoking is present.
5. Superior segment of right lower lobe atelectasis versus
nodule, should be evaluated in three months for documentation of
stability/resolution.
.
Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2161-7-30**] 2:53 PM
SPIROMETRY 2:53 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 3.28 3.51 94
FEV1 2.10 2.12 99
MMF 1.07 1.75 61
FEV1/FVC 64 60 106
LUNG VOLUMES 2:53 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 6.19 6.13 101
FRC 3.80 3.55 107
RV 3.18 2.63 121
VC 3.14 3.51 89
IC 2.38 2.58 92
ERV 0.62 0.93 67
RV/TLC 51 43 120
He Mix Time 1.50
DLCO 2:53 PM
Actual Pred %Pred
DSB 13.38 21.28 63
VA(sb) 5.65 6.13 92
HB 14.60
DSB(HB) 13.38 21.28 63
DL/VA 2.37 3.47 68
.
ECHO [**7-30**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). 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 are severely thickened/deformed. There is critical
aortic valve stenosis (valve area 0.5 cm2). Mild to moderate
([**12-27**]+) 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 left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
.
Carotid series [**7-30**] Final Report
Study: Carotid Series Complete
Reason:87 year old man s/p CABG, with worsening AS, work-up for
AVR..
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On
the right there is bulky heterogeneous plaque in the ICA and
ECA. On the left there is significant heterogeneous plaque in
the ICA and a tiny plaque in the ECA. Both CCA waveforms are
blunted consistent with know AS.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 93/10, 76/15, 77/17,
cm/sec. CCA peak systolic
velocity is 86 cm/sec. ECA peak systolic velocity is 107 cm/sec.
The ICA/CCA ratio is 1.0. These findings are consistent with
<40% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 479/105, 223/39, 144/39, cm/sec. CCA
peak systolic
velocity is 77 cm/sec. ECA peak systolic velocity is 147 cm/sec.
The ICA/CCA ratio is 6.2. These findings are consistent with
80-99% stenosis.
There is antegrade right vertebral artery flow. There is
antegrade left vertebral artery flow.
Impression: Right ICA stenosis <40%. Left ICA stenosis 80-99%
.
Brief Hospital Course:
Patient is an 87 y/o male with PMHx CAD s/p CABG, iCM (EF 35%),
AS who presented to the ED with chest pain, DOE, and a near
syncopal episode secondarily to severe AS, not a surgical
candidate now s/p valvuloplasty.
.
# CORONARIES: Pt with 3V CAD s/p CABG and with cath showing LMCA
Nl; LAD 100% proximal, D1 80% mid; Cx 100% prox, Rca 100% prox;
SVG to OMB 40-50% ostial, SVG-PDA 60-70%, SVG-D 90% ostial. Pt
underwent valvuloplasty via cardiac cath on [**8-3**] and had BMS to
SVG-D1 placed at same time. He was continued on ASA, plavix,
statin, ACEi and betablocker therapy. He tolerated the
valvuloplasty well and was shown to have some improvement in his
AV gradient post-procedure. He was monitored overnight after the
valvuloplasty and discharged from the CCU in apparent good
health, without SOB, palpitations, chest pain, or
lightheadedness. PT was consulted and cleared pt for discharge
to home.
.
# PUMP: Pt with EF of 45% on TTE performed [**7-29**]. Currently no
signs of acute diastolic heart failure. He was continued on
ACEi, betablocker therapy and was diuresed with lasix to
improve cardiopulmonary and volume status. Exam was monitored
closely and pt was stable at discharge.
.
# RHYTHM: Pt with new LBBB. He is pain free. No signs if
ischemia or dynamic changes. Likely secondarily to pacing or
balloon dilation s/p valvuloplasty. He was followed on serial
ECGs which did not show progression suggestive of cardiac
ischemia.
.
#. Chronic kidney disease: Stage 3b CKD with eGFR 51 ml/min
(MDRD). PTH goal 35-70. At his baseline. Continued on home ACEi
with inpt monitoring of serum creatinine. He had good urine
output during his admission. To be be followed as an
outpatient.
.
#. Anemia: Normocytic, normochromic, normal RDW (13.5). HCT
stable. Guaiac stools was negative for occult blood. To
followed and worked up as an outpatient.
.
#. Diabetes Mellitus: New diagnosis. Pt with A1C of 6.5% on
admission. He had diabetes education and kept on ISS. He was
continued on ACEi therapy. He will follow this issue as an
outpatient.
.
# Hypertension: Continued home-medications.
.
#. Hyperlipidemia: Continued simvastatin.
Medications on Admission:
Lasix 40mg daily
Metoprolol 25mg twice daily
Ramipril 2.5mg daily
Zocor 40mg daily
Aspirin 81mg daily
(Coumadin recently discontinued)
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Succinate 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*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic Stenosis s/p valvuloplasty
CAD
DM type 2
diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 85550**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
through the emergency department with complaints of chest pain
and difficulty breathing. You described difficulty walking up
stairs and you had a near-fainting episode as well. We believe
these symptoms were due to your history of heart valve disease.
You underwent a heart catheterization procedure on [**7-29**] which
confirmed your heart valve disease.
You were scheduled and taken for repeat catheterization
procedure, this time to fix your valve on [**8-3**]. A bare metal
stent was also placed in one of the blood vessels of your heart.
.
You were also diagnosed as having diabetes mellitus. This will
need to be followed by your primary care physician.
.
The following changes were made to your medications:
START Metoprolol Succinate 50mg Daily
START Clopidogrel 75mg daily
INCREASE Aspirin 325mg daily
STOP Aspirin 81mg daily
STOP Metoprolol tartrate
CONTINUE Lasix 40mg daily
CONTINUE Ramipril 2.5mg daily
CONTINUE Zocor 40mg daily
.
Please follow up with your physician at the appt below:
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] ([**Hospital1 **] MA) on Wed [**8-12**], at 3pm
ph: [**Telephone/Fax (1) 45578**] fax: [**Telephone/Fax (1) 85551**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"414.8",
"414.02",
"530.81",
"427.31",
"414.01",
"424.1",
"V45.82",
"428.23",
"428.0",
"585.3",
"403.90",
"553.3",
"250.00",
"285.9",
"458.29",
"578.0",
"412",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"36.06",
"88.42",
"00.45",
"00.66",
"88.57",
"00.40",
"35.96"
] |
icd9pcs
|
[
[
[]
]
] |
16823, 16829
|
13898, 16044
|
277, 347
|
16935, 16935
|
4159, 8159
|
18225, 18549
|
2993, 3109
|
16230, 16800
|
16850, 16914
|
16070, 16207
|
8176, 13875
|
17086, 18202
|
3124, 4140
|
2400, 2842
|
222, 239
|
376, 2075
|
16950, 17062
|
2098, 2380
|
2858, 2977
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,221
| 103,319
|
38214
|
Discharge summary
|
report
|
Admission Date: [**2156-7-8**] Discharge Date: [**2156-7-12**]
Date of Birth: [**2086-1-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic stenosis/regurgitation
Major Surgical or Invasive Procedure:
Aortic valve replacement (927mm Mosaic tissue) [**2156-7-8**]
History of Present Illness:
This 70 year old white male has a long standing history of
aortic stenosis. recent echocardiograms have shown worsening
stenosis ([**Location (un) 109**] 0.8 cm2 and >100 gradient)with new regurgitation
with dilatation of the aortic root. He was admitted now for
elective replacement.
Past Medical History:
hypertension
hyperlipidemia
aortic stenosis/regurgitation
Remote history of sternal fracture
Social History:
Race: Caucasian
Last Dental Exam: 1 month
Lives with: wife
Occupation: Counselor
Tobacco: Never
ETOH: one-two drinks per day
Family History:
father died age 65 of MI
Physical Exam:
admission:
Pulse: 74 Resp: 16 O2 sat: 98%
B/P Right: 147/83 Left: 139/87
Height: 66" Weight: 178
General: WDWN in NAD
Skin: Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X] Anicteric sclera
Neck: Supple [X] Full ROM [X] No JVD[X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI harsh systolic ejection murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] No HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Mild bilateral spider veins
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit- Murmur radiates bilaterally
Pertinent Results:
[**2156-7-12**] 05:13AM BLOOD WBC-9.8 RBC-3.89* Hgb-11.5* Hct-33.5*
MCV-86 MCH-29.4 MCHC-34.2 RDW-13.2 Plt Ct-315#
[**2156-7-12**] 05:13AM BLOOD Plt Ct-315#
[**2156-7-12**] 05:13AM BLOOD UreaN-10 Creat-0.7 Na-139 K-4.0 Cl-105
[**2156-7-10**] 04:40AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-134
K-4.2 Cl-100 HCO3-27 AnGap-11
[**2156-7-12**] 05:13AM BLOOD Mg-2.2
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Biventricular systolic function remains normal. There is a well
seated, well functioning bioprosthesis in the aortic position.
No AI is visualized. The MR is now trace. The study is otherwise
unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2156-7-8**] 10:49
Brief Hospital Course:
Following admission he went to the Operating Room where aortic
valve replacement was undertaken. he weaned from bypass on Neo
Synephrine and Propofol. he remained stable, was weaned and
extubated and came off pressor easily. See operative note for
details.
He was in complete heart block immediaitely after surgery, but
in sinus rhythm by POD 1. He developed atrial fibrillation with
a ventricular response of 130 on POD 2 and beta blockade was
begun. He was diuresed towards his preoperative weight.
Physical therapy worked with him for mobility and strengthening.
CTs were discontinued on POD 1 and temporary wires per protocol.
Made good progress and was cleared for discharge to home with
VNA on POD #4. All f/u appts were advised.
Medications on Admission:
amlodipine 5 mg daily
lipitor 10 mg daily
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed for post op.
Disp:*90 Tablet(s)* Refills:*1*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of S.E Ct.
Discharge Diagnosis:
s/p aortic valve replacement
aortic stenosis/regurgitation
hypertension
hyperlipidemia
postop A Fib
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 -none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on Tuesday [**8-10**] @ 1:15 pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17811**] in [**11-29**] weeks[**Telephone/Fax (1) 85193**]
Cardiologist: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 9241**] [**Last Name (NamePattern1) 85194**] in [**11-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2156-7-12**]
|
[
"272.4",
"401.9",
"427.31",
"426.0",
"424.1",
"441.2",
"E878.2",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
5089, 5134
|
3129, 3873
|
305, 369
|
5278, 5455
|
1758, 3106
|
6210, 6880
|
961, 987
|
3982, 5066
|
5155, 5257
|
3899, 3959
|
5479, 6187
|
1002, 1739
|
236, 267
|
397, 684
|
706, 801
|
817, 945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,831
| 116,836
|
36245
|
Discharge summary
|
report
|
Admission Date: [**2126-4-12**] Discharge Date: [**2126-4-14**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
EKG changes
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2126-4-12**]
History of Present Illness:
86 yo female with COPD, pulm HTN, TR who presented to OSH after
a stranger knocked into her at her [**Hospital3 **] facility
causing her to fall and fracture her left hip. She did not have
any LOC. In addition, she sustained a laceration to her right
lower leg and received 6 stiches at OSH. At OSH, pt had CT scan
of Left hip which showed a cervical neck fracture of the left
proximal femur. She had a routine pre-op evaluation; however
her pre-op EKG showed ST elevations in V2-V4. The patient was
completely asymptomatic. She denied chest pain or pressure.
Her SOB was at baseline. She did have some nausea, vomiting and
diaphoresis at the OSH. She was transferred to [**Hospital1 18**] for
cardiac cath. Her cardiac cath earlier today showed clean
coronaries. The patient tolerated the procedure without
complication. The orthopedic team was consulted for management
of her hip fracture.
.
The patient denies any chest pain or pressure currently. She
reports that she does not want to undergo hip repair despite
being informed of the risks. She refuses to go to get x-rays
for further evaluation.
.
ROS: She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, or hemoptysis. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. Has occasional abdominal pain, alternating diarrhea and
constipation but has not had a colonoscopy, occasional blood in
stool with straining.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Pulmonary HTN
Tricuspid regurgitation
CPD
Osteoporosis c/b thoracic spine fracture resulting in chronic
mid back pain
Hypertension
h/o pyelonephritis
h/o left hydronephrosis of uncertain eitology
h/o pneumonia - required stay in rehab prior to transfer to
[**Hospital3 **]
s/p appendectomy
s/p oophrectomy
Social History:
She lives in an [**Hospital3 **] facility at [**Location (un) 582**]. Had been
living independently until 3 months ago when she had a pneumonia
and required inpatient rehab prior to her transfer to [**Hospital 4382**]. Son is an administrator and internist at [**Hospital1 3325**]. Has 2 daughters who live locally.
-Tobacco history: She started smoking as a teenager and quit
smoking 3 months ago.
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=98.1 BP=102/49 HR=63 RR=15 O2 sat=96% 4L
GENERAL: thin elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: LLE shortened and externally rotated. No c/c/e. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2126-4-12**] 09:28PM BLOOD WBC-10.4 RBC-3.87* Hgb-12.0 Hct-36.9
MCV-95 MCH-31.0 MCHC-32.5 RDW-13.5 Plt Ct-259
[**2126-4-13**] 03:58AM BLOOD WBC-10.5 RBC-3.75* Hgb-11.7* Hct-35.4*
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.4 Plt Ct-235
[**2126-4-12**] 09:28PM BLOOD Glucose-123* UreaN-27* Creat-1.2* Na-132*
K-5.5* Cl-101 HCO3-26 AnGap-11
[**2126-4-13**] 03:58AM BLOOD Glucose-105 UreaN-28* Creat-1.2* Na-133
K-5.5* Cl-101 HCO3-28 AnGap-10
[**2126-4-13**] 01:24PM BLOOD Glucose-158* UreaN-27* Creat-1.1 Na-135
K-4.2 Cl-103 HCO3-25 AnGap-11
[**2126-4-12**] 09:28PM BLOOD CK(CPK)-52
[**2126-4-13**] 03:58AM BLOOD CK(CPK)-41
[**2126-4-13**] 01:24PM BLOOD proBNP-[**Numeric Identifier 82170**]*
[**2126-4-12**] 09:28PM BLOOD Mg-1.9
[**2126-4-13**] 03:58AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
[**2126-4-13**] 01:24PM BLOOD Mg-1.8
[**2126-4-12**] 02:26PM BLOOD Type-ART O2 Flow-100 pO2-319* pCO2-58*
pH-7.26* calTCO2-27 Base XS--1
[**2126-4-12**] 02:46PM BLOOD Type-ART pO2-74* pCO2-54* pH-7.27*
calTCO2-26 Base XS--2 Intubat-NOT INTUBA
.
Cardiac Catheterization [**2126-4-12**]
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had no angiographically apparent disease
--the LAD had no angiographically apparent disease
--the LCX had no angiographically apparent disease
--the RCA had a calcified proximal 50% stenosis.
2. Limited resting hemodynamics revealed elevated systemic
arterial
systolic pressures, with SBP 156 mmHg.
FINAL DIAGNOSIS:
1. No obstructive CAD
2. Moderate systemic arterial systolic hypertension.
.
[**2126-4-12**] TTE
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.8 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.3 m/sec
Mitral Valve - E/A ratio: 0.62
Mitral Valve - E Wave deceleration time: 235 ms 140-250 ms
TR Gradient (+ RA = PASP): *59 to 66 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Increased IVC
diameter (>2.1cm) with <35% decrease during respiration
(estimated RA pressure (10-20mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline
normal RV systolic function. Abnormal systolic septal
motion/position consistent with RV pressure overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Moderate to
severe [3+] TR. Severe PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is small. Overall left
ventricular systolic function is normal (LVEF 70%). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with borderline normal free wall function.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic valve
leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2126-4-13**] CXR
The lung volumes are near normal, the hemidiaphragms are
relatively low, but not flattened. Moderate scoliosis leads to
asymmetry of the rib cage. In both lungs, right more than left,
a reticular pattern of opacities is seen in both perihilar
regions and in the right upper region. Without comparison, the
nature of these lesions is difficult to determine, they could be
the result of fibrotic or a chronic inflammatory process, but
could also result from chronic overhydration.
Moderately enlarged cardiac silhouette, slightly enlarged right
and left
hilus, potentially suggesting pulmonary hypertension. No
evidence of pleural effusions, no acute overhydration. Bilateral
apical thickening.
.
[**2126-4-13**] Lower extremity doppler U/S
Preliminary Report !! WET READ !!
no dvt seen in either lower extremity
.
[**2126-4-13**] CTA CHEST
Preliminary Report !! PFI !!
Pulmonary embolus within the right middle lobe segmental artery.
Bilateral pleural effusions. Extensive COPD, cardiomegaly,
vascular calcifications. Areas of increased opacity in the right
upper lobe may represent infection. Additional areas of opacity
in the right middle lobe may represent infarct or atelectasis.
Brief Hospital Course:
1) EKG changes - Perioperative EKG prior to transfer to [**Hospital1 18**]
showed ST elevations in V3-V4 and to a lesser extent in
II,III,F,V5-V6. TnI was 1.9 with normal CK. She was given
aspirin, plavix, lovenox, and lopressor. A similar EKG was
obtained upon transfer to [**Hospital1 18**]. Cardiac cath [**4-12**] revealed a
right-dominant system with a calcified 50% proximal stenosis in
the RCA but no angiographically apparent disease in the LMCA,
LAD, and LCX. TTE [**2126-4-12**] revealed normal left atrial size with
an estimated right atrial pressure 10-20mmHg, normal left
ventricular wall thickness and a small left ventricular cavity,
normal left ventricular systolic function (LVEF 70%),
hypertrophied right ventricular free wall, dilated right
ventricular cavity with borderline normal free wall function,
abnormal systolic septal motion/position consistent with right
ventricular pressure overload, moderately thickened aortic valve
leaflets with a minimally increased gradient consistent with
minimal aortic valve stenosis, mildly thickened mitral valve
leaflets, left ventricular inflow pattern suggesting impaired
relaxation, mildly thickened tricuspid valve leaflets with
moderate to severe [3+] tricuspid regurgitation, and severe
pulmonary artery systolic hypertension. Cardiac enzymes were
trended with no elevation in her CK's threfore this was felt not
to be cardiac ischemia.
.
2) Pulmonary Embolus - On hospital day 2, the patient had
low-grade fever, tachycardia, worsening hypoxemia with resting
oxygen saturation in the mid 90's on 6 L NC, new T-wave
inversions in V3 and deeper T-wave inversions in V4. CTA of the
chest revealed right middle lobe segmental pulmonary emboli,
right middle lobe pulmonary infarct vs. atelectasis, moderate
bilateral pleural effusions, and volume overload. Heparin and
lasix infusions were started. Lower extremity doppler ultrasound
was negative for DVT.
.
3) Left femoral neck fracture - Seen in consultation by
orthopaedic surgery who recommended proceeding with ORIF.
However, based on the preference of the patient and her family,
she was transferred to [**Hospital3 3583**] for further management.
Medications on Admission:
Celexa 10mg PO daily
Omeprazole 20mg PO daily
Senna 2 tabs daily at 4pm
Lisinopril 5 mg PO daily
Lidoderm 5% patch, one patch to lower back 12 hrs each day
Calcium with Vit D 600mg PO BID
Tylenol 650mg Q4hrs PRN for pain
Compazine 10mg PO BID PRN nausea/vomiting
Ibuprofen prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): do not exceed 4 grams in 24 hours.
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place
on between 8 AM and 8 PM then remove.
5. Heparin (Porcine) in NS 10 unit/mL Kit Sig: ASDIR units
Intravenous every six (6) hours: Diagnosis: Pulmonary Embolism
Patient Weight: 40.824 kg
Initial Bolus: 1000 units IVP
Initial Infusion Rate: 750 units/hr
Target PTT: 60 - 100 seconds
PTT <40: 1600 units Bolus then Increase infusion rate by 150
units/hr
PTT 40 - 59: 800 units Bolus then Increase infusion rate by 100
units/hr
PTT 60 - 100*:
PTT 101 - 120: Reduce infusion rate by 100 units/hr
PTT >120: Hold 60 mins then Reduce infusion rate by 150
units/hr.
6. Furosemide 10 mg/mL Solution Sig: 2.5 mg Injection INFUSION
(continuous infusion).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Calcium Carbonate 500 mg (1,250 mg) Capsule Sig: One (1)
Capsule PO once a day.
9. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1) Left femoral neck fracture
2) Pulmonary embolus
3) Pleural effusions
4) Pulmonary hypertension
5) Tricuspid regurgitation
6) Emphysema
Discharge Condition:
Transfer to [**Hospital3 3583**].
Discharge Instructions:
You were admitted to the hospital following a fall and left hip
fracture. You declined surgery at [**Hospital1 18**] and were transferred to
[**Hospital3 3583**] at your request.
You were diagnosed with blood clots in the lung, also known as
pulmonary emboli, and were started on blood thinning medication.
Followup Instructions:
Please follow the recommendations of your medical and
orthopaedic doctors [**First Name (Titles) **] [**Hospital3 3583**].
Completed by:[**2126-4-14**]
|
[
"415.19",
"733.00",
"530.81",
"794.31",
"401.9",
"511.9",
"250.00",
"E888.1",
"397.0",
"492.8",
"276.7",
"820.8",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"37.22",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
13485, 13500
|
9701, 11871
|
255, 297
|
13682, 13718
|
3897, 5337
|
14074, 14228
|
2824, 2939
|
12199, 13462
|
13521, 13661
|
11897, 12176
|
5354, 9678
|
13742, 14051
|
2954, 3878
|
204, 217
|
325, 2023
|
2045, 2352
|
2368, 2808
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,045
| 174,095
|
11273
|
Discharge summary
|
report
|
Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-8**]
Date of Birth: [**2119-9-1**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
History of Present Illness:
30 F w/ HTN, IDDM c/b gastroparesis, w/ several admits for DKA,
p/w nausea/vomiting and abdominal discomfort for the past
several days. She was recently discharged [**3-30**] for w/u
hypotension and 2 falls at home which were thought to be [**3-18**]
medication nonadherence.
She was sent to ED by her PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] today because her
mother reported [**Name (NI) 2270**] had been having fevers to 103 at home
around 7pm, with nausea, vomiting abominal pain and new severe
flank pain. She asked her to present to ED for evaluation of
pyelonephritis or other infection.
.
In the ED VS: 82 169/93 20 100 % RA. Her emesis in the ED
appeared as dark coffee-ground material, although she was guiaic
negative from below. Her physical exam was unremarkable and labs
were notable for HCT of 25 that decreased to 22 on repeat a few
hours later. In the ED she was started on a pantoprazole drip
and GI was curbsided who did not leave formal recs but mentioned
scoping patient if she were to become hemodynamically unstable.
.
On the floors, pt is somnolent and uncomfortable appearing. She
is vomiting coffee-ground like dark material into emesis basin.
She reports onset of sx 7pm yesterday and feeling in her USOH
prior
.
Review of systems:
(+/-) Unable to obtain given patient's somnolence.
Past Medical History:
1. Type 1 diabetes mellitus complicated by peripheral
neuropathy, followed by [**Last Name (un) **].
2. Multiple admissions for DKA (last at [**Hospital3 3583**] in [**2-21**])
3. Depression.
4. History of perirectal abscess.
5. Eating disorder, bulimia.
6. Bacterial overgrowth
7. Chronic Renal failure of Unknown Etiology (baseline 1.3-1.8
since [**1-/2150**])
Social History:
Lives with her parents and brother and sister-in-law. [**Name (NI) 1403**] as a
CNA at an [**Hospital3 **] facility in [**Location (un) 3320**]. Usually works
[**8-16**], sometimes picks up extra shifts. No smoking, occasional
alcohol (1-2 drinks per week), no drug use.
Family History:
PGF died of MI in his early 70s.
Physical Exam:
On admission:
VS: afebrile 181/91 91 SaO2 97% RA
GEN: somnolent F arousable to voice and touch and would follow
all commands but would intermittently fall asleep during the
interview; did not flinch to pain with ABG or [**Month/Day (3) **] draws. AOx1
('[**Known firstname 2270**]')
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: poor nail hygeine and macerated fingertips c/w chronic
wretching
Neuro/Psych: CNs II-XII intact. symmetric strength in U/L
extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation
grossly intact. cerebellar fxn intact (FTN). gait deferred.
following all commands.
.
On discharge:
AF HR 60s-80s BP 160s/90s 94% on RA
A&Ox3; lungs with diminished bs at bases but otherwise clear
ambulating without difficulty
Pertinent Results:
ADMISSION LABS:
[**2150-4-2**] 10:35PM WBC-9.7# RBC-3.11* HGB-9.4* HCT-25.4* MCV-80*
MCH-30.3 MCHC-38.0* RDW-12.9
[**2150-4-2**] 10:35PM NEUTS-88.6* LYMPHS-7.0* MONOS-3.7 EOS-0.2
BASOS-0.5
[**2150-4-2**] 10:35PM PLT COUNT-198
[**2150-4-2**] 10:35PM GLUCOSE-173* UREA N-31* CREAT-1.4* SODIUM-136
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-18
[**2150-4-2**] 10:35PM ALT(SGPT)-27 AST(SGOT)-35 ALK PHOS-86
AMYLASE-37 TOT BILI-0.3
[**2150-4-2**] 10:35PM LIPASE-20
[**2150-4-2**] 10:46PM LACTATE-1.1
[**2150-4-3**] 01:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2150-4-3**] 01:40AM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2150-4-3**] 01:40AM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2150-4-3**] 01:40AM URINE UCG-NEGATIVE
[**2150-4-3**] 06:44PM TYPE-ART PO2-65* PCO2-32* PH-7.45 TOTAL
CO2-23 BASE XS-0
[**2150-4-3**] 05:09PM LD(LDH)-536* CK(CPK)-468* AMYLASE-29 TOT
BILI-0.5
[**2150-4-3**] 05:09PM HAPTOGLOB-112
STUDIES:
[**4-3**] CXR: Diffuse bilateral opacities most consistent with
pulmonary edema. Although most frequently due to congestive
heart failure, the differential diagnosis for pulmonary edema is
broad and includes central nervous system disorders, sensitivity
reaction, aspiration, and hemorrhage.
[**4-3**] KUB: Non-obstructive bowel gas pattern with NG tube
visualized with
the tip in the stomach.
[**4-4**] TTE: No echocardiographic evidence of endocarditis. EF
60-65%. Normal regional and global biventricular systolic
function. The valves are well seen without significant
regurgitation making endocarditis unlikely.
.
[**4-8**] TEE:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. A central line is seen in the SVC/right
atrium without evidence of overlying thrombus/vegetation.
Overall left ventricular systolic function is normal (LVEF>55%).
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 42 cm
from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Trace aortic regurgitation with normal valve
morphology.
[**Month/Year (2) **] culture: [**4-2**], [**4-3**] MSSA in [**3-18**] bottles
[**Date Range **] culture [**4-4**] and thereafter: NGTD
Urine culture: negative
.
Renal U/S:
IMPRESSION:
Echogenic kidneys concerning for diffuse parenchymal kidney
disease. No
stones, perinephric collection or hydronephrosis noted.
.
Discharge labs:
[**2150-4-8**] 05:18AM [**Month/Day/Year 3143**] WBC-6.4 RBC-2.97* Hgb-8.6* Hct-24.2*
MCV-81* MCH-29.0 MCHC-35.6* RDW-12.9 Plt Ct-208
[**2150-4-8**] 05:18AM [**Month/Day/Year 3143**] ESR-92*
[**2150-4-7**] 05:40AM [**Month/Day/Year 3143**] Ret Aut-1.1*
[**2150-4-8**] 05:18AM [**Month/Day/Year 3143**] Glucose-87 UreaN-34* Creat-2.2* Na-140
K-3.8 Cl-107 HCO3-26 AnGap-11
[**2150-4-7**] 05:40AM [**Month/Day/Year 3143**] ALT-14 AST-16 LD(LDH)-321* AlkPhos-67
TotBili-0.2
[**2150-4-8**] 05:18AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.6 Mg-2.4
[**2150-4-3**] 01:40AM [**Month/Day/Year 3143**] %HbA1c-10.0* eAG-240*
[**2150-4-8**] 05:18AM [**Month/Day/Year 3143**] CRP-48.5*
Brief Hospital Course:
30 F w/ IDDM c/b gastroparesis and HTN p/w n/v and coffee-ground
emesis concerning for UGIB.
In the MICU, patient was transfused 1U PRBC with hematocrit
remaining stable and stool guaiac negative. She was seen by GI
who felt that the NG return showed brown, not coffee-ground
emesis and deferred endoscopy given hemodynamic and hematocrit
stability. Her MICU course was otherwise notable for respiratory
distress attributed to possible aspiration in the setting of her
emesis. She required a non-rebreather to keep up her sats in the
morning, but was quickly weaned to 3L nasal canula. [**Month/Day/Year **]
cultures were significant for coag positive S. aureus. Patient
was started on vancomycin and zosyn for broad coverage. A TTE
was done which was read with a low likelihood of endocarditis.
Stool cultures, urine cultures negative to date. Influenza swab
was negative. NGT was clamped and removed prior to call out to
the floor. Finally, patient presented with [**Last Name (un) **]- FeNa was 0.21%
consistent with a prerenal process. Renal was consulted.
.
Pt was transferred to the floor on [**4-5**]. On the floor, issues
were managed as follows:
# MSSA Bactermia: MSSA grew in [**3-18**] bottles on [**2-25**].
Surveillance cultures were negative. From prior hospitalization,
[**Month/Year (2) **] culture from [**3-28**] was negative. the bacteremia was thought
to be [**3-18**] PIV. No vegetations were seen on TTE. Vancomycin was
initially started. ID was consulted on HD #4 and recommended
TEE, which was performed on [**4-8**] and showed no vegetation. PICC
line was placed. Patient was discharged to complete 14-days of
cefazolin 2g q8h. Outpatient MRI order was entered for [**2150-4-17**]
with plans to obtain BUN/Cr prior to study.
.
# Hypoxia: Initial CXR showed pulmonary edema. Pt was on
non-rebreather in the ICU. She was treated for HAP initially
with Vancomycin/Zosyn. There was also concern for aspiration
pneumonia given aspiration history, however radiographs were not
consistent with this diagnosis. On HD #4, zosyn and vancomycin
were discontinued. Pt was weaned from oxygen and was ambulating
comfortably on room air prior to discharge.
.
# ? GI bleeding: Treated as above in the ICU. On the floor, the
patient had no further episodes of nausea/vomiting. Hct was
stable. Pantoprazole 40 mg PO BID was continued but stopped
prior to discharge. Aspirin was held initially, restarted upon
discharge.
.
# Acute on chronic kidney injury: Creatinine increased to 3.1
from baseline of ~ 1.4. Renal was consulted and felt the
clinical picture and urine sediment were most consistent with
ATN. Medications were renally dosed. Cr improved to 2.2 and BUN
to 34 from a peak of 45.
.
# HTN: On the floor, [**Month/Day/Year **] pressure was managed with verapamil
40 mg q8h, which was uptitrated to 120 mg q8h. Lisinopril was
held due to acute kidney injury. [**Month/Day/Year **] pressures were
consistently 160s-170s/80s-90s. Plans were for her to see her
PCP in [**Name9 (PRE) 702**] to restart lisinopril and uptitrate BP
medications as necessary. Patient was discharged on 360 mg ER
Verapamil.
.
# IDDM: A1C = 10%. Lantus eventually uptitrate to 20 U (home
dose). Gabapentin was renally dosed. Diabetic diet was ordered.
.
# Hypothyroidism: TSH slightly elevated but normal free T4.
Continued Levoxyl 75 mcg qday.
.
# Depression/anxiety: Continued home risperdal, fluoxetine.
.
Transitional Issues:
- BP control: likely restart lisinopril as Cr normalizes;
titrate verapamil as needed
- MRI back: Ordered for [**2150-4-17**]; BUN/Cr to be drawn prior to
study (concern for osteomyelitis given MSSA bacteremia)
- 2 weeks cefazolin (finishes [**2150-4-17**])
- improved DM control
Medications on Admission:
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1 Capsule(s) by mouth qweekly once a week for 8 weeks, then
start [**2139**] units daily
FLUOXETINE -40 mg Capsule - 2 Capsule(s) by mouth daily
FUROSEMIDE - (Dose adjustment - no new Rx) (On Hold from
[**2150-3-13**] to unknown for Cr increased to 2.0) - 40 mg Tablet -
1 Tablet(s) by mouth qday
GABAPENTIN [NEURONTIN] - 400 mg Capsule - 3 Capsule(s) by mouth
twice a day
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 100 unit/mL Cartridge - 20units/ day
once a day
INSULIN GLULISINE [APIDRA] - (Prescribed by Other Provider) -
100 unit/mL Cartridge - per sliding scale as needed
LEVOTHYROXINE - (Dose adjustment - no new Rx) - 25 mcg Tablet -
2 Tablet(s) by mouth DAILY (Daily)
LISINOPRIL - (Prescribed by Other Provider) (On Hold from
[**2150-2-20**] to unknown for [**3-18**] elevated Cr) - 10 mg Tablet -
Tablet(s) by mouth
METOCLOPRAMIDE - (Prescribed by Other Provider) (Not Taking as
Prescribed: not taking) - 5 mg Tablet - 1 Tablet(s) by mouth
before meals
RISPERIDONE - (Prescribed by Other Provider: [**Name Initial (NameIs) 16471**]) - 0.5 mg
Tablet - 0.5 (One half) Tablet(s) by mouth HS (at bedtime)
Carvedilol 12.5 mg PO BID
Medications - OTC
ASPIRIN [ASPIR-81] - (OTC) - 81 mg Tablet, Delayed Release
(E.C.) - Tablet(s) by mouth
CALCIUM CARBONATE-VIT D3-MIN - (Prescribed by Other Provider) -
600 mg-400 unit Tablet - 1 Tablet(s)(s) by mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule - 1
Capsule(s) by mouth qday start daily after you finish the 8
weeks replacement
LOPERAMIDE [IMODIUM A-D] - (OTC) - 2 mg Tablet - 1/2-1 Tablet(s)
by mouth morning of diarrhea and up to 4 times per day as needed
MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other
Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet - 1
Tablet(s) by mouth once a day
Discharge Medications:
1. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
every eight (8) hours for 10 days: Last day of antibiotics is
[**2150-4-17**].
Disp:*30 doses* Refills:*0*
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
4. Lantus 100 unit/mL Solution Sig: Twenty (20) Units
Subcutaneous once a day.
5. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
7. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
8. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
9. Apidra 100 unit/mL Solution Sig: 1-12 Units Subcutaneous TID
w/ meals: Sliding scale insulin.
10. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. verapamil 120 mg Cap,Ext Release Pellets 24 hr Sig: Three
(3) Cap,Ext Release Pellets 24 hr PO once a day.
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
14. Work excuse
Please excuse [**Known firstname 2270**] [**Known lastname 12997**] from work between the dates of
[**2150-4-3**] to [**2150-4-17**]. She was an inpatient at [**Hospital1 18**] from [**2150-4-3**] to
[**2150-4-8**] and requires IV medication until [**2150-4-17**].
Thanks.
15. Outpatient Lab Work
Please draw Chem7 on [**2150-4-15**] so that renal function is known
prior to MRI. Thanks. These should be faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital 18**] [**Hospital 191**] clinic.
Discharge Disposition:
Home With Service
Facility:
critical care systems
Discharge Diagnosis:
Primary:
MSSA Bacteremia
Acute on chronic kidney disease
Acute on chronic diastolic CHF
Hypertension
.
Secondary:
Insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for nausea, vomiting, and
fever. There was concern that you had gastrointestinal bleeding
when you were vomiting, though this is not certain. [**Hospital1 **]
cultures showed that you had bacteria in your [**Hospital1 **] - called
staphylococcus aureus. For this infection, you will need to
complete 2 weeks of antibiotics and you will need an MRI to rule
out infection in your back (since you had persistent back pain).
You had an echo, which ruled out infection of your heart valves.
Also, we worked to bring your [**Hospital1 **] pressure under better
control though it was still high. Your kidneys showed acute
dysfunction, but the function began to improve after you were
transferred out of the intensive care unit.
.
We made the following changes to your medications:
We HELD Lisinopril because of kidney dysfunction; you will
likely restart this medication after meeting with Dr. [**Last Name (STitle) **]
We INCREASED Verapamil to better control your [**Last Name (STitle) **] pressure;
Dr. [**Last Name (STitle) **] may decrease the dose of this medicine as lisinopril is
restarted
We STARTED lidocaine patch for back pain
We STARTED Cefazolin to treat your bacteremia; you will complete
14-days of antibiotics; last day is [**2150-4-17**].
.
Your follow-up information is listed below. You will need an MRI
of your thoracic and lumbar spine to rule out osteomyelitis in
your spine within the next 2 weeks. You need to have [**Month/Day/Year **] tests
of your kidney function performed prior to this study.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2150-4-10**] at 10:20 AM
With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"578.9",
"585.9",
"403.10",
"357.2",
"428.0",
"996.62",
"285.1",
"300.4",
"536.3",
"250.61",
"790.7",
"584.5",
"041.11",
"428.31",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
14566, 14618
|
7147, 10548
|
289, 322
|
14812, 14812
|
3447, 3447
|
16582, 16922
|
2384, 2418
|
12808, 14543
|
14639, 14791
|
10877, 12785
|
14963, 15787
|
6446, 7124
|
2433, 2433
|
3297, 3428
|
10569, 10851
|
15816, 16559
|
1639, 1691
|
228, 251
|
350, 1620
|
3463, 6430
|
2447, 3283
|
14827, 14939
|
1713, 2079
|
2095, 2368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,395
| 102,137
|
651
|
Discharge summary
|
report
|
Admission Date: [**2140-8-11**] Discharge Date: [**2140-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Surgical Wound Draining
Major Surgical or Invasive Procedure:
Debridement of Laminectomy Wound
History of Present Illness:
Ms. [**Known lastname 4643**] is a [**Age over 90 **] year woman with a h/o CAD, HTN, CHF with EF
of 25% s/p L4-L5 laminectomy with Dr. [**Last Name (STitle) 1352**] in [**5-/2140**],
presented from rehab facility with nonhealing lumbar surgical
wound. Wound began producing serous drainage a week prior to
presentation, and started on Keflex [**8-6**]. Drainage was cultured
on [**8-6**] which grew heavy growth of MSSA and moderate alpha
strep, as a result was switched to Levaquin on [**8-8**], then
transferred to [**Hospital1 18**] [**8-11**].
Past Medical History:
s/p L4-5 laminectomy/fusion
CAD
HTN
Hyperlipidemia
Osteoporosis
Osteoarthritis
Skin Cancer
Restless leg syndrome
Social History:
She lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons, two of whom live close by.
Family History:
No premature CAD, SCD
Physical Exam:
O: Tm:98.1 BP:115/64 HR:78 RR:18 SpO2:97% on RA
General: Alert, oriented to Person and Place, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Fine crackles on BL lung bases, no wheezes, ronchi
CV: Regular rate and rhythm
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2140-8-11**] 06:10PM BLOOD WBC-6.5 RBC-4.30# Hgb-11.1* Hct-35.0*
MCV-82# MCH-25.7*# MCHC-31.5 RDW-17.9* Plt Ct-472*
[**2140-8-19**] 05:42AM BLOOD WBC-7.9 RBC-3.47* Hgb-8.6* Hct-27.0*
MCV-78* MCH-24.9* MCHC-32.0 RDW-18.6* Plt Ct-454*
.
.
.
[**2140-8-11**] 06:10PM BLOOD Glucose-86 UreaN-11 Creat-0.6 Na-136
K-4.7 Cl-101 HCO3-28 AnGap-12
[**2140-8-20**] 04:45AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-138 K-3.6
Cl-102 HCO3-29 AnGap-11
[**2140-8-20**] 10:06AM BLOOD Na-142 K-4.2 Cl-103
.
.
[**2140-8-18**] 8:56 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2140-8-18**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-8-18**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
.
[**2140-8-12**] 10:45 am SWAB LUMBAR CERVICAL WOUND.
**FINAL REPORT [**2140-8-18**]**
GRAM STAIN (Final [**2140-8-12**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2140-8-16**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2140-8-18**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Mrs. [**Known lastname 4643**] is a [**Age over 90 **] year old woman with a h/o CAD, HTN, CHF with
EF of 25% s/p L4-L5 laminectomy with Dr. [**Last Name (STitle) 1352**] in [**5-/2140**], who
presented from a rehab facility with nonhealing lumbar surgical
wound.
#) Wound Infection/Sepsis: She had been started on Keflex [**8-6**] at
the rehab facility and the drainage was cultured on [**8-6**], which
grew heavy growth of MSSA and moderate alpha strep. As a result,
she was switched to Levaquin on [**8-8**] and then transferred to
[**Hospital1 18**] [**8-11**]. She was started on Vancomycin and Unasyn on [**8-12**].
She was taken to the OR on [**8-12**], where copious purulent fluid
was encountered, bathing the hardware. This was thoroughly
irrigated, and samples sent to micro, cultures ultimately grew
CoNS. She was initially placed on vancomycin and cefepime and
then transitioned
to a combination of Unasyn 2 q 12 hours (given her renal
function) and vancomycin 1 q 24 hours. Her OR course was
complicated by the fact that she was required requiring a
fiberoptic intubation, and was noted to have significant
tracheomalacia from midtrachea through carina. She was
successfully extubated in the PACU and required Levophed for
blood pressure support in the ICU for two days post operatively.
She was transferred to the general medicine floor from the ICU
on [**8-15**] where she remained afebrile and had reduced wound
drainage requiring twice daily dry sterile dressing changes. She
received a PICC line for the purpose of administering IV
antibiotics at her rehab facility. Finial infectious disease
recommendations are as follows:
Plan for 8-10 weeks for spinal osteomyelitis with hardware in
place, followed by life-long oral suppression given the presence
of hardware in infected bed.
Opat Antibiotic regimen and projected duration
Unasyn 2 q 12 hours x 8-10 weeks from time of operative
debridement, [**Date range (1) 4981**].
Vancomycin 1 q 24 hours x 8-10 weeks from time of operative
debridement, [**Date range (1) 4981**].
Cultura data (organism and susceptibilities)
MSSA, GAS (OSH)
CoNS ([**Hospital1 18**])
Essential diagnostic date for OPAT rx (TEE< bx, ect) baseline
Pertinent co-morbidities or complications:
Laboratory monitoring required: Weekly CBC with differential,
BUN, Cr, AST, ALT, Alk phos, Tbili, vancomycin trough, ESR, CRP.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient
antibiotics should be directed to the infectious disease R.Ns.
at
.
#) AMS: She was noted to have fluctuating mental status with
narcotic pain [**Telephone/Fax (1) 4982**], thus these were avoided to the extent
possible with pain control primarily with Tylenol and subsequent
improvement in her mentation to baseline per family. At her
baseline dementia she can answer questions about her care
appropriately.
.
#) Respiratory Failure: She was weaned off the ventilator post
operatively and was subsequently weaned from a non-rebreather to
4L O2 on nasal canula in the ICU and finally to room air with
excellent oxygen saturation on the general medicine floor.
.
#) Systolic CHF: She has a reported LVEF of 25% and requires 20
mg of Lasix daily at home. Because of the intravenous fluids she
as received while admitted this dose should be increased to 40
mg daily and titrated to her daily weight and creatinine.
.
#) Hypokalemia: Secondary to diuresis with Lasix required
monitoring and potassium repletion to reflect Lasix dose as
appropriate.
.
#) Iron Deficiency Anemia: She was started on ferrous sulfate
325mg daily while admitted.
.
#) Incontinence: She was incontinent at baseline and thus
requires absorbent undergarment and miconazole powder QID.
.
#) Depression: She was not restarted on her Citalopram 10mg
daily while admitted, however this may be restarted after
discharge if her mental status is believed to be at baseline
.
#) Loose stools were noted by the nursing staff - however her C.
Diff studies were negative and this may be her baseline.
.
#) DVT Prophylaxis was achieved with 5000 units of SC Heparin
TID.
[**Telephone/Fax (1) **] on Admission:
Trazodone 25mg Q6H PRN Anxiety or Insomnia
Aspirin 325mg daily
Citalopram 10mg daily
Metoprolol ER 25mg daily
Celebrex 200mg daily
Lasix 20mg daily
Tylenol 650mg Q4H PRN pain (not to exceed 4gms daily)
Guaifenein 100mg/5ml 10ml every 4 hrs as needed for cough
Levaquin 500mg daily
Lipitor 80mg daily
Gabapentin 400mg TID
Tramadol 50mg Q6H while awake
Senna 2 tabs PO BID PRN constipation
Debrox gtts 5 gtts in each ear [**Hospital1 **] x 5 days
NTG 0.6mg SL q5min PRN chest pain
Milk of Magnesia 400mg/5ml 30ml daily for constipation
Bisacodyl 10mg supp. rectally
Citrucel powder daily
Oxycodone 5mg every 8 hours as needed for pain
Calcium 500mg tab chewable
Multiday plus minerals
Discharge [**Hospital1 **]:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Acetaminophen 650 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q6H (every 6 hours) as needed for
pain.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Vancomycin 1000 mg IV Q 24H
please hold dose for trough >20
10. Ampicillin-Sulbactam 3 g IV Q12H
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Nitroglycerin 0.6 mg Tablet, Sublingual Sig: One (1)
Sublingual Q 5 Minutes x 3 as needed for chest pain.
13. Milk of Magnesia 400 mg/5 mL Suspension Sig: 30 ml PO once
a day as needed for constipation.
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
Hardware associated lumbar infection
Systolic Congestive 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:
Mrs. [**Known lastname 4643**]
You were admitted to the hospital for an infection of your
spinal surgical wound. Your infection required surgical
treatment in addition to intravenous antibiotics. You will need
to continue these antibiotics for 8 to 10 weeks as recommeded by
your infectious disease doctors. You should take your
[**Known lastname 4982**] as described in this discharge document and keep
your outpatient appointments with your spine docotrs and
infectious disease doctors.
The following changes have been made to your [**Known lastname 4982**]:
1.) Your Furosemide has been INCREASED to 40mg daily
2.) Your Aspirin has been DECREASED to 81mg daily
3.) Your Metoprolol has been INCREASED to 25mg three times daily
4.) Your Citalopram has been HELD and may be resumed as your
mental status continues to improve.
5.) You have been STARTED on Heparin SC 5000 units TID
6.) You have been STARTED on Unasyn and Vancomycin antibiotics
IV please follow instructions from you infectious disease
doctors about these [**Name5 (PTitle) 4982**].
Followup Instructions:
Department: SPINE CENTER
When: TUESDAY [**2140-8-30**] at 11:30 AM
With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 3736**] (works with Dr [**Last Name (STitle) 1352**])
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2140-9-16**] at 9:00 AM
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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[
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[
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icd9pcs
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[
[
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|
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|
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223, 248
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1050, 1166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,709
| 130,207
|
8762
|
Discharge summary
|
report
|
Admission Date: [**2110-3-10**] Discharge Date: [**2110-3-19**]
Date of Birth: [**2046-12-20**] Sex: M
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old man
with a [**5-17**] month period of episodic chest pain which has been
progressively becoming worse. These episodes occur up to
three times per week, developed at rest or with exertion.
They are associated with dizziness and left arm numbness
which radiates down to his fingers. He had noted using
Nitroglycerin in the past with some relief but he has not
used any recently. When these occur, he performs some
relaxation techniques which help in shortening the length of
the episode. Sometimes they persist up to three hours. He
notes that he has had similar symptoms in the past and has
had a cardiac catheterization twice in the early [**2097**]'s, all
of which have been reported as negative, though they reported
valvular abnormalities. A work-up in the past has also
included an echocardiogram which showed a dilated left atrium
with normal left ventricular function, positive mitral
stenosis with a mean gradient of 5 mmHg with a valvular area
of 1.6 cm sq., mean aortic gradient of 45 mmHg with a
valvular area of 1.1 cm sq. Due to the fact that his
symptoms have progressively become worse over the last year,
the patient presents to [**Hospital1 69**]
for cardiac catheterization and then question AVR, MVR
performed by the cardiothoracic team led by Dr. [**Last Name (STitle) 70**].
PAST MEDICAL HISTORY: Significant for hypercholesterolemia,
status post TIA. TIA reports about 1-2 times per week, they
present as loss of vision, passing out, dizziness or migraine
symptoms and now patient was placed on Coumadin. Also
history of anxiety, congestive heart failure, decreased PFTs
and diabetes mellitus.
PAST SURGICAL HISTORY: Significant for status post
cholecystectomy.
MEDICATIONS: On admission include Coumadin 2.5 mg on Tuesday
and Thursday and 5 mg on all other days (Coumadin was held on
[**2-27**]). Also Glucophage 500 mg po q 12 hours p.m., Lasix 20
mg po q d, Lipitor 10 mg po q d, Folate 0.4 mg q h.s., Toprol
25 mg po q d, Serzone 100 mg po bid, Buspar 5 mg po tid,
Ambien 5 mg q h.s. prn.
SOCIAL HISTORY: The patient is married, retired manager for
a local company. Occasional etoh use. Occasional pipe use.
PHYSICAL EXAMINATION: Patient is a white male in no acute
distress, temperature 97.8, heart rate 56, blood pressure
107/46, breathing at 18, 90% on room air. His neck is supple
with no lymphadenopathy. His lungs are clear. Heart is
regular rate and rhythm with systolic and diastolic murmurs.
Abdomen is soft and nontender. No peripheral edema. Distal
pulses intact. He is alert and oriented times three,
neurologically intact.
LABORATORY DATA: On admission include white count of 8.9,
hematocrit 43.9, platelet count 280,000, sodium 135,
potassium 4.2, chloride 98, CO2 31, BUN 18, creatinine 1.2.
Chest x-ray shows within normal limits, no evidence of
pneumothorax or infiltrate.
HOSPITAL COURSE: The patient was brought to [**Hospital1 346**] where he underwent cardiac
catheterization. We felt this was significant for right
dominant circulation with no flow limiting coronary artery
disease. Also there was a significant aortic stenosis with
[**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 cm sq and a mean gradient of [**3-15**] mmHg. There
is mitral stenosis with mean gradient of 5 mmHg and MVA of
1.8 cm sq. There was an EF of 60%. Also significant for 2+
aortic regurgitation. The patient procedure well and then on
[**2110-3-10**] the patient went to the operating room where he
underwent AVR with a Carbomedics #21 and MVR with Carbomedics
#27. The patient tolerated this procedure well, was
transferred to the SICU, AV paced on Propofol drip.
Postoperatively the patient's systolic blood pressure was
labile initially. He was placed on IV Nitroglycerin. On
arriving to the unit he proceeded to have a high chest tube
output of 450 ml in 90 minutes. He received 50 mg of
Protamine times two, two units of FP and two units of packed
red blood cells. Hematocrit then went from 23 to 29. The
patient was weaned to extubate on postoperative day #1. The
patient was weaned off of drips, was awake, alert and
oriented times three. He continued to be paced with
underlying nodal rhythm in the 50's. Postoperative day #2
the patient was transfused with one unit of packed red blood
cells for hematocrit of 22.7. He was continued to be on VVI
at a rate of 58. He was otherwise stable when transferred to
the floor. On the floor the patient was reporting feeling
jolts with the pacer. In place, the pacer was turned off and
the underlying rhythm was junctional with a rate in the 60's.
His blood pressure was stable at 115-120/60-70. He was left
in this rhythm. He was evaluated by the EP service who
determined he would benefit from the placement of a pacemaker
secondary to arrest of sinus node. Postoperative day #3 the
patient went into atrial fibrillation. With the rate up to
100's, blood pressure remained stable. Then on the morning
of postoperative day #4 the patient continued in an irregular
rhythm with rates up into the 100's, had an 8 second pause on
the monitor. The patient stated he felt a hot burst through
his body and a dull feeling in his heart. The staff ran into
the room and upon entering, the monitor spontaneously showed
the start of a junctional rhythm. That day patient went to
the EP lab where he underwent placement of a DDD pacer.
Since that time, patient has remained AV paced. Blood
pressures remained stable. The patient has been Coumadinized
to the appropriate INR of greater than 2 and for his valve
and atrial fibrillation. The patient has been ambulating,
tolerating a regular diet and is now ready for discharge to
home.
DISCHARGE DIAGNOSIS:
1. Valvular disease status post AVR, MVR with Carbomedics 21
and 27 respectively.
2. Status post pacemaker placement for the rest of sinus
node.
3. Atrial fibrillation.
4. Hypercholesterolemia.
5. TIA.
6. Anxiety.
7. Diabetes mellitus.
8. Congestive heart failure.
DISCHARGE MEDICATIONS: Include Lasix 20 mg po bid times 7
days, Colace 100 mg po bid, Zantac 150 mg po bid, Buspar 5 mg
po tid, Serzone 100 mg po bid, Flomax 0.4 mg po q d, Ambien 5
mg po q h.s. prn, Lipitor 10 mg po q d, Glucophage 500 mg po
q noon, Niferex 150 mg q d, ASA 81 mg po q d, Coumadin 7.5 mg
po q d which will be dosed [**Name8 (MD) **] M.D., Lopressor 25 mg po bid,
Percocet 5/325 [**12-11**] po q 4 hours prn.
The patient, on discharge, is stable.
DISCHARGE INSTRUCTIONS: Follow-up with Dr. [**Last Name (STitle) 70**] in 6
weeks. Follow-up with pacemaker clinic on [**2110-3-26**] at 11 a.m.
in [**Hospital Ward Name 23**] Bldg. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12982**] in two
weeks, [**Telephone/Fax (1) 30648**]. Patient will receive VNA home care for
wound check and likely INR drawing to be adjusted by Dr.
[**Last Name (STitle) 12982**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2110-3-19**] 09:51
T: [**2110-3-19**] 21:46
JOB#: [**Job Number 30649**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"35.24",
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icd9pcs
|
[
[
[]
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6197, 6639
|
5899, 6173
|
3067, 5878
|
6664, 7392
|
1853, 2233
|
2379, 3049
|
173, 1505
|
1528, 1829
|
2250, 2356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,740
| 139,761
|
42901
|
Discharge summary
|
report
|
Admission Date: [**2118-11-28**] Discharge Date: [**2118-12-3**]
Date of Birth: [**2057-4-28**] Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
generalized tonic-clonic seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61M who presents after a generalized tonic-clonic seizure at
home on the morning of admission. According to patient's wife,
he was in bed on the morning of admission when his whole body
began to shake uncontrollably and he began foaming at mouth. The
episode lasted approximately 15 minutes before resolving
spontaneously. The patient's wife states that the patient has
had low grade fevers and a weight loss of 15 pounds over the
past month. For the past 3 days the patient has been
experiencing night sweats. He has never experienced a seizure
prior to the morning of admission.
.
As the patient was being transferred into the ambulance, he
began seizing once again. He was given 2 mg Ativan x 2, after
which time the seizure stopped; however, the patient's
respiratory status deteriorated quickly requiring RSI. On
arrival to ED, VS: T 100.8 rectal 106 24 100% on vent. He was
moving all extremities. Labs were significant for WBC 28.3,
lactate 10.2, INR 1.4. The patient was given vecuronium in order
to obtain a head CT. CT head showed large mass centered in left
frontal sinus with lytic bony destruction and posterior
extention into left frontal lobe. Neurology was consulted, who
recommended an MRI w/ and w/out contrast to r/o an infectious
process. Neurosurgery was consulted who agreed with STAT MRI.
Decision was made not to LP patient in ED given low likelihood
of infection. CXR showed a large right hilar pulmonary mass
causing post obstructive atelectasis. The patient was given
ceftriaxone and azithromycin. He was given Fosphenytoin 1000 mg
and Dexamethasone 10 mg IV X 1. Vent settings on transfer were:
FiO2 100%, RR 24, PEEP 5, O2 100%.
.
According to OMR notes, the patient was admitted to [**Hospital3 **] 3
weeks prior with flu-like symptoms and R shoulder pain. His CXR
showed a RUL consolidation, however there was concern for an
underlying lesion on a CT. He was treated witha course of
Augmentin. After discharge from the hospital, he continued to
have low-grade fevers and night sweats. He had a bronchoscopy
performed at [**Hospital3 **] on Friday [**2118-11-25**] along with a biopsy of
a presumed lesion. The pathology results are pending at this
time.
Past Medical History:
- Recent RUL pneumonia and likely underlying mass
- Hypertension
- Hyperlipidemia
Social History:
Lives in [**Location 669**], MA. On disability due to back pain from
Merchant Marines. Quit smoking in [**2091**] - smoked from teenage
years. 1
drink/night. No illicit drug use.
Family History:
Mother - died in old age
Father - prostate cancer
Physical Exam:
Admission Physical Exam:
Vitals: T: 36.7 BP: 123/72 P: 90
General: Intubated, sedated
HEENT: PERRL 4 to 3mm and brisk, ET Tube in place
Neck: JVP not elevated
Lungs: Diminished bilaterally, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no edema
Discharge Physical Exam:
Pertinent Results:
Admission labs:
WBC-28.6* RBC-3.95* HGB-11.0* HCT-35.2* MCV-89 MCH-27.9
MCHC-31.3 RDW-13.9
PT-14.6* PTT-31.2 INR(PT)-1.4*
FIBRINOGE-969*
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-1 WBC-1
BACTERIA-NONE YEAST-NONE EPI-0
UREA N-19 CREAT-1.1 GLUCOSE-204 LACTATE-10.2 NA-139 K-4.6 CL-105
TCO2-16
CSF
WBC 150 RBC [**Numeric Identifier 92603**]
Poly 89 Lymph 11 Mono 0 EOs
Total protein 119* Glucose 83 LDH 21
HSV PCR- negative
Negative for malignant cells on cytology
MICROBIOLOGY:
Blood culture ([**2118-11-28**])- x3, no growth to date
CSF ([**2118-11-28**])- cultures
GRAM STAIN (Final [**2118-11-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2118-12-2**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Aspergillus galactomannan- negative
Beta glucan- negative
IMAGING:
CT head w/o contrast ([**2118-11-28**])- Large predominantly
hyperattenuating mass centered in the left frontal sinus
associated with aggressive lytic osseous destruction and
posterior extension into the left frontal lobe, most concerning
for neoplastic process, particularly given known right lung
mass. Supervening infection must be considered. Recommend
correlation with prior exams when available, and MRI for
assessment of full disease extent.
MRI head w&w/o contrast ([**2118-11-28**])- Large heterogeneously
enhancing mass in the frontal sinus with intracranial extension
and destruction of inner and outer tables of the frontal sinus,
bilateral cribriform plates and invasion of the anterior portion
of the superior sagittal sinus. In view of history of lung mass,
this is likely to represent metastasis. However, a primary sinus
neoplasm with intracranial lesion cannot be entirely ruled out.
Wegener's granulomatosis is another differential consideration.
CT head w&w/o contrast ([**2118-11-28**])- Large peripherally enhancing
mass centered predominantly in frontal sinuses with associated
vasogenic edema and mild mass effect on the frontal [**Doctor Last Name 534**] of the
left lateral ventricle. Adjacent bones demonstrate a permeative
destructive pattern. The above findings are most compatible with
metastatic disease, given the reported history of right upper
lung mass lesion. Alternative differential considerations
include aggressive infectious, inflammatory processes or a
primary sinus neoplasm.
EEG ([**2118-11-28**])- This portable bedside EEG gives evidence for
focal slowing
in the left frontal quadrant compatible with a structural lesion
of that
area with superimposed high voltage interictal epileptiform
transients
in the left frontal polar region and short runs of brief
electrographic
seizure activity that were without any obvious clinical
accompaniment.
EEG ([**2118-11-29**])- This EEG gives evidence for a focal slow wave
abnormality
over the left frontal polar region suggestive of a
subcortical/cortical
junctional structural abnormality. Superimposed upon this are
frequent
epileptiform discharges in short runs of epileptic activity
without a
clear clinical accompaniment.
CT Abd/pelvis ([**2118-11-29**])-
1. Right hilar mass with mediastinal invasion and a right
paratracheal mass or nodal conglomeration. Probable malignant
right pleural effusion.
Bilateral adrenal metastasis, left greater than right.
2. Near complete collapse of the right upper lobe due to
bronchial
obstruction. Partial compression of the right lower and right
middle lobe
bronchi with resulting areas of postobstructive pneumonia in the
right lung.
3. Indeterminate right renal mass. The differential would
include metastatic disease to the right kidney or a primary
renal lesion and biopsy should be considered to help
differentiate between these two possibilities.
4. Soft tissue nodule posterior to the left psoas muscle in the
retroperitoneum.
CT Chest ([**2118-11-29**])-
1. Right hilar mass with mediastinal invasion and a right
paratracheal mass or nodal conglomeration. Probable malignant
right pleural effusion.
Bilateral adrenal metastasis, left greater than right.
2. Near complete collapse of the right upper lobe due to
bronchial
obstruction. Partial compression of the right lower and right
middle lobe
bronchi with resulting areas of postobstructive pneumonia in the
right lung.
3. Indeterminate right renal mass. The differential would
include metastatic disease to the right kidney or a primary
renal lesion and biopsy should be considered to help
differentiate between these two possibilities.
4. Soft tissue nodule posterior to the left psoas muscle in the
retroperitoneum.
Fusion Protocol Maxillofacial CT ([**2118-11-30**])- Unchanged NSCLC
metastasis in the frontal sinus with destruction of surrounding
osseous structures and invasion into the ethmoid air cells and
frontal lobe of the brain.
CT Neck w/contrast ([**2118-11-30**])- No evidence of metastasis in the
neck.
DISCHARGE LABS:
[**2118-12-2**] 06:00AM BLOOD WBC-63.3* RBC-3.50* Hgb-9.8* Hct-31.5*
MCV-90 MCH-27.9 MCHC-30.9* RDW-14.1 Plt Ct-386
[**2118-12-3**] 05:30AM BLOOD WBC-53.4* RBC-3.34* Hgb-9.4* Hct-30.4*
MCV-91 MCH-28.1 MCHC-30.8* RDW-14.7 Plt Ct-405
[**2118-12-1**] 05:45AM BLOOD Neuts-93.1* Lymphs-4.7* Monos-1.7*
Eos-0.4 Baso-0.1
[**2118-12-3**] 05:30AM BLOOD Glucose-88 UreaN-10 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
[**2118-12-1**] 05:45AM BLOOD Phenyto-10.2
[**2118-11-29**] 05:51AM BLOOD Lactate-1.5
Brief Hospital Course:
69M with recently bx confirmed NSLC presenting with new onset
seizures, CXR evidence of post-obstructive pneumonia and CT
findings of left frontal brain mass.
#. Respiratory distress: In the ED, patient was initially
intubated as he was somnolent likely due to benzodiazepine
dosing to decrease seizures. Patient remained intubated on the
day of admission as he was undergoing many CT/MRI scans and
there was potential for ENT procedure in the nasopharynx.
Patient was moving all four extremities and responding to
commands throughout his intubation. He was extubated
successfully on HD1 and was weaned off of nasal cannula by HD2.
#. Seizures: Patient presented with generalized tonic clonic
seizures. He had no history of prior seizures and toxicology
screens were negative. CT scan of head in the ED showed a large
mass in the frontal lobe. With further imaging (MRI, CT with
contrast, fusion maxillofacial CT), it was noted that the mass
invaded through the bone into the frontal sinus and ethmoid air
cells. Patient has known RUL mass, so concern that brain mass
was metastatic lesion, however, as lesion crossed midline and
invaded through bone, it did not follow pattern of typical
hematogenously spread met. Patient was loaded with dilantin in
the ED, and kept on EEG in the ICU. He had no further clinical
seizures, but on EEG continued to have subclinical focal
seizures in the frontal lobe. Dilantin was titrated up for goal
trough >15. On HD2, patient was no longer having seizures per
EEG, so EEG was discontinued. LP performed on day of admission
was not consistent with an infectious process. ENT was
consulted and did not feel that it was safe to biopsy this
lesion, given invasion through bone and risk for post-procedure
CSF leak. Patient was started on dexamethasone to decrease
vasogenic edema.
# RUL and sinus mass: Patient had a recent admission at [**Hospital1 **] with pneumonia. CXR showed a right
upper lobe mass, which was followed by a CT scan which showed
the same, with resulting post-obstructive pneumonia. Patient
was treated with antibiotics, and underwent bronchoscopy with
biopsies of mass. Preliminary reports of this biopsy showed
poorly differentiated non-small cells. Pathology and CT imaging
was sent from [**Hospital3 **] for further interpretation. Regarding
newfound pulmonary mass, it was felt by neurosurgery and ENT at
[**Hospital1 **] that the location of the mass made a biopsy too high-risk of
a procedure. Pt was seen by neuro-onc and rad-onc, discharged
with follow up appt with rad-onc to begin XRT to sinus mass. Of
note, pathology was confirmed at [**Hospital1 **] and showed that the lung
mass was poorly differentiated adenocarcinoma. Block was sent
for k-ras, alk, and EGFR mutations.
# Leukocytosis/fever: Elevated white count thought to be partly
due to stress response, however, CXR with large post-obstructive
pneumonia. Patient was treated for hospital acquired pneumonia
with vancomycin, cefepime and flagyl sent home with augmentin to
finish a 7 day course. A PICC line was placed for IV antibiotic
administration in house but was pulled before discharge. Blood
and CSF cultures showed no growth to date. It was felt that a
large component of this leukocytosis was secondary to a
leukemoid reaction in the setting of pulmonary malignancy.
# Hypertension: Normotensive throughout admission, requiring
only fluid boluses, never pressors. Home antihypertensives were
held.
# Hyperlipidemia: held home statin
TRANSITIONAL ISSUES:
Pt to follow up with Dr. [**Last Name (STitle) 6570**], neuro-oncology, Dr. [**Last Name (STitle) 3929**]
(rad-onc) and Dr. [**Last Name (STitle) 3274**].
.
Path sent for tumor marker studies, pending at the time of
discharge.
Medications on Admission:
- Lisinopril/HCTZ 20/12.5 mg
- Simvastatin 5 mg daily
- Amlodipine 5 mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for headache.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO as Directed:
Take three tabs daily on [**12-14**], [**12-5**], and [**12-6**]. Take
two tabs daily until follow up with Dr. [**Last Name (STitle) **].
Disp:*50 Tablet(s)* Refills:*1*
6. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 15 days.
Disp:*30 Tablet(s)* Refills:*0*
7. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*0*
8. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
seizures
non-small cell lung carcinoma
mass in frontal brain and ethmoid sinus area
SECONDARY DIAGNOSES
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You were admitted to the ICU after having a
seizure, and a large mass was found in the sinus area of your
head communicating with the brain, which was most likely the
cause of the seizures. It was decided that it would be unsafe to
biopsy in this area, and most likely this was the same kind of
tumor as the one in your lung. You will have follow up with
radiation oncology and thoracic oncology to determine the best
course of treatment. We also started antibiotics out of concern
for pneumonia and we will send you home with antibiotics to
continue a 14 day course. We sent you home with anti-seizure
medicine (dilantin) and steroids (dexamethasone) to decrease
swelling in the head.
The following CHANGES were made to your medications:
STARTED dilantin 200mg by mouth twice a day(for seizures)
STARTED Dexamethasone 4mg by mouth three times a day for 7 more
days, then twice a day until follow up with Dr. [**Last Name (STitle) **]. take
this 3 times a day but BEFORE 4pm otherwise it will keep you up
all night!) (to decrease inflammation in lungs and brain -
STARTED ambien (for sleep - we gave you trazodone originally
which gave you heartburn so switched to ambien)
STARTED augmentin 875mg my mouth twice daily (antibiotic for
pneumonia)
STARTED tylenol for headaches
STARTED docusate and senna (for constipation)
In summary, the complete list of your medications is:
Followup Instructions:
Please follow up with the radiation oncology appointment below.
RADIATION ONCOLOGY APPOINTMENT:
[**2118-11-29**] 11:15a XCT (H3) [**Apartment Address(1) **]
GZ [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
RADIOLOGY
You will have a follow up appointment with Dr. [**Last Name (STitle) 6570**],
neuro-oncology. His office will call to schedule an appointment,
but if you don't hear from them in 2 business days, the number
is: ([**Telephone/Fax (1) 6574**]
.
You will also have an appointment with Dr. [**Last Name (STitle) 3274**]. You will
also be called about the scheduling of that appointment. If you
do not hear from anyone in 2 business days please call his
office to schedule at [**0-0-**].
.
Please call Dr.[**Name (NI) 83926**] office on Monday to schedule a follow-up
appointment with him this week. You will need to have a
dilantin level checked at that visit.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,426
| 151,295
|
7321
|
Discharge summary
|
report
|
Admission Date: [**2155-7-10**] Discharge Date: [**2155-7-13**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
woman who was admitted for an elective cardiac
catheterization. The patient's cardiac history includes an
anterior MI in [**2153-12-12**] which led to a VF arrest. On
catheterization lesion was found in the LAD which was
stented. In [**2154-12-13**] the LAD stent occluded and led
to a recurrent anterior MI. The patient underwent PTCA of
the LAD. On catheterization the patient's ejection fraction
was found to be 25% and the post cath course was complicated
by a groin bleed after the patient was discharged home and
the patient was readmitted. An echocardiogram in [**2154-12-13**] revealed mild MR with severe systolic dysfunction. On
admission the patient denied any chest pain or pressure or
shortness of breath, no nausea or vomiting since the last
procedure. She did have severe chest pain with her heart
attacks. Her cardiac risk factors include hypertension,
hypercholesterolemia, smoking history, but is negative for
diabetes.
PAST MEDICAL HISTORY: Anterior wall MI times two in [**2153**] and
[**2154**], coronary artery disease stenting [**2153**], reocclusion and
PTCA [**2154**]. Upper GI bleed [**2155-3-13**] on Coumadin, requiring
transfusion of three units packed red blood cells. Subdural
hematoma. Status post appendectomy. Status post TAH BSO.
Osteoporosis. Hiatal hernia. Esophageal ulcer.
SOCIAL HISTORY: The patient lives with her sisters and her
brother. Another brother died one week prior to this
admission.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is in the [**Last Name (un) 27029**] study (Captopril
vs Captopril and Valsartan tid). Aspirin 81 mg po q d,
Prilosec 20 mg po bid, Plavix 75 mg po q d, Lipitor 10 mg po
q d, Lopressor 12.5 mg po q d, Calcium 1500 mg po q d,
Multivitamin.
LABORATORY DATA: Pending on admission. Chest x-ray revealed
no infiltrate or failure and question hiatal hernia vs
post-op changes in the retrocardiac region.
HOSPITAL COURSE: The patient underwent elective coronary
cardiac catheterization on [**7-10**]. Her post catheterization
course was complicated by GI bleed.
1. Cardiovascular: The patient was admitted on the [**Last Name (un) 27029**]
study drug. She had a history of two anterior wall MIs and
LAD stenting in [**2153-12-12**] and repeat PTCA in [**2154-12-13**]. She was admitted for an elective re-look. On the
catheterization on [**7-10**], the patient was found to have
restenosed and a second stent was placed to the LAD. Her
ejection fraction on the catheterization was found to be 25%.
The post cath course was complicated by an upper GI bleed and
hypotension requiring transfer to the CCU and support with
intravenous fluids and packed red blood cells. The patient's
Integrilin was discontinued, however, she was continued on
Aspirin and Plavix.
2. GI: Following the catheterization the patient vomited
black coffee grounds times two. Her hematocrit fell from an
admission level of 28 to 18.6. She was supported with IV
fluids and received a total of four units of packed red blood
cells. She was placed on Protonix IV. GI was consulted and
an upper endoscopy was performed which revealed a small
hiatal hernia, non bleeding esophageal ulcers, and blood in
the stomach with friable mucosa in the antrum of the stomach
which was electrocauterized. The patient's hematocrit was
subsequently stable. The patient was discharged from the CCU
in stable condition with follow-up scheduled with Dr.
[**Last Name (STitle) **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Restenosis of LAD.
2. Stent to LAD.
3. Upper GI bleed.
DISCHARGE MEDICATIONS: Plavix 75 mg q d, Aspirin 325 mg q d,
Atenolol 25 mg q d, Protonix 40 mg q d, Lipitor 10 mg q d,
[**Last Name (un) 27029**] study drug as directed.
[**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 12203**], MD [**MD Number(1) 12204**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2155-11-22**] 06:33
T: [**2155-11-23**] 21:23
JOB#: [**Job Number 27030**]
|
[
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"412",
"530.2"
] |
icd9cm
|
[
[
[]
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] |
[
"37.22",
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"88.56",
"36.01",
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icd9pcs
|
[
[
[]
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] |
3791, 4223
|
3705, 3767
|
2122, 3650
|
151, 1128
|
1151, 1511
|
1528, 2104
|
3675, 3684
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,621
| 125,997
|
34410
|
Discharge summary
|
report
|
Admission Date: [**2127-9-29**] Discharge Date: [**2127-10-7**]
Date of Birth: [**2044-10-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
hypertensive urgency (tx from neurosurg)
Major Surgical or Invasive Procedure:
1) Central line in the right internal jugular vein.
2) Hemodialysis
History of Present Illness:
82 yom with hx of ESRD on HD, HTN, DM Type II with Peripheral
Neuropathy, Afib on Coumadin who presented from an OSH with SDH
s/p fall. Patient states he was at home organizing his kithcen
when he suddenly fell. He denies LOC, chest pain, shortness of
breath, convulsions, incontinence, pre-syncope, dizziness or
lightheadedness. He does report inability to get up after the
fall as his legs felt weak. He has an emergency call button that
he activated and EMS arrived and took him to an OSH. He had a CT
head done which showed a small 5mm left parietal subdural
hematoma, INR 3.1 and was given Vit K and 2u FFP. He was
transferred to [**Hospital1 18**] for further care. He was initially admitted
to the Neurosurgical service. He developed uncontrolled HTN with
SBP in 180s and was given multiple doses of Hydralazine PO/IV
and Metoprolol PO/IV with minimal response. He was subsequently
placed on Nicardipine gtt and transferred to SICU. Repeat CT
Head today showed stable SDH. Due to his uncontrolled HTN and
stable SDH, he was transferred to the MICU for further
management.
.
On exam on MICU admission, patient was alert and oriented. He
was feeling well and denied any current CP, SOB, dizzines, LH,
N/V, abdominal pain, fevers or chills. He did report numbness in
bilateral feet which has been stable for many months.
Nicardipine gtt was titrated off at the time of my examination
with SBP in 150s.
Past Medical History:
ESRD on HD M/W/F
HTN
DM II
Afib on Coumadin
Peripheral Neuropathy
Social History:
Denies EtOH use, Denies Tobacco use, no illicit drug use.
Patient lives by himself. Has a visiting nurse who comes to his
home. He is divorced with no children.
Family History:
NC
Physical Exam:
VS: T 96 BP 154/56 HR 74 RR 20 97%RA
GEN: NAD, Lying comfortably in bed
HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema
or exudate
NECK: Supple, no LAD, no appreciable JVD
CV: RRR, normal S1S2, no murmurs, rubs or gallops
PULM: CTAB, no w/r/r, good air movement bilaterally
ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, no
abdominal bruit appreciated
EXT: Warm and well perfused, full and symmetric distal pulses,
no pedal edema
NEURO: AAOx3, CN 2-12 intact, 5/5 strength all extremities
Pertinent Results:
[**2127-9-29**] UA
Yellow, Clear SpecGr 1.007 pH 7.0
Urobil Neg Bili Neg Leuk Tr Bld Neg Nitr Neg Prot 100 Glu
100
Ket Neg
RBC 0-2 WBC [**4-2**] Bact Few Yeast None Epi 0 Sperm: Few
131 93 46
-------------< 55 AGap=22
4.9 21 7.2
estGFR: [**8-6**] (click for details)
89
8.2 > 11.5 < 255
-----
35.2
N:72.7 L:18.5 M:5.8 E:2.6 Bas:0.3
PT: 30.0 PTT: 42.7 INR: 3.1
.
CT Head W/O Contrast ([**2127-9-29**]):
IMPRESSION:
1. Small, acute left parietal subdural hematoma as described
above. No
overlying soft tissue or osseous injuries identified.
2. Diffuse dilatation of the lateral, third, and fourth
ventricles appear
disproportionate to the degree of underlying atrophy. The
finding may simply represent a greater extent of brain atrophy
centrally, as opposed to normal pressure hydrocehpalus-
correlate clinically.
.
.
Ultrasound RUE ([**2127-10-2**]):
IMPRESSION:
Somewhat technically limited study, but no deep vein thrombosis
seen in the right arm.
.
.
Left Hip XR ([**2127-10-4**]):
IMPRESSION:
1. Abnormal appearance of the femoral neck on one view raises
the possibility for a mildly displaced fracture. Recommend
further evaluation with CT scan of the hip to exclude an
underlying fracture.
2. Degenerative changes of the hips bilaterally.
.
.
Pelvic CT W/O Contrast ([**2127-10-6**]):
IMPRESSION:
1. No evidence of acute hip fracture.
2. Large lucent lesion of the left femoral head with a scalloped
contour
suggests the possibility of a joint-based process, possibly
bilateral given the slightly abnormal contour of the inferior
right femoral head. Differential possibilities would include
amyloid in this patient with end- stage renal disease. Further
evaluation could be achieved with MR [**First Name (Titles) **] [**Last Name (Titles) **] when
appropriate.
3. Degenerative changes of the hips bilaterally.
.
.
Brief Hospital Course:
Assessment and Plan: 82 yom w/ ESRD on HD, HTN, DM Type II with
peripheral neuropathy, Afib on Coumadin who presented from OSH
with SDH.
.
1) Subdural hematoma: Mr. [**Known lastname **] presented with small, acute left
parietal subdural hematoma sustained during a mechanical fall
with head impact. The patient's SDH was found to be stable on
repeat CT scan the day following admission. Mr. [**Known lastname **] had an
INR of 3.1 at presentation, anticoagulated on coumadin, which
was reversed with 1 unit FFP and 10 mg of Vitamin K. Neurologic
exam was unremarkable and stable throughout hospital stay.
Patient was initiated on Keppra as seizure prophylaxis. Per
Neurosurgery recommendations, he will remain off his Coumadin
for 4 weeks and will follow-up in [**Hospital 4695**] clinic for repeat
CT scan to assess for resolution of his bleed. At that time, he
should be resumed on coumadin if bleed is resolved and fall risk
is minimal.
.
2) Hypotension: On the neurosurgery service, he developed
hypertensive urgency and was treated unsuccessfully with IV/PO
metoprolol and IV/PO hydralazine. His blood pressure finally
came down treated w/ Nicardipine and -3.5L HD. However, the
Nicardipine resulted in hypotension. At this point, the patient
was transferred to the MICU for persistent hypotension, likely
in the setting of stacking of multiple blood pressure meds
combined with large volume removal during dialysis. A central
line was placed in the setting of progressive hypotension out of
concern for sepsis. However, sepsis was unlikely given that he
remained afebrile and without a white count. Blood and urine
cultures were negative. Additionally, the pt underwent dialysis
on the evening of [**10-3**] and upon return to the ICU developed Afib
with RVR in the context of large volume removal. The patient
converted back to sinus rhythm after being bolused with 1000 cc
NS. Ultimately, no antibiotics were required, and hypotension
resolved with fluid resuscitation.
.
3) Hypertension: Following resolution of hypotension, he
developed hypertension. The patient takes diltiazem and long
acting metoprolol at home. His metoprolol was uptitrated, and
diltiazam 30 TID was added due to persistent elevation of BPs.
Upon arrival to the floor, the patient's blood pressure was
periodically elevated in the SBPs 180s. Calcium channel blocker
was changed from Diltiazem to Nifedipine. Both Nifedipine and
Metoprolol were uptitrated to achieve goal SBP<130, per JNC7
guidelines.
.
4) Atrial fibrillation: The patient remained in normal sinus
rhthym while he was on the floor with combination therapy from
rate controlling agents metoprolol and diltiazem. On [**2127-10-5**],
Diltiazem was switched Nifedipine CR given concern for
over-blockade with two anti-nodal agents. With regard to his
coumadin use, the patient was taken off his coumadin upon
arrival to the neurosurgery team on [**2127-9-29**] in the setting of
subdural hematoma. However, per his CHADS score of 3 (age,
hypertension, and diabetes), the patient is at substantial risk
for thrombotic complications of his atrial fibrillation. For
this reason, he should be restarted on coumadin after he has
been re-evaluated by neurosurgery in 4 weeks. During his
hospital stay he was continued on aspirin 81 mg for
anti-coagulation. He will remain on aspirin 81 mg as an
outpatient until coumadin can be resumed.
.
5) ESRD: The patient has chronic renal failure and was followed
by Nephrology while he was an inpatient. He is dialyzed on
Tuesday, Thursday, and Saturday. During HD, he received 11,000
U Epo and and 8 mcg of Zemplar. His electrolytes and renal
function were otherwise at baseline throughout his hospital
stay. He will continue on Nephrocaps and Sevelamer.
.
6) DM Type II: Upon admission, the patient's glypizide was held
and he was started on an insulin sliding scale. On [**2127-10-2**], in
the MICU, the patient was found to be drowsy with a blood sugar
of 47. His symptoms resolved with D50 bolus and his insulin
sliding scale was halved. He continued on this sliding scale
with fair control of blood glucose levels (<200). Glipizide was
resumed prior to discharge.
.
7) Peripheral Neuropathy: Remained stable throughout the
patient's stay in the hospital. Will be followed as an
outpatient by his PCP. [**Name10 (NameIs) **] may be a primary reason for his
original fall.
.
8) RUE swelling: On [**2127-10-2**], the patient was noted to have
swelling of his right upper extremity from his hand distally to
his shoulder proximally. Because of immobility as well as the
presence of the central line in the right internal jugular vein,
there was concern for possible thrombosis. A RUE ultrasound
showed no thrombi and the RUE continued to have strong pulses.
Upon transfer to the medicine service, the swelling improved
slightly after hemodialysis and with mobilization.
.
9) Left Hip Pain: On [**2127-10-5**], the patient complained of
worsening pain in his left hip and anterior thigh and
deomonstrated increased pain with ambulation. He was observed
to favor his left leg during Physical Therapy. There was no
history of trauma but there was concern for an occult fracture
secondary to the patient's original fall on [**2127-9-29**]. The
patient's hip was imaged with a left pelvic xray which showed
degenerative changes of the hip bilaterally as well as lucency
in the left femoral neck, but low suspicion of fracture. A left
pelvic CT w/o contrast was then performed which demonstrated a
"Large lucent lesion of the left femoral head with a scalloped
contour suggests the possibility of a joint-based process,
possibly bilateral given the slightly abnormal contour of the
inferior right femoral head. Differential possibilities would
include amyloid in this patient with end- stage renal disease."
Per discussion with Orthopaedic team, this is likely consistent
with amyloid vs. bone cyst related to DJD. At discharge, was
referred to the Total Joint [**Hospital 9696**] Clinic for follow-up and
consideration of future hip replacement. Patient is currently
weight-bearing on the left lower extremity and is ambulating
with the assistance of a walker. His oxycontin was discontinued
due to concerns regarding fall risk, and he was started on
standing tylenol for pain control. He was discharged to a
skilled nursing facility for acute rehabilitation.
.
10) Prophylaxis: Patient was on heparin 5000u SC TID as DVT
while inpatient as DVT prophylaxis, approved by Neurosurgery
from the standpoint of his subdural bleed.
Medications on Admission:
Oxycontin
Coumadin
Synthroid
Lopressor
Glipizide
.
Medications [**First Name8 (NamePattern2) **] [**Hospital1 1474**] VA pharmacy:
flexeril 5mg
lasix 80mg daily
glipizide 10mg [**Hospital1 **]
hydroxyzine 10mg tid prn itching
metoprololSA 75mg (1.5 tabs) daily
levothyroxine 100mcg dailysevelamer 3200mg tid
.
Per CVS in [**Location (un) 2973**]:
cartiaXT180mg daily
coumadin 5mg daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA): Give after hemodialysis.
4. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Flexeril 5 mg Tablet Sig: One (1) Tablet PO QHS PRN.
7. Lasix 80 mg Tablet Sig: One (1) Tablet PO daily.
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-29**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day: Hold on morning of HD;
to be administered post-HD. Hold for SBP<90.
14. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO qHD.
15. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day: Hold on AM of HD.
Give post-HD if SBP>100.
16. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO at bedtime:
[**Month (only) 116**] titrate up dose for restless legs as needed after 4-7 days
at this current dose.
17. Humalog insulin Sig: Per attached sliding scale QACHS.
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Primary:
Subdural hematoma
Atrial Fibrillation with rapid ventricular response
Mechanical fall
Hypotension
Hypertension
.
Secondary:
Diabetes Mellitus Type II
End stage renal disease
Peripheral Neuropathy
Degenerative joint disease of left hip
Discharge Condition:
Ambulating with walker. SpO2 94% on room air.
Discharge Instructions:
Mr. [**Known lastname **], you have been diagnosed with a subdural hematoma, a
bleed in your brain that occurred after your fall. You were
admitted to neurosurgery where the bleed was determined to be
stable through imaging. You will follow up with neurosurgery in
4 weeks. It is very important that you are available for this
re-evaluation. Because of the bleed, we had to discontinue your
coumadin which you were taking for your atrial fibrillation.
You will remain off the coumadin until you are re-evaluated by
the neurosurgery team. If your bleed is stable after
reevaluation, it will be important for you to restart your
Coumadin. Please continue to take the aspirin 81 mg daily.
.
Additionally, you have been treated for hypertension and atrial
fibrillation during your current admission to the hospital.
Your medications for hypertension and atrial fibrillation have
been changed to Toprol XL 150 mg PO daily and Nifedipine CR 120
mg PO daily.
.
During this admission, you have also received hemodialysis for
your kidney disease. We will continue hemodialysis once you
leave the hospital on Tues, Thursday, and Saturday. We will
continue your nephrocaps, sevelamer, and lasix medications that
you were taking prior to coming into the hospital.
.
You also underwent several studies for left hip pain. This
included a left hip xray and a left hip CT scan. There was no
bone fracture detected on these studies. However, you will need
to follow up with the orthopedic doctor in the clinic at the
appointment listed below to receive further treatment for your
left hip pain.
Followup Instructions:
Please follow up with:
.
1) Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-10-29**] 2:30
at the [**Location (un) **] radiology department in the [**Hospital Ward Name 517**]
Clinical Center.
.
2) Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD in the Department of
Neurosurgery. Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2127-10-29**] 3:15 p.m.
located at [**Hospital Unit Name 18400**].
.
3) Dr. [**Last Name (STitle) 17025**] on [**2127-10-15**] at 12:45.
.
4) You are scheduled to see Dr. [**Last Name (STitle) **] in the Department of
Orthopaedic Surgery on [**12-12**]. Please arrive early for
scheduled XRAY (SCC 2) at 1:55 p.m. Phone:[**Telephone/Fax (1) 1228**].
|
[
"715.95",
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icd9cm
|
[
[
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[
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] |
icd9pcs
|
[
[
[]
]
] |
13115, 13174
|
4554, 11103
|
314, 384
|
13462, 13511
|
2661, 4531
|
15148, 15886
|
2103, 2107
|
11539, 13092
|
13195, 13441
|
11129, 11516
|
13535, 15125
|
2122, 2642
|
234, 276
|
412, 1819
|
1841, 1909
|
1925, 2087
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,597
| 180,160
|
34480
|
Discharge summary
|
report
|
Admission Date: [**2199-7-6**] Discharge Date: [**2199-7-30**]
Date of Birth: [**2139-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
LE swelling/Shortness of Breath
Major Surgical or Invasive Procedure:
L IJ hemodialysis catheter placement (used for plasmaphoresis
that your recieved), removed
History of Present Illness:
This is a 60 year-old male with distant hx nephrolithiasis who
was transferred from OSH for LE edema/pain, SOB on exertion x
2-3weeks, found to be have acute renal failure, anemia, and
pulmonary hemorrhage on bronchoscopy.
OSH course:
Though sx started 2-3 weeks ago, pt did not seek care until now
due to having no PCP (regular PCP had retired.) He finally
presented for care when he could not put his shoes on in the
a.m. due to pedal edema. Upon presentation to the OSH, pt
complained of bilateral LE pain/edema. Pt reports that LE
symptons started in the feet, progressing to swelling of his
legs to his knees over 3 weeks. He also noted a diffuse macular
rash in the LE of the same distribution. He also complained of
some SOB on exertion and decreased appetite.
In the OSH ED, VS was tachycardic (126), afebrile (97F), BP
131/70. He was noted as having mild wheezing and productive
cough of white sputum. Mental status was clear. Initial
bloodwork showed K 5.6, BUN 130, Cr 9.6. Tp nml at 0.3. BNP
elevated at 625. Urinary protein elevated at 2410. Hct was 14.1
on admission, up to 23 after transfusion of 5 units. Occult
blood stool negative. U/A significant for protein 400mg/dl,
blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative.
Urine microscopy positive for RBCs, granular casts.
Pt was seen by Renal consult, who thought there might possibly
be a pulmonary-renal syndrome or vasculitis, with ESR>140. He
was given Solumedrol 1g IV x 1. Cyclophosphamide was started
after UOP was confirmed to be adequate. Work-up by Renal
included C3/C4, [**Doctor First Name **], anti-GBM, anti-DNA, cryglobulins, ANCA,
HepB/C serology.
CXR on admission showed underlying COPD with diffuse bilateral
pulmonary infiltrates. Pt underwent bronchoscopy on [**2199-7-6**], and
was found to have active low grade blood emanating from the RLL
and LLL.
EKG on admission showed atrial flutter at 2:1 block rate 150.
The patient was transferred to [**Hospital1 18**] for further management. On
arrival here, pt appeared comfortable. He reported that LE edema
had improved, and that pain had resolved in LE. He complained of
only mild nausea recently without vomiting, and a productive
cough. Otherwise denies sore throat, fevers, chills, abdominal
pain, diarrhea, constipation, melena, hematochezia, chest pain,
urinary frequency/urgency, dysuria, lightheadedness, vision
changes, headache, no epistaxis. Last BM was yesterday, and was
formed.
Past Medical History:
none known prior
Social History:
Pt works full-time as a machine operator. Mostly stationary job.
Divorced, college-age son lives with wife. Lives alone.
Smoked 1-1/2 ppd until [**2194**] when he quit (possibly 50 pack year
hx prior). Drinks ~2 drinks/day, and on social occasions. Denies
other drug use.
Family History:
Mother passed from CVA in 80s. Father passed in 70s from unknown
cause. Twin brother passed from MI, another brother with hx
cardiac artery bypass graft. Denies family hx renal or pulmonary
disease.
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Thin, pale, mildly distressed, tachypneic
HEENT: EOMI, PERRL, sclera anicteric, conjunctiva pale, no
epistaxis or rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, shotty anterior
cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: diffuse rhonchi/crackles bilaterally almost to apices
ABD: Soft, NT, ND, +BS, +hepatomegaly (four finger-breaths below
costal margin)
EXT: +1pitting edema lower extremities bilaterally, no palpable
cords, no cyanosis/clubbing, diffuse faint non-pruritic macular
rash from feet -> knees
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: Diffuse macular rash in LE bilaterally from feet -> kness,
scattered telangiectasias in malar area of face
.
Pertinent Results:
[**2199-7-6**] 11:05PM GLUCOSE-219* UREA N-144* CREAT-9.7*
SODIUM-143 POTASSIUM-6.2* CHLORIDE-107 TOTAL CO2-16* ANION
GAP-26*
CXR: [**2199-7-7**]
There is mild enlargement of the cardiac silhouette. Diffuse
bilateral asymmetric alveolar opacifications involving almost
all of both lungs. This would be consistent with diffuse
alveolar hemorrhage as clinically suspected. Fibrocalcific
changes in the apices are consistent with old granulomatous
disease.
<br>
SPECIMEN SUBMITTED: Native renal biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2199-7-8**] [**2199-7-8**] [**2199-7-11**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/axg
Diagnosis:
Renal Biopsy, needle: Pauci-immune crescentic
glomerulonephritis, see note.
Light Microscopy: The specimen consists of renal cortex and
medulla, containing approximately 23 glomeruli, of which 2 are
globally sclerotic. The remainder all show either cellular or
fibrocellular crescents. Many show neutrophilic infiltrate.
The [**Hospital1 **] themselves show no significant endocapillary
proliferation.
There is moderate interstitial fibrosis and tubular atrophy.
Patchy [**Hospital1 **] inflammation accompanies the scarring. Intact
areas show acute and [**Hospital1 **] inflammation. Red cell casts are
present.
Arteries show moderate intimal fibroplasia.
Arterioles show moderate mural thickening with some hyaline
change. No active vasculitis is noted.
Immunofluorescence: The specimen consists of renal cortex only,
containing approximately 8 glomeruli, of which 1 is globally
sclerotic. There is patchy mesangial staining for IgG (trace),
and C3 (trace-1+ as well as in vessels). IgA, IgM, Kappa,
Lambda, and C1q are negative. Three [**Hospital1 **] show fibrin
positivity in crescents. Albumin is non-contributory.
Electron microscopy: Findings will be issued in an addendum.
Comment:
The varied "ages" of the crescents, as well as the
tubulo-interstitial scarring, suggest some chronicity to this
process.
Clinical: No significant PMH. Presented in ARF; SCr=9.6
Pulmonary hemorrhage on bronchoscopy. 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.
<br>
anca positive
<br>
AFB negative x3
<br>
galactomannan negative
<br>
CT Chest without contrast [**2199-7-22**]:
IMPRESSION:
1. Widespread pulmonary abnormalities including consolidation,
ground glass
in poorly defined lung nodules, slightly worse, but no new areas
involved. As
previously mentioned vasculitis and associated pulmonary
hemorrhage are the
primary diagnosis. Coexisting infection such as bacterial
infection or
aspergillosis cannot be excluded.
2. Spiculated right apical lesion raise concern for possible
primary lung
cancer especially on a patient with underlying emphysema. It is
still
potentially can be related to diffuse lung abnormalities thus
three months
followup chest CT is highly recommended.
3. Extensive intrathoracic lymphadenopathy: related to
vasculitis and/or
reactive to infection.
4. Slightly increased but still small bilateral pleural effusion
in minimal
amount of ascites.
Brief Hospital Course:
60 yo [**Male First Name (un) 4746**] presents w/ dyspnea and peripheral edema, admitted
initially to ICU as above with severe anemia, acute renal
failure, pulmonary hemorrhage with w/u (as above) consistant
with anca+ vasculitis - Wegner's Granulomatosis. Pt with
prolonged hospitalization, tx with cytoxan, 7 rounds of
plasamphoresis, steroids - pt with slow pulm course (as
expected), multiple unit transfusion as noted above in the ICU -
required only 2units [**2199-7-19**] on floor with h/h remaining stable
while in-house. Pt with rare aspergillus on [**7-12**] sputum, ID
consulted - decision to treat with voriconazole for 3 mo (can
truncate treatment course if LFTs increase with plan below). ID
also with concern for latent TB - AFBx3 neg as checked prior to
d/c - decision to treat with INH/vit b6, LFTs to be monitored as
outpt, scheduled staggerred consultant appointments for each
medical consultant to follow LFTs with voriconazole/INH plan as
below. Consultant f/u as detailed in summary (Rheum, Renal, ID,
ENT, and Pulmonary).
<br>
1. Wegner's Granulomatosis -presented w/ pulm hemorrhage, severe
anemia, and ARF.
-Appreciated Rheum and Renal input
-s/p 7 treatments of plasmapheresis, completed on [**7-19**]. Per
Renal, removed pheresis catheter on [**7-20**]
-Appreciate Rheum input, increased Cyclophosphamide to 125mg QD
and [**Month (only) **] prednisone to 50mg QD on [**7-26**] - with plan for further
changes per outpt, f/u time schedule per rheum and renal
services
-Dyspnea, cough improved and oxygen requirement stable, with
cont need for pulm support (more at night time, though recently
relatively stable), overall this will be a [**Month/Year (2) **] process with
pt about his expected baseline at this point in his disease
process - pulm f/u in 1 month, has VNA set upt and home for o2,
nebs, pulm support
-Renal function stable, Cr monitored. Continued to make good
urine, foley discontnued. Appreciate Renal recs, plan for outpt
f/u with Dr. [**Last Name (STitle) 118**] [**2199-8-7**], lytes stable at time of d/c.
<br>
2. Hypoxia/Aspergillus infection/concern for tuberculosis.
-Initially thought to be [**12-29**] from Wegener's disease, and is
likely main contributor. Pt significantly improved from initial
presentation and continues to have stable oxygen requirement. Is
afebrile wnl WBC but also immunosupressed, (WBC relatively
stable at time of d/c - 4.9).
-Treating w/ voriconazole given rare aspergillus growth in one
sputum sample ([**7-12**]) given significant immunosuppression, plan
for 4-6wk treatment course (has [**Hospital **] clinic f/u this month)
-shorter course give neg galactomannan and rare cx initially
along with INH/cytoxan regime as well.
-Oxygen requirement stable, pt worked w PT w/o increased oxygen
requirement. Appreciate pulm recs, but they do not think repeat
bronchoscopy is necessary. Overall pt stable with treatment,
but exam still with sig wheezing, at this point still with
benefit from neb tx prn - has VNA set up for support here
-PPD placed on [**7-21**] is neg but given exposure to TB (father had
tb) and immunosupression, result difficult to interpret,
quantiferon study considered, though given difficulty with
result interpretation - plan to treat if AFB neg x3 (3rd
pending, have to resend due to poor sample [**7-26**], awaiting [**7-28**]
sample's results). Given this regime will need very close
monitoring of LFTs, would appreciate consulting services to also
monitor LFTs and to assist coordinating appts (staggering) to
keep pt consistantly monitored along with pt's PCP (should be
checked q2 wks for next [**3-3**] wks. - d/c on INH 300mg qd and B6
25mg qd.
-AFB neg x3 at time of d/c.
-Pt will be treated for latent TB given hx of exposure to tb and
being immunocompromised as above
<br>
3. Possible Aspergillus infection - Sputum Cx showed rare
Aspergillus. ID consulted given pt is immunosuppresed.
Clinically pt was afebrile w/ nl WBC but given abn Chest and
sinus CT finding (which can be seen either with Wegner's or
aspergillous) and given the fact that pt will be immunosupressed
longterm, pt was started on Voriconazole (LFTs wnl). (LFTs
remain stable, will check monday again (hold tomorrow)
-ENT initially consulted given abn sinus CT. They did rhinoscopy
and cultures from nasal region, which have not shown
aspergillous.
-Discussed w ENT about ID's request for sinus sampling and they
strongly feel that he does not have acute invasive sinusitis and
will defer on sinus sampling
-Per ID, repeated sputm cx and sputum from [**7-18**] and [**7-21**] neg for
fungal cx. Nasal swab by ENT showing no fungal growth.
-Serum galactomannan noted negative
-Per ID recs, ppd placed given that pt will be on
immunosupressives for a longtime, ppd placed on [**7-21**] has been
neg (no induration noted)
-Treat with voriconazole for 4-6wks with possibility of shorter
course if change in LFTs (with plan for INH to be held at that
point till voriconazole tx completed)
<br>
4. Anemia, [**Month/Year (2) **] disease and recent active and [**Month/Year (2) **] losses
- combination of ACD and acute blood loss from pulm hemorrhage.
S/p 2 units PRBC on [**7-19**] as HCT was 18 w appropriate correction
to 25. Continue FeSo4 and continue to monitor as outpt, H/H
stable at time of d/c.
<br>
5. Tachycardia, suprventricular- Pt noted to have Aflutter w/
2:1 block since admission. Pt is asymptomatic during tachycardia
and has no hx of it. Tachycardia exacerbation by pulm disease
and deconditioning. TTE this admission showed EF 45-50% w trace
MR/TR. TSH wnl. HR under good control w repletion of lytes and
combination of metoprolol and diltiazem, will continue. PCP to
[**Name Initial (PRE) **]/u and titrate as indicated, may return to sinus with
improvements of pulm status, again to f/u.
<br>
6. Longterm immunosupression
-Bactrim SS MWF for PCP [**Name Initial (PRE) 1102**] (changed from initial
atorovoquone with renal fx more stable now)
-Calcium/VitD and Fosamax for osteoporosis prophylaxis (CaCO3
increased past week to help with repletion)
-PPI for ulcer prophylaxis
.
7. Hyperglycemia
-likely [**12-29**] high dose prednisone. Since pt is going to be on
longterm steroids and has persistent hyperglycemia,pt started on
low dose glyburide on [**7-24**]. BS improved, fluctuates, will
continue current dose, with note pt will need this monitored
once able to be weaned off steroids as outpt. VNA to check BS
intermittantly, keep BS log for PCP to [**Name Initial (PRE) **]/u.
<br>
8. Constipation - continue senna and dulcolax in addition to
colace, pt instructed to take as needed prn.
. FEN - Reg diet.
. Code status - Full
. Disposition - To home today now that AFB neg x3, with
extensive home VNA set up with home 02, resp support long with
prn nebs, and home PT along with close family support. Pt given
instructions, with close f/u arranged.
<br>
Medications on Admission:
none
Discharge Medications:
1. Home Oxygen
Please provide 3-4liters/min of oxygen via Nasal cannula to keep
sats >90%
Diagnosis: Wegener's Granulomatosis
2. Nebulizer
Please provide a nebulizer machine
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): for prophalaxis - ID service can refill if
needed.
Disp:*600 ML(s)* Refills:*1*
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
Disp:*qs 1 month supply * Refills:*0*
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Voriconazole 50 mg Tablet Sig: Six (6) Tablet PO Q12H (every
12 hours) as needed for aspergillus: take 300mg po q12, please
take till told otherwise by any of your doctors as they follow
your labs. Plan for 4-6weeks of treatment, if you need 6 weeks,
your ID doctor [**First Name (Titles) **] [**Last Name (Titles) **] you your refill.
Disp:*360 Tablet(s)* Refills:*0*
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday) as needed for PCP
[**Name Initial (PRE) 1102**].
Disp:*13 Tablet(s)* Refills:*2*
14. 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*
15. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for steroid induced hyperglycemia.
Disp:*30 Tablet(s)* Refills:*1*
16. 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*
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*qs 1 month supply* Refills:*0*
18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
19. Cyclophosphamide 25 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily): Your rheumatologist will adjust this medication dose as
needed.
Disp:*150 Tablet(s)* Refills:*2*
20. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
21. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
22. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO once a day:
for latent tuberculosis.
Disp:*30 Tablet(s)* Refills:*2*
23. Vitamin B-6 25 mg Tablet Sig: One (1) Tablet PO once a day:
to be taken while taking isoniazid therapy.
Disp:*30 Tablet(s)* Refills:*2*
24. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week:
take while on your prednisone (take today and then once a week
from there after).
Disp:*4 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care service
Discharge Diagnosis:
Primary: Wegeners Granulomatosis - causing pulmonary hemorrhage
and renal failure
Secondary/other Diagnosis:
1. Possible Aspergillosis
2. Hx of tuberculosis, with plan for treatment for latent
tuberculosis
3. Steroid-induced Hyperglycemia
4. A-flutter
5. [**Hospital1 8304**] sinusitis (more secondary to changes from Wegener's
disease)
6. Anemia, of [**Hospital1 8304**] Disease and with [**Hospital1 **] blood loss (again
from Wegener's disease)
7. Hyperglycemia (likely from your steroid treatment, your PCP
will [**Name Initial (PRE) **]/u with this, continue glyburide as prescribed
Discharge Condition:
Stable
Discharge Instructions:
Your new diagnoses are as listed below with the main process
called Wegener's. You will need close follow-up with your
primary care doctor along with multiple consulting services for
the care of your disease and to monitor your labs closely while
your recieve your therapy.
<br>
At home, use your home o2 as instructed, the visiting nursing
will assist with this care, and if needed use your nebulizing
treatments during moments you feel your breathing is worse (as
prescribed).
<br>
If your symptoms worsen, particularly related to your breathing
or any symptoms of new and worsened abdominal pain, worsened
blood in your sputum or urine - call your PCP or Rheumatologist
immediately or return to an emergency center.
Followup Instructions:
1. Kidney doctor. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2199-8-7**] 3:00
<br>
2. Rheumatologist. The doctor who will manage the prednisone and
Cyclophosphamide. DR.[**First Name (STitle) **] [**Name (STitle) **], PH:[**Telephone/Fax (1) 2226**]
Date/Time:[**2199-8-13**] 12:00
<br>
3. Infectious disease doctor who will take care of Tuberculosis
and Fungal Infection Treatment, Dr. [**Last Name (STitle) **] [**Name (STitle) **], on [**2199-8-20**] at
10:00 AM
<br>
4. Primary care Physician, [**Last Name (NamePattern4) **].[**First Name (STitle) **] [**Name (STitle) **],
PH:[**Telephone/Fax (1) 250**]. Appt is on at [**2199-8-8**] 2:30pm. Please
inform/remind PCP or ID doctor to order CT Chest for f/u
evaluation as requested in ID staff note.
<br>
5. ENT doctor [**First Name (Titles) **] [**Last Name (Titles) **] sinusitis with an 'ENT FELLOW
RESIDENT' on [**2199-8-21**] at 12:00 PM.
<br>
6. Pulmonary (Lung doctor): Wed [**8-28**], you have to check
in at 12:30pm for breathing test and vitals, then will see
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] at 1pm, location is [**Hospital Ward Name 23**] 7.
<br>
Completed by:[**2199-7-30**]
|
[
"117.3",
"564.09",
"496",
"518.5",
"790.29",
"584.9",
"473.9",
"580.4",
"786.3",
"137.0",
"285.29",
"446.4",
"348.39",
"280.0",
"427.32",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23",
"38.93",
"99.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
18668, 18737
|
8049, 14924
|
345, 438
|
19370, 19378
|
4488, 8026
|
20148, 21465
|
3266, 3466
|
14979, 18645
|
18758, 19349
|
14950, 14956
|
19402, 20125
|
3481, 4469
|
274, 307
|
466, 2920
|
2942, 2960
|
2976, 3250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,295
| 173,741
|
34292
|
Discharge summary
|
report
|
Admission Date: [**2181-9-4**] Discharge Date: [**2181-9-7**]
Date of Birth: [**2104-12-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
coma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 y [**Hospital 78924**] transferred to [**Hospital3 **] ED after being found
unresponsive at [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**] Rehab/NH. His GCS on arrival to
the
ED was assessed to be 3 on arrival. According to his wife [**Name (NI) 2127**]
and his daughters, he had fallen 2 days ago at his residence,
and
had fallen some time at night, although this is unclear. At
[**Hospital3 9717**] ED, he was intubated and sedated (etomidate 20/succ
100/lidocaine 100, then given fentanyl 25/versed 2 at 7 am). He
received 50 g mannitol.
His daughters [**Name (NI) **] [**Last Name (NamePattern1) 16229**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] were present with
their Mother [**Name (NI) 2127**] [**Name (NI) 805**].
Past Medical History:
1. [**2181-8-22**] - Surgeon Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) 1132**] at [**Hospital1 3278**]:
Left ACOM clipped (wide neck) post-op report: 12 mm
(unruptured),
left sided approach.
2. [**3-31**] - left carotid artery stent (at the bifurcation)
started on ASA and Plavix
3. [**3-31**] TIA as per [**Hospital1 3278**] Neurosurgical Resident, and stroke
according to the family.
4. CAD: Angioplasty 15-20 y ago
5. "Borderline diabetic"
6. HTN
7. Hyperlipidemia
8. Prostate cancer (3 monthly hormonal treatment at the [**Hospital3 **])
Social History:
Retired Government worker. Ran a cab company in
[**Hospital1 8**]. Gave up smoking after his angioplasty. Minimal
alcohol
intake. No IVDA. Lived with his wife [**Name (NI) 2127**]
(cell: [**Numeric Identifier 78925**]).
Family History:
Family Hx: Not known (did check with family).
ROS: Not known, as Mr [**Known lastname 805**] was found in a coma.
Brief Hospital Course:
Patient admitted to ICU and made CMO, then extubated. Passed
away on the floor. Autopsy pending.
Medications on Admission:
N/A
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2181-9-8**]
|
[
"433.10",
"348.4",
"401.9",
"V10.46",
"414.01",
"272.4",
"E888.9",
"852.25",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2293, 2302
|
2112, 2210
|
320, 326
|
2363, 2372
|
2425, 2577
|
1973, 2089
|
2264, 2270
|
2323, 2342
|
2236, 2241
|
2396, 2402
|
276, 282
|
354, 1138
|
1160, 1719
|
1735, 1957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,592
| 115,663
|
42344
|
Discharge summary
|
report
|
Admission Date: [**2187-10-21**] Discharge Date: [**2187-10-23**]
Date of Birth: [**2119-5-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Irregular Heart Rate
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year old female with history of
coronary artery disease s/p stent and diabetes that recently had
a Coronary artery bypass grafting x4: Left internal mammary
artery graft to left anterior descending, reverse saphenous vein
of the marginal branch, diagonal branch and left-sided PDA. This
was done on [**2187-10-16**]. Pt did well from the procedure was
discharged to Rehab on BB 12.5 [**Hospital1 **]. She now presents to the ER
with Atrial Fibrillation. Was on IV Diltiazem. She lost venous
access. She recieved one dose of PO Diltiazem.
Past Medical History:
Coronary artery disease s/p CABG [**2187-10-16**]
Atrial Fibrillation (post-op)
PMH:
Myocardial infarction [**2164**] s/p stent
Psoriasis
Pneumonia
Diabetes Mellitus type 2
Hypertension
Depression
Chronic bone on bone pain - Right ankle after fracture
Anxiety
Social History:
Last Dental Exam: 6 months ago
Lives with: Alone (separated from spouse)
Contact: [**Name (NI) **] [**Last Name (NamePattern1) **] Phone # [**Telephone/Fax (1) 91723**] cell [**Telephone/Fax (1) 91724**]
Occupation: Intake coordinator
Cigarettes: Smoked yes [x] last cigarette 25 years ago
Hx: 20 pyh
ETOH: < 1 drink/week [] [**1-22**] drinks/week [x] >8 drinks/week []
Illicit drug use none
Family History:
Father deceased 39 MI and pneumonia
Mother deceased 62 MI
Sister deceased 75 amyloidosis
Son [**Name (NI) 3495**] failure
Physical Exam:
Pulse: 116 Resp: 18 O2 sat: 98 % RA
B/P Right: 150/64 Left: 150/68
General: no acute distress sitting laying in bed
Skin: Dry [x] multiple areas of red scaly areas scalp, left
flank
buttock, left elbow, ecchymosis under bilateral eyes s/p door
hitting her in face
HEENT: Left pupil 3mm right 2mm reactive to light bilateral EOMI
[x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade [**12-21**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
deformity right ankle d/e fx Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2187-10-21**] Chest CT
Final Report
INDICATION: [**Hospital 30608**] transferred from [**Hospital6 19155**] for
AFib and RVR
status post CABG.
TECHNIQUE: MDCT-acquired axial images were obtained through the
lungs prior
to and in arterial phase after the uneventful administration of
100 cc of
Optiray contrast medium. Coronal and sagittal reformations were
prepared.
COMPARISONS: Chest radiograph [**2187-10-20**].
FINDINGS: Thyroid gland is normal in appearance. The patient is
status post
CABG with surgical clips and native coronary calcifications
noted along with
median sternotomy wires. In the anterior mediastinum, fluid and
air are seen
compatible with post-surgical state along with trace pericardial
effusion.
The heart is moderately enlarged. Small pericardial effusion is
noted.
Pulmonary arterial enlargement to 3.7 cm is noted and suggests
pulmonary
arterial hypertension. The pulmonary vascular tree is well
opacified without
evidence of embolus. Innumerable tiny pulmonary calcified
nodules are seen
which are likely granulomata given their appearance. Trace right
and small to
moderate left pleural effusions are seen with fluid layering
along the major
fissure on the left. Mild compression atelectasis is noted in
the left lower
lobe. The aorta and major branches are unremarkable with normal
three-vessel
branching arch. No mediastinal, axillary, hilar,
supraclavicular, or
pathologic adenopathy with non-enlarged nodes noted. Though this
study is not
tailored for subdiaphragmatic evaluation, the imaged upper
abdomen is
unremarkable.
OSSEOUS STRUCTURES: Aside from median sternotomy there is no
bony
abnormality.
IMPRESSION:
1. No pulmonary embolus or acute aortic pathology.
2. Changes compatible with recent CABG including fluid and air
in the
anterior mediastinum.
3. Small to moderate left and trace right pleural effusions.
4. Enlarged pulmonary artery up to 3.7 cm suggesting underlying
pulmonary
arterial hypertension.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 815**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SUN [**2187-10-21**] 10:40 PM
Imaging Lab
[**2187-10-23**] 05:45AM BLOOD WBC-11.4* RBC-3.02* Hgb-9.3* Hct-27.5*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-337
[**2187-10-22**] 01:03AM BLOOD WBC-10.6 RBC-3.23* Hgb-9.4* Hct-29.3*
MCV-91 MCH-29.2 MCHC-32.2 RDW-13.5 Plt Ct-344#
[**2187-10-23**] 05:45AM BLOOD PT-14.8* INR(PT)-1.3*
[**2187-10-23**] 05:45AM BLOOD Glucose-150* UreaN-18 Creat-0.7 Na-138
K-4.4 Cl-97 HCO3-33* AnGap-12
[**2187-10-22**] 01:03AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140
K-4.0 Cl-98 HCO3-29 AnGap-17
[**2187-10-23**] 05:45AM BLOOD Mg-2.1
Brief Hospital Course:
The patient was re-admitted for management of Atrial
Fibrillation. Rate control was achieved with Lopressor and
Amiodarone, and she did convert to Sinus Rhythm. She was
anticoagulated with Coumadin. She received two doses of 2.5mg
on [**10-22**] and [**10-23**]. She will be discharged to [**Location (un) 16493**]Rehab.
Medications on Admission:
Simvastatin 20 QD
Colace 100 [**Hospital1 **]
Zantac 150 QD
Gluburide 2.5 QD
Lopressor 12.5 [**Hospital1 **]
Lisinopril 2.5 QD
Lasix 40 QD
K Dur 20 meq TID
ASA 81 QD
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR, Coumadin for a-fib
Goal INR 2-2.5
First draw: [**2187-10-24**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. glyburide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
7. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 5 days.
8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change daily for goal INR 2-2.5, dx: AFib.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Coronary artery disease s/p CABG [**2187-10-16**]
Atrial Fibrillation (post-op)
PMH:
Myocardial infarction [**2164**] s/p stent
Psoriasis
Pneumonia
Diabetes Mellitus type 2
Hypertension
Depression
Chronic bone on bone pain - Right ankle after fracture
Anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Tylenol/Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
trace Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on Wed [**11-7**] at 1:30 PM in
the [**Hospital **] medical office building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-25**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 50167**] in [**3-20**] weeks [**Telephone/Fax (1) 72680**]
**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, Coumadin for a-fib
Goal INR 2-2.5
First draw: [**2187-10-24**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
Completed by:[**2187-10-23**]
|
[
"338.29",
"414.00",
"V15.51",
"300.4",
"427.31",
"V45.81",
"401.9",
"250.00",
"412",
"V15.82",
"696.1",
"V17.3",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7470, 7544
|
5483, 5809
|
334, 341
|
7848, 8073
|
2692, 5460
|
9046, 9886
|
1625, 1749
|
6026, 7447
|
7565, 7827
|
5835, 6003
|
8097, 9023
|
1764, 2673
|
273, 296
|
369, 912
|
934, 1195
|
1211, 1609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,339
| 197,955
|
54311
|
Discharge summary
|
report
|
Admission Date: [**2177-5-26**] Discharge Date: [**2177-6-3**]
Date of Birth: [**2117-8-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Severe midscapular and chest pain
Major Surgical or Invasive Procedure:
[**2177-5-28**] - Endovascular stent graft of thoracic aortic dissection
History of Present Illness:
This 59-year-old lady was admitted to the cardiology service a
couple days ago with an acute type B aortic dissection. This has
been being managed medically.
Subsequent CT scan done in the last 24 hours, because of
continued chest pain, has shown extension of the dissection,
both proximal and distal to the tear. Because of the potential
proximal extension and continued chest pain on good
anti-hypertensive medications and for concerns of possible
rupture, we have decided to try to cover the tear with an
endovascular thoracic stent graft.
Past Medical History:
HTN
Hypercholesterolemia
Hypothyroid
Chronic Back and Neck pain
Social History:
Lives with family. Prvious smoker, wuit several years prior.
Denies drug use or alcohol use. Works as school teacher.
Family History:
Parents with CAD and MI's in their 70's and 90's
Physical Exam:
Temp 98.2 BP 153/77 HR 79 95% RA
GEN: Obese, drowsy female concerned about her current health
HEENT: Anicteric, PERRL, Mucous membranes moist, no JVD
CARD: RRR, Crescendo-decrescendo murmur at LUSB
LUNGS: Slightly diminished BS anteriorly
ABD: Soft, NT, ND, normoative bowel sounds, obese
EXT: Bounding DP/PT pulses. Trace edema
Skin: No lesions
Pertinent Results:
[**2177-6-2**] 06:55AM BLOOD WBC-13.0* RBC-3.31* Hgb-10.0* Hct-28.6*
MCV-86 MCH-30.2 MCHC-35.1* RDW-14.2 Plt Ct-339
[**2177-6-2**] 06:55AM BLOOD Plt Ct-339
[**2177-6-2**] 06:55AM BLOOD Glucose-120* UreaN-10 Creat-0.6 Na-141
K-3.8 Cl-101 HCO3-32 AnGap-12
[**2177-5-27**] CTA
Extensive type B aortic dissection extending from the takeoff of
the left subclavian artery all the way to the iliac artery
bifurcations. The celiac trunk, SMA, [**Female First Name (un) 899**] and renal arteries are
supplied by the true lumen and appear patent.
[**2177-5-28**] ECHO
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The descending thoracic aorta is mildly
dilated. A mobile density is seen in the descending aorta
consistent with an intimal flap/aortic dissection. The
dissection flap appears just distal to the left subclavian
take-off. There is a large intramural hematoma distal to the
left subclavian artery. Flow is seen by Color Doppler in the
left subclavian artery. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen.
Post stenting-The distal end of the stent graft is visualized in
the proximal descending aorta. No further assessment could be
may secondary to acoustic shadowing of the graft. Flow is
visualized in the true lumen distal to the stent.
[**2177-6-1**] CTA
1. Status post aortic stent graft placement. No evidence of
post-surgical complications.
2. Stable extent of aortic dissection at the origin of the major
tributaries of the true lumen.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mrs. [**Known lastname 111259**] was admitted to the [**Hospital1 18**] on [**2177-5-26**] via transfer
from [**Hospital **] Hospital for further work-up of her aortic
dissection. Repeat CT scan revealed extension of her aortic
dissection and the vascular and cardiac surgery service was
consulted. A labetalol drip was started for tight blood pressure
control. On [**2177-5-28**], Ms. [**Known lastname 111259**] was taken to the operating
room where she underwent a thoracic aortic stent graft
placement. Please see operative note for details.
Postoperatively, she was taken to the cardiac surgical intensive
care unit for monitoring. She had some confusion and agitation
postoperatively which resolved over several days. Her lumbar
drain was removed per protocol. She was slow to wean from her
labetalol drip however she ultimately weaned and was transferred
to the step down unit on postoperative day four. Her confusion
slowly improved. Mrs. [**Known lastname 111259**] continued to make steady
progress and was discharged home on postoperative day six. She
will follow-up with Dr. [**Last Name (Prefixes) **], the vascular surgery
service, her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Synthroid
lipitor
Benicar
(Dosages unknown)
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
4. 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*
5. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
Disp:*240 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Thoracic aortic dissection
Discharge Condition:
Satisfactory
Discharge Instructions:
No driving while on narcotics.
Monitor blood pressure and maintain log for physicians.
Monitor wounds for signs of infection.
Followup Instructions:
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Call to schedule
appointment
Follow-up with Dr. [**Last Name (STitle) **] as instructed.
Follow-up with Dr. [**First Name (STitle) **] in [**12-2**] weeks ([**Telephone/Fax (1) 111260**]
Follow-up with cardiologist in [**12-2**] weeks.
Completed by:[**2177-6-5**]
|
[
"723.1",
"441.03",
"244.9",
"250.00",
"272.0",
"724.5",
"401.9",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"39.73",
"88.42",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5573, 5622
|
354, 429
|
5693, 5708
|
1671, 3473
|
5883, 6247
|
1240, 1290
|
4831, 5550
|
5643, 5672
|
4763, 4808
|
5732, 5860
|
1305, 1652
|
3524, 4737
|
281, 316
|
457, 1002
|
1024, 1089
|
1105, 1224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,010
| 146,210
|
51935
|
Discharge summary
|
report
|
Admission Date: [**2167-10-30**] Discharge Date: [**2167-11-6**]
Date of Birth: [**2091-7-12**] Sex: F
Service: MEDICINE
Allergies:
Enalapril / Shellfish
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Dizzy, melena
Major Surgical or Invasive Procedure:
[**2167-10-31**] Small bowel enteroscopy
[**2167-11-3**] Capsule endoscopy
History of Present Illness:
Pt is a 76 y.o female with h.o LGIB [**1-10**] ischemic colitis, ESRD,
recently admitted to ICU/discharged for fatigue, pre-syncope,
hypotension, HCT 21.7 (from 31), diarrhea, nausea, vomiting x2
with minimal amount of blood, and melena. She was transfused
with blood and GI got involved. EGD on [**10-26**] found no source of
bleeding, colonoscopy on [**2167-10-28**] found diverticulosis of
sigmoid and descending colon and dried blood.
.
She was discharged from floor, then was suddenly dizzy,
lightheaded, with non-bloody emesis while on her way to HD.
However she denied abdominal pain, diarrhea, constipation,
melena or fresh blood per rectum. Also, denied fevers/chills,
CP/SOB/cough, dysuria/hematuria, weakness, paresthesias/rash. PT
reports she ate a can of soup yesterday and cheerios this am.
Currently feels better, slightly dizzy.
.
In the ED, She was found to be in Sinus Tachycardia, guaiac of
stools showed "massive melena". EKG with ST depression in v1-v2,
HCT 19 from 26.4 yesterday. She was transfused 1 unit PRBC, and
ordered for 3 units. Initial HR 130's, BP 130/75. She had CT
abdomen which was negative. Repeat vitals afeb. HR 108, BP
140/40 RR 20 sat 98% on RA.
Past Medical History:
1. Type2 diabetes mellitus - insulin-dependent - diag [**2130**].
2. Chronic kidney disease - stage 5 - followed by Dr.
[**Last Name (STitle) 7473**]. Left av-fistula in place . Gets HD MWF
3. CHF - [**2160**] EF 20-30%, [**2-/2166**] ECHO persistent LVH, likely [**1-10**]
hypertensive heart disease, with mild MR, mild-to-moderate TR.
Followed by [**Hospital 1902**] clinic, cardiomyopathy thought [**1-10**] htn dm.
4. Sensory neuropathy.
5. Onychodystrophy
6. Hyperkeratotic lesions plantar aspects feet
7. Ischemic colitis - [**4-/2166**]
8. LGIB - [**4-/2166**] - thought possible [**1-10**] to ischemic colitis
9. Diverticulosis
10. Breast cancer (invasive ductal, dx [**2156**]). diagnosed [**9-/2157**]
with a 1.5 cm grade II infiltrating ductal cancer of the right
breast, clean lymph nodes, ER positive, HER-2/neu negative.
Presumed remission now s/p five years on tamoxifen.
11. Renal osteodystrophy
12. Hypercholesterolemia
13. TB @ 21 yo, s/p lobectomy
14. Fibroids, s/p hysterectomy
Social History:
She is living with her daughter, grandson, his
wife and great granddaughter who is two months old. She is
finding that to be quite acceptable to her. She does not smoke.
She does not drink alcohol.
Family History:
Mother -- breast cancer
[**Name (NI) **] -- breast cancer
Brother -- melanoma
Physical Exam:
Vitals: T. 98.8 BP 139/60 HR 78, sitting 122/56 HR 115.
RR 18, sat 100% on RA. WT 5'9 [**12-10**] WT 81.3kg
GEN:well appearing, NAD, cooperative, alert
HEENT: nc/at, perrla, EOMI, anicteric, MMM, no oropharyngeal
lesions/exudates
neck: +JVP to thyroid cartilage, no LAD, supple
chest:b/l ae no w/c/r
heart: s1s2 rrr 4/6 systolic flow, loudest in LUSB.
abd:+bs, soft, NT, ND
ext: no c/c/e 2+pulses, L.ac fistula with bruit.
neuro:aa0x3, CN2-12 intact, non-focal.
Pertinent Results:
Admission Labs:
[**2167-10-29**] 07:44AM BLOOD WBC-8.5 RBC-2.90* Hgb-8.9* Hct-26.4*
MCV-91 MCH-30.8 MCHC-33.9 RDW-16.2* Plt Ct-209
[**2167-10-30**] 11:20AM BLOOD Neuts-81.9* Lymphs-14.1* Monos-3.0
Eos-0.9 Baso-0.2
[**2167-10-29**] 07:44AM BLOOD Plt Ct-209
[**2167-10-30**] 11:20AM BLOOD PT-12.3 PTT-22.3 INR(PT)-1.0
[**2167-10-29**] 07:44AM BLOOD Glucose-79 UreaN-29* Creat-4.3* Na-145
K-3.8 Cl-107 HCO3-31 AnGap-11
[**2167-10-30**] 11:20AM BLOOD ALT-11 AST-53* CK(CPK)-82 AlkPhos-62
TotBili-0.5
[**2167-10-30**] 11:20AM BLOOD Lipase-36
[**2167-10-30**] 11:20AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2167-10-29**] 07:44AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9
[**2167-10-30**] 11:20AM BLOOD Osmolal-321*
[**2167-10-30**] 11:30AM BLOOD Lactate-4.6*
[**2167-10-31**] 03:10PM BLOOD Lactate-1.5
[**2167-10-30**] CT abd/pelvis:
IMPRESSION:
1. No evidence of free fluid or free air. No acute
intra-abdominal
pathology.
2. Diverticulosis without diverticulitis.
3. Hyperenhancing lesion in the left kidney is concerning for
renal cell
carcinoma. Other high attenuating cystic structures within the
kidneys are
most likely hemorrhagic cysts. Recommend MRI for further
evaluation.
Brief Hospital Course:
This is a 76 year old female with history of ischemic colitis
and lower GIB, ESRD on HD, who presents with light handedness,
HCT drop, and melena. She was recently admitted with HCT
drop/melena and underwent EGD/colonoscopy with only finding of
diverticulosis with old blood. They thought that the source was
small bowel. However, She presented with HCT drop 26 to 19, and
recurrent melena. She was admitted to the ICU and received more
than 7 units of RBC transfusion. She had small bowel enteroscopy
on [**10-31**] which was negative. GI was consulted and she underwent
capsule endoscopy. Tagged RBC scan was never done as it was
thought that the patient was not bleeding enough for this to be
positive. The results of the capsule endoscopy is still pending
at the time of discharge. It will take more several days before
the results are reported. She has been stable for 3 days in the
unit and 3 days on the floor with no further requirement for
more blood transfusion and a stable Hgb/HCT. She was able to
ambulate unassisted without light handedness or presyncope. Her
GI symptoms resolved despite regular diet.
During hospitalization, a CT of the abdomen showed hyper
enhancing lesion in the left kidney which is concerning for
renal cell carcinoma. Other high attenuating cystic structures
within the kidneys are most likely hemorrhagic cysts.
Radiologist recommend MRI for further evaluation.
I have extensively discussed this with the patient. She will
need MRI of the kidneys and Urology follow up. I was unable to
schedule this because of [**Holiday 1451**]. The [**Hospital 159**] clinic will
open on Monday. She was provided with the phone number she
needed to call for appointment.
She will be discharged with Hematocrit check on Monday with
results faxed to PCP.
[**Name10 (NameIs) **] was told about the signs and symptoms of recurrent GI bleed.
.
.
.
.
.
Total Discharge time 98 minutes.
Medications on Admission:
1. Hectorol 2.5 mcg Capsule Sig: One (1) Capsule PO QMWF.
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: take with meals.
5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous once a day: Take dosage and
frequency per prior outpatient regimen.
6. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous twice a day: per prior [**Last Name (un) **] and home sliding
scale and frequency.
7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 40 mg Tablet Sig: One (1) 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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: One
(1) 26 Subcutaneous once a day.
10. Insulin Lispro 100 unit/mL Solution Sig: One (1) per home
sliding scale Subcutaneous three times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel recurrent GI bleeding
acute blood loss anemia
kidney mass
Discharge Condition:
Excellent.
Discharge Instructions:
we think you had bleed from your small bowel. You had blood
transfusions, upper endoscopy and capsule endoscopy. The results
of the latter test will take some time to be reported. I have
scheduled you appointment with DR. [**Last Name (STitle) 4539**] [**Name (STitle) **], the GI fellow, on
[**2167-11-17**] at 3:30 PM. We found cysts on your kidneys. One cyst
was large and concerning for tumor. You need to have MRI of your
kidneys. Please call [**Telephone/Fax (1) **] to get appointment with the
[**Hospital 159**] clinic. I was unable to get you appointment as the
clinic is closed. Please return to the ER or call your PCP if
you develop rectal bleed, continued black stools, vomiting
blood, lightheaded, dizzy, or any new symptoms. you need to have
a blood test on Monday. Please discuss the results with your
PCP.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 7158**] R. [**Telephone/Fax (1) 250**] call to make appointment on Monday.
DR. [**Last Name (STitle) 4539**] [**Name (STitle) **], the GI fellow, on [**2167-11-17**] at 3:30 PM.
Please call [**Telephone/Fax (1) **] to get appointment with the [**Hospital 159**] clinic
on Monday to follow up with the kidney mass.
|
[
"V58.67",
"V10.3",
"428.0",
"703.8",
"578.1",
"588.0",
"V12.01",
"593.2",
"V45.76",
"357.2",
"425.4",
"424.0",
"250.60",
"585.6",
"562.10",
"428.22",
"285.1",
"V88.01",
"404.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.01",
"39.95",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8439, 8445
|
4619, 6526
|
297, 373
|
8560, 8573
|
3426, 3426
|
9444, 9803
|
2848, 2928
|
7442, 8416
|
8466, 8539
|
6553, 7419
|
8597, 9421
|
2943, 3407
|
244, 259
|
401, 1591
|
3443, 4596
|
1613, 2615
|
2631, 2832
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,027
| 198,610
|
8265
|
Discharge summary
|
report
|
Admission Date: [**2125-9-20**] Discharge Date: [**2125-9-27**]
Date of Birth: [**2048-1-6**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 77-year-old white male has
a known history of coronary artery disease. He is status
post MI and stent to the RPDA in [**3-11**]. He presented to an
outside hospital with CHF and a troponin of 0.4. He
complained of dyspnea on exertion, but denied angina,
syncope, or diaphoresis. He has had occasional chest
tightness and lightheadedness. He was transferred here for
cardiac catheterization.
PAST MEDICAL HISTORY: History of coronary artery disease.
Aortic stenosis.
Rheumatic fever.
Paroxysmal atrial fibrillation.
Hypertension.
Hyperlipidemia.
TIA 10-12 years ago.
Benign prostatic hypertrophy.
Subdural hematoma in [**2111**].
Status post cataract removal.
Status post evacuation of a subdural hematoma.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION:
1. Lipitor 20 mg by mouth every day.
2. Aspirin 325 mg by mouth every day.
3. Lopressor 75 mg by mouth twice a day.
4. Lasix 40 mg by mouth every day.
5. Norvasc 5 mg by mouth every day.
6. Plavix 75 mg by mouth every day.
7. Flomax 0.4 mg by mouth every day.
SOCIAL HISTORY: He lives with his wife and daughter in
[**Name (NI) 3786**]. He quit smoking 25 years ago and had a 25 pack year
smoking history. He drinks one drink per day.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Significant for migraines, osteoarthritis
of the left hip, and he had seizures with a subdural, but has
had none since that time.
PHYSICAL EXAMINATION: He is an elderly white male in no
apparent distress. Vital signs are stable and afebrile.
HEENT exam is normocephalic, atraumatic. Extraocular
movements are intact. Oropharynx is benign. Neck is supple,
full range of motion, no lymphadenopathy or thyromegaly.
Carotids are 2 plus and equal bilaterally with bruits versus
radiating murmurs. Respirations were clear to auscultation
and percussion bilaterally. Cardiovascular examination: A
regular rate and rhythm with a 3/6 systolic ejection murmur,
which radiates to the carotids. GI was soft and nontender
with positive bowel sounds. No masses or hepatosplenomegaly.
Extremities were without clubbing, cyanosis, or edema.
Pulses were 2 plus and equal bilaterally throughout.
Neurologic examination was nonfocal.
HOSPITAL COURSE: He underwent cardiac catheterization on
[**9-20**], which revealed severe aortic stenosis with an aortic
valve area of 0.65 cm squared and an EF of 60 percent, no
mitral regurgitation. His coronaries were clean with the
exception of a 30 percent mild left circumflex stenosis and a
patent RCA stenosis prior to the Taxus stent. He tolerated
the procedure well and Dr. [**Last Name (STitle) **] was consulted for AVR, and
he underwent carotid ultrasound, which revealed no
significant stenoses bilaterally.
On [**9-21**], he underwent an AVR of a 23 mm [**Last Name (un) 3843**] [**Doctor Last Name **]
pericardial tissue valve. Cross-clamp time was 68 minutes.
Total bypass time 85 minutes. He was transferred to the CSRU
on propofol and Neo-Synephrine. He had a stable
postoperative night. He did require some volume
resuscitation. He was extubated that night and on
postoperative day one, he had his chest tubes discontinued
and was restarted on his Plavix, and was in stable condition.
On postoperative day one, he went into atrial fibrillation.
He was on an amiodarone drip and then was converted to by
mouth on postoperative day two. On postoperative day three,
he had his wires discontinued. He was started on Coumadin
and he was transferred to the floor in stable condition. He
continued to require aggressive Physical Therapy and was slow
to ambulate. He was anticoagulated with Coumadin.
He did have some more episodes of atrial fibrillation, but
converted to sinus rhythm and on postoperative day number
six, he was discharged to home in stable condition with
visiting nurses and home PT.
LABS ON DISCHARGE: Hematocrit 30.3, white count 7,700,
platelets 227,000. Sodium 137, potassium 4.3, chloride 104,
CO2 25, BUN 20, creatinine 0.9, blood sugar 91. INR 2.7.
MEDICATIONS ON DISCHARGE:
1. Potassium 20 mEq by mouth twice a day for seven days.
2. Colace 100 mg by mouth twice a day.
3. Percocet [**12-8**] by mouth every four to six hours as needed
for pain.
4. Lasix 40 mg by mouth twice a day for seven days and then
decrease to 40 mg by mouth every day.
5. Amiodarone 400 mg by mouth twice a day for seven days and
then decrease to 400 mg by mouth every day for one week,
then decrease to 200 mg by mouth every day.
6. Aspirin 81 mg by mouth every day.
7. Lopressor 100 mg by mouth twice a day.
8. Norvasc 5 mg by mouth every day.
9. Coumadin 3 mg by mouth every day for an INR of 2 to 2.5.
10. Lipitor 20 mg by mouth every day.
11. Flomax 0.4 mg by mouth every day.
FOLLOW UP: He will be followed by Dr. [**Last Name (STitle) **] in [**1-9**] weeks, Dr.
[**Last Name (STitle) 11139**] in [**12-8**] weeks, and by Dr. [**Last Name (STitle) **] in four weeks. Dr.
[**Last Name (STitle) 11139**] was contact[**Name (NI) **] and will follow his Coumadin. He will
having the visiting nurses draw his coags on Monday,
Wednesday, Friday and call the results to Dr. [**Last Name (STitle) 11139**].
DISCHARGE DIAGNOSES: Coronary artery disease.
Aortic stenosis.
Hypertension.
History of rheumatic fever.
Paroxysmal atrial fibrillation.
Hypercholesterolemia.
Benign prostatic hypertrophy.
Transient ischemic attacks in the past.
Subdural hematoma in the past.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2125-9-27**] 18:35:04
T: [**2125-9-28**] 08:21:53
Job#: [**Job Number 29318**]
|
[
"401.9",
"414.01",
"428.0",
"412",
"272.4",
"V45.82",
"427.31",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"39.61",
"88.55",
"37.22",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
1417, 1432
|
5370, 5860
|
4213, 4920
|
959, 1221
|
2397, 4011
|
4932, 5348
|
1606, 2379
|
1452, 1583
|
4031, 4187
|
164, 566
|
589, 933
|
1238, 1400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,010
| 128,495
|
23995
|
Discharge summary
|
report
|
Admission Date: [**2179-5-7**] Discharge Date: [**2179-5-17**]
Date of Birth: [**2111-9-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
abdominal pain and distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 year old female with metastatic cholangiocarcinoma to the
liver and peritoneum status post multiple failed
chemotherapeutic regimens, as well as disease progression
despite palliative chemo and XRT, who initially presented
yesterday with abdominal pain and distention. She was febrile
to 101.5, with peritoneal signs on examination. A CT of her
abdomen demonstrated free air as well as bowel wall edema. She
was seen by surgery who did not feel that she was a surgical
candidate.
.
In the ED she was given levofloxacin, vancomycin, metronidazole
and 4 liters of IVF prior to transfer to the MICU. She was
noted to be oliguric and received 6 liters of IVF in the last 24
hours, with persistent oliguria. Her antibiotics were changed
to vancomycin/zosyn. Her goals of care have been discussed, and
at the present time the patient has decided against aggressive
management such as central lines. She is DNR/DNI. She would,
however, like to continue to receive antibiotics.
Past Medical History:
Metastatic cholangiocarcinoma
Hypertension
GERD
MRSA bacteremia [**2177**]
VRE in bile in [**4-26**]
Anemia
.
PAST SURGICAL HISTORY:
Status post exploratory laparotomy, cholecystectomy, lymph node
biopsy, and peritoneal nodule biopsy
Status post TAH for uncontrollable bleeding during childbirth
Status post laparotomy for lysis of adhesions for small bowel
obstruction ([**2135**])
Status post appendectomy
Social History:
The patient has two children and one grandchild.
She is retired and formally worked for [**Company 22957**].
Denies ETOH, TObacco, IVDU
Family History:
Mother died from kidney cancer.
Father died from a cerebral hemorrhage.
She denies any other family history of cancer.
Physical Exam:
VS: 96.4, 102, 160/78, 20, 97% on 2L
GEN: Resting comfortably in bed, appearing very still.
HEENT: Dry MM.
CV: RR, normal rate, no m/r/g.
LUNGS: Rales bilaterally about [**11-23**] way up.
ABD: NABS, tender to palpation diffusely but no rebound or
guarding. Dressing in place in epigastrium overlying tumor
mass.
EXT: 1+ bipedal edema.
Pertinent Results:
CT ABDOMEN AND PELVIS [**5-7**]: IMPRESSION:
1. Bowel wall thickening, and stranding around the sigmoid colon
in a region of multiple diverticula, as well as new foci of free
intraperitoneal air and an increase in ascites, are consistent
with microperforation from diverticulitis. No drainable fluid
collections.
2. Abnormal appearance to the duodenum and jejunum is likely
related to underdistention.
3. Slight increase in the size of the hepatic metastatic
lesions. Multiple splenic metastatic lesions.
.
[**2179-5-7**] 02:01PM LACTATE-1.3
[**2179-5-7**] 01:40PM GLUCOSE-109* UREA N-14 CREAT-0.7 SODIUM-142
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12
[**2179-5-7**] 01:40PM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-2.1
[**2179-5-7**] 04:20AM LACTATE-2.3*
[**2179-5-7**] 02:17AM LACTATE-3.3*
[**2179-5-7**] 01:55AM GLUCOSE-100 UREA N-21* CREAT-0.8 SODIUM-136
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
[**2179-5-7**] 01:55AM ALT(SGPT)-16 AST(SGOT)-23 ALK PHOS-119*
AMYLASE-16 TOT BILI-1.0
[**2179-5-7**] 01:55AM LIPASE-21
[**2179-5-7**] 01:55AM URINE HOURS-RANDOM
[**2179-5-7**] 01:55AM URINE HOURS-RANDOM
[**2179-5-7**] 01:55AM URINE UHOLD-HOLD
[**2179-5-7**] 01:55AM URINE GR HOLD-HOLD
[**2179-5-7**] 01:55AM WBC-10.6# RBC-3.80*# HGB-11.5* HCT-33.5*
MCV-88 MCH-30.3 MCHC-34.4 RDW-15.3
[**2179-5-7**] 01:55AM NEUTS-84* BANDS-4 LYMPHS-3* MONOS-1* EOS-5*
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2179-5-7**] 01:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
BURR-OCCASIONAL
[**2179-5-7**] 01:55AM PLT COUNT-221
[**2179-5-7**] 01:55AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2179-5-7**] 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
Brief Hospital Course:
Ms. [**Known lastname 61095**] [**Last Name (Titles) **] invasive interventions for her
diverticulitis/colonic perforation and she expired during this
admission.
.
She was managed conservatively with antibiotics, and pain
control. She remained afebrile, and her pain was controlled
initially with a morphine PCA, she was transitioned to a
fentanyl patch with good control of her pain, but also with
associated sedation, which was acceptable to the patient in
discussion prior to initiation. Her antibiotics were
discontinued, as the patient desired to have comfort measures
only. Scopolamine was administered for increasing secretions.
Morphine and ativan were administered with good control of her
pain. She experienced contractures in her right arm, seizurelike
activity, thought associated with the narcotic administration
and she was given ativan, which resulted in somnolence. The
following day, she regained alertness, but had hallucinations
and altered delerium at times. In extensive discussion with the
family, she was told that her mother was clinically and mentally
deteriorated, and was offered both a skilled nursing and home
hospice. In abiding her mother's wishes to pass away at home,
home hospice was arranged. However, the patient continued to
have increasing discomfort, so morphine PCA was titrated to no
pain with abdominal compressions.
.
The patient had oliguria. Kidneys were unremarkable on CT scan,
with normal contrast excretion and creatinine was normal. A
voiding trial was attempted, but after six hours, she was noted
to have bladder distention and the foley was replaced for
comfort.
.
The patient had failed palliative chemotherapy for metastatic
cholangiocarcinoma. In discussion with her primary oncologist,
the focus of her care was on comfort.
.
Medications on Admission:
MEDICATIONS AT HOME:
OxyContin 10 mg in the morning 20 mg at night
Reglan 10 mg p.o. q.i.d.
Ursodiol 300 mg p.o. t.i.d.
Colace 100 mg p.o. b.i.d.
Labetalol 200 mg p.o. b.i.d.
Lipitor 10 mg p.o. daily
Calcium and vitamin D
Protonix 40 mg p.o. daily
Aleve four tablets daily
gabapentin 300 mg p.o. t.i.d.
Metamucil
Norvasc
Ritalin 5mg [**Hospital1 **]
.
MEDICATIONS ON TRANSFER:
Morphine Sulfate IVPCA
Piperacillin-Tazobactam Na 4.5 gm IV Q6H
Dolasetron Mesylate 12.5 mg IV Q8H:PRN
Vancomycin HCl 1000 mg IV Q 12H
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Acetaminophen 650 mg PO Q4-6H:PRN
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"276.2",
"401.9",
"995.91",
"197.7",
"276.51",
"567.89",
"197.8",
"562.11",
"788.5",
"038.9",
"156.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6746, 6802
|
4306, 6097
|
344, 350
|
6854, 6863
|
2454, 4283
|
6916, 6923
|
1961, 2082
|
6823, 6833
|
6123, 6123
|
6887, 6893
|
6144, 6475
|
1515, 1792
|
2097, 2435
|
275, 306
|
378, 1360
|
6500, 6723
|
1382, 1492
|
1808, 1945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,751
| 157,741
|
48569
|
Discharge summary
|
report
|
Admission Date: [**2161-5-8**] Discharge Date: [**2161-5-11**]
Date of Birth: [**2103-9-9**] Sex: F
Service: MEDICINE
Allergies:
Aminobenzoic Acid (B Vit) / lisinopril
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
intubation
extubation
History of Present Illness:
57 y/o female w/ PMHx IDDM, depression, panic attacks who
presents after being found down at [**Hospital **] Health Center. Per
the nurses at BHC, she had a syncopal event this morning around
1130. Her vitals at that time were: 96.4 O2 of 77%, HR 113, BP
143/114, FS: 230. There was no further documentation that the
nurses reported. They state that she had not recently eaten and
had no access to food. They report she's been in good health
with no recent fevers.
In the ED, initial VS were: 98 rectal temp, 105, 81/58, 95% NRB
- Initial Vitals were: 98 rectal, 105, 81/58, 95% NRB. EKG -
sinus tach, RAD, NSST changes. She was noted to not be
protecting her airway so was intubated with. During intubation
food debris was noted in her mouth. She then had an episode of
hypotension into the 70s for which she was started on a neo gtt
initially, although her SBP improved after 3L IVF and was d/c'd.
She had cultures drawn and was empirically started on
vanco/zosyn. Bedside U/S was reportedly unremarkable for an
acute process. CT Head and Torso were unremarkable. Labs were
remarkable for hyperkalemia to 5.8, AST of 58, lactate of 1.8.
Urine and serum tox were negative. ABG showed 7.38/44/202.
Neuro was consulted given her neuro history and recomended a
stat EEG which showed an enecphalopathic pattern slightly fast
pattern may be medication related (barbs or benzos), right
frontal sharp waves likely related to meningioma. There was no
evidence of status epilepticus.
.
On arrival to the MICU, she is intubated and sedated, but able
to follow commands. She states she is not in pain.
Past Medical History:
-Type 2 DM, on insulin
-HTN
-HL
-Obesity
-Multiple meningiomas
-History of hydrocephalus s/p shunt{[**2128**] brain tumor ependymoma
fourth ventricle patient was seen @ [**Hospital1 2177**] where she presented
with hydrocephalus and at the time was shunted and lost to f/u}
[**2138**] the tumor in her 4th ventricle was resected and she has
been wheelchair bound since [**2143**]
Social History:
ves at [**Hospital **] Health Center, wheelchair bound at baseline.
denies smoking, etOH, illicits.
Family History:
noncontributory
Physical Exam:
Admission Exam:
General: intubated but alert, able to follow commands
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: Coarse upper airway sounds transmitted throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley draining clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves all 4 extremities equally, follows commands
Discharge Exam:
VS: 98.4 110/62 94 20 92% RA
Gen: alert, oriented x3. Speech slow but linear
HEENT: EOMI, PERRL, OP clear, MMM. Flaky dry skin in left ear
pinna.
CV: RRR, nl S1 S2, no MRG
Resp: CTAB, slight bilateral rales at bases, no wheezes or
ronchi
Abd: soft, non-tender, non-distended, no rebound or guarding
Ext: warm, well-perfused, no cyanosis clubbing or edema, 2+
DP/PT pulses
Pertinent Results:
Admission labs
[**2161-5-8**] 12:53PM BLOOD WBC-9.0 RBC-4.44 Hgb-13.6 Hct-40.1 MCV-91
MCH-30.6 MCHC-33.8 RDW-14.2 Plt Ct-253
[**2161-5-8**] 12:53PM BLOOD Neuts-73.1* Lymphs-20.5 Monos-3.4 Eos-2.3
Baso-0.6
[**2161-5-8**] 04:17PM BLOOD PT-11.3 PTT-31.4 INR(PT)-1.0
[**2161-5-8**] 12:53PM BLOOD Glucose-204* UreaN-18 Creat-0.9 Na-134
K-5.8* Cl-106 HCO3-24 AnGap-10
[**2161-5-8**] 12:53PM BLOOD ALT-18 AST-58* AlkPhos-86 TotBili-0.3
[**2161-5-8**] 12:53PM BLOOD Lipase-25
[**2161-5-8**] 12:53PM BLOOD cTropnT-<0.01
[**2161-5-8**] 12:53PM BLOOD cTropnT-<0.01
[**2161-5-8**] 12:53PM BLOOD Albumin-3.9 Calcium-8.6 Phos-4.0 Mg-1.8
[**2161-5-8**] 12:53PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2161-5-8**] 12:57PM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-44 pH-7.39
calTCO2-28 Base XS-0 Comment-GREEN TOP
[**2161-5-8**] 02:53PM BLOOD Type-ART FiO2-100 pO2-202* pCO2-44
pH-7.38 calTCO2-27 Base XS-0 AADO2-466 REQ O2-79
[**2161-5-8**] 12:57PM BLOOD Glucose-190* Lactate-1.8 Na-136 K-5.8*
Cl-102 calHCO3-26
[**2161-5-8**] 12:57PM BLOOD Hgb-13.9 calcHCT-42
[**2161-5-8**] 01:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2161-5-8**] 01:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2161-5-8**] 01:20PM URINE
[**2161-5-8**] 03:44PM URINE Hours-RANDOM
[**2161-5-8**] 03:44PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Discharge Labs:
[**2161-5-11**] 07:05AM BLOOD WBC-8.5 RBC-4.41 Hgb-13.0 Hct-40.8 MCV-93
MCH-29.4 MCHC-31.8 RDW-13.6 Plt Ct-213
[**2161-5-11**] 07:05AM BLOOD Glucose-180* UreaN-12 Creat-0.7 Na-139
K-4.5 Cl-102 HCO3-26 AnGap-16
[**2161-5-11**] 07:05AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.5
Microbiology:
[**2161-5-8**] 1:20 pm URINE
**FINAL REPORT [**2161-5-9**]**
URINE CULTURE (Final [**2161-5-9**]):
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
blood cultures ([**5-8**]) pending
Imaging:
CXR [**5-8**]:
FINDINGS: Single portable view of the chest is compared to
previous exam from [**2161-2-24**]. Endotracheal tube is seen
with tip terminating approximately 2.5 cm from the carina.
Enteric tube seen passing below the diaphragm. Low lung volumes
are again noted with bibasilar areas of atelectasis. There is
no large confluent consolidation. Partially visualized catheter
projecting over the right chest wall as on prior, the exact
location of which is uncertain.
IMPRESSION:
1. Endotracheal tube tip approximately 2.5 cm from the carina.
Low lung volumes.
CTA Chest, CT Abdomen/Pelvis [**5-8**]:
CT ANGIOGRAM OF THE CHEST: The contrast bolus is adequate. There
is no central, segmental or subsegmental filling defects in the
pulmonary artery to suggest pulmonary embolism. The thoracic
aorta contains atherosclerotic calcifications but is not
enlarged and there is no evidence of acute aortic dissection or
intramural thrombus. There is no pericardial effusion. Heart
size is normal. There is no mediastinal, hilar, or axillary
lymphadenopathy. There is marked elevation of the right
hemidiaphragm with significant bilateral atelectasis. There is
no pneumothorax or pleural effusion. Large airways are patent.
An endotracheal tube terminates 1 cm above the carina.
ABDOMEN: The liver enhances homogeneously without focal
abnormality. The gallbladder, pancreas, and spleen are normal.
There is a possible right 1 cm adrenal nodule, which is
incompletely characterized (3B:110). The left adrenal gland is
normal. The bilateral kidneys enhance normally. There is a
possible right extrarenal pelvis. There is a nasogastric tube
within stomach terminating at the pylorus. The stomach,
duodenum, and intra-abdominal loops of small and large bowel are
unremarkable. A normal appendix is seen. There is
atherosclerotic calcification of the abdominal aorta. The aortic
caliber is normal and the main branches are patent. There is no
intra-abdominal free air, fluid or fluid collection. There is no
retroperitoneal or mesenteric lymphadenopathy.
PELVIS: There is an inflated Foley catheter within the bladder,
which is decompressed. The rectum and sigmoid are normal. There
is no pelvic free fluid or mass. There is no pelvic or inguinal
lymphadenopathy. The patient is status post hysterectomy.
Ovaries are not seen.
MUSCULOSKELETAL: There are degenerative changes of the spine,
but no fracture and no focal osseous lesions concerning for
malignancy.
IMPRESSION:
1. Low lung volumes with marked right hemidiaphragmatic
elevation with bilateral atelectasis.
2. No evidence of pulmonary embolism or acute aortic syndrome.
3. Possible right adrenal nodule which is incompletely
characterized.
4. ET tube within 1 cm of the carina.
CT Head [**5-8**]:
FINDINGS: There is no acute intracranial hemorrhage, edema,
mass, mass effect, or vascular territorial infarction. There is
a stable 2.8 x 1.7 cm hyperattenuating extra-axial lesion in the
right frontal lobe, which is stable and thought to be a
meningioma. There is another possible stable meningioma in the
anterior falx. There are suboccipital craniectomy changes,
enlargement
of the fourth ventricle, and stable encephalomalacia of the
cerebellum. A focal hypodensity in the pons on the right is
unchanged. The ventricles and sulci are otherwise normal in
size and configuration. There is no fracture. There is minimal
mucosal thickening in the right maxillary sinus. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Orbital and extracranial soft tissues are
unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Stable chronic findings as outlined above.
CXR [**5-9**]:
There are low inspiratory volumes. An ET tube is present, tip
approximately 3.5 cm above the carina. An NG tube is present,
tip beneath diaphragm off film. An additional line overlies the
right chest. There is prominence of the upper zone vessels,
likely accentuated by low lung volumes. There is blunting of
both costophrenic angles reflecting small effusions. There is
patchy opacity at both bases, consistent with collapse and/or
consolidation. The appearances are unchanged compared with
[**2161-5-8**] at 12:47 a.m.
EEG [**5-8**]: (verbal report)
Patient was asleep and not responsive to painful stimuli, so
there is no waking pattern. No epileptiform features.
Brief Hospital Course:
57 yo woman w/ hx of panic attacks and anxiety and admission in
[**Month (only) 404**] for hypoxia of unknown etiology who presents with
hypoxia and altered mental status. It is not exactly clear what
happened to Ms. [**Known lastname **]. At the time of intubation for her
hypoxemia, she was noted to have food in her trachea. It is
possible that she aspirated and became hypoxemic and then lost
consciousness. Alternatively, it is possible that she had a
primary event that resulted in a loss of consciousness (such as
seizure or syncope) and aspirated in this context. EEG was
negative for seizure, however this does not eliminate the
possibility that she had a seizure prior to the event.
# Hypoxic respiratory failure: Per report, was 77% room air on
EMS arrival, but improved to 95% on room air on arrival to ED.
She was intubated for airway protection and during intubation
food products suctioned from mouth. She had a CTA chest abdomen
and pelvis which showed no PE or other acute process. Patient
was admitted to the MICU for further care, where she was quickly
weaned off the vent and extubated. On arrival to the medical
floor, she was on nasal canula with sats in the high 90s. She
was initially given antibiotics in the ED, however these were
not continued on the floor as patient did not have signs or
symptoms of infection. However, she did continue to have an
oxygen requirement with desats to the high 80s, which was
believed to be due to pnuemonitis from her aspiration event, not
a true infection. Therefore she may continue to require some
oxygen supplementation for the next few days as she continues to
recover from her pneumonitis. If she continues to need oxygen
for a longer duration of time, consideration for pulmonary
consultation or other evaluation regarding the etiology of her
underlying hypoxemia would be recommended.
# Asiration: As above, her presentation was associated with an
aspiration event, which may or may not have precipitated her
syncope. Speech and Swallow evaluated the patient and
concluded: "Although a suspected aspiration event may have
precipitated pt's admission for hypoxia, she did not have any
s/sx of aspiration or
residue at the bedside. As such, she is recommended for a PO
diet of thin liquids and regular consistency solids. Meds are
okay to be taken whole with water. If there are further
concerns, please re-consult for a video swallow. This
swallowing pattern correlates to a Functional Oral Intake Scale
(FOIS) rating of 7."
# Altered mental status: The patient's event does not have a
clear precipitant. Troponins negative with unchanged EKG, so
despite her reported chest pain this is unlikely of cardiac
origin. No indication of pulmonary embolism on CTA. No clear
sign of infection on CXR, abdominal imaging. No stroke per CT
head. Per report, EEG showed encephalopathy but no ongoing
seizure. This was most likely a syncopal event, probably due to
choking on food given food found on suctioning. Given low
probability of seizure, no need for prophylactic therapy. She
returned to baseline mental status by [**5-9**]. She is at baseline
somewhat dysarthric, although she is oriented and her speech is
linear.
# UA: Urine culture grew gram positive bacteria with
alpha-hemolytic strep or lactobacillus. [**Month (only) 116**] be contaminant.
Patient was asymptomatic and afebrile. As such, this was not
treated.
# Panic Attack: continued home clonazepam and lorazepam
# DM: provided insulin, held metformin due to contrast load
from CT studies
# HTN: continued on home metoprolol
# HL: continued on home simvastatin
# GERD: continued home omeprazole
# Depression: continued home paroxetine
# Urinary incontinence: hold home Vesicare as not available on
formulary
# Ear itching: The patient complained of itching in her left
ear, which revealed a small amount of flaky skin consistent with
eczema. Provided flucinolone topical.
Transitional Issues:
- Continue to monitor for aspiration
- If the patient has another syncopal event, consider neurology
follow-up for possible seizure or worsening encephalopathy due
to her underlying injury
- CT noted a small right adrenal nodule, incompletely
characterized. This should be followed as an outpatient.
- follow oxygen saturations.
Medications on Admission:
1. metoprolol tartrate12.5 mg [**Hospital1 **]
2. simvastatin 40 mg Tablet qHS
3. Trazodone 50mg qHS
4. lantus 40U qHS
5. Humalog 16U qBreakfast, 6U qdinner
6. Klonopin 0.75mg [**Hospital1 **] (got extra dose of 0.5mg on 5.11)
7. metformin 1500mg daily
8. MVI
9. Omeprazole 20mg
10. paroxetine 40mg daily
11. Vesicare 5mg daily
12. Senna
13. Ca/VitD 600/400
14. Lorazepam 1mg [**Hospital1 **] prn (none documented on [**5-8**])
15. Acetaminophen 650mg prn
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
5. Humalog 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous once a day: at breakfast.
6. Humalog 100 unit/mL Solution Sig: Six (6) units Subcutaneous
once a day: at dinner.
7. clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO twice a day as
needed for anxiety.
8. metformin 500 mg Tablet Extended Rel 24 hr Sig: Three (3)
Tablet Extended Rel 24 hr PO once a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO once a day.
15. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: no more than 3 g/day.
17. fluocinolone 0.025 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
18. Home Oxygen
Please provide home oxygen support to maintain O2 sat > 92%. At
the time of discharge she was 88-95% on room air and 97%+ on 2L
NC. Dx: aspiration pneumonitis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
syncope
hypoxic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You came to the hospital after a fainting spell
at your facility. You were found to have choked on food. This
might have caused your fainting, or it might be that you choked
after fainting. You were briefly intubated to make sure you
could breathe, but we were able to take out the breathing tube
and you were breathing on your own. You were transferred from
the intensive care unit to the general medicine floor. After
another night you no longer needed oxygen support all the time,
although you may need it occasionally for the next few days.
We made the following changes to your medications:
- START fluocinolone for irritation in your left ear
Please continue oxygen via nasal cannula to maintain O2 sat >
92%. You may need this occasionally for the next few days as
you continue to recover.
Please follow-up with your primary care physician after your
discharge.
Followup Instructions:
Please see your primary care physician in the next two weeks.
|
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icd9cm
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[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,557
| 169,275
|
10549
|
Discharge summary
|
report
|
Admission Date: [**2117-4-28**] Discharge Date: [**2117-5-1**]
Date of Birth: [**2040-12-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
BRBPR, bleeding fistula
Major Surgical or Invasive Procedure:
Colonoscopy
Hemodialysis
History of Present Illness:
76 y F with h/o ESRD on HD who generally gets her care at [**Hospital1 112**]
admitted to [**Hospital1 18**] last night for AV fistula bleed and possible
lower GI bleed being transferrred to the MICU for low blood
pressures.
.
She initially presented to [**Hospital1 18**] for concern for left AV fistula
bleeding, which was recently redone and starting to be used last
week. Since then, it has been bleeding after hemodialysis which
she first noticed at home, so came in for evaluation.
.
In the ED, her SBP's ranged from 78-82 persistently. Her initial
HCT was 34, and she was admitted for concern for GI bleeding.
Her coumadin was held. She was admitted to the medical floor,
but triggered in the morning of [**2117-4-29**] for SBP 80 - she was
mentating fine and on further review was felt to be close to her
baseline. ICU admission was requested for closer monitoring in
the setting of possible GI bleeding.
.
ROS: In addition to above, pt had lightheadedness earlier but
currently does not feel dizzy either sitting or standing. She is
hungry. She has no chest pain, shortness of breath, fever,
chills. She had some nausea on Monday with mucoid vomiting but
no blood. She complains of some weakness of both legs, which is
equal and at her baseline.
Past Medical History:
cardiac amyloid
renal amyloidosis
ESRD on HD
HTN
hyperlipidemia
CHF
? CAD
h/o CVA - unclear
PUD
s/p L THR
Paroxysmal atrial fibrillation
baseline low blood pressures
Thrombocytopenia - in 80's in [**3-17**]
Social History:
Pt lives alone but with family close. Gets HD at [**Doctor Last Name 9449**] Center.
No EtOH and quit TOB 20 yrs ago. No significant employee
exposures
Family History:
Noncontributory
Physical Exam:
VS: Tc 97.9 BP 80/62 P90 (nurse) P20 99% RA
lying down - 76/55 P96
standing x 2 mins - BP 95/65 P96
PE:
gen- comfortable, conversational, no distress
heent- sclera muddy but anicteric, OP wnl, MMM
neck- supple, ROMI
chest- bilateral inspiratory wheezes, no crackles
card- RRR no MGR
abd- soft, slight TTP lower quadrants, no masses or HSM, NABS
ext- trace edema, WWP, left arm biceps fistula small, with
thrill, bandage clean/dry/intact
skin- normal turgor of thigh. No rash
neuro- AO3, appropriate, answers questions and follows commands
without problem, CNs [**2-22**] roughly intact, strength 5/5 thru/o
Pertinent Results:
[**2117-4-28**]
6:30p
SLIGHTLY HEMOLYZED
142 95 13 AGap=16
-------------< 71
4.2 35 3.4
Comments: K: Hemolysis Falsely Elevates K
estGFR: 13/16 (click for details)
ALT: 18 AP: 189 Tbili: 1.3 Alb: 4.0
AST: 51 LDH: 338 Dbili: TProt:
[**Doctor First Name **]: Lip:
Comments: ALT: Hemolysis Falsely Increases This Result
AST: Hemolysis Falsely Elevates Ast
LD(LDH): Hemolysis Elevates Ldh
98
5.0 \ 11.0 / 81
/ 34.3 \
N:57.7 L:30.5 M:7.6 E:4.1 Bas:0
Comments: Plt-Ct: Verified By Smear
Hypochr: 2+ Anisocy: 2+ Macrocy: 3+
PT: 21.3 PTT: 100.9 INR: 2.1
Comments: PTT: Verified
PTT: Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 7:27 Pm On [**4-28**]
[**2117-4-30**] 04:45AM BLOOD WBC-4.9 RBC-3.38* Hgb-10.4* Hct-32.9*
MCV-97 MCH-30.9 MCHC-31.8 RDW-20.6* Plt Ct-112*
[**2117-4-30**] 04:45AM BLOOD WBC-4.9 RBC-3.38* Hgb-10.4* Hct-32.9*
MCV-97 MCH-30.9 MCHC-31.8 RDW-20.6* Plt Ct-112*
[**2117-4-29**] 10:30AM BLOOD Hct-30.7*
[**2117-4-29**] 07:00AM BLOOD WBC-4.7 RBC-3.20* Hgb-9.9* Hct-31.7*
MCV-99* MCH-31.1 MCHC-31.4 RDW-21.0* Plt Ct-81*
[**2117-4-28**] 06:30PM BLOOD WBC-5.0# RBC-3.50* Hgb-11.0* Hct-34.3*
MCV-98# MCH-31.3# MCHC-32.0 RDW-20.6* Plt Ct-81*#
CXR [**2117-4-29**]
IMPRESSION: Severe enlargement of the cardiac silhouette, likely
cardiomegaly; however, pericardial effusion cannot be excluded.
No acute pulmonary process
Colonoscopy:
Findings:
Mucosa: Localized ulceration with stigmata of recent bleeding
was noted in the rectum. These findings are compatible with
solitary rectal ulcer syndrome.
Excavated Lesions A few diverticula with small openings were
seen in the sigmoid colon.Diverticulosis appeared to be of mild
severity.
Impression: Ulceration in the rectum compatible with solitary
rectal ulcer syndrome
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to terminal ileum
Brief Hospital Course:
# Hypotension, concern for GI bleed - Blood pressure appeared to
be at her baseline per ED records and according to her is
similar to her baseline. Her blood pressure remained stable at
all times. She was transferred to the ICU where HCT's were
obtained q 6H. She was not transfused. Access was maintained via
2 IV's and the dialysis catheter. She received PPI IV BID. GI
was consulted and performed a colonoscopy. The patient's initial
INR was 1.9 so she was given 5 mg po vitamin K for reversal
prior to colonoscopy and prep with Magnesium Citrate. The
colonoscopy showed a small rectal ulcer. The patient will need
to follow up with a flexible sigmoidoscopy in [**2-14**] weeks as an
outpatient. She should continue colace 200-400 mg [**Hospital1 **] until
then. She can restart coumadin and aspirin now.
.
# ESRD: The patient received hemodialysis on [**4-30**] with no
complications via the catheter. Renal was consulted and
recommended a fistulogram, which could not be performed during
hospitalization, so she should have this arranged as an
outpatient and receive dialysis through the catheter until then.
# Wheezing, bicarb of 37: The patient could potentially have
underlying lung disease. She received combivent with good
response and was discharged with an albuterol inhaler. This
could be from pulmonary amylod or asthma, and should be followed
as an outpatient.
# elevated alk phos/LFT's - her alk phos and AST were noted to
be elevated on admission, with slightly elevated GGT. She should
get
# Thrombocytopenia: Her recent baseline is 80 which were
constant in the hospital.
# History of PAF. An EKG showed no changes and the patient
remained at sinus. An episode of A fib was noted during
hospitalization without increased rate.
# h/o amyloidosis with CHF: her fluid status was carefully
monitored. She will start her outpatient medications when she
returns home.
Medications on Admission:
Meds: [Pt unaware of doses or complete list - should be sent
from PCP]
coumadin
lipitor
prilosec
ASA
colace
nephrocaps
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
3 weeks.
Disp:*60 Capsule(s)* Refills:*3*
2. Lipitor Oral
3. Prilosec Oral
4. Nephrocaps Oral
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*12*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
rectal ulcer causing lower GI bleed
AV fistula bleeding
Wheezing, possibly from pulmonary amyloid
ESRD on hemodialysis
cardiomyopathy
amyloidosis
asymptomatic hypotension at baseline, SBP 80-90
paroxysmal atrial fibrillation
Discharge Condition:
Pt was feeling well, with systolic blood pressure of 85-90 and
no other specific complaints.
Discharge Instructions:
You may return home. Please continue all your previous
medications, with the addition of colace 100 mg po BID for [**2-13**]
weeks or until your gastroenterologist suggests otherwise.
Please have your INR checked on Monday and have your doctor
adjust the dose of your coumadin as necessary. You received some
vitamin K in the hospital so it may take some time for your INR
to become normal again.
If you have more bleeding in your stool that concerns you,
dizziness, feeling that you're going to pass out, or any other
concerns, please return to the ED or call your PCP.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks: [**Last Name (LF) 34719**],[**First Name3 (LF) **] S.
[**Telephone/Fax (1) 34720**].
Please resume hemodialysis as previously arranged, starting on
Monday.
Please have your outpatient nephrologist arrange for an AV
fistulogram. If you need this procedure done at [**Hospital1 18**], please
call [**Telephone/Fax (1) 327**] for an appointment.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**] from GI in [**2-13**] weeks for
repeat flexible sigmoidoscopy to ensure healing of your rectal
ulcer. Call ([**Telephone/Fax (1) 8892**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2117-5-1**]
|
[
"427.31",
"272.4",
"V45.1",
"585.6",
"569.41",
"425.4",
"458.9",
"287.5",
"E878.2",
"425.7",
"403.91",
"428.0",
"569.3",
"583.81",
"V58.61",
"517.8",
"285.1",
"996.73",
"277.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"49.21",
"45.23",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7134, 7186
|
4583, 6472
|
296, 323
|
7455, 7550
|
2684, 4560
|
8171, 9018
|
2024, 2041
|
6642, 7111
|
7207, 7434
|
6498, 6619
|
7574, 8148
|
2056, 2665
|
233, 258
|
351, 1608
|
1630, 1839
|
1855, 2008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,060
| 147,758
|
54467
|
Discharge summary
|
report
|
Admission Date: [**2177-12-18**] Discharge Date: [**2177-12-29**]
Service: [**Hospital1 212**]
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 67494**] is an 84-year-old
admitted for acute renal failure, delirium, white blood cell
count of 38,000 in the context of diarrhea. The patient had
chronic medical conditions including COPD (with a home 02
requirement), hypertension, CAD, and chronic renal failure.
[**2176**] for pneumonia, treated successfully with ceftriaxone,
azithromycin, and levofloxacin. He had acute on chronic
renal failure at this time (admission creatinine 4.3,
baseline approximately 2.0) ascribed to dehydration/prerenal
azotemia. He was discharged to a rehabilitation facility,
and his family states that he has had loose stools about the
time he returned to home from the rehabilitation facility.
The patient developed occipital pain and mouth pain on
[**2177-12-13**] and saw his primary care physician on
[**2177-12-15**], who treated him with hydromorphone,
acyclovir, and diphenoxylate/Atropine for diarrhea. The
patient developed confusion the morning of [**2177-12-17**]
which cleared somewhat in the afternoon, and then returned
the morning of admission.
His family brought him to the Emergency Department for
further evaluation. They noted a decreased p.o. intake
recently, dark, foul smelling stool (Guaiac negative in the
Emergency Department) and crampy abdominal pain.
PAST MEDICAL HISTORY:
1. CAD, status post MI times two, PTCA, stent in [**2174**]
(hypertension).
2. Chronic renal failure.
3. Left renal artery stenosis.
4. Peripheral vascular disease.
5. History of left carotid bruits.
6. COPD.
7. Granulomatous hepatitis.
8. Peptic ulcer disease after gastrectomy.
SOCIAL HISTORY: The patient lives at home with his wife, has
a 150 pack year history of smoking, quit in [**2162**].
FAMILY HISTORY: The patient's mother is deceased from
abdominal cancer. The patient's father died of pneumonia.
Brother has CAD.
REVIEW OF SYSTEMS: No shortness of breath or chest pain,
positive ankle edema, nausea, and vomiting, as above.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
95.5, heart rate 93, blood pressure 140/60, respiratory rate
20, oxygen saturation 97%. General: The patient was a thin
elderly male in no acute distress. HEENT: No tenderness to
palpation of the cranium. Positive oral thrush. No lesions,
dry mucous membranes. Neck: No cervical, supraclavicular,
or axillary lymphadenopathy. Lungs: Bibasilar crackles.
Cardiovascular: Regular rate and rhythm, normal S1 and S2.
Abdomen: Scaphoid, soft, nontender, normoactive bowel
sounds. Extremities: No peripheral edema. Neurologic:
Fluctuating level of consciousness (somnolent to alert), poor
ability to attend to and answer questions, no focal deficits.
LABORATORIES ON ADMISSION: WBC equals 39.0, hematocrit 39.4.
The differential demonstrated 88.3% neutrophils, 0 bands,
10.3% lymphocytes, 1.1% monocytes, 0 eosinophils, 0.2
basophils, platelet count 383,000. PT equaled 14.5, PTT
30.3, INR 1.4. Sodium 132, potassium 5.9, chloride 100,
bicarbonate 17, glucose 70, BUN 63, creatinine 4.6.
NOTABLE STUDIES DURING THE ADMISSION: 1. A CT scan of the
head without contrast on [**2177-12-18**] demonstrated no
acute intracranial hemorrhage.
2. A chest x-ray (PA and lateral) on [**2177-12-18**]
demonstrated right upper lobe and right middle lobe
consolidation, unclear whether it is resolving pneumonia or
recurrence.
3. CT scan of the chest on [**2177-12-25**] demonstrated
consolidation in the posterior segment of the right upper
lobe and to a lesser extent the superior segment of the right
lower lobe. No obstructing endobronchial lesions were
observed. There were moderate to harsh bilateral pleural
partially loculated effusions, emphysema, mildly enlarged
lymph nodes in the mediastinum, and anasarca was seen.
4. A transthoracic echocardiogram on [**2177-12-25**]
demonstrated normal left atrium size, left ventricular cavity
size was normal, normal LVEF (60-70%).
MICROBIOLOGY: Two sets of blood cultures from [**2177-12-18**] and [**2177-12-24**] were negative for growth. Stool on
[**2177-12-19**] was positive for C. difficile.
HOSPITAL COURSE: Mr. [**Known lastname 67494**] was admitted to the medical
floor with a clinical picture consistent with C. difficile
colitis secondary to antibiotic treatment for a pneumonia in
[**2177-10-24**]. Stool study confirmed this diagnosis as
noted in the microbiology section.
He was initially started on intravenous Flagyl for the C.
difficile colitis as his mental status initially precluded
oral medications. A Gastroenterology consult was obtained
secondary to this evaluation. There was a concern for an
underlying ischemic colitis. Empiric antibiotics were added
to his regimen which included ampicillin and ciprofloxacin.
A discussion with the family at this juncture on [**2177-12-19**] revealed that they were not interested in pursuing
aggressive workup for the ischemic bowel, as surgery would
not be pursued for the patient if it was positive. The
evaluation for ischemic colitis would have been complicated
by the patient's renal failure and the requirement for
intravenous contrast with the CT scan.
The patient was continued on IV antibiotics and he remained
afebrile. The patient's blood cultures remained negative
while admitted.
Mr. [**Known lastname 111472**] hospital course was also complicated by acute
renal failure on chronic kidney disease. His fractional
excretion of sodium suggested that he was hypoperfusing his
kidneys which was likely secondary to significant
intravascular depletion. His albumin was 1.5 during this
admission.
The patient's renal function was supported with small fluid
boluses, however, these were of limited benefit as his
oncotic pressure was very low and much of the fluid ended up
extravascular.
On [**2177-12-22**], Mr. [**Known lastname 67494**] experienced a proximal
supraventricular tachycardia. His rate was in the 150s. He
did experience some lightheadedness and shortness of breath
with these episodes, however, experienced no ischemic cardiac
pain.
An Electrophysiology consultation was obtained and the
patient was initiated on a Diltiazem drip. Mr. [**Known lastname 67494**] was
transferred to [**Hospital Ward Name 121**] II for more intensive monitoring while on
the Diltiazem drip. It was difficult to titrate this
medication secondary to his hypotension. Eventually, the
patient reverted back into normal sinus rhythm and was
sustained on an oral regimen of Diltiazem.
Mr. [**Known lastname 111472**] mental status had improved several days after
admission. He was back to his baseline according to the
patient's family and was able to interact very well with the
many family members that visit. He did experience several
episodes of transient asymptomatic hypotension.
His hypotension was not adequately responsive to fluid
boluses and he was transferred to the Medical Intensive Care
Unit for more intensive monitoring. A bedside TTE ruled out
tamponade as a cause for this. The patient was in the MICU
from [**2177-12-24**] through [**2177-12-27**] with worsening
of his hypotension, hypoxia, and acute renal failure.
The Renal service was following the patient and the issue of
dialysis was discussed with the family who was not interested
in this course of therapy for the patient.
Prior to transfer to the MICU, discussion with the family
resulted in respecting the patient's and the family's wishes
for code status of DNR/DNI. Despite intense medical
management in the Intensive Care Unit, Mr. [**Known lastname 111472**] condition
declined.
Discussion with the family on [**2177-12-28**] resulted in the
goal of maximizing the patient's comfort level as his
prognosis was very grim. He was transferred to the medical
floor with the goal of transfer to home hospice.
Unfortunately, on [**2177-12-29**], the patient's clinical
condition continued to decline with significant hypotensive
episodes. The patient's family was notified, and Mr.
[**Known lastname 111472**] wife, sons and daughters, and many members of the
extended family came to the hospital. Mr. [**Known lastname 67494**] died on
[**2177-12-29**] at 11:47 a.m. In discussion with the family,
a voluntary postmortem examination was declined.
TIME OF DEATH: [**2177-12-29**], 11:47 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Last Name (NamePattern1) 20054**]
MEDQUIST36
D: [**2178-1-16**] 10:26
T: [**2178-1-17**] 08:30
JOB#: [**Job Number 111473**]
|
[
"584.5",
"403.91",
"276.5",
"008.45",
"412",
"707.0",
"427.31",
"486",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1877, 1992
|
4248, 8689
|
2012, 2126
|
2855, 4230
|
1452, 1741
|
1758, 1860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,312
| 177,653
|
43590
|
Discharge summary
|
report
|
Admission Date: [**2127-12-6**] Discharge Date: [**2127-12-16**]
Date of Birth: [**2054-7-11**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Augmentin / Benadryl
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73F w/ stage IV colon CA (s/p r hemicolectomy and diverting
colostomy), who presented to the ED with hematemesis that began
at Friday at midnight. The patient reports that she had some
cranberry juice. Thereafter she started having multiple episodes
of dry heaves, periumbilical cramping pain and subsequent
hematemesis. Her ostomy bag was also noted to be bloody.
.
In the ED her vitals were as follows T98 HR 72 BP 157/72 R17
O2sat 96%RA.An NGL was done and cleared after 600cc. The patient
was typed and crossed for 4u. She was never transfused. She
received 2L of IVF. Her Hct on presentation was noted to 37.2,
repeated 32.6. Her INR was 1.1 and PTT 24.1.
.
Of note the patient was recently on Augmentin for a stomal
cellulitis. She developed a diffuse body rash. She never had
compromised of her respiratory function.
.
Pt refused EGD. Admitted to [**Hospital Unit Name 153**] for further monitoring.
Past Medical History:
Stage IV colon CA ( s/p right hemicolectomy and diverting
colostomy)
GERD
Iron Deficiency Anemia
Hypothyroidism
Depression
Stomal Cellulitis
Asthma
h/o DVT
Social History:
Patient lives with her son in [**Name (NI) **]. Her husband died last
year from ESRD. She has three sons two are in prison.
Family History:
noncontributory
Physical Exam:
T98.9 HR70 BP135/65 RR20 O2sat 95%RA
Gen: NAD, speaking in full sentences
HEENT: no conjunctival pallor, MMM dry, OP clear
HEART: nl rate, S1S2, no gmr
LUNGS: poor insp effort
ABD: ostomy bag L mid quadrant surrounded by profound
erythematous, eczematous skin changes, mild tenderness to the R
of the umbilical region and hypoactive bowel sounds
EXT: non-blanching macular-papular rash lower extremities,
2+pitting edema, lanced blister on the plantar surface of the
left foot,
Pertinent Results:
[**2127-12-6**] 02:30PM BLOOD Lipase-33
[**2127-12-6**] 02:30PM BLOOD ALT-14 AST-20 AlkPhos-51 Amylase-72
TotBili-0.4
[**2127-12-6**] 02:30PM BLOOD Glucose-146* UreaN-13 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-22 AnGap-18
[**2127-12-16**] 05:50AM BLOOD Glucose-104 UreaN-7 Creat-1.0 Na-137
K-3.7 Cl-102 HCO3-27 AnGap-12
[**2127-12-6**] 08:50PM BLOOD WBC-12.4* RBC-3.76* Hgb-11.4* Hct-32.6*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.4 Plt Ct-452*
[**2127-12-16**] 05:50AM BLOOD WBC-5.6 RBC-3.60* Hgb-10.7* Hct-31.3*
MCV-87 MCH-29.7 MCHC-34.2 RDW-14.4 Plt Ct-410
.
CT Abdomen:
FINDINGS: The lung bases demonstrate no nodular densities or
focal opacities. The liver is mildly low in attenuation
diffusely consistent with fatty liver. The gallbladder is
colapsed with at least 2 gallstones. No pericholecystic fluid or
stranding noted. The pancreas and spleen are unremarkable. The
adrenal glands are within normal limits. Again demonstrated is a
right-sided hydronephrosis with a soft tissue density
surrounding the right mid ureter just cephalad to the sacral
promontory. Delayed excretion is again identified as on prior
study.
.
Soft tissue thickening is again demonstrated within the
duodenum, however given lack of oral contrast, specific
comparison is difficult. There are multiple fluid filled and
mildly dilated loops of small bowel. The terminal ileum is
collapsed. Grouped small bowel loops make identification of a
discrete transition point difficult. The colon contains air and
stool extending all the way to the colostomy site within the
left lower quadrant. There is wide-mouth parastomal hernia with
no evidence of incarceration as on prior study. There are
multiple omental metastatic lesions as demonstrated on prior
study similar in size.
.
CT PELVIS WITH IV CONTRAST: The urinary bladder is unremarkable.
The prostate is normal size. The sigmoid colon contains multiple
diverticula with no evidence of diverticulitis. There are no
soft tissue foci within the perirectal space.
.
BONE WINDOWS: There are no suspicious lytic or sclerotic bony
lesions.
.
IMPRESSION:
1. Multiple moderately distended loops of small bowel with air
fluid levels with no transition point identified. There is a
small portion of terminal ileum that is collapsed. These
findings are consistent with either ileus or early small-bowel
obstruction. Close interval followup recommended. A small bowel
series under fluoroscopy may be of benefit.
2. Stable-appearing right hydronephrosis and hydroureter. Mass
lesion abutting mid right ureter as above suspicious for
metastatic disease.
3. Stable-appearing parastomal hernia. No evidence of
incarceration
Brief Hospital Course:
Hospital Course by Problem:
.
#UGIB: DDX included peptic ulcer disease (given ?duodenal
inflammation on CT), AVMs, worsening of metastatic disease, or
viral gastroenteritis causing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**]-[**Doctor Last Name **] tear (esp given hx
of prolongued dry heaves). She was lavaged in ED, and then
transferred to [**Hospital Unit Name 153**]. IN the ICU, she remained hemodynamically
stable with serial HCT checks. She was started on PPI IV bid,
she required no blood transfusions. GI was consulted and
intially recommended EGD, however, given her clinical stability
for >24hrs, EGD was deferred. While on the floor she had no
further episodes of hematemesis or blood ostomy output. HCT
remained stable.
.
R sided Hydronephrosis: noted to be stable from prior CT scan.
Conferring with her oncologist, this was thought to represent
metastatic disease encasing the ureter. She will follow up with
her oncologist for systemic chemotherapy.
.
?SBO: several days into the hosptialization, she developed
worsening abdominal pain and distention. KUB showed a few
moderately dilated loops of small bowel thought to represent
early obstruction. Surgery team was consulted, who recommended
bowel rest, NGT, IVF, NPO. Her SBO resolved with conservative
treatments and she was tolerating a full diet on the day of
discharge.
Medications on Admission:
(per [**Company 4916**] Pharmacy, [**Location (un) 3146**])
Advair diskus 500-50
ASA 81
Calcium 600/D one by mouth twice a day
Iron 325mg
Levoxyl 200mcg
Omeprazole 20mg daily
Zoloft 50mg daily
Ketoconazole topical cream
Nystatin
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Aspirin EC 81 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 With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Primary Diagnoses:
Small Bowel Obstruction, resolved
Hematemesis, resolved (?[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear)
R sided hydronephrosis; stable from prior CT scan
Secondary Diagnoses:
Stage IV colon CA ( s/p right hemicolectomy and diverting
colostomy)
GERD
Iron Deficiency Anemia
Hypothyroidism
Depression
h/o Stomal Cellulitis
Asthma
Discharge Condition:
stable, tolerating full POs
Discharge Instructions:
Please contact your primary care doctor should you develop any
fevers, chills, sweats, abdominal pain, blood in your vomit or
stool, black stools, or any other serious complaints.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2127-12-30**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **]/ONCOLOGY-CC9
Date/Time:[**2127-12-30**] 9:30
Provider: [**Name Initial (NameIs) 4426**] 18 Date/Time:[**2127-12-30**] 10:00
[**Last Name (LF) 1576**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**]-[**Doctor Last Name 1576**] APG (SB)
Date/Time:[**2128-1-7**] 11:10
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Date/Time:[**2128-4-13**] 10:10
|
[
"V10.05",
"560.9",
"280.9",
"197.6",
"244.9",
"530.7",
"591",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7519, 7561
|
4772, 4772
|
309, 316
|
7978, 8008
|
2122, 4749
|
8236, 8892
|
1591, 1608
|
6425, 7496
|
7582, 7782
|
6171, 6402
|
8032, 8213
|
1623, 2103
|
7803, 7957
|
258, 271
|
4800, 6145
|
344, 1254
|
1276, 1433
|
1449, 1575
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,206
| 163,365
|
47397+47398
|
Discharge summary
|
report+report
|
Admission Date: [**2154-3-13**] Discharge Date: [**2154-3-18**]
Date of Birth: [**2091-9-27**] Sex: F
Service: SURGERY
Allergies:
Vicodin / Adhesive Tape / Lisinopril
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
fever and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 17562**] is a 62F with h/o breast cancer, DM, and
diverticulitis recently treated with ciprofloxacin and flagyl
who presents with fever to 101.3 and LLQ abdominal pain.
.
She was evaluated in [**Hospital **] clinic [**1-28**] for complaints of chronic
diarrhea. A colonoscopy was performed [**2-19**] showing
diverticulitis with EGD showing gastritis. She was started on 2
weeks of cipro/flagyl which she completed on [**3-5**]. She called GI
on [**2-26**] with complaints of increased LLQ pain. She had a CT scan
at an OSH that showed diverticulitis, and was advised to
continue her antibiotics and low residue diet. She recently left
on a trip for [**State 108**] on [**3-11**] and developed a fever to 101.3 and
was advised to seek evaluation in the ED.
.
Since starting ciprofloxacin and flagyl she describes
"explosive" diarrhea with approximatley 8 bowel movements daily;
she has had diarrhea associated with flagyl in the past per her
report. Stools have been rust-colored, without melena or
hematochezia. She has abdominal discomfort sharp in quality
worse in LLQ radiating to RLQ. She has bloating and nausea,
without vomiting.
.
Review of systems is notable for chronic abdominal discomfort
and alternating constipation and diarrhea with current symptoms
more severe than her baseline. Denies lightheadedness,
dizziness, foreign travel, sick contacts, ingesting undercooked
food. Has mild SOB without CP, no h/o CAD, has heartburn, no
coughing, dysuria.
.
In the ED, vitals were T99.4 P 101 BP 113/69, RR 16, O2 100% on
RA. She was treated with IVF, Unasyn, and tylenol. Blood
cultures were sent prior to antibiotics. CT abdomen showed
uncomplicated diverticulitis, and she was admitted to medicine
for further management.
Past Medical History:
* Breast cancer, stage II hormone positive
- status post lumpectomy, adjuvent chemotherapy and XRT
- [**Month (only) 404**] - [**2149-6-1**]: Adriamycin, Cytoxan and Taxol
- radiation therapy [**Month (only) 205**]-[**2149-8-1**], thirty-three visits.
* PAF
* htn
* DM
* hyperlipidemia
* depression
* anxiety
* severe AS and MR s/p bioprosthetic AVR, MVR
* migraines
* complex sleep disordered breathing
- doesn't use CPAP
* BPPV
* Diverticulosis
* Hypothyroidism
* Hiatal hernia
* GERD
* s/p appy
Social History:
Lives on [**Location (un) **] with her husband. Former 1.5 ppd smoker x 17
yrs. Quit 28 yrs ago. Social EtOH. No drugs.
Family History:
Father w/ DM and died of MI at 57. Mother with COPD and lung ca.
Sister with DM, ESRD on HD, and CAD s/p bypass.
Physical Exam:
T 99.6 P 101 BP 119/53 RR 20 O2 96% RA
General Pleasant somewhat uncomfortable appearing woman
HEENT dry MM, sclera white, conjunctiva pale
Neck no JVD
Pulm few crackles at bases persisting post cough, no wheeze
Back no CVA tenderness
CV regular rate S1 S2 III/VI systolic murmur at base
Abd soft, +bowel sounds, no rigidity or guarding, tender to
palpation LLQ
Extrem warm tr edema
Neuro alert and interactive
Pertinent Results:
CBC WBC 9.9, Hb/Hct 7.4/25.9, plts 454
Chem 140/4.2/107/25/7/0.6<86 Mg 1.9
[**3-12**] lactate 2.4, ALT 17 AST 18 ALKP 93 Tbil 0.3
[**3-12**] [**Doctor First Name **] 40 lip 23 Alb 4
.
EKG NSR 84bpm, normal axis and intervals, no acute ischemia
.
[**3-12**] CXR
PA AND LATERAL CHEST: Heart size is at the normal limits. The
patient is status post midline sternotomy and aortic and mitral
valve replacements. There is stable haziness around the left
heart border, likely stable post-surgical changes. No
consolidations to suggest pneumonia are identified. No
effusions or evidence of CHF is identified.
IMPRESSION: No acute cardiopulmonary process.
.
[**3-12**] CT abd
IMPRESSION: Acute uncomplicated sigmoid diverticulitis with
focal area of sigmoid bowel wall thickening. Follow up CT or
colonoscopy after treatment is recommended to ensure resolution
as an underlying mass lesion cannot be completely excluded.
Brief Hospital Course:
This 62F with h/o breast cancer, DM, and recent diverticulitis
s/p ciprofloxacin and flagyl presents with fever and increased
LLQ pain.
.
1. LLQ pain: Diverticulitis is cause in this patient. CT shows
uncomplicated diverticulitis. No adnexal pathology seen on CT.
--Managed with IVF rehydration, NPO advancing to sips as
tolerated, morphine prn pain
--Unasyn started
--GI consulted, and agreed with plan of care.
--General Surgery consulted. Primary care of this patient
transferred to Dr. [**Last Name (STitle) 1120**]. Surgical intervention no indicated at
this time. Follow-up scheduled in 1 week. Patient will complete
9 day oral course of Augmentin.
.
2. Anemia:
Given gastritis on EGD and diverticular disease, suspect GI
source. Decrease in Hct may also be dilutational in part in
setting of IVF resuscitation. Given h/o breast cancer concern
also for malignant marrow process.
--Type and screen, transfuse Hb>7, follow Hct [**Hospital1 **]-no transfusion
required with this admission.
-Started on Ferrous sulfate. Prescription provided. Follow-up
with continue with PCP and Oncologist.
.
3. Fever:
Likely due to GI source, agree that C. diff important
consideration in this patient recently treated with antibiotics
(would be less commonly associated with flagyl, though not
impossible). No pulmonary or GU symptoms to suggest pna or UTI.
--Blood, urine, and stool cultures are all negative.
.
During this admission, patient was maintained on home medication
regimen once tolerating oral intake:
-h/o breast cancer: continue arimidex
-atrial fibrillation: continue beta blocker
-DM: hold avandia, cover with sliding scale insulin
-HTN: continue metoprolol
-hypothyroidism: continue levothyroxine
-hyperlipidemia: continue statin
-depression and anxiety: continue home psych meds
-GERD: continue PPI
.
The patient was managed conservatively. Once her abdominal
tenderness subsided, and normal bowel function resumed, her diet
was advanced. She has been tolerating a regular diet. Denies
abdominal pain. Vital signs have remained stable, and WBC
normal. She responded well to IV antibiotics and re-hydration.
She was advised to make a follow-up appointment with Dr. [**Last Name (STitle) 1120**]
next, and to continue the oral Augmentin.
Medications on Admission:
cipro/flagyl completed [**3-6**]
aspirin 81 mg daily
Toprol XL 50 mg daily
Arimidex 1 mg daily
Claritin 10 mg daily
Cymbalta 150 mg daily
Lasix 20 mg daily
levothyroxine 150 mctg daily
simvastatin 40 mg daily
Singulair 10 mg daily
trazodone 175 mg qhs
desipramine 50 mg [**Hospital1 **]
lorazepam 2.5 mg daily
Prilosec 20 mg [**Hospital1 **]
Mirapex 0.125 mg qhs
avandia 4 mg daily
ca/vit D
MVI
Discharge Medications:
1. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Five (5)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Desipramine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
11. Ativan 1 mg Tablet Sig: 2.5 Tablets PO every 6-8 hours as
needed for anxiety.
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Calcium 600 + D 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
14. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
15. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
18. Mirapex 0.125 mg Tablet Sig: 0.5-1 Tablet PO once a day.
19. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
22. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
23. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 2 weeks.
24. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
25. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diverticultitis
.
Secondary:
breast cancer s/p lumpectomy and chemoradiation, severe AS and
MR s/p bioprosthetic AVR and MVR, PAF, HTN, DM, hyperlipidemia,
diverticulosis, GERD, hiatal hernia, migraines, complex sleep
disordered breathing, BPPV, hypothyroidism, depression, anxiety,
appy
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) 1120**] ([**Telephone/Fax (1) 6316**] for next week.
2. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2154-3-28**] 10:30
3. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 17688**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-4-3**] 12:30
4. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2154-4-8**] 11:45
Completed by:[**2154-3-18**] Admission Date: [**2154-3-23**] Discharge Date: [**2154-4-5**]
Date of Birth: [**2091-9-27**] Sex: F
Service: SURGERY
Allergies:
Vicodin / Adhesive Tape / Lisinopril
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Recurrent diveticulitis
Major Surgical or Invasive Procedure:
s/p lap assisted sigmoid colectomy [**2154-3-25**]
s/p ex lap for free air, and EGD [**2154-3-29**]
History of Present Illness:
Ms. [**Known lastname 17562**] is a 62F with h/o breast cancer, DM, and
diverticulitis recently treated with ciprofloxacin and flagyl
who presents with fever to 101.3 and LLQ abdominal pain.
.
She was evaluated in [**Hospital **] clinic [**2154-1-28**] for complaints of chronic
diarrhea. A colonoscopy was performed [**2-19**] showing
diverticulitis with EGD showing gastritis. She was started on 2
weeks of cipro/flagyl which she completed on [**3-5**]. She called GI
on [**2-26**] with complaints of increased LLQ pain. She had a CT scan
at an OSH that showed diverticulitis, and was advised to
continue her antibiotics and low residue diet. She recently left
on a trip for [**State 108**] on [**3-11**] and developed a fever to 101.3 and
was advised to seek evaluation in the ED.
.
Since starting ciprofloxacin and flagyl she describes
"explosive" diarrhea with approximatley 8 bowel movements daily;
she has had diarrhea associated with flagyl in the past per her
report. Stools have been rust-colored, without melena or
hematochezia. She has abdominal discomfort sharp in quality
worse in LLQ radiating to RLQ. She has bloating and nausea,
without vomiting.
.
Review of systems is notable for chronic abdominal discomfort
and alternating constipation and diarrhea with current symptoms
more severe than her baseline. Denies lightheadedness,
dizziness, foreign travel, sick contacts, ingesting undercooked
food. Has mild SOB without CP, no h/o CAD, has heartburn, no
coughing, dysuria.
.
At her first presentation to ED, vitals were T99.4 P 101 BP
113/69, RR 16, O2 100% on RA. She was treated with IVF, Unasyn,
and tylenol. Blood
cultures were sent prior to antibiotics. CT abdomen showed
uncomplicated diverticulitis, and she was admitted to medicine
for further management.
.
Discharged [**2154-3-18**] with Augmentin for sigmoid diverticulitis,
surgical intervention was not indicated at that time. At
discharge she was tolerating a regular diet well and was
non-tender. She [**Name (NI) 653**] Colorectal NP ([**First Name4 (NamePattern1) 3742**] [**Name (NI) **]) on
[**2154-3-21**] with c/o LLQ ache rated as [**2-10**] worsening to a [**3-11**] with
palpation. Last bowel movement noted as [**2154-3-18**]. She has not
passed gas since discharge. She has been
tolerating a regular diet and had toast for breakfast. She is on
day [**4-10**] Augmentin [**Hospital1 **] and taking Colace [**Hospital1 **]. She was also
started
on Iron Sulfate for anemia. Temperature today is 98.3 po. She
denies: fever, chills, nausea, decreased appetite, diarrhea.
Past Medical History:
* Breast cancer, stage II hormone positive
- status post lumpectomy, adjuvent chemotherapy and XRT
- [**Month (only) 404**] - [**2149-6-1**]: Adriamycin, Cytoxan and Taxol
- radiation therapy [**Month (only) 205**]-[**2149-8-1**], thirty-three visits.
* PAF
* htn
* DM
* hyperlipidemia
* depression
* anxiety
* severe AS and MR s/p bioprosthetic AVR, MVR
* migraines
* complex sleep disordered breathing
- doesn't use CPAP
* BPPV
* Diverticulosis
* Hypothyroidism
* Hiatal hernia
* GERD
* s/p appy
Social History:
Lives on [**Location (un) **] with her husband. Former 1.5 ppd smoker x 17
yrs. Quit 28 yrs ago. Social EtOH. No drugs.
Family History:
Father w/ DM and died of MI at 57. Mother with COPD and lung ca.
Sister with DM, ESRD on HD, and CAD s/p bypass.
Physical Exam:
Vitals: 99, 99, 88, 154/82, 18, 100% on RA
Gen: NAD, A/Ox3
CV: RRR
RESP: CTAB
ABD: +BS, soft, ND, appropriately tender
Incision: OTA with alternating staples and steri-strips. Distal
portion opened-packed with guaze, serous drainage. No s/s of
infection.
Extrem: 1+ b/l upper extremity edema, [**2-3**]+ b/l lower extremity
edema. CSM's intact. +pedal pulses bilaterally.
Pertinent Results:
[**2154-4-1**] 06:06AM BLOOD WBC-9.3 RBC-2.78* Hgb-6.8* Hct-20.7*
MCV-75* MCH-24.7* MCHC-33.1 RDW-22.0* Plt Ct-490*
[**2154-3-22**] 09:00PM BLOOD WBC-9.9 RBC-4.52 Hgb-9.6* Hct-33.5*
MCV-74* MCH-21.3* MCHC-28.7* RDW-19.1* Plt Ct-775*
[**2154-4-1**] 06:06AM BLOOD Plt Ct-490*
[**2154-3-24**] 10:35AM BLOOD PT-14.5* PTT-27.7 INR(PT)-1.3*
[**2154-3-22**] 09:00PM BLOOD Plt Ct-775*
[**2154-4-1**] 06:06AM BLOOD Glucose-74 UreaN-10 Creat-0.5 Na-137
K-3.4 Cl-104 HCO3-28 AnGap-8
[**2154-3-22**] 09:00PM BLOOD Glucose-80 UreaN-15 Creat-0.9 Na-139
K-4.7 Cl-101 HCO3-28 AnGap-15
[**2154-4-1**] 06:06AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.6
[**2154-3-23**] 07:00AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
[**2154-3-27**] 06:26AM BLOOD CEA-32*
.
[**Month/Day/Year 706**] Final Report
CT PELVIS W/CONTRAST [**2154-3-22**] 11:32 PM
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with abx tx x 1 week for diverticulitis
presents with worsening LLQ pain and LGF
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
Degenerative disease of the lumbar spine is noted.
IMPRESSION:
1. Interval worsening of the uncomplicated diverticulitis of the
sigmoid colon with worsening of the bowel wall thickening and
surrounding fatty stranding. However, no abscess or fistulous
connection is identified. Followup CT or colonoscopy after
treatment is recommended to ensure resolution as an underlying
mass lesion cannot be completely excluded.
2. Horseshoe kidney with no hydronephrosis.
.
[**Hospital 706**] Final Report
CHEST (PA & LAT) [**2154-3-29**] 4:16 AM
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with fever pod 4 from sigmoid colectomy
HISTORY: 62-year-old woman with fever for four days from sigmoid
colectomy. Please evaluate for pneumonia, effusion or
atelectasis.
FINDINGS:
A right subclavian PICC line tip is at the caval/atrial
junction. Extensive subcutaneous emphysema is noted along the
left axilla.
IMPRESSION:
1. Significant pneumoperitoneum. The findings were discussed by
the on-call resident with [**Doctor Last Name **] at 5 a.m. This note has been
placed on the PACS report.
2. Atelectasis in both lungs, left more than right.
3. Mild increased size of the heart. Stable valve replacements
are seen of the mitral and aortic. No overt CHF.
4. Extensive left subcutaneous axillary emphysema.
.
[**Doctor Last Name 706**] Preliminary Report
CHEST (PA & LAT) [**2154-4-1**] 9:37 AM
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with adeno s/p lap sigmoid and reop for ex lap
REASON FOR THIS EXAMINATION:
please eval for intraabdominal air
HISTORY: 62-year-old woman with adenocarcinoma, status post
laparoscopic sigmoidoscopy and reoperation for exploratory
laparotomy.
COMPARISON: [**2154-3-29**].
CHEST, PA AND LATERAL: Cardiac, mediastinal, and hilar contours
are stable, status post median sternotomy and valve
replacements. Right-sided PICC is in unchanged position. There
is linear mid right lung atelectasis. Elevation of the right
hemidiaphragm is persistent. There is a small amount of air
inferior to the left hemidiaphragm which could be within the
stomach. Left-sided subcutaneous emphysema is again noted.
IMPRESSION: No large amounts of intraperitoneal free air are
identified. Small focus of air beneath the left hemidiaphragm
may lie within the stomach.
Brief Hospital Course:
HD1-2: Mrs. [**Known lastname 17562**] was advised to return to ED due to worsening
LLQ pain. She underwent a CT scan which revealed persistent
inflammation and diverticulitis, no major changes from CT scan
completed with recent admission for similar complaints. General
Surgery consulted. RE-started IV fluid, IV antibiotics, and made
NPO. Admitted to 12 [**Hospital Ward Name 1827**]. Plan for surgical resection. DL
PICC line inserted in IR for antibiotics, and possible TPN.
Cardiology consulted for cardiac clearance. Current cardiac
status stable for intended surgery. GI consulted.
.
HD3: To OR on [**2154-3-25**] for lap sigmoidectomy. Uncomplicated
procedure. Patient tolerated well. Routinely observed in PACU.
Received multiple fluid boluses for tachycardia, and low urine
output. Responded well. Transferred to 12 [**Hospital Ward Name 1827**].
.
POD1/HD4: Started on sips. Continued with IV hydration.
Anitbiotics discontinued. Assisted OOB, ambulated. Abdominal
incision dressing CDI. Pain well managed. Patho specimen postive
for adenocarcinoma-patient informed per Dr. [**Last Name (STitle) 1120**]. No flatus or
BM.
.
POD2/HD5: Continues to progress, vitals stable. Foley remained
in palce for marginal UOP. Continued on sips. Reported scant
flatus. Diet advanced to clears. Continued to ambulate with
nursing.
.
POD3/HD6:JP drain removed. Tolerating clears. Continued to pass
flatus. IV fluid stopped. Culture data followed. Continued with
IV Lasix. Appeared well.
.
POD4/HD7-POD5/HD8: Acute change overnight.Difficulty tolerating
clears. Feeling worse. Underwent EGD-no esophageal/duodenal
perforation noted. Febrile to 101.4 with leukocytosis. Reports
flatus, however abdomen distended. CXR revealed free air in
abdomen. Evaluated per Dr. [**Last Name (STitle) 1120**], and patient taken to OR for
re-exploration of abdomen. Tolerated procedure well. Refer to
operative note for more details. Transferred to ICU for
tachycardia management.
.
POD1-2/5-6/HD9-10: Monitored in ICU post-op, monitored for pain
and tachycardia. Transferred from ICU on HD10, Adjustments made
to IV PCA for increased pain with adequate effect. NGT & central
line removed. Started on Lasix IV for fluid overload. Resp
status stable, sats >95% on RA. Nutrition consulted.
.
HD [**11-13**]: Continued with clear liquids. Abdomen distention
decreasing. Scant flatus. Incision with unchanged erythema OTA
with staples. No fever or leukocytosis. Cleared per Physical
Therapy for discharge home. No home PT required. Continues to
ambulate independently. Culture data being followed.
.
HD13: Medications transitioned to PO, including Lasix.
Electrolytes repleted accordingly. Started on Lactulose in AM
resulting in 3 BM's. Lactulose discontinued. Abdominal
distention improved, reports feeling better. Abdominal incision
continues to be erythematous. Few staples removed distally,
serous fluid noted, and packed with gauze. Remains afebrile, and
no leukocytosis. Diet advanced to regular food.
.
HD14: Tolerating Regular food. PICC line removed at bedside.
Appears well. Abdominal dressing changed, wound clean and
healing well. Guaze packing inserted. Erythema decreased. Steri
strips applied, and alternating staples intact. Ambulating well.
Potassium repleted orally. VNA services arranged for wound care.
Medications on Admission:
arimidex 1', asa 81', lipitor 20', toprol 50', lasix 20', kcl
20', avandia 4', prilosec 20'', claritin 10', singulair 10',
flonase 2 sprays', cymbalta 150', desipramine 50'', trazodone
175', ativan 2.5', mirapex 0.125', calcium 600 + D 600/400'',
centrum silver', vitamin E 400'
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
6. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
7. Cymbalta 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Desipramine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Trazodone 150 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime)
as needed.
10. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO once a day.
11. Calcium 600 + D 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
14. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
17. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
19. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Ativan 1 mg Tablet Sig: 2.5 Tablets PO at bedtime as needed
for insomnia.
21. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
22. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for 2 weeks.
Disp:*1500 ml* Refills:*0*
23. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for HA/fever/pain: Do not exceed
4000mg in 24 hours. .
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses
Discharge Diagnosis:
Primary:
Recurrent diverticulitis
Post-op atelectasis
Post-op hypovolemia
Post-op incisional seroma
.
Secondary:
breast cancer s/p lumpectomy and chemorads, severe AS and MR s/p
bioprosthetic AVR and MVR, PAF, HTN, DM, hyperlipidemia,
diverticulosis, GERD, hiatal hernia, migraines, complex sleep
disordered breathing, BPPV, hypothyroidism, depression, anxiety,
appy
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Instruction for prevention of Heart Failure:
-Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
-Adhere to 2 gm sodium diet
.
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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-The opened part of your incision requires packing with dry
guaze twice a day, and as needed. A Visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **]
you with this at home, and teach you and your family proper
care.
-Your remaining staples will be removed at your follow-up
appointment with Dr. [**Last Name (STitle) 1120**].
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) 1120**]
[**Telephone/Fax (1) **] in [**7-11**] days.
2. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 17688**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-4-3**] 12:30
3. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2154-4-8**] 11:45
4. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2154-4-29**]
1:25
5. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 6733**]
Date/Time:[**2154-5-6**] 1:15
6. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**]
Date/Time:[**2154-11-11**] 10:00
Completed by:[**2154-4-5**]
|
[
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"496",
"427.31",
"562.11",
"E878.6",
"998.13",
"153.3",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"45.13",
"54.11",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
24611, 24655
|
19045, 22346
|
11806, 11907
|
25065, 25142
|
15699, 16513
|
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|
15177, 15291
|
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|
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|
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|
18253, 19022
|
11935, 14502
|
14524, 15023
|
15039, 15161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,194
| 149,348
|
45599
|
Discharge summary
|
report
|
Admission Date: [**2143-2-13**] Discharge Date: [**2143-2-19**]
Date of Birth: [**2059-6-4**] Sex: M
Service: MEDICINE
Allergies:
Quinolones / Oxacillin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Central Venous Line
History of Present Illness:
83 year old male with history of CAD, CRI, PAF on coumadin, DM
presents from rehab for unresponsiveness with a finger stick in
the 20s discovered at rehab. He was noted to be cold and clammy
and very restless. He was given glucose gel with improvement to
the 150s initially. Also per the NH notes, the patient had a
seizure like episode lasting <1 minute and was persistantly
unresponsive despite giving the glucose. EMS saw him and got FS
100 but unarousable enroute to the ED.
.
Of note, patient was recently admitted to [**Hospital1 2025**] for Urosepsis; at
which time he was treated with Meropenem and subsequently
Tigecycline with cultures growing MDR Klebsiella sensetive only
to Tigecycline. Renal U/S at the time did not show evidence of
collection and blood cultures remained negative. He was
discharged to rehab [**1-29**] and per the notes, he has not been
eating over the past few days. They were also doing straight
caths for poor UOP (but was getting his flomax)
.
On arrival to the ED vitals were BP 105/50 T96 HR 90 100%RA;
fingerstick 15 on arrival and he was given Dextrose with
improvement to 92 and mental status improved. CT head done
initially neegative. but then BP started to drop around 7:30am
to SBP70s. He was given 4L IVF, Vanc/Zosyn given initially and
CVL placed. Additional history per the wife obtained regarding
recent UTI and thus Tigecycline given. Blood cultures were drawn
and PICC line removed. He started to desat to 93% and make brisk
UOP; so fluids held and patient was started on low dose
Levophed. Finger stick done again and noted to be 40 so D5
started. Patients labs notable for WBC 10.2, Lactate 0.8, INR
3.0, CK 40 Trop 0.03, Cr 2.3. Glucose 17-->repeat 92 but then 42
and started on D5. His mental status improved after the
Dextrose. U/A was grossly positive and given history he was
given 100mg Tigecycline. A CXR showed no evidence of pneumonia,
Blood cultures were sent. CVL was placed and patient received 4L
IVF. Levophed was started for persitant hypotension. PICC line
was removed and sent for culture.
.
Currently patient denies any pain. Denies cough, fevers, chills,
N/V, abdominal discomfort, urinary urgency/frequency.
Past Medical History:
- Uroepithelial Cancer s/p left radical nephrectomy s/p uretal
thrombus after biopsy s/p stent placement and recent removal
- Frequent UTI's, recent urosepsis [**2059-1-24**] treated with
Tigecycline for MDR Klebsiella; started [**1-25**] for 3 week course
- CAD s/p MI with BMS to LAD x3, PTCA to OM'[**28**]
- CRI baseline 2.5
- DM on insulin
- HTN
- PVD
- h/o TIA
- Paroxysmal Atrial Fibrillation on coumadin
- Right CEA [**2142**]
- CHF EF 55%; symtpoms are wheezing
- CVAs when off coumadin for procedure
- Rheumatoid Arthritis- previously on Methotrexate
- Duodenal ulcer s/p UGIB
- h/o kidney stones
- Gout- exacerbated by diuresis; on colchicine
- Peripheral Neuropathy
- Foot Drop (R) s/p back surgery
- Depression
Social History:
Lives at [**Location 19168**] on [**Doctor Last Name **] [**Telephone/Fax (1) 97249**]
Family History:
nc
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals - BP 120/70 HR 62 RR16 100%2L
GENERAL: NAD, lying in bed, conversant
HEENT: Pupils 2mm reactive/equal bilaterally, Mucous membranes
dry
Neck: JVD not appreciated
CARDIAC:Irregularly Irregular, no murmur appreciated
LUNG: Clear bilaterally, no wheeze or rhonchi
ABDOMEN: Slightly firm but nontender, nondistended +BS in all
quadrants
EXT: Trace edema bilaterally
NEURO: Alert to person, not place/date, slight L. facial droop
.
PHYSICAL EXAM ON TRANSFER:
Vitals - T:97.6 BP 131/62 HR 103 RR21 100% on room air
GENERAL: NAD, lying in bed, conversant, not oriented to time or
place
HEENT: Pupils 2mm reactive/equal bilaterally, Mucous membranes
moist
Neck: JVD not appreciated
CARDIAC: Irregularly Irregular, no murmur appreciated
LUNG: Clear bilaterally, no wheeze or rhonchi
ABDOMEN: Slightly firm but nontender, nondistended +BS in all
quadrants
EXT: Trace edema bilaterally. Diffuse erythema and warmth from
right toes to mid-dorsum of right foot, tender to palpation.
Erythema also noted at right medial maleolus and left big toe
and second toe.
NEURO: Alert to person, not place/date, slight L. facial droop
DERM: Well-demarcated erythematous large patch at right
antecubital region, non-tender to palpation. Not warm to touch.
Diffuse erythema and warmth from right toes to mid-dorsum of
right foot, tender to palpation. Erythema also noted at right
medial maleolus and left big toe and second toe.
Pertinent Results:
ADMISSION LABS:
[**2143-2-13**] 05:45AM BLOOD WBC-10.2 RBC-4.69 Hgb-11.9* Hct-38.7*
MCV-82 MCH-25.3* MCHC-30.6* RDW-16.0* Plt Ct-292
[**2143-2-13**] 05:45AM BLOOD Neuts-67.6 Lymphs-25.1 Monos-5.3 Eos-1.6
Baso-0.3
[**2143-2-13**] 05:45AM BLOOD PT-30.5* PTT-48.2* INR(PT)-3.0*
[**2143-2-13**] 05:45AM BLOOD Glucose-17* UreaN-77* Creat-2.3* Na-135
K-4.8 Cl-100 HCO3-29 AnGap-11
[**2143-2-13**] 05:45AM BLOOD Lipase-70*
[**2143-2-13**] 05:45AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
CARDIAC ENZYMES:
[**2143-2-13**] 08:57PM CK(CPK)-36*
[**2143-2-13**] 08:57PM CK-MB-NotDone cTropnT-0.03*
[**2143-2-13**] 02:51PM GLUCOSE-77 LACTATE-0.9
[**2143-2-13**] 02:30PM CK(CPK)-37*
[**2143-2-13**] 02:30PM cTropnT-0.03*
DISCHARGE LABS:
[**2143-2-19**] 06:22AM BLOOD WBC-6.5 RBC-4.19* Hgb-11.3* Hct-36.5*
MCV-87 MCH-27.0 MCHC-31.0 RDW-16.9* Plt Ct-207
[**2143-2-19**] 06:22AM BLOOD PT-26.4* PTT-42.6* INR(PT)-2.6*
[**2143-2-19**] 06:22AM BLOOD Glucose-150* UreaN-38* Creat-1.6* Na-137
K-5.4* Cl-104 HCO3-25 AnGap-13
[**2143-2-19**] 06:22AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0
MICROBIOLOGY:
[**2143-2-13**] 7:50 am URINE Site: CATHETER
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Tigecycline SENSITIVITY REQUESTED PER [**First Name8 (NamePattern2) 156**] [**Last Name (NamePattern1) **]
[**2143-2-15**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
.
PICC Catheter tip [**2-13**]: no growth.
Blood cx [**2-13**]: no growth.
.
STUDIES:
.
EKG: Atrial fibrillation, TWI in II, III, AVF and V4-6.
.
CXR [**2-13**]: IMPRESSION:
1. Normal study.
2. Paramedian radiopaque wires not located or fully identified,
could be external to the patient. Correlation physical
examination if needed additional views is recommended.
.
CT Head [**2-13**]:
IMPRESSION:
1. No acute intracranial process.
2. Age-appropriate involutional changes.
3. Chronic small vessel ischemic disease and lacunar infarcts.
.
Renal US [**2-13**]: IMPRESSION:
1. No hydronephrosis or discrete fluid collection seen.
2. Heterogeneous appearance of the right kidney. Examination is
limited for evaluation of known right metastasis. Recommend
correlation with prior imaging and/or CT/MRI as indicated.
Brief Hospital Course:
83 yo male with h/o CAD, PAF, CHF, Renal Cell CA, CRI presents
with unresponsiveness found to be hypoglycemic and have UTI.
.
# Hypotension: On presentation, patient presented with SBP into
70s with a CVL placed and he was given fluids(4L) with modest
improvement and subsequently started on Levophed. The etiology
may have been sepsis vs volume depletion. Patient's blood
pressure quickly stabilized. He was continued on Tigecycline and
weaned off of Levophed within 24 hours of arrival to the ICU.
Aside from the urine culture, the blood and PICC line cultures
showed no growth. Patient was normotensive during the rest of
his hospital stay.
.
# Urinary Tract Infection: He was found to have a positive U/A
with >50WBCS (he was getting straight cath'd at rehab); he was
currently being treated for a UTI at rehab (PICC in place);
sensetivities from [**Hospital1 2025**] reveal Klebsiella UTI sensetive only to
Tigecycline (MIC of 1 and urine cultures at [**Hospital1 2025**] had cleared by
[**2056-1-24**]). Repeat urine cultures returned on [**2-14**] show
Klebsiella sensetive to Gentamycin, ertapenem and meropenem.
Tigecycline sensitivity at MIC 3 mcg/ml. Therefore, it appears
that the two ESBL klebsiella strains (the [**Hospital1 2025**] strain and the
[**Hospital1 18**] strain) are different. The fact that the urine culture
grew out ESBL klebsiella when patient was taking Tigecycline was
concerning for colonization of the urinary tract by these very
resistant bacteria. Renal ultrasound was done which showed no
evidence of fluid collection/abscess. ID was consulted who
recommended to continue Tigecycline for the planned 3 week
course. Patient was set up to see his outpatient urologist at
[**Hospital1 2025**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], after discharge. Patient's PCP was
informed of the strain differences between the two ESBL
klebsiella strains, and was asked to refer the patient to
outpatient ID for followup.
.
# Urinary retention: Patient's flomax was initially held in the
setting of hypotension, which was restarted when blood pressure
was more stabilized. Patient required scheduled straight cath.
Urinary retention is very likely contributing to patient's
persistent UTI. Patient's outpatient urologist, Dr. [**Last Name (STitle) **],
was contact[**Name (NI) **] and updated, and a followup appointment was made
for him. On discussion with Dr. [**Last Name (STitle) **], it appears that
suprapubic cath is planned in the future.
.
# Unresponsiveness: Pt was found unresponsive; glucose on
presentation was 15; mental status improved after dextrose load.
CT Head was negative. Mental status changes were due to
profound hypoglycemia as it was back at baseline with
normalization of glucose.
.
# Hypoglycemia/DM: Patient presented with a finger stick of 15;
he was persistantly hypoglycemic despite dextrose, which may
have been due to the long acting Lantus that was just resumed at
rehab in the setting of poor PO intake. He was initially
monitored with q1 hour finger sticks and started on D10 gtt;
finger sticks then began to improve and D10 stopped. Insulin
sliding scale was resumed gently after glucose was in the 200s.
Patient was discharged with 5u glargine qhs and humalog sliding
scale.
.
# CRI: Pt's Creatinine was 2.1 on admission, which is baseline
per his PCP. [**Name10 (NameIs) **] creatinine was stable during this hospital
stay.
.
# CAD: Pt has history of CAD; EKG with TWI and no old EKG for
comparison. Cardiac enzymes remained flat. He was continued on
aspirin. Metoprolol was re-introduced after blood pressure was
stabilized. His statin was continued. Patient had no chest
pain or shortness of breath during this admission.
.
# PAF: Patient is V-paced but intermittently in Afib. Coumadin
was continued. Metoprolol was re-introduced after blood
pressure was stabilized. HR remained well controlled.
.
# CHF: Lasix was held on admission, and restarted on discharge.
.
# Right Foot pain with erythema: Differential includes
cellulitis vs gout. He was given colchicine per his home regimen
but the erythema was worsening on hospital day 2. ID was then
consulted. Given that he was on such broad spectrum antibiotics
(Tigecycline), ID thought this is unlikely cellulitis, and more
consistent with gout. Patient was continued on colchicine, and
gout continued to improve on this treatment.
.
# Code: full (confirmed)
.
# Contact: Wife [**Name (NI) 26698**] [**Name (NI) 1159**] [**Telephone/Fax (1) 97250**](h) [**Telephone/Fax (1) 97251**](c)
Medications on Admission:
Lopressor 100mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Simvastatin 20mg daily
Flomax 0.8mg (does not urine without this per PCP)
Coumadin- 2.5mg qhs
Cymbalta 60mg daily
Colchicine 0.6mg qod
Insulin (lantus 20qhs, regular ISS)
Lasix 40mg daily
Tigecycline 50mg q12
Nystatin [**Hospital1 **] prn
Iron 325mg daily
Latrisone
Lactinex
Tylenol 650mg prn
Bisacodyl 20mg rectal daily
Senna powder daily
Vitamin D 1000U daily
Calcium carbonate 650 [**Hospital1 **]
MVI
Loperamide 2mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day).
9. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed for yeast.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Tigecycline 50 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours): last dose on [**2-20**].
12. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO once a day.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once
a day.
15. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a
day as needed for fever or pain.
16. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
17. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: One (1)
Tablet PO twice a day.
18. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
19. Insulin Glargine Subcutaneous
20. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS.
21. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
22. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
23. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: hold
if SBP<95.
24. Insulin Glargine 100 unit/mL Cartridge Sig: Five (5) unit
Subcutaneous at bedtime.
25. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS.
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Primary diagnoses:
- hypoglycemia
- hypotension
- UTI with ESBL klebsiella
.
Secondary diagnoses:
- CAD
- CKD
- HTN
- PVD
- h/o TIA
- Paroxysmal Atrial Fibrillation on coumadin
- CHF
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 1159**]. You
were admitted to [**Hospital1 69**] because
you had low blood sugar, and your blood pressure was low. You
were initially stabilized in the intensive care unit, and
transferred to the regular medicine floor for continued care.
Your blood sugar and blood pressure have been stable during the
hospital stay. While in the hospital, your urine culture grew
out the same bacteria that you had while you were admitted to
[**Hospital1 2025**] last time. You were continued on the antibiotic,
tigecycline. You also had a gout flare on your right foot, and
were treated with colchicine.
Your medications have been changed:
- insulin dose was adjusted to avoid another episode of low
blood sugar
- metoprolol dose was decreased
- please continue tigecycline until Wednesday [**2-20**]
Followup Instructions:
We have made a followup appointment for you to be seen by your
urologist at [**Hospital1 2025**] on Monday [**2143-3-11**] at 11am. Please go
to the [**Hospital1 2025**] [**Doctor Last Name **] Building [**Apartment Address(1) 97252**] for your appointment. Please
call ([**2143**] if you have any questions.
Please follow up with your primary care doctor, Dr. [**First Name (STitle) **],[**First Name3 (LF) **]
J. at [**Telephone/Fax (1) 65780**], within the next week.
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14829, 14945
|
7519, 12071
|
298, 319
|
15172, 15172
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4876, 4876
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3397, 3401
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5602, 6007
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3416, 3430
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15064, 15151
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5367, 5586
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242, 260
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6042, 7496
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347, 2530
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4892, 5350
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3444, 4857
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15186, 15320
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2552, 3277
|
3293, 3381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,527
| 186,680
|
20957
|
Discharge summary
|
report
|
Admission Date: [**2201-8-7**] Discharge Date: [**2201-8-17**]
Date of Birth: [**2123-4-14**] Sex: M
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
GI bleeding, CHF
Major Surgical or Invasive Procedure:
[**2201-8-10**] EGD
History of Present Illness:
78 y/o M with PMHx of CAD s/p STEMI with 3VD, AAA, HTN, h/o
arterial clot on coumadin presented to ED today with c/o SOB,
worsened lower extremity swelling and weakness. Pt described
baseline lower extremity swelling that has been getting worse
over the last few days, he also reports general exhaustion with
exertion & mild SOB but denies chest pain, BRBPR, melena or
loose stools.
.
In arrival to the ED, T-98.9 HR 109 BP 106/54 RR 24 Sat 90% on
RA. Pt was found to have acute hct drop down from 40 to 22.8,
INR of 4.7 and BNP of 4504. He was found to have guaic+ brown
stool and received Vitamin 10mg IV, 1u FFP and CT abd was
performed and found AAA was stable. Pt was being transfused
with his first unit of prbcs on arrival to ICU.
.
He was denying any chest pain, abd pain or shortness of breath.
He does report recent worsening in lower extremity swelling and
profound exhaustion with exertion. Pt has 5 pillow orthopnea at
baseline, but denies PND and reports that the swelling in his
legs fluctuates frequently but is currently much worse than
baseline.
.
ROS: denies any fevers, chills, weight change, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
PND, cough, dysuria.
.
He was initially admitted to the Intenssive Care Unit and
transfered to floor care on [**2201-8-12**].
Past Medical History:
#. Coronary Artery Disease
- h/o STEMI in [**4-/2197**], with 3VD on cath
- 5 stents placed (mid RCA, proximal RCA of the ostium, distal
posterior lateral RCA with two overlapping stents as well as
obtuse marginal)
- Cardiac cath was c/b pericardial effusion with tamponade, s/p
evacuation of a pericardial thrombus
#. Atrial fibrillation with h/o RVR
#. Chronic Diastolic CHF with EF of 50%, rate control and
Coumadin
#. Vasculopathy
- Bilateral carotid stenosis, less than 40% ([**2200-1-1**])
- Thoracic & abdominal aortic aneurysms
- h/o Left external iliac arterial clot, s/p stenting and
embolectomy, currently on coumadin
#. Iron-deficiency Anemia
#. Chronic obstructive pulmonary disease, on home O2
#. Chronic Kidney Disease - Stage III
#. h/o Acute renal failure
#. h/o Renal cysts per CT
#. h/o UTI
#. Peptic ulcer disease.
#. Constipation
#. Bilateral inguinal hernias
#. Colonic diverticulosis
#. Gallstones
#. Depression
#. Chronic Low back pain
#. Multilevel DJD of spine, wedge compression of the superior
endplate of T9 as well as a hemangioma in the body of L2
#. h/o Alcohol abuse (vodka)
#. Tobacco use (2 PPD x's 10 yrs)
.
PSHx:
s/p EGD ([**2201-8-10**])
s/p Pericardiotomy, evacuation of pericardial clot, repair of
cardiac perforation ([**2197-5-23**])
s/p interventional thrombectomy and left iliac stenting and he
subsequently underwent an open below-knee left popliteal
exploration and embolectomy ([**2197-5-26**])
Social History:
Widower, [**Month/Day/Year 24075**]-speaking (only fair English), retired, lives in
[**Location (un) 3844**] with son. [**Name (NI) 24075**] speaking, only fair English. Past
h/o EtOH abuse, no h/o DTs or seizure, reports last drink was
with family on [**Holiday **] of this year. 20 PYHx of tobacco abuse.
.
Functional Status: needs assist with ADLs; denpendent on family
for IADLs.
.
Assistive devices: cane, home o2
Family History:
FAMILY HISTORY: non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T 97.5 BP 117/59 HR 71 RR 22 Sats 96% on 2L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM
NECK: No JVD, carotid pulses brisk, no cervical lymphadenopathy
COR: RRR, no appreciable murmurs
PULM: Lungs CTAB, scattered exp wheeze apprec on RLL base
ABD: Soft, NT, ND, +BS, obese, no hepatojugular reflex
EXT: [**1-25**]+ pitting edema bilaterally, chronic venous stasis
changes
NEURO: alert, oriented to person, place. CN II ?????? XII grossly
intact. Moves all 4 extremities well.
Pertinent Results:
Chem7:
[**2201-8-10**]: 140/ 5.2/ 102/30/ 19/1.3/138*
[**2201-8-9**]: 141/3.5/101/32/21/1.4/122
[**2201-8-8**]: 140/4/102/30/29/1.4/90
[**2201-8-7**]: 140/4.1/102/29/34/1.7/131
CBC:
[**2201-8-10**]: 4.9 / 30.7* / 144*
[**2201-8-9**]: Hct 30.0*
[**2201-8-9**]: 7.1 / 30.4* / 153
[**2201-8-8**]: Hct 30.6*; Hct 30.2*
[**2201-8-8**]: Hct 28.1*
[**2201-8-8**]: 5.3/ 31.9/ 201
[**2201-8-7**]: 4.5 / 31.6 /253#
Smear: Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy
Schisto Tear Dr [**Last Name (STitle) **] 3+1 1+ 1+ 3+ NORMAL 1+ 1+ 1+ 1+ 1+
Coags:
[**2201-8-10**]; 16.5* 25.4 1.5*
[**2201-8-9**]: 17.3* 27.5 1.6*
[**2201-8-8**]: 22.8*1 29.6 2.1*
[**2201-8-7**]: 42.5* 33.8 4.7*
ECG: ?Coarse Afib with rate in 70s. Inferior Q waves & TWI in
AVL, V2-V5 all unchanged from prior tracings other than Afib new
as compared to tracings in [**3-29**].
.
CT Abd/pelv [**2201-8-7**]: CONCLUSION:
1. Limited examination due to lack of oral and intravenous
contrast as per clinician's request. Within these limitations
there is stable appearance to the size of the abdominal aortic
aneurysm. There is extensive atherosclerosis again noted in the
abdominal and pelvic vasculature. There is no retroperitoneal
hematoma.
2. Atelectasis at the lung bases with bibasal effusions, larger
on the right.
3. Calculi in an otherwise unremarkable gallbladder.
LENIs [**2201-8-8**]: no DVT
ECHO [**2201-8-10**]: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. LVEF 50% with
normal free wall contractility. mildly dilated aortic root,
ascending aorta, aortic arch. Mild (1+) aortic regurgitation.
borderline pulmonary artery systolic hypertension.
EGD [**2201-8-10**]: Findings: Esophagus: Normal esophagus. Stomach:
Mucosa: Diffuse erythema, friability, congestion and nodularity
of the mucosa with contact bleeding were noted in the whole
stomach. The gastric folds appeared thickened and edematous
diffusely. These findings are compatible with gastritis.
Duodenum: Normal duodenum. Impression: Erythema, friability,
congestion and nodularity in the whole stomach compatible with
gastritis Otherwise normal EGD to second part of the duodenum
Recommendations: PPI [**Hospital1 **]
Outpatient colonoscopy.
The source of his guaiac positive stools and melena was most
likely bleeidng from his gastritis in the setting of a
supertherapeutic INR.
Check H. pylori serology and treat if positive.
Discharge Labs:
[**2201-8-17**] 07:10AM BLOOD WBC-5.7 RBC-3.32* Hgb-10.2* Hct-32.9*
MCV-99* MCH-30.7 MCHC-30.9* RDW-17.0* Plt Ct-170
[**2201-8-7**] 05:15PM BLOOD Neuts-63 Bands-0 Lymphs-15* Monos-8
Eos-13* Baso-0 Atyps-1* Metas-0 Myelos-0
[**2201-8-17**] 07:10AM BLOOD Plt Ct-170
[**2201-8-17**] 07:10AM BLOOD Ret Man-3.0*
[**2201-8-17**] 07:10AM BLOOD Glucose-79 UreaN-27* Creat-1.4* Na-141
K-3.6 Cl-95* HCO3-40* AnGap-10
[**2201-8-17**] 07:10AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.8
Brief Hospital Course:
ASSESSMENT & PLAN: 78 y/o M with PMHx of CAD & CHF presented to
the ED c/o lower extremity edema. In the ED he was noted to
have an acute hct drop to 22.8 from a baseline of 30 in the
setting of an INR of 4.7 (on coumadin) and guaiac positive brown
stool.
.
# UGIB: In the ED the patient's was noted to be 22.8 from his
baseline Hct 30, his INR was 4.7 and he had guaiac positive
brown stool. He was started on an IN PPI and transferred to the
ICU. In the ICU he received a total of 4 units of pRBCs (with
IV lasix in between to prevent fluid overload given his CHF
history) and his HCT increased appropriately to 30. He remained
hemodynamically stable during his hospital stay. His
anticoagulation was held and his INR decreased to <1.5. On ICU
day 4, EGD by the GI consult service performed revealed
gastritis but no acute bleed. Recommended PPI [**Hospital1 **], outpatient
colonoscopy. H pylori serology negative. Hematocrir remained
stable during this hospitalization. He will follow-up with GI as
an outpatient and should be monitored for signs and symptoms of
GI bleeding. He will continue on PPI [**Hospital1 **] until outpt follow-up.
.
# CHF: His LE edema and BNP of 4045 was concerning for CHF
exacerbation given his history of of CHF s/p MI and known EF of
50% and elevated BNP 4054. Pt was diuresed while receiving blood
products for a goal of -500cc to -1L/day. He was also given
supplemental 02. Given his marginal BP in the ED, his
captoril/metoprolol were held until hospital day 3 when they
were restarted. Lower extremity dopplers were negative for DVT.
TTE on ICU day 4 showed no change in EF (50%). He continued to
diurese during the hospitalization. His diuretics were changed
to lasix qd on day of discharge. Daily weights should be
monitored.
# COPD: During ICU stay, patient became more wheezy on exam.
Had hypercarbic respiratory distress at times. O2 sats were
decreased to goal of 88-92%, which seemed to improve his
breathing. Patient was given q4 hour nebulizers. Started on
Prednisone taper for increased work of breathing and diffuse
expiratory wheezes. Wheezing resolved with steroids,
supplemental O2, and nebulizers. He completed 5 days of
concomitant antibiotics therapy. He was started on prednisone 40
on [**8-12**] and changed to 30mg on [**8-16**]. he should continue a 2 week
taper. He is on 2L O2 at home. AT discharge his sats were good
at rest on 2L, but did desat to low 80s with ambulation.
.
# CAD s/p STEMI and 3VD with 5 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**]: ECG obtained on
admission did not show ischemic changes. Aspirin was held given
GIB on admission. Once HD stable after pRBC transfusions,
metoprolol, captopril were restarted. Following EGD, the patient
was taking po and was restarted on his home statin. He had no
active symptoms of ischemia during the remainder of the
hospitalization,
.
# AFib: Was on coumadin for afib, INR >4 on admission. Coumadin
held and patient remained in NSR and sinus tach on telemetry.
Beta blocker held until ICU day 3, then restarted with good rate
control. Coumadin was restarted. Ventricular rate was rapid
intermittently in the ICU with rates upto 160s. Metoprolol dose
was increased to 37.5 mg po bid. After this change was made,
patient's HR was well controlled in 90s to 100s.
# hx of ETOH abuse: per patient, he had not had a drink since
[**Month (only) 116**]. He was maintained on CIWA protocol but did not require
ativan during his ICU stay.
# Hyperglycemia: Developed hyperglycemia on steroids. Started on
regular insulin sliding scale.
# Chronic kidney disease: Cr 1.2 at baseline which appears to be
around his baseline.
# Code: FULL confirmed with patient
Medications on Admission:
Aspirin 81mg
Coumadin [**Name8 (MD) **] MD
Captopril 25mg [**Hospital1 **]
Ferrous Sulfate 325mg daily
Lipitor 10mg daily
Metoprolol 25mg [**Hospital1 **]
Lasix 40mg daily
Protonix 40mg
Colace
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inh
Inhalation Q6H (every 6 hours).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-24**] Sprays Nasal
[**Hospital1 **] (2 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin/[**Female First Name (un) **] for 10 days.
12. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) INH Inhalation Q6H (every 6 hours).
14. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): started 40 mg on [**8-9**]; changed to 30 mg on [**8-17**];
please continue taper and then D/C over 2 weeks.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Lasix changed from 40 mg PO BID -> 40 mg PO QD on
[**2201-8-17**].
16. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO Once Daily at 4 PM.
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per
Sliding Scale Injection ASDIR (AS DIRECTED): See attached
Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
Courtbille at [**Location (un) 8117**]
Discharge Diagnosis:
Primary Diagnosis:
=================
UGI Bleed
Gastritis
Supra-Therapuetic INR
CHF
.
Secondary Diagnosis:
===================
#. Coronary Artery Disease
- h/o STEMI in [**4-/2197**], with 3VD on cath
- 5 stents placed (mid RCA, proximal RCA of the ostium, distal
posterior lateral RCA with two overlapping stents as well as
obtuse marginal)
- Cardiac cath was c/b pericardial effusion with tamponade, s/p
evacuation of a pericardial thrombus
#. Atrial fibrillation with h/o RVR
#. Chronic Diastolic CHF with EF of 50%, rate control and
Coumadin
#. Vasculopathy
- Bilateral carotid stenosis, less than 40% ([**2200-1-1**])
- Thoracic & abdominal aortic aneurysms
- h/o Left external iliac arterial clot, s/p stenting and
embolectomy, currently on coumadin
#. Iron-deficiency Anemia
#. Chronic obstructive pulmonary disease, on home O2
#. Chronic Kidney Disease - Stage III
#. h/o Acute renal failure
#. h/o Renal cysts per CT
#. h/o UTI
#. Peptic ulcer disease.
#. Constipation
#. Bilateral inguinal hernias
#. Colonic diverticulosis
#. Gallstones
#. Depression
#. Chronic Low back pain
#. Multilevel DJD of spine, wedge compression of the superior
endplate of T9 as well as a hemangioma in the body of L2
#. h/o Alcohol abuse
#. Tobacco use (2 PPD x's 10 yrs)
.
PSHx:
s/p EGD ([**2201-8-10**])
s/p Pericardiotomy, evacuation of pericardial clot, repair of
cardiac perforation ([**2197-5-23**])
s/p interventional thrombectomy and left iliac stenting and he
subsequently underwent an open below-knee left popliteal
exploration and embolectomy ([**2197-5-26**])
Discharge Condition:
Stable: Weight 199.1 lbs; ambulates with min assist of one but
needs at least 4L/nc; eating & retaining diet; last BM [**2201-8-15**]
Discharge Instructions:
You were admitted to the hospital with a low blood count
(anemia) and blood in your stool, after several days of
increased fatigue and trouble breathing. Testing showed that a
medicine you take to thin your blood (Coumadin), because of your
history of occluded arteries, was working too well. You were
admitted to the ICU and an endoscopy showed irritation and some
bleeding from your stomach (gastritis). You also had evidence of
heart failure. You were treated with transfusions, medicine to
ease the irritation in your stomach, medicines to make your body
get rid of the extra fluid and other medicines to initially
reverse the over-therapeutic effects of the Coumadin. You
continue to need oxygen when you walk (more than your usual home
o2) so we are discharging you to a rehabilitation facility so
you can get stronger before going back home.
.
Please take all of your medications as prescribed. Please make &
keep all of your follow-up appointments.
.
Please call you Primary Care Provider [**Name Initial (PRE) **]/or come to the
Emergency Room if you have any of the following: fever > 100.5,
shaking/chills, chest pain/pressure, increased difficulty
breathing, abdominal pain, pain relieved with medicines, acute
changes in mental functioning, blood in vomitus or stools or any
other health related concerns.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000cc per day
Followup Instructions:
***** GI Follow-up - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2201-8-21**] 1:40 ******
.
Please call your Primary Care Provider for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**]
appointment with a week of being discharged.
Completed by:[**2201-8-17**]
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53,596
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1297
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Discharge summary
|
report
|
Admission Date: [**2162-8-27**] Discharge Date: [**2162-9-6**]
Date of Birth: [**2086-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalothin / Trazodone / Avelox /
piperacillin-tazobactam
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Right internal jugular central line placement
Left hemi-arthroplasty for left femur fracture repair
History of Present Illness:
76yo M PMHx recent arthroscopic knee surgery 1d prior to
presentation, recent cystoscopy 9d prior to presentation,
presenting w fever to 104.1, hypotension. Patient reports that
1d prior to presentation he underwent arthoscopic knee surgery
for meniscal tear; after returning home he reports onset of
chills and decreased urine output. Fevers persisted, patient
reports associated increased aches with mild abdominal pain,
denies vomitting/diarrhea/CP/SOB.
.
On presentation to [**Hospital1 18**], initial vital signs 100.8 80 96/60 12
95%NRB. Patient's SBPs began to fall into the 60, O2sat at that
time was 86%RA. Labs were significant for WBC 8.9, Hct 38.9, Cr
1.7, Trop .22, UA w >182WBCs, Mod Bacteria; CTA torso was
performed given patient's hypoxia, that did not demonstrate PE
or acute abdominal process, but did demonstrate new L femoral
neck fx; CT head did not demonstrate any acute changes. Ortho
evaluated felt that knee did not demonstrate signs of being the
source of infection; they were made aware of new fracture and
agreed to follow patient; Patient had RIJ placed and received
5LNS for fluid resuscitation, but he remained w MAPs<65, so he
was started on norepinephrine 0.3mcg; patient also received
vanco/clinda/gentamycin; patient was admitted to MICU for
further management; prior to transfer, vital signs were 98.4 80
164/78 14 100%facemask.
.
On arrival to floor, patient was comfortable on facemask w
norepi no longer running. On review of systems, he reported
fevers, chills; also reported some constipation w abd pain;
denied recent weight loss or gain; denied headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea.
Denies rashes or skin changes.
Past Medical History:
- Large B-cell lymphoma w metastasis to the spinal cord with
resultant paraplegia (followed per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Company 2860**])
- Neurogenic Bladder w Indwelling foley
- Prior L4 compression fracture s/p posterior fusion
- Hypertension
- History of C.diff
- Large basal cell carcinoma of L upper eyelid s/p Mohs excision
- h/o DVT, PE after surgery in [**10-14**]
- Spinal myoclonus and tremor
- Anxiety/Depression
- Chronic Nephrolithiasis
- Dyslipidemia
- h/o UTIs
Social History:
Was an artist and continues to be involved with MFA. Denies
history or current use of tobacco, also denies ETOH and IVDU.
Lives at home with aides. Wheelchair-bound.
Family History:
per prior DCS "Father had a tremor and he believes his paternal
GF also had a tremor. No lymphoma. No PD." Tremor in father and
likely paternal GF. No one with lymphoma.
Physical Exam:
Admission exam:
Vitals: 97.5 99/59 68 12 100%RA
General: Comfortable, NAD
HEENT: Sclera anicteric, MM dry, OP clear,
Neck: supple, no JVD, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, mild distension, nontender, naBS, no
rebound/guarding
GU: +foley
Ext: WWP, 1+ DP/PT/radial, no c/c/e
Discharge exam:
PHYSICAL EXAM:
VS - Temp 98.4, BP 122/58, HR 80, R 20, O2 95% on RA
GENERAL - chronically ill and feeble-appearing man in NAD,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear;
dentition has multiple caries. Left eyelid s/o MOHs.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no fluid wave. No masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c. 2+ peripheral pulses (radials, DPs).
No extremity edema. Dressing over left hip clean, dry & intact
without visible erythema or edema.left knee: arthroscopy
incisions well healed.Edema in left hand, improved from previous
days. Right hand with some edema at PIV site, improving.
SKIN - no rashes or lesions
LYMPH - No cervical, or axillary LAD.
NEURO - Awake, A&Ox3. Essential tremor most pronounced in right
arm and also present in left arm with frequency of approximately
3-4Hz. Left leg motor exam limited by pain. No movement in
ankles or feet bilaterally. Sensation intact to pain and light
touch in upper extremities. No pain/light touch discrimination
below knees. No sensation to pain or light touch below ankles.
Pertinent Results:
[**2162-8-27**] 07:50PM GLUCOSE-127* UREA N-23* CREAT-1.5* SODIUM-138
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
[**2162-8-27**] 07:50PM CK(CPK)-187
[**2162-8-27**] 07:50PM CK-MB-14* MB INDX-7.5* cTropnT-0.28*
[**2162-8-27**] 07:50PM CALCIUM-7.5* PHOSPHATE-3.1 MAGNESIUM-1.7
[**2162-8-27**] 07:50PM WBC-10.9 RBC-4.19* HGB-12.5* HCT-35.9* MCV-86
MCH-29.9 MCHC-34.9 RDW-15.8*
[**2162-8-27**] 07:50PM NEUTS-80* BANDS-0 LYMPHS-11* MONOS-8 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2162-8-27**] 07:50PM PT-15.4* PTT-33.5 INR(PT)-1.3*
[**2162-8-27**] 03:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
[**2162-8-27**] 03:10PM URINE RBC-8* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
[**2162-8-27**] 03:10PM URINE GRANULAR-10* HYALINE-52*
[**2162-8-27**] 12:27PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-7.5 LEUK-LG
[**2162-8-27**] 12:27PM URINE RBC-54* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0
[**2162-8-27**] 12:06PM GLUCOSE-121* LACTATE-2.1* NA+-136 K+-4.3
CL--95* TCO2-28
[**2162-8-27**] 11:55AM GLUCOSE-128* UREA N-26* CREAT-1.7* SODIUM-135
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-29 ANION GAP-14
[**2162-8-27**] 11:55AM ALT(SGPT)-20 AST(SGOT)-30 CK(CPK)-34* ALK
PHOS-135* TOT BILI-0.8
[**2162-8-27**] 11:55AM LIPASE-17
[**2162-8-27**] 11:55AM CALCIUM-8.7 PHOSPHATE-2.1* MAGNESIUM-1.8
[**2162-8-27**] 11:55AM WBC-8.9 RBC-4.66 HGB-13.9* HCT-38.9* MCV-84
MCH-29.8 MCHC-35.7* RDW-15.7*
[**2162-8-27**] 11:55AM NEUTS-84* BANDS-0 LYMPHS-9* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
[**2162-8-29**] 02:44PM BLOOD WBC-5.1 RBC-3.32* Hgb-10.0* Hct-28.6*
MCV-86 MCH-30.3 MCHC-35.1* RDW-15.7* Plt Ct-128*
[**2162-8-30**] 07:15AM BLOOD WBC-5.4 RBC-3.64* Hgb-10.9* Hct-31.4*
MCV-86 MCH-29.9 MCHC-34.6 RDW-16.3* Plt Ct-176
[**2162-8-31**] 06:20AM BLOOD WBC-4.7 RBC-3.44* Hgb-10.2* Hct-29.1*
MCV-84 MCH-29.7 MCHC-35.2* RDW-15.9* Plt Ct-181
[**2162-8-31**] 07:53PM BLOOD WBC-6.7 RBC-4.09* Hgb-12.2* Hct-34.8*
MCV-85 MCH-30.0 MCHC-35.2* RDW-15.6* Plt Ct-170
[**2162-9-1**] 07:15AM BLOOD WBC-5.6 RBC-3.59* Hgb-10.7* Hct-30.9*
MCV-86 MCH-29.9 MCHC-34.7 RDW-15.7* Plt Ct-219
[**2162-9-2**] 02:10AM BLOOD Hct-27.4*
[**2162-9-2**] 06:25AM BLOOD WBC-6.8 RBC-3.39* Hgb-10.2* Hct-29.8*
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.6* Plt Ct-245
[**2162-9-4**] 05:15AM BLOOD WBC-4.0 RBC-3.00* Hgb-9.0* Hct-25.8*
MCV-86 MCH-29.8 MCHC-34.7 RDW-15.2 Plt Ct-316
[**2162-9-3**] 06:10AM BLOOD WBC-4.9 RBC-3.11* Hgb-9.0* Hct-27.2*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.4 Plt Ct-303
[**2162-9-5**] 05:52AM BLOOD WBC-4.0 RBC-3.05* Hgb-9.0* Hct-26.7*
MCV-88 MCH-29.4 MCHC-33.6 RDW-14.9 Plt Ct-393
[**2162-8-31**] 06:20AM BLOOD Neuts-61.6 Lymphs-20.2 Monos-12.5*
Eos-5.0* Baso-0.8
[**2162-9-2**] 06:25AM BLOOD Neuts-57 Bands-0 Lymphs-15* Monos-19*
Eos-9* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2162-9-3**] 06:10AM BLOOD Neuts-67.1 Lymphs-19.9 Monos-5.2 Eos-7.5*
Baso-0.3
[**2162-9-4**] 05:15AM BLOOD Neuts-63.9 Lymphs-23.3 Monos-5.0 Eos-7.3*
Baso-0.5
[**2162-9-5**] 05:52AM BLOOD Neuts-57 Bands-0 Lymphs-22 Monos-13*
Eos-7* Baso-0 Atyps-1* Metas-0 Myelos-0
[**2162-9-4**] 05:15AM BLOOD PT-21.8* PTT-39.6* INR(PT)-2.0*
[**2162-9-5**] 05:52AM BLOOD PT-30.0* PTT-41.4* INR(PT)-2.9*
[**2162-8-29**] 02:44PM BLOOD Glucose-98 UreaN-14 Creat-1.0 Na-132*
K-3.8 Cl-101 HCO3-23 AnGap-12
[**2162-8-30**] 07:15AM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-136
K-3.9 Cl-102 HCO3-21* AnGap-17
[**2162-8-31**] 06:20AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-137
K-3.9 Cl-103 HCO3-25 AnGap-13
[**2162-8-31**] 07:53PM BLOOD Glucose-94 UreaN-10 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-23 AnGap-17
[**2162-9-1**] 07:15AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
[**2162-9-1**] 01:15PM BLOOD Glucose-110* UreaN-9 Creat-0.9 Na-134
K-3.9 Cl-101 HCO3-28 AnGap-9
[**2162-9-2**] 06:25AM BLOOD Glucose-93 UreaN-13 Creat-1.2 Na-135
K-4.5 Cl-99 HCO3-27 AnGap-14
[**2162-9-3**] 06:10AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-141
K-3.9 Cl-101 HCO3-34* AnGap-10
[**2162-9-4**] 05:15AM BLOOD Glucose-111* UreaN-13 Creat-1.0 Na-139
K-3.4 Cl-99 HCO3-36* AnGap-7*
[**2162-9-5**] 05:52AM BLOOD Glucose-114* UreaN-11 Creat-1.0 Na-141
K-3.5 Cl-100 HCO3-38* AnGap-7*
[**2162-9-1**] 07:15AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.0
[**2162-8-31**] 07:53PM BLOOD Calcium-8.0* Mg-1.8
[**2162-8-30**] 07:15AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1
[**2162-9-2**] 06:25AM BLOOD Cortsol-20.2*
[**2162-8-31**] 07:52PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2162-8-31**] 07:52PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2162-8-31**] 07:52PM URINE RBC-7* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
[**2162-8-27**] 11:55AM GLUCOSE-128* UREA N-26* CREAT-1.7* SODIUM-135
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-29 ANION GAP-14
[**2162-9-6**] 07:10AM BLOOD WBC-3.2* RBC-3.18* Hgb-9.2* Hct-27.5*
MCV-87 MCH-28.9 MCHC-33.3 RDW-14.8 Plt Ct-463*
[**2162-9-6**] 07:10AM BLOOD Plt Ct-463*
[**2162-9-6**] 07:10AM BLOOD Glucose-98 UreaN-8 Creat-0.9 Na-141
K-3.2* Cl-95* HCO3-39* AnGap-10
[**2162-9-6**] 07:10AM BLOOD PT-40.7* PTT-42.6* INR(PT)-4.2*
CXR
Low lung volumes with patchy opacities in lung bases. Findings
most likely relate to atelectasis, though infection cannot be
excluded. Probable small bilateral pleural effusions.
.
NCHCT
No acute intracranial process
.
CT Torso w Contrast
1. no PE.
2. small 5 mm in RLL pulm nodule. rec f/u chest CT in 12 mos.
3. left femoral neck fx, new since [**2-19**] and likely acute given
lack of callous formation.
4. no acute abd process.
.
CXR
New right internal jugular central venous line with the catheter
tip in the superior vena cava. No pneumothorax. Otherwise, no
significant interval change in comparison to prior study from
11:58 a.m. on the same day.
.
URINE CULTURE (Final [**2162-8-29**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
[**2162-8-31**] 7:52 pm URINE Source: Catheter.
**FINAL REPORT [**2162-9-2**]**
URINE CULTURE (Final [**2162-9-2**]): NO GROWTH.
[**2162-8-29**] 10:49 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2162-9-3**]**
GRAM STAIN (Final [**2162-8-30**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2162-9-3**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy. .
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
STAPH AUREUS COAG +. SPARSE GROWTH. SECOND TYPE.
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.
VANCOMYCIN Sensitivity testing confirmed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 2 S
Blood Cultures
[**2162-8-27**] 11:55 am BLOOD CULTURE #2.
**FINAL REPORT [**2162-9-2**]**
Blood Culture, Routine (Final [**2162-9-2**]): NO GROWTH.
[**2162-8-27**] 11:50 am BLOOD CULTURE #1.
**FINAL REPORT [**2162-9-2**]**
Blood Culture, Routine (Final [**2162-9-2**]): NO GROWTH.
[**2162-9-2**] Blood Cultures pending
Brief Hospital Course:
76yo M PMHx recent arthroscopic knee surgery 1d prior to
presentation, recent cystoscopy 9d prior to presentation,
presenting w fever to 104.1, hypotension
# Hypotension / Sepsis - Patient presented with hypotension,
fever, tachycardia, meeting SIRS criteria, on review of likely
infection sources, UA appearing most likely source, especially
given recent cystoscopy 1wk prior to presentation, although
would lung and knee s/p arthroscopy were also considered. Ortho
consulted felt arthroscopy unlikely source. Urine was grossly
positive with cultures + for GNRs, no sensitivites performed
because felt to have fecal contamination. He was covered
empirically with Vancomycin, Ciprofloxacin and Meropenem. He
required norepinephrine in ED but was off norepinephrine in MICU
with MAP >65. Hypotension was considered [**2-10**] sepsis and he
responded to 500cc fluid boluses. Patient was then transferred
to the medicine floor. On the floor, his vancomycin was
discontinued as his infection was felt likely to be due to a
UTI. Of note while on floor patient had episodes of asymptomatic
Sys BP to 80s overnight after being fluid diuresed for flash
pulmonary edema after surgey (see L femoral neck fracture
section) During first episode patient was given fluid boluses
with response. However, as patient was asymptomatic also not
tachycardic, episodes of hypotension also felt to have
dysautomic component. Patient's BPs were monitored with no
episodes of hypotension after the previously mentioned event.
Patient's discharge BP was 122/58.
#UTI: Patient had UA which indicated a UTI. The final urine
culture showed likely fecal contamination. The patient was
continued on ciprofloxacin and meropenem and a second urine
culture was negative for growth. The patient finished his 10 day
course of ciprofloxacin and meropenem on [**2162-9-6**].
#Thrombocytoenia: All cell lines trended down, though platelets
appeared to drop more dramatically. Considered hemodilution from
fluid boluses, cell lines were trended and remained stable.
# Elevated Troponin - Pt never had chest pain but w troponins
elevated in ED in setting of sinus tachycardia; EKG w ST
depressions in V4-V5; no prior cardiac history, likely demand
ischemia in setting of tachycardia, hypotension, chronic kidney
disease; no suspicion for STEMI. He was started on Aspirin and
Trops peaked at 0.28 before trending down to 0.04.
# L femoral neck fracture - The patient was incidentally found
to have L femoral neck fracture on CT abd on [**2162-8-27**], acute in
appearance; patient denying any recent trauma; pt w h/o
osteoporosis; orthopedic surgery was aware and performed a
hemi-arthroplasty on [**2162-8-31**]. During surgery the patient
received 1700mL, as well as blood products and the patient
developed shortness of breath and an oxygen requirement from
pulmonary edema as evidenced on CXR, he was sent to the MICU and
diuresed with improvement of symptoms and transferred to the
floor over night. The patient continued to be diuresed on the
floor and was weaned off of oxygen to room air on [**2162-9-3**]. The
patient also complained of pain at hip after surgery, Pain
service was consulted and a pain regimen was instituted with
standing oxycontin, oxycodone PRN, and dilaudid for breakthrough
pain. This regimen controlled his pain.
# Paraplegia: Chronic, stable. Patient continued on
Fludrocortisone, Baclofen, Gabapentin continued however at lower
dose for concern for hypotension and lethargy.
# Tremor - Essential Tremor, chronic, stable:
carbidopa-levodopa. Held primidone, and initially propranolol in
setting of acute illness. Propanolol restarted, he became
hypotensive which responded to 2 - 500cc boluses and he was
stable thereafter. Propanolol continued at lower dose than home
medication.
# Psych: Chronic, stable. Citalopram continued. Held quetiapine
in setting of acute illness.
# Dermatitis: Chronic, Stable: cont desonide cream.
# Osteoporosis: Chronic, Stable. Continued calcium/vitaminD.
Held alendronate, may be restarted at rehab.
# Blepharitis: cont erythromycin ophthalmic PRN, however patient
did not request this, so it was discontinued. Patient also given
warm compresses for eyes.
# GERD: cont metoclopramide and pantoprazole
# h/o DVT - Restarted Coumadin which was held for arthroscopy.
We restarted at a reduced dose to 4mg in setting of systemic
antibiotics. In preparation for surgery, the coumadin was
stopped the day prior to surgery, the patient was also given
vitamin K. He was also given FFP by the orthopedics team for the
surgery. The patient was placed on prophylactic lovenox after
surgery and his warfarin was restarted. Once INR was at
therapeutic levels, lovenox was discontinued. However, his INR
was supratherapeutic at day of discharge (4.2) likely [**2-10**] to
ciprofloxacin interaction. His warfarin was held at discharge
and INR should be monitored with warfarin adjusted accordingly.
# Chronic Abd Distention: continued bowel regimen, simethicone.
Transitional Issues:
-BCx pending from [**9-2**]
Home medication which we held and need to be titrated to home
doses:
-Gabapentin: Patient home dose is 600mg q8, he is currently
getting 300mg q12. Please titrate to home dose as blood pressure
and mental status allow
-Primidone: Patient home dose is 125mg qhs. Medication currently
held. Please titrate to home dose as blood pressure and mental
status allow
-Propanolol: Patient home dose is 30mg TID, currently on 5mg
TID. Please titrate to home dose as blood pressure and mental
status allow
-Quetiapine: Patient home dose is 12.5mg qhs. Medication
currently held. Please titrate to home dose as blood pressure
and mental status allow
-Warfarin: Patient was supratherapeutic day of discharge (INR
4.2). Held dose this AM. Pt home dose is 6mg, but has been on
4mg [**2-10**] ciproflox interaction. Please restart at 4mg and titrate
to 6mg in accordance with INR.
# Communication: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8015**]: [**Telephone/Fax (1) 8016**]; HCP Mr. [**Last Name (Titles) **]:
[**Telephone/Fax (1) 8017**]
# Code: Full (clarified [**8-31**]).
Medications on Admission:
- alendronate 70mg qSaturday
- baclofen 20mg TID
- carbidopa-levodopa 25-100mg daily
- citalopram 20mg daily
- desonide .05% cream [**Hospital1 **]
- ergocalciferol (vitamin D2) 50,000 unit 1X/WEEK (TH)
- erythromycin 5 mg/gram (0.5 %) Ophthalmic HS
- fludrocortisone 0.1mg daily
- furosemide 40mg qAM, 20mg qPM
- gabapentin 600mg q8H
- metoclopramide 10mg TID
- pantoprazole 40mg daily
- primidone 125mg qhs
- propranolol 30mg TID
- quetiapine 12.5mg qhs
- warfarin 6mg daily
- acetaminophen 1000mg q6hrs prn
- calcium carbonate daily
- bisacodyl 10mg suppository daily
- simethicone 180mg QID
- cranberry
Discharge Medications:
1. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. carbidopa-levodopa 25-100 mg Tablet Sig: [**1-12**] (one to four)
Tablets PO TID (3 times a day).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. desonide 0.05 % Cream Sig: One (1) thin amount Topical twice
a day.
5. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: check
INR on [**2162-9-7**] and consider restarting on [**2162-9-8**] based on INR.
DO NOT GIVE DOSE [**2162-9-6**]- INR of 4.2 on [**2162-9-6**].
6. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
saturday.
8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week: thursday.
9. furosemide 20 mg Tablet Sig: see below Tablet PO DAILY
(Daily): Take 2 tablets in the morning and 1 tablet in the
evening every day.
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for Constipation.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8 () as
needed for pain.
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
16. simethicone 180 mg Capsule Sig: One (1) Capsule PO four
times a day as needed for gas.
17. propranolol 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): Hold for SBP<100.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
21. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob, wheeze.
22. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-10**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
23. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for Nausea.
24. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours) as needed
for pain.
25. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
urinary tract infection
sepsis
left femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound- Patient is a paraplegic at baseline
and during this hospitalization had a hemi-arthroplasty for a
left femur fracture.
Discharge Instructions:
Dear Mr. [**Known lastname 8004**],
It was a pleasure taking care of you during this
hospitalization. You were treated for an infection; you recently
had a knee arthroscopy and a bladder cystoscopy. Our orthopedic
surgeons came and saw you and we felt the likely the source of
your infection was your urine. You were kept in the ICU briefly
because of the infection and sepsis (infection in your
bloodstream) and placed on IV antibiotics. You have finished
your course of antibiotics.
While here you were also found to have a fracture of your left
femoral neck. Our orthopedic surgeons performed a
hemi-arthoplasy to repair this fracture. Our Physical Therapists
also saw you and recommended you go to a rehab hospital after
discharge.
Your coumadin (warfarin) was briefly stopped in preparation for
your surgery, at discharge your home dose was restarted. Your
INR and coumadin dosing will continue to be monitored at the
rehab hospital.
Changes to your medication:
STOP taking erythromycin eye ointment
START Aspirin
START albuterol sulfate inhaler PRN wheezing/shortness of breath
START Ipratropium Bromide Neb PRN wheezing/shortness of breath
START Artificial Tears as needed for dry eyes
START ondansetron 4mg IV PRN nausea
START oxycontin 10mg [**Hospital1 **] for pain
START oxycodone 5-10mg Q4h as needed for pain
Home medication adjustments
-Coumadin
-Gabapentin
-Primidone
-Propanolol
-Quetiapine
Followup Instructions:
Department: ORTHOPEDICS
When: FRIDAY [**2162-9-10**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PA [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2162-9-15**] at 9:30 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2162-9-15**] at 9:50 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
Completed by:[**2162-9-6**]
|
[
"733.00",
"344.1",
"038.9",
"599.0",
"596.54",
"300.4",
"518.4",
"585.9",
"272.4",
"799.02",
"333.1",
"733.14",
"202.80",
"995.91",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.97",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
22888, 22973
|
13539, 18526
|
339, 442
|
23068, 23068
|
4936, 13516
|
24760, 25833
|
3051, 3224
|
20323, 22865
|
22994, 23047
|
19691, 20300
|
23322, 24737
|
3636, 4917
|
3621, 3621
|
18547, 19665
|
293, 301
|
470, 2297
|
23083, 23298
|
2319, 2850
|
2866, 3035
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,851
| 102,536
|
39253
|
Discharge summary
|
report
|
Admission Date: [**2106-9-13**] Discharge Date: [**2106-9-24**]
Date of Birth: [**2035-12-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
lethargy, worsening left weakness
Major Surgical or Invasive Procedure:
[**2106-9-14**]: Right Craniotomy for evacuation of hematoma
History of Present Illness:
70 woman who was diagnosed with breast cancer in [**2104**] with
metastatic spread to bone. The patient is currently on
emcitabine and was to begin cycle 2 on [**9-1**]; however, the
patient
presented to [**Hospital1 18**] [**Location (un) 620**] with complaints of weakness for the
past two days. The weakness has been mainly noticed in the BLE.
Imaging revealed Right SDH and she subsequently underwent a
craniotomy and evacuation of the SDH on [**9-2**]. She was discharged
to rehab. On [**9-13**] she returned to the ED with reported lethargy.
CT scan revealed increasing chronic R SDH with increased MLS.
She
was afebrile and WBC=10, but U/A was positive.
Past Medical History:
Metastatic breast cancer to bone dx'd [**2104**], colostomy, CHF,
diverticulitis, HTN, hypothyroidism, Cdiff, uveitis, depression,
anemia of chronic disease, GERD, vit B12 deficiency
Social History:
Lives with daughter, [**Name (NI) **], who is the HCP. Quit smoking 2yrs
ago.
Prior to admission and current status, patient was walking with
a
walker.
Family History:
nc
Physical Exam:
On Admission:
O: T:97.2 BP: 148/62 HR: 74 R20 O2Sats 99% 2L
Gen: laying on stretcher, NAD.
HEENT: Pupils: R surgical/irregular L 3mm-2mm EOMs grossly
intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: lethargic, arouses to voice but requires frequent
stimulation to stay awake.
Orientation: Oriented to [**Hospital3 **] & year only. (with
persistant asking)
Language: Speech slow
Cranial Nerves:
I: Not tested
II: Pupils: R surgical/irregular L 3mm-2mm
III, IV, VI: Extraocular movements grossly 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: weak bilaterally and difficult to examine 2.2 lethargy.
antigravity b/l UE's and withdraws b/l LE's. following commands
in b/l UE's.
Sensation: Intact to light touch
Incision- well healing, staples in place
On Discharge:
A&Ox3
PERRL
EOMs intact
Motor: 4-/5 BUE, wiggles toes bilateral LE
Incision: c/d/i
Pertinent Results:
[**2106-9-13**] CT head: IMPRESSION: Increased size of predominantly
hypodense right cerebral subdural collection, likely a CSF
hygroma, with increased shift of midline structures. Effacement
of suprasellar cistern is new and compatible with early
transtentorial herniation.
[**2106-9-13**] CXR: Left lower lobe consolidation could be secondary to
pneumonia, aspiration, or atelectasis. Pleural effusions are
small if any. Volume overload is mild. Left-sided Port-A-Cath
ends in cavoatrial junction. Mediastinal and cardiac contours
are normal.
[**2106-9-14**] CT head postop: Decreased right subdural collection, now
consisting of fluid and air, with improvement in associated mass
effect. No new hemorrhage.
[**2106-9-15**] Chest Xray:FINDINGS: As compared to the previous
radiograph, the pre-existing bilateral pleural effusions have
increased. Also increased are the signs suggestive of moderate
pulmonary edema. Increase in extent of the pre-existing
retrocardiac atelectasis. Unchanged mild cardiomegaly.
Cardiovascular Report ECG Study Date of [**2106-9-15**] 1:58:56 PM
Sinus rhythm with premature atrial contractions. Diffuse
non-spefific
ST-T wave changes. Low voltage in the axial leads. Compared to
the previous tracing of [**2104-8-25**] the heart rate is slower and the
T wave inversion in leads V2-V3 is more prominent. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 176 80 [**Telephone/Fax (2) 86871**] 156
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**2106-9-16**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen (may be underestimated due
to the suboptimal nature of this study). There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CT HEAD W/O CONTRAST Study Date of [**2106-9-16**] 11:37 AM
FINDINGS: The right-sided subdural drainage catheter has been
removed. There is no change in the size of the subdural
hematoma. There has been reduction in extra-axial
pneumocephalus when compared to the prior study. The leftward
shift of midline structures is unchanged, approximately 6 mm.
The ventricular size and configuration is unchanged from the
prior study. There is no evidence of new hemorrhage or acute
vascular territorial infarction. The imaged portion of the
mastoid air cells and paranasal sinuses are well aerated.
IMPRESSION: No significant interval change since removal of the
right
subdural drainage catheter.
CHEST (PORTABLE AP) Study Date of [**2106-9-17**] 4:25 AM
Mild pulmonary edema has improved, now persisting mainly at the
lung bases. Moderate left pleural effusion stable. Heart size
normal. No pneumothorax. Infusion port catheter ends in the
low SVC. Heart size normal. No pneumothorax.
[**9-17**] CT Head- 1. Status post evacuation of the right subdural
hemorrhage. Minimally increased right lateral ventricular
effacement and increased size of the right subdural collection
by measurements. This may be technical as there are no new
hyperdense blood products, but small interval reaccumulation
cannot be entirely excluded.
COMMENTS ON ATTENING REVIEW: There is interval enlargement of
the right
epidural fluid collection underlying the craniotomy flap, which
explains the slightly increased effacement of the right lateral
ventricle, compression of the third ventricle, and slightly
increased leftward shift of midline structures. The right
subdural fluid collection is stable.
[**9-18**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of continuous focal slowing and
attenuation of faster frequencies in the right hemisphere. There
are occasional runs of very rhythmic delta activity or sharp and
slow wave discharges in the right posterior quadrant which do
not clearly involved in frequency or field. These findings are
indicative of a highly potentially epileptogenic focal
structural lesion in the right posterior quadrant. The
background on the left shows mixed theta and delta activity,
suggesting moderate diffuse encephalopathy. There are no
definite electrographic seizures.
[**9-18**] CT Head: IMPRESSION:
1. Increased right epidural fluid collection underlying the
right craniotomy flap, compared to [**2106-9-16**], with associated
increased effacement of the right lateral ventricle, compression
of the third ventricle, and slightly increased leftward shift of
midline structures.
2. Stable right subdural fluid collection.
[**9-18**] CXR: NG tube tip is coiled in the stomach that is
intrathoracic in a moderate hiatal hernia, the tip projects at
the level of the hemidiaphragm . Cardiac size is top normal,
accentuated by low lung volumes. Port-A-Cath is in standard
position. Small-to-moderate bilateral pleural effusions with
adjacent atelectases are unchanged allowing the difference in
positioning of the patient. Of note, the atelectasis in the
right lower lobe has minimally increased. Mild-to-moderate
pulmonary edema is stable.
[**9-19**] EEG: IMPRESSION: This is an abnormal continuous ICU EEG
monitoring study because of continuous focal attenuation and
prolonged runs of quasi-rhythmic 1 Hz delta activity with
intermixed sharp waves in the right posterior quadrant. These
findings are indicative of a potentially epileptogenic focal
structural lesion in the right posterior quadrant. The
background shows disorganized mixed delta and theta activities
suggestive of moderate to severe encephalopathy of non-specific
etiology. Compared to the prior day's recording, there are no
significant changes.
[**9-20**] EEG: IMPRESSION: This is an abnormal continuous ICU EEG
monitoring study because of continuous focal attenuation and
prolonged runs of quasi-rhythmic 1 Hz delta activity with
intermixed sharp waves in the right posterior quadrant. These
runs of delta activity do not evolve into clear electrographic
seizures. Focal attenuation and runs of delta activity with
intermixed sharp waves are indicative of a potentially
epileptogenic focal structural lesion in the right posterior
quadrant. Background activity is characterized by disorganized
mixed delta and theta activities indicative of moderate to
severe encephalopathy of non-specific etiology. There are no
electrographic seizures. Compared to the prior day's recording,
there are no significant changes.
[**9-20**] CT Head: IMPRESSION: The right epidural collection is
minimally decreased. Unchanged subdural collection along the
right convexity. Stable 9 mm leftward shift of normally midline
structures.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Neuro ICU for frequent neuro
checks and blood pressure control with a plan for evacuation of
right SDH. She was maintained on Cipro for treatment for UTI.
On [**9-14**] she underwent right craniotomy for evacuation of SDH. A
subdural drain was placed and set on thumbprint JP suction.
Postoperatively she was extubated and transferred to the ICU.
POstop head CT showed good evacuation of SD collection without
new hemorrhage.
POD 1 [**9-15**] her HCT was noted to be 23 and she was hypotensive to
the low 90s. Otherwise she was asymptomatic. She was
transfused 1 unit PRBCs and post transfusion HCT bumped to 27.
On [**9-16**], The sub dural drain was discontinued. A repeat head
CT was performed and was stable. The SQH was restarted after the
drain was discontiued. The cardiac echocardiogram, but
suggestive of Right Heart failure. The patient was initiated on
midodrine while trying to wean off intravenous vasopressors.
On [**9-17**], The foley catheter was discontinued. Physical and
occupational therapy consults were placed. The intravenous
vasopressors were weaned as tolerated. A chest X ray was
consistent with mild pulmonary edema which has improved,
persisting mainly at the lung bases.moderate left pleural
effusion stable. heart size normal. No pneumothorax. Infusion
port catheter ends in the low SVC. Heart size normal.
Overnight she was noted to be more lethargic. A CT was performed
which was questionable for slightly enlarging SDH vs
positioning. On [**9-18**] her exam continued to decline with less left
sided movement. Another CT was performed which revealed
increased MLS. She was started on EEG to evaluate for seizures.
These findings were conveyed to the family who stated that they
would not consent to another surgery if things were to progress
to that. She was started on tube feeds. On [**9-19**] she remained
stable. Her SQH was decreased to 5000units [**Hospital1 **] due to an
increased ptt on AM labs. A palliative care consult was called
per her primary oncologists recommendation.
[**9-18**], A head CT demonstrated worsening changes and the patient
exhibited less movement on the left. CXR demonstrated pleural
effusions.
[**9-20**], A repeat head CT was stable and a family meeting resulted
in the decision to progress toward palliative care.
[**9-21**], She was transferred to the floor with palliative care
following. On [**9-22**] her NGT was removed and she was started on a
PO diet. Morphine concentrate was added. The process was
initiated to find a discharge facility. On [**9-23**], patient's exam
was unchanged. She was eating with assistance and OOB to chair.
No changes were made to her medication regimen. On [**9-24**], patient
was discharged to hospice in stable condition.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Rehab [**3-18**]. Calcium Carbonate 750 mg PO BID
2. Citalopram 10 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
11. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Heparin 5000 UNIT SC TID
Start in AM on [**9-3**]
16. Morphine Sulfate 2-4 mg IV Q3H:PRN pain
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
19. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever
20. Docusate Sodium 100 mg PO BID
21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
22. LeVETiracetam 500 mg PO BID
23. Cyanocobalamin 1000 mcg IM/SC MONTHLY
24. Alendronate Sodium 4 mg PO EVERY 3 MONTHS
25. Ondansetron 8 mg PO Q8H:PRN nausea
26. Vitamin D 50,000 UNIT PO MONTHLY
27. Milk of Magnesia 60 mL PO Q12H:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever
2. Calcium Carbonate 750 mg PO BID
3. Citalopram 10 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC TID
Start in AM on [**9-3**]
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. LeVETiracetam 500 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Levothyroxine Sodium 75 mcg PO DAILY
16. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
17. Fentanyl Patch 37 mcg/h TP Q72H
18. Midodrine 10 mg PO TID
19. Morphine Sulfate (Concentrated Oral Soln) 10-15 mg PO
Q2H:PRN resp distress/pain
20. Senna 2 TAB PO BID:PRN constipation
21. Alendronate Sodium 4 mg PO EVERY 3 MONTHS
22. Cyanocobalamin 1000 mcg IM/SC MONTHLY
23. Diltiazem Extended-Release 240 mg PO DAILY
24. Furosemide 20 mg PO DAILY
25. Milk of Magnesia 60 mL PO Q12H:PRN constipation
26. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
27. Prochlorperazine 10 mg PO Q8H:PRN nausea
28. Vitamin D 50,000 UNIT PO MONTHLY
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1894**] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Right Subdural Hematoma
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:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
You are currently being discharged to hospice. Please contact
our office if you have any further questions. Neurosurgery can
be contact[**Name (NI) **] by calling [**Telephone/Fax (1) 1669**].
Completed by:[**2106-9-24**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"01.31"
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icd9pcs
|
[
[
[]
]
] |
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341, 404
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15628, 15766
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|
1319, 1473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,036
| 156,550
|
39891+58333
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-11-2**] Discharge Date: [**2106-11-10**]
Date of Birth: [**2022-6-10**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Bialteral upper extremity weakness
Major Surgical or Invasive Procedure:
Halo placement [**2106-11-4**]
History of Present Illness:
This is an 84 year old female previously evaluated for C2 fx on
[**2106-10-21**] (managed conservatively w/ Aspin collar) who presented
with new onset bilateral
UE weakness. She is unable to clearly recall when her symptoms
started but does report having difficulty lifting her arms and
using either hand for at least 3 days. She has been unable to
grip or lift objects but denies any tingling, numbness, or
muscle twitching. She is slightly confused/poor historian at
baseline but her extended care facility records do not report
major changes in
her physical functioning until late last night or first thing
this morning.
Pt is otherwise in her usual state of health w/ mild/moderate
neck pain s/p fall in [**Month (only) **] and w/ C-collar at all times.
Past Medical History:
RA
GERD
HTN
DM 2
Depression
Social History:
married, lives with husband. no tobacco, occas etoh,
no drugs. ambulates with walker at baseline.
Family History:
N/C
Physical Exam:
On admission: O: T: 98.82 BP: 109/29 HR: 76 R: 16 O2Sats: 98%
2L
Gen: comfortable, NAD, sitting up w/ air padding over both lower
extremities
HEENT: Pupils: ERRL (4-3mm) EOMs intact
Neck: Supple. C-collar in place. minimal c-spine tenderness over
the proximal C-spine. No other spinal/paraspinal tenderness (No
lower c-spine tenderness)
Extrem: Warm and well-perfused. brisk cap refill bilat LE and
UE.
palp radial, DP, PT bilat. no skin breakdown. RUE PROM
significantly limited at the shoulder (10 degrees of ABduction,
5
deg ext, 0 flexion) due to physical impediment. Pt deltoid only
minimally firing when ranging the joint. Significantly limited
ROM (active/passive) throughout both hands at the MCPs w/ large
joint nodules over 2nd-4th joints bilat.
Neuro:
Mental status: Awake and alert, cooperative with exam,
normal/depressed affect. Pt able to follow commands but slowed
in
her response
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 0/1 1 1 1 1 2 4 4 3 3 4
L 1 1 1 1 1 2 4 4 3 3 4
Sensation: Intact to light touch, proprioception, and pinprick
bilaterally. There were no sensory deficits in either upper
extrem compared to each other or w/ lower extrems
Reflexes: B T Br Pa Ac
Right 1 1 2 2 1
Left 0 1 2 2 1
Proprioception intact
Toes downgoing bilaterally
On Discharge:She has a halo in place. The pin sites are clean
and dry
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 2 4- 4 4 4 4- 4 4 4+ 4+ +4
L 4- 4 4 4 4 41 4 4 4+ 4+ 4+
Her motor exam can vary based on pain and participation. Her
right shoulder is severly limited by pain as are her knees. She
is becoming deconditioned with generalized fatique.
Pertinent Results:
[**2106-11-2**] CT C-spine
1. Type II dens fracture which has increased in posterior
angulation from 20 degrees to 39 degrees and in posterior
displacement from 4 mm to 9 mm. No evidence of new fractures.
2. Significant degenerative disease with moderate-to-severe
spinal canal
stenosis has remained stable. If clinical suspicion for cord
compression is high, MRI is the recommended study of choice.
[**2106-11-2**] MRI C-spine
Fractures of the posterior arch of C1 are better seen on the
preceding cervical spine CT. There is a type II fracture of the
odontoid
process, with posterior displacement and posterior angulation of
the odontoid process, as seen on the preceding CT scan. There is
bone marrow edema along the fracture line. There is a focal
disruption of the anterior longitudinal ligament at the level of
the fracture. The posterior longitudinal ligament is lifted from
the posterior cortex of the C2 vertebral body, but no definite
focal disruption is seen. There is a small epidural hematoma
posterior to C2 and the odontoid process. The spinal cord is
expanded at the level of C2 and C3 vertebral bodies with central
high signal, consistent with edema. There is a grade 1
anterolisthesis at C7-T1, as seen on the prior CT scan.
THe C3 and C4 vertebral bodies are partially fused. There is no
spinal canal narrowing at C3-4. There is at least mild neural
foraminal narrowing due to uncovertebral osteophytes, but
evaluation is limited by artifacts on the axial images.
[**2106-11-4**] Cspine X-rays
Dens fracture with traction, to assess for change.
FINDINGS: In comparison with the study of earlier in this date,
there appears to be little change in the appearance of the
fracture of the dens with the traction device in place. Severe
degenerative changes seen from C3 through C6.
[**2106-11-4**] Right Shoulder Xrays
There is an impacted fracture of the right humeral neck, with
resultant
deformity, and secondary degenerative changes about the right
glenohumeral
joint. There is evidence of callus formation about the fracture
margin,
suggesting that it is subacute to chronic, though without prior
comparisons, the age is indeterminate. There are
acromioclavicular degenerative changes,which are partially
obscured by the halo collar. Soft tissues are otherwise
unremarkable.
[**2106-11-4**] C-spine x-rays
Halo collar is in place, and there is no significant change in
malalignment at the C1-2 interface. Better depicted on today's
exam is
fracture involving the base of the dens, and probable additional
fracture in the posterior elements of C1. Severe degenerative
changes from C3 through C6 are unchanged.
[**2106-11-5**] Ct C-spine
1. Type 2 dens fracture with slight improvement in posterior
displacement of the superior fragment and in posterior
angulation.
2. Similar-appearing fractures in the anterior and posterior
arches of C1.
3. No visualized bony bridging at the dens fracture.
[**2106-11-8**]
1. C-spine x-ray: Minimal increased posterior displacement of
the dens fracture fragment.
2. Mild increased posterior displacement of the dens fracture.
3. No significant interval change in displaced type 2 dens
fracture.
[**2106-11-9**] Cspine x-ray
Fractures at the posterior arch of C1 and the base of the
odontoid process remain evident. There is some residual
posterior
displacement of the odontoid process with respect to remainder
of C2. This
appears somewhat less than on prior study though some blurring
limits accurate measurement.
Brief Hospital Course:
Ms. [**Known lastname 7188**] was admitted to [**Hospital1 18**] on [**11-2**]. She had CT and MRI of
the Cspine. She was put in traction up to 15 lbs on [**11-3**] and a
halo was placed on [**11-4**]. Her right shoulder was imaged to follow
up on fracture from [**Month (only) 547**] and continued pain. There was evidence
of healing. Cipro was started for a UTI. She had some
bradycardia with hypercapnea and was observed over night in the
SICU. On [**11-5**], patient was transferred to the floor. Speech and
swallow recommended a Dobbhoff which was attempted and
unsuccessful. She was started on purees. She was placed in the
halo vest on [**11-7**] and was able to get OOB to chair. Exam
remained stable. On [**11-8**], patient was seen by speech and
swallow again who recommended puree solids and thin liquids with
ensure as a nutritional supplement. Due to low nutritional
intake, a nutrition consult was placed. Cervical spine imaging
was done and fracture was stable. The halos was adjusted
anteriorly on [**11-9**].
She was cleared for rehab on [**2106-11-10**].
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. hydralazine 20 mg/mL Solution Sig: 0.5 Injection Q6 PRN ()
as needed for SBP>160.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin regular human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED): see sheet.
6. morphine 5 mg/mL Solution Sig: 1-2 mg Injection Q3H (every 3
hours) as needed for breakthrough pain.
7. hydralazine 20 mg/mL Solution Sig: Twenty (20) mg Injection
Q6H (every 6 hours) as needed for SBP >160.
8. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
Twenty (20) mg Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Type 2 Dens fracture
Ligamentous instability
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:
?????? Do not smoke.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Have a friend or family member check your pin sites daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Worsening weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 4 weeks.
??????You will need a C-spine CT-scan prior to your appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2106-11-10**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 13928**]
Admission Date: [**2106-11-2**] Discharge Date: [**2106-11-10**]
Date of Birth: [**2022-6-10**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1698**]
Addendum:
The patients IV pepcid was chnaged to PO and IV morhine and
hydralzine were discontinued. She can have oxycodone for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2106-11-10**]
|
[
"401.9",
"714.0",
"427.89",
"707.25",
"786.03",
"V49.86",
"530.81",
"707.09",
"599.0",
"V54.11",
"E888.9",
"311",
"250.00",
"806.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.41",
"02.94"
] |
icd9pcs
|
[
[
[]
]
] |
11824, 12023
|
6813, 7888
|
344, 377
|
9561, 9561
|
3307, 6790
|
10939, 11801
|
1348, 1353
|
8581, 9377
|
9493, 9540
|
7914, 8558
|
9737, 10916
|
1368, 1368
|
2841, 3288
|
270, 306
|
405, 1165
|
1382, 2134
|
9576, 9713
|
1187, 1217
|
1233, 1332
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,365
| 197,050
|
5300
|
Discharge summary
|
report
|
Admission Date: [**2185-2-8**] Discharge Date: [**2185-2-15**]
Date of Birth: [**2119-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yoM w/ a h/o DMII, ESRD on PD, CAD, CHF w/ an EF of 25% and
lymphoplasmocytic lymphoma (waldenstrom's) presents with 5 days
of nausea, vomiting and diarrhea- having missed peritoneal
dialysis for 2 days he became confused and was brought to the
ER. Since admission he was found to have an elevated WBC count
in his peritoneal fluid and started on vanc / ceftriaxone for
possible bacterial peritonitis which is thus far culture
negative. Since his admission his mental status has improved,
abd pain and diarrhea has resolved, he is not nauseas but does
lack an appetite. He denies any CP, SOB, orthopnea or PND. His
main complaint is overall fatigue, no muscle aches. He had a
cough and sore throat and these symptoms also remain. Of note
his wife had exactly the same constellation of symptoms
beginning roughly 1 week prior to his onset of symptoms (which
was 1 week ago). No fevers or chills. Has noticed dry skin
over the past few months. Patient is on PD and does make urine
(small amount), he lives at home with his wife and states he is
fully independent.
Past Medical History:
-ESRD on PD since [**2183**]
-DM
-CAD s/p angioplasty in [**2165**] and [**2166**]
-CHF (EF 20-25%)
-HTN
-Hypercholesterolemia
-Sleep apnea, on CPAP at home
-Gout
-GERD
-H/o gallstones
-Hypothyroid
-H/o Waldenstrom's macroglobulinemia --> Lymphoplasmacytis
lymphoma
Social History:
The patient denies tobacco use. No EtOH. He is married. ?h/o
EtOH use for him and ?his wife. [**Name (NI) **] is semi-retired. He used to
be the Director of Human Relations and Vice President of
Hospital. The patient was also a lawyer and does a small amount
of law practice on the side. He has 4 grown children who are
healthy.
Family History:
The patient's father died of colon cancer at age 55; mother is
alive in her late 80s with hypertension, status post CABG for an
MI, and with history of stroke.
Physical Exam:
VS: 96.3 BP 108/76 HR 77 RR 20 O2 96% RA
GEN: NAD, AOx3
HEENT: PERRL, EOMI, sclera anicteric, slight posterior OP
erythemia, JVP is 14 without a kussmauls sign
CARD: RRR, no m/r/g, soft heart sounds
PULM: CTAB
ABD: soft, NT, ND, no masses or organomegaly
EXT: WWP, no c/c/e
NEURO: CN2-12 intact, AOx3, appropriate affect, able to hold
conversation, [**4-25**] stregnth in all 4 extremities
Pertinent Results:
[**2185-2-8**] 01:08PM BLOOD WBC-17.2*# RBC-3.02* Hgb-9.4* Hct-28.0*
MCV-93 MCH-31.0 MCHC-33.5 RDW-14.8 Plt Ct-379
[**2185-2-13**] 06:45AM BLOOD WBC-7.5 RBC-2.71* Hgb-8.2* Hct-24.6*
MCV-91 MCH-30.1 MCHC-33.1 RDW-16.7* Plt Ct-249
[**2185-2-8**] 01:08PM BLOOD Neuts-91.5* Bands-0 Lymphs-5.8* Monos-2.1
Eos-0.2 Baso-0.4
[**2185-2-9**] 03:12AM BLOOD Neuts-90.8* Lymphs-5.0* Monos-2.7 Eos-1.1
Baso-0.3
[**2185-2-8**] 01:08PM BLOOD Glucose-515* UreaN-125* Creat-13.7*#
Na-136 K-6.3* Cl-89* HCO3-17* AnGap-36*
[**2185-2-13**] 06:45AM BLOOD Glucose-131* UreaN-74* Creat-9.0* Na-135
K-3.9 Cl-94* HCO3-31 AnGap-14
[**2185-2-13**] 06:45AM BLOOD Calcium-8.4 Phos-6.5* Mg-1.8 Iron-19*
[**2185-2-13**] 06:45AM BLOOD calTIBC-142* Ferritn-1043* TRF-109*
[**2185-2-10**] 06:45AM BLOOD %HbA1c-13.3*
[**2185-2-10**] 06:45AM BLOOD TSH-6.1*
[**2185-2-13**] 06:45AM BLOOD PTH-158*
[**2185-2-13**] 06:45AM BLOOD Vanco-17.5
[**2185-2-9**] 03:34AM BLOOD Lactate-2.6*
[**2185-2-8**] 03:47PM BLOOD Lactate-5.2*
[**12-9**] CXR:
Resolved left pleural effusion. Suspect persistent right
pleural
effusion in predominantly subpulmonic distribution. Decubitus
views may be of benefit if useful for clinical management. No
consolidation or edema.
[**12-10**] CXR:
Portable AP chest radiograph compared to [**2185-2-8**],
obtained at 6:50.
The left internal jugular line tip terminates in left
brachiocephalic vein. The cardiomegaly is stable. Mediastinal
contours are unremarkable.
The patient is still in mild volume overload/failure. New
opacity overlying the right lung most likely is due to layering
pleural effusion which was predominantly concentrated at the
right base on previous study. There is no significant change in
bibasilar atelectasis.
IMPRESSION:
1. Mild volume overload/failure.
2. Bilateral pleural effusions, right more than left.
[**2185-12-10**] FOOT X RAYS: BILATERAL
HISTORY: Diabetes. Foot ulcers. Rule out osteomyelitis.
Six radiographs of the bilateral feet are submitted.
Mineralization is normal. The joint spaces are maintained
without
periarticular erosion. No fracture. Atherosclerotic
calcifications are
present. No localizing history is provided. No discrete soft
tissue loss is evident. No subcutaneous emphysema is seen. No
cortical fragmentation is identified. No change compared with
[**2183-8-8**].
IMPRESSION:
Unremarkable bilateral feet.
[**2185-2-10**] 2:02 pm SWAB Source: right hallux.
GRAM STAIN (Final [**2185-2-10**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2185-2-13**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
[**2185-2-10**] 2:02 pm SWAB Source: left 2nd digit.
GRAM STAIN (Final [**2185-2-10**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2185-2-13**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
URINE CULTURE [**2-8**] NEGATIVE
BLOOD CX [**2-8**] NO GROWTH TO DATE ON [**2-13**]
Brief Hospital Course:
CONFUSION: likely related to viral syndrome in addition to
uremia, this may have been due in part to a few days of missed
peritoneal dialysis due to weakness. Patient's mental status
cleared as he was treated for his infection, his electrolytes
normalized and he was dialyzed (PD) for his uremia.
BACTERIAL PERITONITIS: initially started on antibiotics for
bacterial peritonitis given initial WBC count of 300 on initial
peritoneal fluid, however, this could have been due to no
peritoneal dialysis for 2 days, 5 hours later her WBC count in
his peritoneal fluid was in the 30s. His antibiotics for SBP
were discontinued.
HYPOTENSION: In setting of Peritoneal dialysis. Patient remained
asymptomatic and was ambulatory with PT.
DIABETIC FOOT INFECTION: seen by podiatry, purulence drained
from R hallux and L second toe. Not deep, did not probe to
bone, dressed w/ clean dry dressings. Heel laceration due to
dry skin and fissuring, given amlactin cream for this. MSSA
from wounds, started on levofloxacin for this (on vanc until
sensitivities returned). Levo 250mg po q48hrs renally dosed,
coverage for infection starting on [**2-9**], should continue until
[**1-/2106**] or [**2-19**]. Insulin regimen adjusted, initially hyperglycemic;
near date of discharge was hypoglycemic but after adjustment of
insulin dosage had a normal glucose. Patient should have
non-invasive vascular studies to evaluate arterial blood flow,
this has been ordered for outpatient.
Anemia: on epo, iron studies reveal ferritin > 1000, iron
supplementation stopped.
DMII: A1C 13.3%, patient should follow up with [**Last Name (un) 387**] upon
discharge.
Chronic systolic heart failure: Medications were adjusted before
discharge due to hypotension. Patient will need to be
re-assessed to re-start ace inhibitor. Please see medication
section for details.
Medications on Admission:
allopurinol 75 per day
metoprolol tartrate [**Hospital1 **]
levothyroxine 75 mcg daily
Nexium 40mg daily
Niaspan ER 50mg daily
ICaps
Humulin R and N ?dose
Lipitor 20 mg daily
lisinopril 20mg daily
iron 65?
aspirin 81mg daily
Effexor XR 150 daily
lorazepam 1mg ?daily
zolpidem 10 q.h.s.
Procrit 6000 every week
Fosrenol 1000 TID with meals
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 3 doses: next dose 2/26.
Disp:*3 Tablet(s)* Refills:*0*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day: 30 minutes after aspirin.
6. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous as directed: NPH 10 units at breakfast
time and NPH 8 units at bedtime.
10. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous as directed: Lispro (humalog) insulin based on a
sliding scale for breakfast, lunch, dinner and at bedtime.
11. ICaps Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
14. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
15. Procrit 3,000 unit/mL Solution Sig: Two (2) mL Injection
once a week.
16. FOSRENOL 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
17. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*2*
18. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
19. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis:
Infected toe ulceration / abscess
viral syndrome
uremia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for confusion and infection in your abdomen
and of your toes. You have been treated with antibiotics and
are improving.
You will need outpatient "vascular studies" to look at the blood
pressures in your arms compared to your legs. Your primary care
physician can help set this up for you, if you have narrowed
vessels in your legs this may be the reason that you have ulcers
and infections of your feet.
Please note, we have held the dose of Lisinopril. Please do not
take this medication until you see Dr [**Last Name (STitle) 1007**].
We have also decreased the amount of metoprolol you take; please
discard the bottle you have at home and take the new Toprol XL
25mg daily we have prescribed until you see Dr [**Last Name (STitle) 1007**].
Followup Instructions:
Please follow up with your Primary Care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]
on Friday, [**2-18**] at 10:30 a.m., Phone ([**Telephone/Fax (1) 21461**].
In addition please follow up with your podiatrist Dr. [**Last Name (STitle) **] on
Friday, [**2-18**] 2:40 p.m. in the [**Hospital Ward Name 121**] Building [**Location (un) 470**],
Phone: ([**Telephone/Fax (1) 4335**]
Please call your kidney Doctor for an appointment within 2 weeks
of your discharge.
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2185-5-19**] 1:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
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"585.6",
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"250.80",
"428.32",
"200.80",
"682.7",
"428.0",
"327.23",
"414.01",
"584.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11783, 11854
|
7483, 9331
|
324, 331
|
11973, 11982
|
2673, 6146
|
12795, 13591
|
2084, 2245
|
9720, 11760
|
11875, 11875
|
9357, 9697
|
12006, 12772
|
2260, 2654
|
275, 286
|
359, 1433
|
11894, 11952
|
7350, 7460
|
1455, 1722
|
1738, 2068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,247
| 130,612
|
11535
|
Discharge summary
|
report
|
Admission Date: [**2123-11-30**] Discharge Date: [**2123-12-16**]
Date of Birth: [**2038-1-28**] Sex: F
Service: MEDICINE
Allergies:
Biaxin / Morphine / Codeine
Attending:[**Doctor First Name 7926**]
Chief Complaint:
Left lower extremity ischemia with rest pain
Major Surgical or Invasive Procedure:
[**2123-12-2**]:
1. Ultrasound-guided puncture of right common femoral artery.
2. Contralateral second-order catheterization of the left
external iliac artery.
3. Serial arteriogram of left lower extremity.
.
[**2123-12-8**]:
1. Re-do left femoral to peroneal bypass via lateral approach
with right non-reverse greater saphenous vein.
2. Angioscopy with valve lysis.
.
[**2123-12-14**]: Cardiac catheterization with coronary stent
History of Present Illness:
85F s/p L AK [**Doctor Last Name **]-DP artery bypass left basilic vein in [**2114**] who
presented to [**Hospital6 17032**] on [**11-26**] with
worsening pain and redness in left 1st toe. Symptoms initially
began 1 month ago and have been slowly progressing w/ purulent
drainage. She was admitted to [**Location (un) **] and started on ceftriaxone
and azithromycin. Symptoms continued to persist and she
underwent NIAS which were reportedly poor. She was transferred
to [**Hospital1 18**] for further care. She reports pain in toe only improves
after dangling legs off of the bed. She denies any recent fevers
or chills.
Past Medical History:
CARDIAC RISK FACTORS: diabetes, dyslipidemia, HTN
CARDIAC HISTORY:
- CABG in [**2114**] with SVG to RCA
- PCIs:
[**8-/2120**]: mid LAD with 3.0 X 8 and 2.5 X 8 overlapping bare metal
Mini Vision stents
[**11/2118**]: with POBA to mid RCA ISR
[**6-/2118**]: cypher DES 2.5 x 18mm and 2.5 x 23mm to RCA
[**7-/2117**]: cypher DES 2.5 x 13mm to mid-LAD)
- Aortic Stenosis s/p AVR with 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] bovine
prosthesis
OTHER PAST MEDICAL HISTORY:
- PVD s/p left popliteal artery to dorsalis pedis artery bypass
using left basilic arm vein [**2114**]
- Hypothyroidism
- Renal Stones s/p right nephrectomy
- Chronic renal insufficiency s/p (baseline Cr~1.2-1.4)
- GERD
- Possible epilepsy evaluated by neurology (Dr. [**Last Name (STitle) **]
PSH:
hysterectomy '[**83**], R breast bx '[**04**], aortic valve replacement w/
bovine valve and CABG x 1 w/ L saphenous vein '[**13**], L AK [**Doctor Last Name **]-DP
artery bypass L basilic vein '[**14**], b/l cataract surgery, R knee
arthroscopy '[**17**], multiple finger surgeries
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Daughter lives out of
town; son lives in town near mother, but relationship somewhat
strained.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PHYSICAL EXAM AT DISCHARGE:
Vitals: T 98.6, BP 90/50, HR 60, R 18, 95% on RA
General: Very [**Last Name (un) 664**] elderly woman in NAD. A&Ox3.
HEENT: EOMI, MMM, no oral lesions.
Neck: Supple, no LAD or increased JVP.
Chest: Well-healed midline scar, RR, 3/6 SEM at RUSB, no r/g.
Lungs: CTAB with scant bibasilar crackles.
Abdomen: Obese, soft, NT, ND, NABS.
Extrem: WWP, [**12-12**]+ LE edema bilaterally to knees. Well-healing
incisions on both legs with staples intact. Bandages intact.
+lesion on left great toe.
Pulses:
Right: 2+ carotid, 2+ radial, 2+ femoral, 1+ DP
Left: 2+ carotid, 2+ radial, 2+ femoral, non-palpable DP/PT
pulses
Pertinent Results:
ADMISSION LABS:
[**2123-11-30**] 08:20PM BLOOD WBC-7.0 RBC-4.07*# Hgb-12.3 Hct-36.8#
MCV-91 MCH-30.2 MCHC-33.4 RDW-13.6 Plt Ct-217
[**2123-11-30**] 08:20PM BLOOD PT-13.3 PTT-24.5 INR(PT)-1.1
[**2123-11-30**] 08:20PM BLOOD Glucose-237* UreaN-39* Creat-1.8* Na-139
K-3.6 Cl-103 HCO3-21* AnGap-19
[**2123-11-30**] 08:20PM BLOOD Calcium-9.1 Phos-3.9# Mg-2.1
.
DISCHARGE LABS:
[**2123-12-16**] 06:40AM BLOOD WBC-7.8 RBC-2.68* Hgb-8.0* Hct-24.6*
MCV-92 MCH-30.0 MCHC-32.7 RDW-16.4* Plt Ct-239
[**2123-12-16**] 06:40AM BLOOD PT-13.5* PTT-34.5 INR(PT)-1.2*
[**2123-12-16**] 06:40AM BLOOD Glucose-125* UreaN-22* Creat-1.8* Na-139
K-3.8 Cl-99 HCO3-31 AnGap-13
.
[**2123-12-10**] EKG: Sinus tachycardia at 106 bpm, left axis deviation,
poor R-wave progression, left ventricular hypertrophy. Lateral,
anterolateral, and inferior ST depressions which are not seen on
most recent EKG.
.
IMAGING:
[**2123-12-1**] Non-invasive arterial rest studies of lower exremity:
Doppler waveform analysis reveals triphasic waveforms at the
common femoral arteries bilaterally. On the right, there is a
triphasic popliteal waveform and monophasic DP and PT waveforms.
On the left, there are monophasic popliteal, DP, and PT
waveforms. ABIs are 0.69 on the right and 0.63 on the left.
Pulse volume recordings show essentially normal waveforms in the
thighs bilaterally. There is absence of calf augmentation
bilaterally. There is further dampening at the metatarsal level
on the left. Significant left SFA and bilateral tibial arterial
disease.
.
[**2123-12-2**] Left lower extremity angiogram:
1. Normal-appearing left common femoral artery and profunda
femoris artery. Mild to moderate calcification along the
mid and proximal portion of the left superficial femoral
artery.
2. Patent distal portion of left superficial femoral artery
and above-knee popliteal artery.
3. Patent proximal anastomosis of the above-knee popliteal
artery to dorsalis pedis bypass graft.
4. Patent distal anastomosis and proximal region of
anterior tibial artery with immediate occlusion just at
the or just beyond the distal anastomosis. Vessels were
observed to reconstitute from collaterals in the lower
calf. However dorsalis pedis was diminutive in size.
5. Occlusion of peroneal artery just beyond its origin with
reconstitution above the level of the ankle and flow
below down to the foot.
6. Complete obstruction of the posterior tibial artery at
its origin with reconstitution off of the peroneal
artery at the level of the ankle.
.
[**2123-12-10**] CXR: There is a fracture of the uppermost median
sternotomy wire, chronic. The right IJ central venous catheter
has the distal lead tip in the mid to distal SVC, unchanged.
There is a persistent cardiomegaly. There is a persistent
blunting of the left hemidiaphragm suggestive of pleural fluid,
atelectasis, or focal infiltrate. Overall, the findings are
stable.
.
[**2123-12-11**] ECHO: The left atrium is mildly dilated. The right atrium
is markedly dilated. 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 hypokinesis of the basal,
mid, and distal inferoseptal segments. Overall left ventricular
systolic function is mildly depressed (LVEF= 40%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. A bioprosthetic aortic
valve prosthesis is present. The aortic valve prosthesis appears
well seated, with normal leaflet/disc motion and transvalvular
gradients. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild left ventricular hypertrophy with normal cavity
size. Mildly depressed left ventricular systolic funciton with
regional wall motion abnormalities as described above. Increased
left ventricular filling pressures. Normally functioning
bioprosthetic aortic valve. Biatrial enlargement. Mild mitral
and tricuspid regurgitation. Mild pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
[**2120-8-5**], wall motion abnormalities are new. The aortic sinus
and aortic root are no longer dilated.
.
[**2123-12-14**] Cardiac Cath:
1. Two vessel coronary artery disease.
2. Continue aspirin indefinetly. Plavix 75mg daily for minimum
of 12 months, preferably indefinetly
3. Follow renal function with careful hydration.
4. Successful PCI of OM1 with DES.
5. Successful RRA TR band.
Brief Hospital Course:
85 year old woman with HTN, HL, DM, CRI (s/p nephrectomy), CAD
(s/p SVG-RCA CABG '[**14**], multiple subsequent PCIs), AVR with
bioprosthetic valve ('[**14**],), systolic CHF (EF 40%), PVD (s/p
[**Doctor Last Name **]-DP bx), who was admitted with a non-healing infected left
great toe ulcer, and underwent a re-do of her left
femoral-peroneal arterial bypass. She developed post-op chest
pain and was found to have an NSTEMI with worsening CHF. Cardiac
cath revealed a severe lesion in OM s/p DES. Brief hospital
course by problem:
.
# Left toe ulcer/cellulitis/leg pain: LLE angiogram revealed
occlusion of the peroneal artery just beyond its origin with
reconstitution above the level of the ankle and flow below down
to the foot. There was also complete obstruction of the
posterior tibial artery at its origin with reconstitution off of
the peroneal artery at the level of the ankle. On [**12-7**] she
underwent a re-do of the left femoral-peroneal arterial bypass
and tolerated the surgery well. She was trasfused 4units of
PRBCs peri-operatively. Pain was initally controlled with IV
dilaudid and tylenol, and then transitioned to oxycodone and
tylenol. She was treated with vancomycin, ciprofloxacin, and
flagyl, and then transitioned to bactrim upon discharge.
- Continue bactrim 1 DS tab [**Hospital1 **] for a 10-day course
- She will follow up with Dr. [**Last Name (STitle) 1391**] from vascular surgery in
2 weeks
.
# NSTEMI s/p DES to OM: On POD2 she complained of chest pressure
and SOB. Cardiac enzymes showed a peak troponin of 2.79 with
anterolateral and inferior ST depressions on EKG. She was noted
to be fluid overloaded on exam with evidence of pulmonary edema
on CXR so she was diuresed with IV lasix. An ECHO revealed new
hypokinesis of the basal, mid, and distal inferoseptal segments
of the left ventricle with a LVEF 40%. Cardiac catheterization
revealed a >95% lesion in the mid-major OM which was
successfully stented with a DES.
- It is recommended that she continue aspirin 325mg daily
indefinitely, and plavix 75mg daily for a minimum of 12 months
(though preferably indefinitely)
- Simvastatin was continued at discharge
.
# CHF: An ECHO on [**12-11**] revealed new hypokinesis of the basal,
mid, and distal inferoseptal segments of the left ventricle with
a LVEF 40%. She is s/p DES to the mid-major OM as mentioned
above. She is currently still mildly fluid up on exam with 1-2+
LE edema bilaterally.
- Continued lasix 40mg daily and metoprolol 12.5mg [**Hospital1 **]
- Patient is not currently on an ACE-I, likely due to CRI
.
# Hypertension: Post-operatively, her blood pressure has been
well controlled with a few SBPs in the 80s-90s though
asymptomatic.
- Continued home BP regimen including amlodipine 2.5mg daily,
metoprolol 12.5mg [**Hospital1 **], lasix 40mg daily, and nitro patch 0.4mg
daily
.
# Chronic renal insufficiency: Baseline Cr appears to be
~1.2-1.4. She was hydrated peri-operatively as well as prior to
and after the cardiac catheterization. Creatinine is currently
1.8, likely from the contrast during catheterization on [**12-14**].
.
# Anemia: Hct has been stable in the mid-20s. She has a history
of anemia with Hct in the mid-20s to low 30s over the past
several years. No signs of bleeding and stool is guiac negative.
She believes that she had a colonoscopy some time within the
past that was reportedly normal.
- Recommend follow-up by PCP
.
# Diabetes: Held glimepiride during this admission. Increased
humalog to 6 units with meals and increased lantus to 14 units
QHS, with humalog sliding scale.
.
# Hyperlipidemia: She was treated with full dose atorvastatin in
setting of NSTEMI and transitioned back to home dose simvastatin
at discharge. This should be further evaluated as an outpatient.
.
# Hypothyroidism: Stable. Continued levothyroxine 50mcg daily.
.
# GERD: Stable. Continued omeprazole 20mg daily.
.
# H/o Seizures: No seizure activity during this admission.
Continued Trileptal 150mg qHS.
.
# Disposition: Patient was discharged to rehab.
.
**A copy of this discharge summary was faxed to Ms. [**Known lastname 36728**] PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **]**
Medications on Admission:
1. Aspirin 325mg Daily
2. Plavix 75mg Daily
3. Simvastatin 40mg QHS
4. Amlodipine 2.5mg Daily
5. Metoprolol 12.5mg [**Hospital1 **]
6. Lasix 40mg Daily
7. Nitro patch 0.4mg daily
8. Glimepirde 4mg [**Hospital1 **]
9. Humalog 4units w/ meals TID,
10. Lantus 12units qHS
11. Levothyroxine 50mcg Daily
12. Omeprazole 20mg Daily
13. Allopurinol 100mg Daily
14. Celexa 20mg Daily
15. Trileptal 150mg qHS
16. Vitamin D 400units Daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
11. Lantus 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous QHS.
12. Humalog 100 unit/mL Solution Sig: Six (6) units Subcutaneous
three times a day: with meals.
13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain. Tablet(s)
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
16. glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
18. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day: Take through [**2123-12-26**].
Disp:*20 Tablet(s)* Refills:*0*
19. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
20. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: See separate sheet with scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] at [**Hospital1 189**] ([**First Name8 (NamePattern2) **] [**Doctor Last Name 11042**])
Discharge Diagnosis:
Left lower extremity ischemia with rest pain with revision of
bypass
Myocardial infarction with coronary artery stenting
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:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-13**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
.
Division of Cardiology:
You had a heart attack and had a cardiac catheterization with
stenting of one of your cornonary arteries. You should weigh
yourself every morning, and call your doctor if your weight goes
up more than 3 lbs.
.
We made the following changes to your medications:
- INCREASED insulin humalog to 6 units three times daily with
meals
- INCREASED insulin glargine to 14 units at bedtime
- STARTED a humalog insulin sliding scale while in the hospital
- STARTED oxycodone 5mg every 6 hours as needed for pain
- STARTED tylenol 500mg every 8 hours as needed for pain
- STARTED bactrim 2 tablets twice daily for the sore on your
toe. Please take through [**2123-12-26**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] in 2 to 3 weeks. Call
[**Telephone/Fax (1) 1393**] for an appointment.
.
When you leave rehab, you should follow-up with your PCP and
your cardiologist.
Completed by:[**2123-12-16**]
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icd9cm
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47,045
| 190,917
|
7743
|
Discharge summary
|
report
|
Admission Date: [**2127-3-12**] Discharge Date: [**2127-3-17**]
Date of Birth: [**2050-2-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Hypoxemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 year-old male with CAD, ischemic cardiomyopathy (EF 25-30%),
CKD, and atrial fibrillation admitted with decreased oxygen
saturation, fever, productive cough. He is telemonitored for
oxygen saturation. One week prior to admission he was noted to
have oxygen saturation in low 90s. Over the week his oxygen
saturation progressively decreased, dropping to 81% without
improvement with cough/deep breathing on day of admission.
During this time period he has also had fevers to 101.8 (and has
since taken Tylenol on scheduled basis), night sweats, cough
initially dry and now productive with yellow/white sputum. He
has also had clear rhinorrhea, nausea without emesis. Also with
chest pressure this morning relieved with SLNTG x1.
.
[**Name (NI) **] wife spoke with his providers this morning and planned
to bring him in for urgent appointment. He progressively became
more dyspneic and nauseous and was brought from home via EMS to
the emergency department.
.
In the ED, 99.8 82 124/37 22 95% 3L NC. Laboratory data
significant for BNP 3272, trop 0.07, creatinine 2.2, hematocrit
29.1. ABG on facemask 7.49/33/163, lactate 1.0. Chest radiograph
2V with LLL opacity, left pleural effusion, and mild prominence
of pulmonary vasculature. EKG with LAD, 1st degree AV block,
RBBB reportedly unchanged from prior. He received levofloxacin,
vancomycin, albuterol neb, and Lasix 100mg IV x1.
.
On arrival to the medical service, he was noted to be dyspneic
and having difficulty speaking in complete sentences. He was
also diaphoretic and transitioned to NRB for low oxygen
saturation; also noted to be tachypneic to upper 30s. Repeat ABG
on NRB 7.46/36/77. He emphasized he does not want to be
intubated, but stated he would be willing to try BiPAP briefly
if it helps with his shortness of breath.
.
Review of Systems:
(+) Per HPI.
(-) Denies recent weight changes (weighs daily). Denies
headache, sinus tenderness. Denies wheezing, palpitations.
Denies vomiting, diarrhea, constipation, abdominal pain. Denies
dysuria, urinary frequency. Denies rashes.
Past Medical History:
- CAD-3V CAD s/p CABGx2 and stents x6 with multiple ISRS
- Systolic CHF with EF 25-30%
- HTN
- Dyslipidemia
- Peripheral vascular disease-aorto fem bypass in early 90s.
- Chronic Kidney disease stage III
- Carotid stenosis 60-69% right ICA stenosis, 70-79% left ICA
stenosis in [**7-/2125**]
- DMII
- Mixed sleep disordered breathing
- Gout
- PVD s/p aortobifemoral bypass
- Depression and anxiety
Social History:
Retired. Machine operator in [**Last Name (un) 27903**] stethoscope factory.
Married with three children. Stopped smoking 30 years ago.
Smoked 2-3 packs per day. No EtOH. No drugs. He typically is
able to walk short distances in his house. He just recently
started going for daily walks.
Family History:
Multiple family members with CAD and diabetes mellitus, type II
Physical Exam:
At admission:
97.2, 144/55, 84, 100% BiPAP 5/5 Fi02 100%
General: Initially tachypneic, unable to speak in full
sentences, accessory muscle use; now more comfortable with BiPAP
in place
HEENT: No rhinorrhea; dry mucous membranes
Neck: Prominent jugular venous pulsation
Lungs: Coarse rhonchi with scattered expiratory wheezes; no
appreciable crackles
CV: RRR, normal S1/S2, no murmurs appreciated
Abdomen: Normoactive bowel sounds; soft, nontender, not
distended
Ext: Trace lower extremity edema to knees; cool lower
extremities; DP/PT pulses 1+, radial pulses 2+ and symmetric
Pertinent Results:
HEMATOLOGY:
[**2127-3-12**] 11:24AM BLOOD WBC-5.4 RBC-3.77* Hgb-9.5* Hct-31.1*
MCV-82 MCH-25.1* MCHC-30.5* RDW-17.6* Plt Ct-172
[**2127-3-17**] 02:56AM BLOOD WBC-10.0 RBC-3.86* Hgb-9.5* Hct-32.4*
MCV-84 MCH-24.7* MCHC-29.4* RDW-17.3* Plt Ct-132*
[**2127-3-12**] 11:24AM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-5 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
CHEMISTRY:
[**2127-3-12**] 11:24AM BLOOD Glucose-263* UreaN-73* Creat-2.2* Na-136
K-4.4 Cl-98 HCO3-25 AnGap-17
[**2127-3-14**] 03:43AM BLOOD Glucose-96 UreaN-60* Creat-2.4* Na-143
K-4.5 Cl-104 HCO3-26 AnGap-18
[**2127-3-17**] 02:56AM BLOOD Glucose-199* UreaN-125* Creat-3.9* Na-144
K-5.3* Cl-105 HCO3-24 AnGap-20
CARDIAC ENZYMES:
[**2127-3-12**] 11:24AM BLOOD cTropnT-0.07*
[**2127-3-13**] 03:10AM BLOOD CK-MB-2 cTropnT-0.10*
ABG:
[**2127-3-13**] 06:10AM BLOOD Type-ART Temp-38.9 FiO2-100 pO2-139*
pCO2-37 pH-7.47* calTCO2-28 Base XS-4 AADO2-555 REQ O2-90
Intubat-NOT INTUBA
MICROBIOLOGY:
[**2127-3-12**] 5:30 pm Influenza A/B by DFA (nasopharyngeal swab)
**FINAL REPORT [**2127-3-13**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2127-3-13**]): POSITIVE FOR
INFLUENZA A VIRAL ANTIGEN.
CHEST (PA & LAT) Study Date of [**2127-3-12**]:
IMPRESSION:
1. Opacity obscuring left hemidiaphragm, which may be reflective
of atelectasis, pleural effusion, and superimposed infection,
cannot be entirely excluded.
2. Small left pleural effusion.
3. Reticular opacities involving the right lung base, better
characterized on CT chest of [**2126-8-13**], unchanged.
4. Mild prominence of pulmonary vasculature, likely reflective
of increased pulmonary vascular pressure.
CHEST (PORTABLE AP) Study Date of [**2127-3-17**]:
FINDINGS: In comparison with the study of [**3-14**], there is
continued diffuse
bilateral pulmonary opacifications. Considering the clinical
history, this
most likely represents a combination of widespread pneumonia and
severe
pulmonary edema, though superimposed development of ARDS would
have to be
considered. There is mild left pleural effusion. Intact midline
sternal
wires persist.
Brief Hospital Course:
Patient admitted with hypoxemia and dyspnea. Was originally sent
to medical floor, though quickly decompensated there and had to
be transferred to MICU after requiring non-rebreather to
maintain oxygen sats in 90s. Patient clearly stated he would not
want intubation, but initially agreed to try non-invasive
ventilation. Upon arrival to the MICU, patient had desat to 70s
on facemask and thus was placed on non-invasive ventilation. He
was treated with broad antibiotics for pneumonia. Had a flu swab
sent for rule-out of influenza and was started on empiric
oseltamivir. Also treated for acute heart failure decompensation
with furosemide and morphine. Patient did not tolerate the
non-invasive ventilation due to discomfort with mask and thus
was placed on non-rebreather. On [**2127-3-14**], influenza screen
returned position. Due to worsening CXR and intermittent
hypoxemia to low 80s on non-rebreather, the team had a
discussion with family that patient may not make it through
illness. They were presented option of continued maximal care
short of intubation or CMO and after discussion with patient's
primary care physician, [**Name10 (NameIs) 28092**] to see if patient could recover in
next several days. Patient was given morphine intermittently for
dyspnea, from [**3-14**] to [**3-17**]. He was also diuresed with furosemide
drip and bolus furosemide until creatine increased and urine
output slowed. He remained hypoxemic despite diuresis. On
morning of [**3-17**] he became unresponsive to his wife and continued
to fatigue from his breathing. [**Name (NI) **] wife and family decided
on morning of [**2127-3-17**] to gather family and pursue comfort
measures only. Patient was started on morphine drip and
non-rebreather was removed, patient was pronounced dead at 1701
on [**2127-3-17**]. Family declined autopsy.
Medications on Admission:
Allopurinol 200mg PO daily
Atorvastatin 40mg PO daily
Carvedilol 12.5mg PO BID
Citalopram 10mg PO daily
Plavix 75mg PO daily
Colchicine 0.6mg PO EOD
Furosemide 160mg PO BID
Isosorbide mononitrate 30mg PO BID
Lisinopril 2.5mg PO daily
Metolazone 2.5mg PO daily
SLNTG
Pentoxifylline 400mg PO BID
ASA 325mg PO daily
NPH 40 units QAM, QPM
Humalog sliding scale insulin
Discharge Medications:
None, patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Acute Respiratory Distress Syndrome
Influenza A
Secondary:
Acute congestive heart failure
Discharge Condition:
Expired
Discharge Instructions:
None, patient expired
Followup Instructions:
None, patient expired
|
[
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8159, 8168
|
5864, 7697
|
280, 286
|
8310, 8319
|
3786, 4451
|
8389, 8413
|
3108, 3173
|
8113, 8136
|
8189, 8289
|
7723, 8090
|
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3188, 3767
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2128, 2364
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4468, 5841
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231, 242
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314, 2109
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2386, 2786
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2802, 3092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,847
| 189,964
|
39972
|
Discharge summary
|
report
|
Admission Date: [**2190-12-31**] Discharge Date: [**2191-1-4**]
Date of Birth: [**2127-3-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Prochlorperazine / Aspirin / Nsaids
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Acomm and L MCA aneurysm
Major Surgical or Invasive Procedure:
[**2190-12-31**] Cerebral Angiogram w/coiling of ACOMM aneurysm
History of Present Illness:
63F with ACOMM aneurysm and L MCA aneurysm who underwent stent
placement in Novemeber [**2190**] and returns today for coiling of the
ACOMM aneurysm.
Past Medical History:
Fibromyalgia, anxiety, depression
PSH for colon cancer surgery, tubal ligation, laminectomy and
spinal fusion, hemorrhoidectomy, exploratory exposure surgery
for ovarian cysts appendectomy.
Social History:
Smoker 1ppd for 30 years
Family History:
Noncontributory
Physical Exam:
Pre-angio Exam:
Nonfocal exam. Oriented x3. MAE [**5-26**].
Post-angio Exam:
Stable Neurological exam. Alert and orientented x3, following
commands with fluent speech. PERRLA, EOMs intact, VF full.
V1-V3 intact. Face symmetric, tongue midline. Motor exam shows
full 5/5 strength in the upper and lower extremities
bilaterally. Sensation intact to light touch. Left groin site
had a small dime-sized hematoma. Right groin site was
ecchymotic with no hematoma. Distal lower extremity pulses were
bounding bilaterally.
Pertinent Results:
[**2191-1-3**]: HCT 31
Brief Hospital Course:
63F who underwent a cerebral angiogram for coiling of ACOMM
aneurysm. Coiling of the Left MCA aneurysm was deferred for the
risk of stroke and will be done at a later date. Post-angio the
patient remained in the PACU for observation as ICU was full.
Patient's SBP was in the 80's and patient received 2 fluid
boluses for a total of 1000 mL, SBP remained high 70's to 80's
and a neo drip was started to keep pressures above 100. A
Heparin gtt was started and ASA was maintained. Patient was
noted to have oozing from her angio site and the Heparin gtt was
discontinued. Pt was transfused 1 unit of PRBCs for HCT of 24
on [**1-1**]. Post transfusion HCT was 26.9 and on [**1-3**] HCT
returned to a preoperative level of 31. Pt was weaned of of the
neo gtt by [**1-2**] and she was transitioned to the regular floor.
In the setting of fluctuating HCTs and pt's complaint of
generalized weakness orthostatics were perfomed on [**1-3**] that
demostrated the patient to be orthostatic with a 25pt drop in
systolic blood pressure from supine to standing without
significant change in her heart rate. She was given a 500cc NS
bolus. The patient was asymptomatic. Systolic blood pressures
ranged from 135-175 with heart rates 55-65. Repeat orthostatics
were again positive however patient remained asymptomatic and
was able to work with Physical Therapy without difficulty. She
remained inhouse for subsequent hypertension and restarted on
her home dose of Diovan 320mg on [**1-3**].
At the time of discharge her neurological exam was stable and
intact. Groin sites remained stable without further oozing.
There was a small dime-sized left groin hematoma. Right groin
site was ecchymotic with no hematoma. Distal lower extremity
pulses were bounding bilaterally. She was tolerating a regular
diet, ambulating without difficulty, afebrile with Systoloc
Blood pressures 90-180. She will followup with her PCP for
close followup of her blood pressure.
Medications on Admission:
clopidogrel 75 mg QD
aspirin 325 mg (EC) QD
butalbital-acetaminophen-caff PRN
escitalopram 20 mg
diazepam 5 mg Q6 hr PRN
famotidine 20 mg QD
Diovan 320mg Daily
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headaches.
Disp:*30 Tablet(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. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior communicating artery aneurysm
Left MCA aneurysm
Discharge Condition:
At discharge the patient is stable, tolerating a regular diet,
ambulating without assistance and afebrile. Blood pressure
continues to fluctuate between
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coiling:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Plavix is no longer needed.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
***PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN [**Name Initial (PRE) **] 2
WEEKS FOR BLOOD PRESSURE MANAGEMENT: During your hospitalization
your blood pressure fluctuated greatly and you were orthostatic
at times. Initially you were managed with fluid boluses for low
blood pressure and then you were restarted on your home dose of
Diovan for high blood pressure. After restarting your Diovan
your blood pressure continued to fluctuate. You will need to be
closely followed by your PCP to titrate your antihypertensive
medications.
Please follow-up with Dr. [**Known lastname **] in 6 weeks for follow-up with
an MRA brain to evaluate the Acomm aneurysm coiling. You will
need a follow-up also in 3 months to discuss further treatment
of the L MCA aneurysm. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Completed by:[**2191-1-4**]
|
[
"V45.4",
"300.4",
"305.1",
"451.82",
"430",
"458.29",
"790.01",
"401.9",
"E879.8",
"998.12",
"729.1",
"V10.05",
"999.2",
"780.79",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
4386, 4392
|
1466, 3425
|
323, 389
|
4493, 4647
|
1416, 1440
|
6769, 7634
|
841, 858
|
3635, 4363
|
4413, 4472
|
3451, 3612
|
4798, 5827
|
5853, 6746
|
873, 1397
|
259, 285
|
417, 568
|
4662, 4774
|
590, 782
|
798, 825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,304
| 154,856
|
49860
|
Discharge summary
|
report
|
Admission Date: [**2148-9-11**] Discharge Date: [**2148-9-18**]
Date of Birth: [**2084-5-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
adhesive tape
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
64 year old with symptomatic paroxysmal atrial fibrillation
status post pulmonary vein isolation now with palpitations on
dofetilide admitted for re-do pulmonary vein isolation -
complicated by perforated left atrial appendage requiring
emergent evauation of cardiac tamponade/ exploration/Maze
Major Surgical or Invasive Procedure:
Emergent mediastinal exploration and evacuation of
pericardial tamponade and control of hemorrhage.
Pulmonary vein isolation using the AtriCure
bipolar RF system with resection of left atrial
appendage.
History of Present Illness:
This patient is a 64 year old
female with paroxysmal atrial fibrillation status post pulmonary
vein isolation by Dr [**Last Name (STitle) **] at [**Hospital 792**]Hospital on
[**2146-7-20**].
She has been doing well until recently when she was hospitalized
in [**Month (only) **] and [**Month (only) 205**] with episodes of symptomatic atrial
fibrillation. During her [**Month (only) 205**] admission she was started on
dofetilide. She continues to have intermittent palpitations on
dofetilide, but no prolonged episodes. She was referred for
re-do pulmonary vein isolation. On admission she complained of
palpitations, shortness of breath, fatigued, and feels clammy
when in atrial fibrillation with occasional lightheadedness.
Denies claudication, edema, orthopnea, PND
Past Medical History:
Atrial fibrillation s/p PVI [**2146-7-20**]
Diabetes mellitus
Hypertension
Arthritis
Thyroid nodule, recent with biopsy negative biopsy for
malignancy
Dyslipidemia
GERD
Recent urinary tract infection
History of anemia
Degenerative disease lower back per patient
S/P Uterine surgery
S/P C-section
S/P lysis of adhesions
S/P Hysterectomy
S/P bone spur removal
Social History:
Lives alone. Recently widowed. Son visiting
until [**9-19**]. Retired teaching assistant at high school level.
Tobacco: Never
ETOH: None
Contact upon discharge: [**Name (NI) **], [**First Name3 (LF) **], will accompany. C:
[**Telephone/Fax (1) 104183**]
Family History:
non-contributory
Physical Exam:
emergent case- unable to obtain admission physical
Pertinent Results:
[**2148-9-16**] 05:50AM BLOOD WBC-8.1 RBC-3.94* Hgb-12.1 Hct-34.2*
MCV-87 MCH-30.8 MCHC-35.4* RDW-14.7 Plt Ct-252#
[**2148-9-11**] 03:30PM BLOOD Neuts-70.1* Lymphs-23.8 Monos-4.2 Eos-1.7
Baso-0.3
[**2148-9-16**] 05:50AM BLOOD PT-15.1* INR(PT)-1.3*
[**2148-9-16**] 05:50AM BLOOD UreaN-15 Creat-0.6 Na-136 K-4.0 Cl-99
PA AND LATERAL CXR
Widened mediastinum has improved. Cardiomegaly is stable.
Pulmonary edema
has almost resolved. Bibasilar atelectasis, larger on the right
side, have
improved. Small bilateral pleural effusions have improved.
Sternal wires are
aligned. There is no evident pneumothorax
TEE
PRE-BYPASS: A small right-to-left shunt across the interatrial
septum is seen at rest which may represent the site of
transseptal puncture from the patient's pulmonary vein isolation
procedure.
There is mild-to-moderate ([**1-21**]+) tricuspid regurgitation.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is no aortic valve stenosis. No aortic regurgitation is
seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. Mitral inflow velocity profile demonstrates
little to no respiratory variation.
There is a moderate sized pericardial effusion. The effusion
appears circumferential. A catheter is seen within the effusion
with a thrombus at the tip.
There is sustained right atrial collapse, consistent with low
filling pressures or early tamponade. Dr. [**Last Name (STitle) 914**] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is on no inotropes. Biventricular
function is good.
There is no pericardial effusion.
There is trivial mitral regurgitation.
No aortic regurgitation is seen.
There is mild to moderate tricuspid regurgitation which is
unchanged from pre-bypass.
The aorta appears intact after removal of the aortic cannula.
Brief Hospital Course:
64 yr old female admitted s/p emergent repair of LAA perforation
(due to perforated left atial appendage in the cath lab during
redo pulmonary vein isolation) and MAZE on [**9-11**]. The surgery was
performed by Dr. [**Last Name (STitle) 914**] please see intraop note for further
details. She arrived from the OR intubated on proprofol. She
weaned and extubated without difficulty by POD#1. Awoke
neurologically intact. She remained hemodynamically stable her
1st night, on POD#1 she had burst of a-fib and was restarted on
dofetilide. On POD #2 she transferred to floor in stable
condition. She was started on lopressor and lasix. Pacing wires
and chest tubes were removed in timely fashion. She had recieved
multiple blood products intraop and postop she was mildly
throbocytopenic. Her platlets have rebounded and she was
restarted on coumadin, her INR goal 2-2.5. She has been followed
by the EP service, her QTC has remained stable and at their
request she is to remain on protonix for one month post-op. She
was started on lasix and gently diuresed, her renal function has
remained stable. Her blood sugars were within normal range on
her preoperative dose of glucophage. She was seen by the PT
service and deem safe for discharge to home. ON POD#5 she was
cleared for discharge to home. All follow-up appointments were
arranged.
Medications on Admission:
Active Medication list as of [**2148-9-10**]:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
DICLOFENAC SODIUM [VOLTAREN-XR] - (Prescribed by Other
Provider)
- Dosage uncertain
DOFETILIDE [TIKOSYN] - (Prescribed by Other Provider) - 500 mcg
Capsule - 1 Capsule(s) by mouth twice daily
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other
Provider)
- 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
as needed
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other
Provider)
- Dosage uncertain
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2
Tablet(s) by mouth twice daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth twice daily
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth every evening
WARFARIN - (Prescribed by Other Provider) - 3 mg Tablet -
Tablet(s) by mouth on Tuesday, Thursday and Saturday as directed
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) -
Dosage uncertain
Discharge Medications:
1. warfarin 1 mg Tablet Sig: as directed based on INR tablets PO
DAILY (Daily): Indication afib
Goal INR 2.0-2.5
.
Disp:*90 tablets* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
12. Outpatient Lab Work
INR check [**9-19**] then 3x/ weekly until stable or as instructed by
DR. [**Last Name (STitle) 7594**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Cardiac tamponade with left atrial tear status post percutaneous
pulmonary vein isolation procedure.
Left atrial repair
MAZE
Paroxysmal atrial fibrillation.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
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**] on [**2148-10-22**] 1:30 in the [**Hospital **] medical
office building [**Hospital Unit Name **]
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2148-9-24**] 10:45 in
the [**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2148-11-21**] 1:40
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 104184**] in [**1-21**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2148-9-19**]
Results to phone fax Dr. [**Last Name (STitle) 7594**] (P) [**Telephone/Fax (1) 104185**]; Fax
[**Telephone/Fax (1) 104186**]
INRs are drawn at Lifespan in [**Location (un) **], RI. [**Telephone/Fax (1) 104187**]
Completed by:[**2148-9-18**]
|
[
"272.4",
"401.9",
"241.0",
"E870.6",
"427.31",
"998.2",
"278.00",
"423.3",
"530.81",
"420.90",
"458.29",
"250.00",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"37.28",
"37.12",
"39.61",
"37.0",
"37.33",
"37.36"
] |
icd9pcs
|
[
[
[]
]
] |
8513, 8576
|
4454, 5792
|
574, 792
|
8777, 8938
|
2381, 4431
|
9855, 11000
|
2277, 2295
|
7001, 8490
|
8597, 8756
|
5818, 6978
|
8962, 9832
|
2310, 2362
|
239, 536
|
2165, 2261
|
821, 1600
|
1622, 1982
|
1999, 2149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,092
| 166,884
|
43451
|
Discharge summary
|
report
|
Admission Date: [**2170-2-10**] Discharge Date: [**2170-2-14**]
Date of Birth: [**2129-6-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Pyridium / Bactrim / Nitrofurantoin /
Dapsone / Quinine / Quinidine / Methylene Blue
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
CC:[**CC Contact Info 93503**]
Major Surgical or Invasive Procedure:
PICC line placement
EGD
History of Present Illness:
This is a 40 year old male with a hx of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] disease, hx
of hepatic adenomas who presented with hypoglycemia. For the
past 2-3 days the patient's glucometer was not working at home.
Per his father his sugars have been erratic. He came in tonight
for further evaluation of his hypoglycemia. While waiting in
the ED, he was noted to have a melanotic stool. His hct was
16.8 (prior to that it had been 25).
.
His vitals were as follows: BP 110/50 P 120s. NGL did not
clear after 1L. The patient did not want to keep the NGT in.
He declined any central access. The patient was seen by GI who
recommended PRBCs, FFP and vitamin K. The patient received 1U
FFP, 1U PRBC and 10mg vitamin K SC. He had an 18 gauge and 20
gauge peripherals placed. The patient was transferred to the
unit for further monitoring.
.
Per the patient's parents for the past several days he has been
taking advil for neck pain. A total of 14 pills.
.
ROS: He denies any chest pain, shortness of breath. He
endorses decreases PO intake [**12-30**] to TMJ pain. He had not
noticed any melanotic stool at home.
Past Medical History:
1)[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] disease
2)s/p porto-caval shunt
3)Anemia
Social History:
Lives independently in [**Location (un) 745**]. No current tobacco, alcohol, or
IVDA.
Family History:
Brother passed away from complications of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] diease.
Physical Exam:
Physical Exam:
T: 97.6 BP: 123/67 P: 105 (105-118) RR: 20 (18-25) O2 sats:
100%
Gen: thin chronically ill appearing male in NAD
HEENT: MM dry, OP clear
CV: tachy, S1S2, no gmr
Resp: CT b/l no rrw
Abd: distended abdomen, hepatomegaly, caput medusae
Ext: 1+pitting edema, 2+ dp b/l
Neuro: A&O X3
Pertinent Results:
[**2170-2-11**] EGD
Findings:
Esophagus:
No blood, varices or lesions in the esophagus.
Stomach:
Lumen: An extrinsic gastric deformity was noted in the stomach
body. It is unclear if this represents external compression from
the hepatic adenomas or a large hiatal hernia.
Other There was no blood or lesions seen in stomach.
Duodenum:
Excavated Lesions
A single acute 2cm ulcer was found in the proximal bulb. An
adherent clot with oozing blood was seen. 4 2 cc.Epinephrine
1/[**Numeric Identifier 961**] injections were applied around ulcer base. The clot was
irrigated extensively but could not be dislodged. [**Hospital1 **]-CAP
Electrocautery probe was used to attempt to dislodge clot
unsuccessfully. Electrocautery was performed around ulcer and
then in middle of clot. 3 2cc Epi 1/[**Numeric Identifier 961**] injections were again
applied around ulcer base with successful hemostasis.
Impression: No blood, varices or lesions in the esophagus.
Deformity of the stomach body
There was no blood or lesions seen in stomach.
Ulcer in the proximal bulb (injection, thermal therapy)
Otherwise normal EGD to second part of the duodenum
.
[**2170-2-11**] CXR:
IMPRESSION:
1. Left basilic PICC line terminates in superior vena cava.
2. No active disease in the chest.
.
PERTINENT RESULTS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2170-2-14**] 05:59AM 9.5 3.00* 8.7* 26.5* 89 29.1 32.9
18.4* 355
[**2170-2-14**] 12:00AM 27.0*
[**2170-2-13**] 06:26PM 27.1*
[**2170-2-13**] 12:25PM 27.2*
[**2170-2-13**] 06:00AM 13.0* 3.03* 8.8* 26.4* 87 29.2 33.5
17.2* 328
[**2170-2-13**] 12:14AM 23.1*
[**2170-2-12**] 05:21PM 24.9*
[**2170-2-12**] 01:09PM 25.1*
[**2170-2-12**] 06:00AM 24.9*
[**2170-2-12**] 01:21AM 11.3*1 2.94*# 8.7* 24.8* 85 29.6 35.0
17.5* 313
[**2170-2-11**] 07:28PM 25.4*
[**2170-2-11**] 03:13PM 25.3*#
[**2170-2-11**] 12:09PM 10.71 2.29*# 6.7*# 19.7* 86 29.2 34.0#
17.6* 336
[**2170-2-11**] 07:07AM 20.2*#
[**2170-2-11**] 03:20AM 10.2# 1.80* 4.9* 15.9* 88 27.0 30.6*
18.6* 394
[**2170-2-10**] 11:55PM 7.21 1.63* 4.3* 14.9* 92 26.5* 28.8*
19.3* 432
[**2170-2-10**] 04:25PM 9.81 1.79*# 4.6*# 16.8*# 94 25.7* 27.4*
20.8* 594
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-2-14**] 05:59AM 71 6 0.3* 137 3.8 97 21* 23
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
[**2170-2-14**] 05:59AM 14 28 [**2170**]* 2.4*
[**2170-2-13**] 06:00AM 15 47* 1872* 2.5*
[**2170-2-12**] 01:21AM 16 109* [**2170**]* 3.7*
.
Lactate Na K Cl calHCO3
[**2170-2-13**] 06:35PM 7.6*1
[**2170-2-11**] 12:30AM 15.2*
[**2170-2-10**] 05:21PM 16.1
Brief Hospital Course:
A/P: 40 y/o male with [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) **] disease who presented with
erratic glucose levels, course now complicated by melanotic
stools.
.
# GIB: The etiology of the patient's bleeding was most likely
NSAID related given his underlying ESLD from [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**]
disease, coagulopathy and hemangiomas. He initially had a
normal EGD several weeks ago. Patient has been taking NSAIDS
for the past couple days for neck pain which have caused a
gastritis. Pt refused PIVs, he accepted a PICC Line for labs
and transfusions. After receiving 4U of PRBCs, the patient's Hct
went from 14.9 to 15.9. He received another 4U. His Hct would
finally improve to 25.4, his baseline. d\Due to the need for
aggressive resuscitation, an EGD was done which showed a 2 cm
ulcer in the proximal bulb. An adherent clot was oozing.
Despite irrigration it could not be dislodged. Epi and bicap
were used. He was continued on PPI [**Hospital1 **], H pylori serology was
negative. His HCT remained stable, tolerated POs well. Pt and
family did not discuss the possibility of re-bleeding, per pt he
stated he "was not going to re-bleed and the problem was fixed".
Per GI team, it was concerning that he may re-bleed given his
severe liver disease. Plan was to have pt, family and PCP have
this discussion given high risk of rebleeding. He was advised to
never take NSAIDs, ibuprophen or aspirin again. If he were to
rebleed he would require IR for cauterization. He did not
rebleed at time of discharge. He had no further
melena/hematochezia at time of discharge.
.
#[**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**]: He was continued on allopurinol. He was Cont D10
1/2 NS, must always be on until patient is transitioned to corn
starch. His fs were checked q1h to q2h, keep BS >70. He was then
transitioned to his cornstarch regimen per his specialists
recommendations. He tolerated POs and cornstarch regimen at time
of discharge. His lactate improved at time of discharge.
.
#. Neck Pain: c/w MSK in origin, no NSAIDs/ibuprophen due to
GIB. He was given low dose oxycodone for pain prn.
.
#. Thrush: pt noted to have thrush, he was started on nystatin
S&S for short course.
.
#. Code: Full
#. Dispo: Home with prior private services to be resumed as an
outpt
Medications on Admission:
allopurinol
corn starch
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Corn Starch Powder Sig: Per protocol PO q4h ().
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Nystatin 100,000 unit/mL Suspension Sig: 5-10 MLs PO QID (4
times a day) as needed for thrush for 5 days.
Disp:*200 ML(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
-UGIB
-Hypoglycemia
.
Secondary:
-[**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**]
-s/p porto-caval shunt
-chronic anemia
-hepatic adenomas/hemangiomas
Discharge Condition:
Stable, no melena, no hematochezia, tolerating cornstarch
regimen, tolerating POs, ambulated with PT.
Discharge Instructions:
You were admitted for an upper GIB, you hematocrit was stable,
you received 1 unit packed red blood cells. You had no further
rectal bleeding or melena.
.
If you have further rectal bleeding, black/tarry stools, feel
lightheaded, dizzy, have chest pain, have difficulty breathing
please call your physician or go to the emergency.
.
You were started on nystatin swish and swallow for thrush,
please take this for 5 days. You may take oxycodone for pain.
You must never take ibuprophen, advil or any other NSAIDs given
your significant bleeding risk and bleed during this admission.
Followup Instructions:
You need to follow up with your primary care physician [**Last Name (NamePattern4) **] 1
week, please call Dr.[**Name (NI) 16259**] office at [**Telephone/Fax (1) 19196**] for an
appointment.
Follow up with your specialist in [**State 108**], as directed.
Completed by:[**2170-2-20**]
|
[
"276.2",
"251.2",
"E935.9",
"532.40",
"211.5",
"271.0",
"280.0",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"38.93",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8222, 8280
|
5210, 7565
|
398, 423
|
8503, 8607
|
3635, 5187
|
9239, 9527
|
1858, 1976
|
7639, 8199
|
8301, 8482
|
7591, 7616
|
8631, 9216
|
2006, 2291
|
329, 360
|
451, 1606
|
1628, 1738
|
1754, 1842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,977
| 160,489
|
111
|
Discharge summary
|
report
|
Admission Date: [**2194-2-16**] Discharge Date: [**2194-2-19**]
Date of Birth: [**2130-11-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
Hyperglycemia, unsteady gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 yof with history of of DM Type I, CAD s/p MI s/p CABG, HTN,
Hyperlipidemia, PVD s/p left popliteal bypass who presents with
hyperglycemia. Pt was recently discharged after admission for
hyperglycemia and TIA. Patient states she was home and not
feeling herself. +LH when walking and felt unsteady with gait.
Normally has no issues with her gait and for the past few days
has had to hold onto the wall while walking. Denies any HA,
dizziness, weakness or numbness. Patient reports confusion with
her medications at home. Her home VNA separates her medications
but she did not understand how to use the boxes and therefore
did not take her medications. She denies insulin non-compliance
but reports that her VNA asked her to take insulin today and she
only drew air into the syringe without fluid. She feels very
distressed about this as she has been taking insulin all of her
life and does not understand why she is having trouble. She
reports +nausea two night ago with several bouts of emesis,
non-bloody. Emesis resolved yesterday morning. She denies any
CP, SOB, cough, fevers, chills, abd pain, diarrhea, or dyuria.
She does report polydypsia but denies polyphagia or polyuria.
She instead endorses decreased appetite over the past few days.
Patient states she stated she "wanted to kill herself" in the ED
but denies any SI or HI currently. She denies feeling depressed
but just feels distressed about feeling ill over the past few
weeks.
In the ED, initial vs were: T 98.1 P 87 BP 146/66, HR 16 100% on
RAO2 sat. Patient was given 10u Humalog insulin SQ and then 1h
later stared on Regular Insulin gtt. She received 1.5L IVF.
EKG with new ST depressions laterally, first set negative . No
abnormalities on neuro exam. Denying CP. Pt is having passive
SI, no active plan.
Past Medical History:
PVD,s/p left femoral to above knee popliteal bypass
in [**1-/2191**] with redo s/p left femoral to below-knee popliteal
artery bypass graft [**8-/2192**]
Type I DM
CAD,s/p MI [**2170**] and post op in [**8-/2192**], s/p CABG x 3(LIMA-LAD,
SVG-PDA, SVG-OM) in [**11/2181**]
Hypertension
H/o tendonitis
S/P TIA in 7/94
S/P remote bilateral CEA
Hyperlipidemia
Hypothyroidism
h/o hyperkalemia
Chronic renal insufficiency
Atrial fibrillation post operatively
Retinopathy
H/O cataracts, s/p bilateral lens implants
Arthritis
Depression
Social History:
Quit smoking 5-6 days ago, prior 0.5 ppd x 20-30 years tobbacco,
denies alcohol, IVDU. lives at home alone, former real estate
employee. Married X 2 but now divorced.
Family History:
Mother died of neuroblastoma at age 60, father had
[**Name2 (NI) 1249**] and CHF, her sister is healthy. No children.
Physical Exam:
Vitals: T: 97.3 BP: 147/39 P: 75 R: 18 99%RA
General: Alert, oriented to person, place and time, no acute
distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, +II/VI SEM at apex,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, +abdominal
bruit
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, 5/5 strength all extremities, sensation
intact, reflexes intact
Pertinent Results:
[**2194-2-16**] 11:35AM BLOOD WBC-9.2 RBC-3.79* Hgb-11.0* Hct-34.0*
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.7 Plt Ct-316
[**2194-2-17**] 06:06AM BLOOD WBC-7.4 RBC-3.46* Hgb-10.0* Hct-29.7*
MCV-86 MCH-28.8 MCHC-33.5 RDW-14.6 Plt Ct-273
[**2194-2-16**] 11:35AM BLOOD Glucose-566* UreaN-46* Creat-2.7*#
Na-132* K-4.9 Cl-89* HCO3-23 AnGap-25*
[**2194-2-16**] 05:18PM BLOOD Glucose-52* UreaN-40* Creat-2.1* Na-141
K-3.6 Cl-101 HCO3-29 AnGap-15
[**2194-2-17**] 06:06AM BLOOD Glucose-131* UreaN-29* Creat-1.6* Na-137
K-4.0 Cl-104 HCO3-24 AnGap-13
[**2194-2-16**] 11:35AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2194-2-17**] 06:06AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2194-2-16**] 11:35AM BLOOD Acetone-SMALL
[**2194-2-16**] 02:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2194-2-16**] 05:18PM BLOOD Calcium-9.2 Phos-2.7 Mg-2.0
[**2194-2-17**] 06:06AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9
Images:
CXR [**2194-2-16**]: prelim
no acute process
CT Head w/o contrast [**2194-2-16**]:
No acute intracranial pathology identified
EKG: NSR, TWI Lead I, II, aVF. ST depressions V4-V6. Previous
ECGs reviewed with similar finding in the past, currently
depression slightly worsened.
Brief Hospital Course:
63 yof with history of of DM Type I, CAD s/p MI s/p CABG, HTN,
Hyperlipidemia, PVD s/p left popliteal bypass who presents with
DKA, ARF and unsteady gait.
# DKA: Patient presented with AG of 20, Glucose > 500 along with
small amt of serum acetone and +ketones in her urine which are
all consistent with DKA. Following ICU admission with an insulin
drip pt was transitioned to Insulin SQ regimen of Glargine 8u
qAM, 17u qPM. Cause of DKA likely poor techniquie with insulin
administration. VNA noticed pt was drawing up air rather than
insulin, during hospitalization pt was observed giving her own
insulin and again was seen drawing up air. Also concerned that
Chantix may have contributed; numerous reports of porr diabetes
control submitted to FDA but not in medical literature. [**Last Name (un) **]
were consulted during admission and pt was set up for an
appointment with [**Last Name (un) **] to undergo transition to insulin pain
for ease of administration.
# Acute Kidney Injury: Patient's baseline Creatinine was 1.6-2.
On admission she was noted be 2.7, likely pre-renaal in the
setting of DKA. Following IV fluid administration pt's
Creatinine and responded and trended back to baseline.
# CAD: Pt has a history of coronary disease, on admission she
was noted to have some increase in ST depression in the lateral
leads. Cardiac enzymes were cycled and were negative. Recommend
pt undergo a stress test as an outpatient.
# Depression: Pt was continued on her home regimen of
Citalopram.
Medications on Admission:
Atorvastatin 40 mg PO DAILY
Calcitriol 0.25 mcg PO DAILY
Clopidogrel 75 mg Tablet PO DAILY
Levothyroxine 112 mcg PO DAILY
Pantoprazole 40 mg PO Q12H
Aspirin 81 mg Tablet PO DAILY
Docusate 100 mg PO BID
Senna 8.6 mg Tablet PO BID PRN
Irbesartan 300 mg PO QDAILY
Misoprostol 200 mcg PO QIDPCHS
Sucralfate 1 gram PO QID
Citalopram 20 mg PO DAILY
Amlodipine 5 mg PO DAILY
Insulin Glargine 8 U every morning and 17 U at bedtime units
Subcutaneous twice a day.
Metoprolol Succinate 25 mg PO once a day.
Insulin Lispro 100 unit/mL Solution Sig: per sliding scale U
Subcutaneous four times a day: please check prior to every meal
and before bedtime; give in addition to glargine.
Discharge Medications:
1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
11. Misoprostol 200 mcg Tablet Sig: One (1) Tablet PO QIDPCHS (4
times a day (after meals and at bedtime)).
12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
15. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous qAM.
16. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17)
units Subcutaneous at bedtime.
17. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
unit Subcutaneous four times a day: Please see sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital for a condition called
Diabetic Ketoacidosis (something that occurs when you have high
blood sugars). Whilst in the hospital we monitored your blood
sugars and had the diabetes specialists see you. We think you
may have to change the way you give your insulin to an insulin
pen, you will need to get teaching at the [**Last Name (un) **] centre for it.
Please follow up with all of your appointments.
***We made changes to your insulin medication.***
1. Please take 8 units of your Insulin Glargine in the morning.
2. Please take 17 units of your Insulin Glargine before bedtime.
3. Please take your regular insulin per sliding scale.
4. Please increase your aspirin to 325mg once a day.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1252**], [**Name Initial (NameIs) **].D. Date/Time:[**2194-2-21**] 1130
([**Last Name (un) **] DIABETES CENTRE)
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. Date/Time:[**2194-2-27**] 12:20
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2194-3-10**] 1:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2194-3-11**] 11:00
|
[
"403.90",
"584.9",
"585.9",
"250.13",
"414.00",
"244.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8696, 8754
|
4966, 6473
|
345, 351
|
8820, 8839
|
3745, 4943
|
9612, 10307
|
2931, 3050
|
7196, 8673
|
8775, 8799
|
6499, 7173
|
8863, 9589
|
3065, 3726
|
277, 307
|
379, 2176
|
2198, 2730
|
2746, 2915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,710
| 185,394
|
47722
|
Discharge summary
|
report
|
Admission Date: [**2167-7-10**] Discharge Date: [**2167-7-20**]
Date of Birth: [**2105-10-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin /
Clindamycin
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
nonhealing foot ulcer
Major Surgical or Invasive Procedure:
Foot Debridement
Angiogram
History of Present Illness:
61 yo woman with complicated PMH dominated by CAD,
multifactorial paraplegia, DM, recurrent VTE, PVD, reactive
airways
disease and other issues listed below admitted for left lower
extremity foot ulceration. She was seen in podiatry clinic today
and was admitted for IV antibiotics and vascular evaluation.
Currently she has no complaints and no pain in the left lower
extremity. She was switched over to lower dose of NPH for last
48 hrs and has had better control of her blood glucose, this AM
was 102 per what she tells me. She was also placed empirically
on Keflex 2 days ago for presumed right lower extremity
cellulitis. She denies any chest pain, dyspnea, DOE, PND,
abdominal pain, diarrhea, increased edema.
Past Medical History:
PMH: reviewed with patient
History of recurrent DVTs
--first DVT in [**2148**], given coumadin for 6 months, unknown why
she had DVT
--second DVT in [**2162**], given coumadin then plavix
--third DVT in [**2164-4-11**], now on coumadin and plavix
MS diagnosed in [**2150**], wheelchair bound since [**2151**]
[**12-19**] s/p 2 stents placed
s/p CVA in [**2152**]
h/o spinal cord compression s/p C3-7 and T2-11 laminectomies and
fusion, with residual paraparesis and absent sensation in
bilateral LE. No sensation below T10
Seizure disorder, with staring spells due to MS
T2DM
Hypertension
Hypercholesterolemia
Sarcoidosis
Uterine/cervix cancer s/p radical hysterectomy
Asthma
Cardiac arrest after delivery of her 1st child at 36 yo
COPD
OSA no BiPAP use
C section at 36 yo
Social History:
Social History: Lives in [**Location 2312**], Wheelchair bound, lives
with daughter (24 yo), but is able to cook own meals and clean
around the house; former alcoholic, sober since [**94**] y/o when
pregnant, 70 pack-year tobacco quit at 36yo; no hx of drug use;
retired RN at [**Hospital1 756**]. She is single.
Family History:
Family History: Multiple relatives with DM, CAD, HTN, asthma,
and cancers (at least two with brain cancers). Mother died age
50 brain cancer had DMII and "mild [**Hospital1 **]", father died age 48 MI
and had DMII. No FH of MS, or DVT/PE. Brother deceased 53yo had
3 bypass surgery.
Physical Exam:
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: bilaterally feet are wrapped
Pertinent Results:
[**2167-7-10**] 03:50PM GLUCOSE-202* UREA N-27* CREAT-1.0 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-30 ANION GAP-12
[**2167-7-10**] 03:50PM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-2.1
[**2167-7-10**] 03:50PM WBC-9.6 RBC-4.09* HGB-11.9* HCT-35.4* MCV-87
MCH-29.1 MCHC-33.6 RDW-14.7
[**2167-7-10**] 03:50PM NEUTS-75.2* LYMPHS-19.4 MONOS-3.3 EOS-1.8
BASOS-0.3
[**2167-7-10**] 03:50PM PLT COUNT-271
[**2167-7-10**] 03:50PM PT-15.6* PTT-25.9 INR(PT)-1.4*
[**2167-7-10**] Right and Left Foot XRays
LEFT FOOT:
A soft tissue defect is seen along the medial aspect of the
first MTP joint.
There is no evidence of underlying periosteal reaction,
osteopenia or cortical
destruction to suggest osteomyelitis.
Degenerative changes are seen throughout the DIP joints and
great toe IP joint
as well as the intertarsal joints. Note is made of both plantar
and dorsal
calcaneal spurs. Degenerative changes are also seen at the
tibiotalar joint.
RIGHT FOOT:
No soft tissue abnormalities appreciated on this right foot
x-ray. No
evidence of subcutaneous gas. No evidence of periosteal
reaction,
osteopenia or cortical destruction to suggest osteomyelitis.
Arterial
calcifications are visualized.
Degenerative changes are seen throughout the IP joints,
intertarsal joints and
tibiotalar joint. Plantar and dorsal calcaneal spurs are also
seen in the
right foot.
---------------
[**2167-7-10**] CXR - Bibasilar atelectasis. No acute cardiopulmonary
abnormality.
----------------
Right LE US - [**2167-7-14**] -
Limited study. No evidence of deep venous thrombosis in the
right common
femoral vein, proximal superficial femoral vein, popliteal or
calf veins.
Evaluation of the right mid and distal superficial femoral vein
was limited, and deep venous thrombosis cannot be excluded
secondary to limitations
--------------
LABS ON DISCHARGE:
[**2167-7-20**] 05:30AM BLOOD WBC-8.9 RBC-3.46* Hgb-10.3* Hct-31.2*
MCV-90 MCH-29.9 MCHC-33.1 RDW-15.6* Plt Ct-340
[**2167-7-20**] 05:30AM BLOOD Glucose-183* UreaN-23* Creat-1.1 Na-139
K-5.0 Cl-104 HCO3-29 AnGap-11
[**2167-7-20**] 05:30AM BLOOD ALT-38 AST-26 AlkPhos-42 TotBili-0.1
[**2167-7-20**] 05:30AM BLOOD Lipase-76*
[**2167-7-15**] 09:40AM BLOOD TSH-2.0
[**2167-7-16**] 05:50AM BLOOD Carbamz-5.7
[**2167-7-15**] 09:40AM BLOOD Carbamz-7.5
MICRO:
[**2167-7-10**] Blood cx: negative
[**2167-7-15**] Urine cx: negative
Brief Hospital Course:
1. Foot Ulcers
She was initially admitted to the podiatry service on [**2167-7-10**]
for debridement of left foot wound. She was evaluated by
vascular surgery who performed right side angiography, revealing
significant SFA and popliteal disease which was not intervened
upon. She was covered with cipro/flagyl/vanco (Day 1 = [**2167-7-10**]),
and remained afebrile without leukocytosis throughout her
hospital course. She was then transitioned to bactrim to
complete a 2 week course of outpatient therapy, last day
[**2167-7-28**]. She will be following up in 1 week with Dr. [**Last Name (STitle) **]. She
will have home VNA for assistance with daily dressing changes.
2. Seizures
She was to be discharged to home with TMP/SMX and then follow-up
with podiatry in one week. On the morning of likely discharge
while eating breakfast, she asked to be transferred to the
comode to pass a BM. On the comode she describes acute onset of
nausea and weakness. She then was witnessed to have multiple,
recurrent brief episodes of "staring spells" during which she
was unresponsive. In between these episodes she responded
appropriately to voice. Based on concern for seizures, she was
given ativan 1mg x 2 without response. Neurology consult was
obtained who described persistant complex partial status, and
recommended ativan 2mg x 1 with subsequent dilantin loading. The
pt remained in status for ~30-45 min.
By report, during the episode, her O2 sats dropped to 79%RA,
but BP was stable. Post event, transfer note indicates VS 98.8
109/68 92 14 98%3L. Immediately after her the seizures, pt was
with the above vital signs, sitting up in bed, somnolent,
responsive to voice. Her somnolence intermittently resolved,
notably upon the arrival of her PCP whom she recognized and
spoke with. MICU transfer was requested in the setting of
persistent complex partial status for closer airway monitoring
and for evaluation of potential contribution by patient's
multiple medical conditions. Etiology of her seizures was
thought likely related to poorly controlled seizures, further
triggered by infection and decreased seizure threshold in the
setting of quinolone therapy.
On the floor, she remained seizure free. She refused EEG as
recommended by Neuro. She was started on Zonegram per Neuro in
addition to her home Carbamazepine. IV Dilantin was
discontinued. CT Head was negative for bleed. She was resumed on
her home coumadin. Pt has an appt scheduled with neuro for
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], given limited availability of
appts with Dr. [**Last Name (STitle) **]. She was given the number to call to
check for cancellations with Dr. [**Last Name (STitle) **].
.
#. h/o DVT
Pt had been transitioned off coumadin in anticipation of wound
debridgement/surgical intervention. She was resumed on Coumadin
with Lovenox bridge after CT Head negative for bleed. She was
discharged home on her home coumadin dose (no Lovenox bridge,
with hx of remote and fully treated DVT), with INR to be checked
and followed by the [**Hospital 2786**] clinic.
.
# Transaminitis. New on [**7-15**] AM labs (but no LFTs done prior in
admission). Etiology unclear - ?new drug effect. Seems soon for
dilantin (within ~1 hour). Cipro a rare cause; should not be
flagyl or vanco related. No rash or other evidence of drug
reaction. Could also possibly be related to anesthesia meds
during angiography. Atorvastatin was held and will be
re-evaluated for resumption as outpatient. On day of discharge
transaminitis had resolved. Further etiology will be evaluated
as outpatient.
.
# Elevated lipase: unclear etiology. Appears to have remained
chronically elevated over past few years. Pt otherwise
asymptomatic. Will be followed up further as outpatient.
.
# Deconditioning: pt with difficulty transferring from bed to
commode/wheelchair, which improved during her stay.
#. DM: stable, with sugars occasionally elevated in the pm.
Continue SSI and fixed dose, with further adjustment at PCP
[**Last Name (NamePattern4) 702**].
.
#. Coronary Artery Disease: stable, continue beta blocker, ACEI,
plavix, nitrate. Atorvastatin held given new transaminitis.
Consider resuming this as outpatient. Not on aspirin due to
allergy.
.
# Abnormal UA- trace leuks, large blood. Asymptomatic with
negative urine culture. Most likely [**3-16**] foley trauma. Was
removed with incident, and no hematuria resulting.
.
# FEN: diabetic (though refuses, switched to regular), replete
electrolytes prn
# Prophylaxis: anticoagulated with coumadin
# Access: peripherals
# Code: FULL CODE
Medications on Admission:
HOME MEDICATIONS:
1. Albuterol nebs prn
2. Atorvastatin 80mg PO daily
3. Carbamazepine 200mg PO qid
4. Cephalexin 500mg PO qid (Day 1 - [**2167-7-8**], 10 day course)
5. Clopidogrel 75mg PO bid
6. Fluticasone 4400mcg puffs [**Hospital1 **]
7. Vicodon tab qid
8. Imdur 90mg PO daily
9. Lisinopril 5mg PO daily
10. Metoprolol Succinate 200mg PO daily
11. Nitroglycerin prn
12. Ranitidine 150mg daily
13. Tramadol 50mg PO qid
14. Warfarin 5mg PO daily
15. Acetaminophen 650mg PO q6-8h prn headache
16. Regular insulin 15 units q AM / 10 units q PM
17. NPH 70 units q AM / 40 units q PM
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
8. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO QHS (once
a day (at bedtime)).
Disp:*30 Capsule(s)* Refills:*1*
9. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): see sliding scale.
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Seventy
(70) units Subcutaneous qAM.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
(40) mg Subcutaneous qPM.
12. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Ten
(10) units Subcutaneous qAM.
13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Ten
(10) units Subcutaneous qPM.
14. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) ampule Inhalation every six (6) hours.
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
16. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 mins as needed for chest pain.
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever.
19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO twice a day.
20. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): Last day [**2167-7-28**].
Disp:*17 Tablet(s)* Refills:*0*
21. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
L foot ulcer infection
Status epilepticus
Secondary:
Partial complex seizure disorder
Coronary artery disease
Multiple sclerosis
Sarcoidosis
Diabetes mellitus
Hypertension
History of deep vein thrombosis/pulmonary embolism
Hx of cerebrovascular disease and transient ischemic attacks
Discharge Condition:
Good, hemodynamically stable, seizure-free on day of discharge
Discharge Instructions:
You were admitted for management of your L foot ulcer. You were
seen by Podiatry and started on IV antibiotics. Your ulcer was
also debrided. You will be finishing a course of PO antibiotics.
.
You experienced persistent seizures while here, and were briefly
in the MICU for further management. You were seen by Neuro, and
will be going home with a new anti-seizure medication in
addition to your current meds.
.
Please have your INR checked Wednesday, [**2167-7-22**] with results
faxed to Dr.[**Name (NI) 10373**] office Fax:([**Telephone/Fax (1) 8137**]. Continue
your home dose of Warfarin 10mg PO daily. The [**Hospital 2786**]
clinic will be in contact with you regarding further INR checks
and dose changes.
.
The following changes were made to your medications:
- DECREASE morning Regular insulin to 10 units
- STOP Cephalexin antibiotic
- Zonegran 300mg PO every night for seizures
- Bactrim DS 1 tab PO twice daily for foot ulcer x 2 weeks, last
day [**2167-7-28**]
- STOP Atorvastatin for now given elevated liver enzymes
If you experience any new weakness, numbness, confusion, nausea,
vomiting, increased drainage/pain/redness near your ulcers,
fevers, chills, increase in or change in type of seizures, or
Followup Instructions:
Please attend your follow-up appointments below:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine
Date and time: Tuesday [**2167-7-28**] at1:10 PM
Location: [**Hospital 18**] [**Hospital3 **] [**Location (un) 895**] [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 1300**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**]
Specialty: Neurology
Date and time: Monday [**2167-8-3**] at 10:00
Location [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) 858**]
Phone number: ([**Telephone/Fax (1) 40691**]
Special instructions if applicable: Please make sure a referral
is in place for this appointment. Call Dr.[**Name (NI) 10373**] office
for this referral prior to the appointment. Dr. [**Last Name (STitle) **] was
booked far into the late year, so you can call the number above
to check for cancellations.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2167-7-17**] 1:20
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2167-7-24**] 1:00
Provider: [**Name10 (NameIs) **] RM 3 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2167-7-28**]
9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2167-7-20**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.42",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
12738, 12796
|
5408, 10008
|
354, 382
|
13134, 13199
|
3021, 4842
|
14469, 16093
|
2288, 2556
|
10642, 12715
|
12817, 13113
|
10034, 10034
|
13223, 14446
|
2571, 3002
|
10052, 10619
|
293, 316
|
4861, 5385
|
411, 1129
|
1151, 1925
|
1957, 2256
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,516
| 160,629
|
8155
|
Discharge summary
|
report
|
Admission Date: [**2107-3-12**] Discharge Date: [**2107-3-13**]
Date of Birth: Sex: M
Service:
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman
with a history of cirrhosis, end-stage renal disease, severe
right sided heart failure with severe pulmonary hypertension
and a recent admission here in [**2106-12-23**] for CHF and
pulmonary edema, and again in [**2107-1-23**] for sepsis and
hypotension. His echocardiogram revealed severe pulmonary
hypertension and right-sided heart failure as well as
mild-to-moderate effusions. He was sent home 2-3 weeks prior
to admission on low-dose metoprolol and lisinopril for CHF.
He had been doing relatively well for the initial 2-3 days,
but had to discontinue lisinopril and metoprolol for
persistent hypotension. His clinical condition continued to
deteriorate with more weakness, more anorexia, and worsening
hypotension. He was started on midodrine for hypotension,
but without any improvement. He was not able to tolerate his
regular hemodialysis scheduled yesterday due to hypotension.
While in the Emergency Room, his bedside echocardiogram
revealed moderate effusions, but otherwise he remained
afebrile with persistent hypotension.
REVIEW OF SYSTEMS: No fever or chills. No cough, chronic
chest pressure. No worsening of shortness of breath, feeling
weak, but no dizziness or lightheadedness. He complained of
anorexia, but no nausea or vomiting. No abdominal pain. No
headache.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to reflux disease.
2. Cirrhosis of unknown etiology.
3. CHF.
4. Paroxysmal atrial fibrillation.
5. Right sided heart failure with severe pulmonary
hypertension.
6. Adrenal insufficiency.
7. Pericardial effusion.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Prednisone 10 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Midodrine 2.5 mg q.[**3-29**]. prn.
4. Protonix 40 mg p.o. q.d.
5. Renagel.
6. Nephrocaps.
7. Colace.
8. Metoprolol 12.5 mg b.i.d.
9. Lisinopril 2.5 mg p.o. q.d. Metoprolol and lisinopril had
been held in the past few days.
10. Nystatin swish and swallow.
SOCIAL HISTORY: No tobacco or alcohol.
FAMILY HISTORY: No coronary artery disease or renal disease.
EXAM IN THE EMERGENCY ROOM: Afebrile, blood pressure 77/54,
heart rate 100, respirations 99% on room air. General: He
is a cachectic man, elderly looking than his stated age.
Head and neck exams: Increased JVP up to the jaw.
Oropharynx clear. Cardiovascular: Regular, rate, and
rhythm, [**2-26**] holosystolic murmur at the left lower sternal
border. Lungs: Decreased breath sounds at base halfway up,
no egophony. Abdomen is soft and nontender. Extremities:
1+ pitting edema. Neurologic: No flaps.
LABORATORY WORK ON ADMISSION: White count of 9.8,
differential of 89% neutrophils, 2% bands, 5% lymphocytes, 3%
monocytes, hematocrit of 37.9, platelets 201. Coags: PT
13.1, PTT 32, INR of 1.1. Chem-7: Sodium 135, potassium
4.4, chloride 95, bicarb 30, BUN 38, creatinine 5.5, glucose
86.
Chest x-ray showed increased left pleural effusion with left
lower lobe collapse or consolidation. There is a small right
pleural effusion present as well.
HOSPITAL COURSE: Patient was initially admitted to MICU for
his complete medical history and persistent hypotension.
However, given his continuing deterioration and poor
prognosis, the patient and his family decided not to go for
aggressive management. He was made CMO, and he was
transferred out to the floor and passed away the next day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ACV
Dictated By:[**Last Name (NamePattern1) 4432**]
MEDQUIST36
D: [**2107-5-3**] 16:16
T: [**2107-5-4**] 08:23
JOB#: [**Job Number 29036**]
|
[
"403.91",
"572.3",
"416.8",
"423.9",
"458.9",
"571.5",
"428.0",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2215, 2789
|
3244, 3797
|
1282, 1516
|
140, 154
|
183, 1262
|
2804, 3226
|
1538, 2157
|
2174, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,808
| 147,377
|
3090
|
Discharge summary
|
report
|
Admission Date: [**2130-10-20**] Discharge Date: [**2130-10-27**]
Date of Birth: [**2076-4-6**] Sex: M
Service: SURGERY
Allergies:
Phenergan
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Left adrenal pheochromocytoma.
Major Surgical or Invasive Procedure:
Left adrenalectomy.
History of Present Illness:
The patient is a 54-year-old man with a previous somewhat
complicated medical history significant for placement of a
mechanical mitral valve approximately 15 years ago. The patient
is on Coumadin for this valve prosthesis since then. In
addition,the patient has atrial fibrillation and occasional
supraventricular tachycardia which are additional indications
for his Coumadin treatment.On a recent abdominal CT scan, the
incidental finding of an approximately 4.5 cm left adrenal mass
was found.This prompted an endocrinological workup providing
evidence of pheochromocytoma with elevated both plasma and
urinary catecholamines.The patient has now been appropriately
alpha blocked for approximately 2 weeks with the most recent
dose of phenoxybenzamine being 30 mg b.i.d. The patient has
been admitted to the hospital a couple of days before surgery to
be bridged with heparin drip considering his mitral valve
prosthesis and after having stopped his Coumadin about 5 days
ago.The patient is scheduled to undergo a left adrenalectomy
today.Risks and benefits associated with procedure have been
discussed in great detail and the consent form has been signed.
Past Medical History:
- Hyperlipidemia
- Hypertension (patient and wife both deny this history)
- History of Atrial fibrillation/flutter s/p DCCV ([**8-16**]) and
ablation ([**9-16**])
- History of Prostatitis
- Herpes Simplex I (takes Valtrex prn)
- Hemorrhoids
PSH:
- Reveal Device Implant [**2129-11-5**]
- cardiac ablation ([**8-16**])
- s/p Mechanical St. [**Male First Name (un) 923**] mitral valve replacement in [**2115**]
- s/p Left knee Surgery
- Umbilical hernia repair
- Lipoma removal, right shoulder
Social History:
Married, lives at home with his wife. [**Name (NI) **] is employed as a
facilities manager.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Mother - htn, DM, arthritis, [**Name (NI) 2091**].
Father had quadruple CABG and deceased [**3-9**] cancer.
Brother - htn, hyperlipidemia, sister - thyroid abnormalities.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Vitals:98.6,77, 110/69,18, 98% RA
General-NAD,alert,oriented
Respiratory:clear
Cardiac:RRR,audible S1S2 with mechanical click over left lateral
cardiac border
Abdomen:soft,nontender,non-distended
Incision: left abdominal incision c/d/i, no erythema
Extremities:warm,well,perfused, no C/C/E
Pertinent Results:
[**2130-10-26**] 05:00AM BLOOD WBC-10.0 RBC-3.39* Hgb-10.3* Hct-30.3*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.6 Plt Ct-107*
[**2130-10-25**] 05:30PM BLOOD WBC-11.6* RBC-3.70* Hgb-11.4* Hct-33.1*
MCV-90 MCH-30.8 MCHC-34.4 RDW-14.2 Plt Ct-130*
[**2130-10-25**] 03:40AM BLOOD WBC-10.0 RBC-3.43* Hgb-10.6* Hct-30.3*
MCV-89 MCH-31.1 MCHC-35.1* RDW-13.5 Plt Ct-117*
[**2130-10-24**] 02:08PM BLOOD Hct-35.3*
[**2130-10-23**] 02:35PM BLOOD WBC-10.9 RBC-3.83* Hgb-11.6* Hct-33.9*
MCV-89 MCH-30.4 MCHC-34.3 RDW-14.3 Plt Ct-139*
[**2130-10-23**] 07:05AM BLOOD WBC-7.7 RBC-4.32* Hgb-13.1* Hct-38.7*
MCV-90 MCH-30.3 MCHC-33.9 RDW-13.7 Plt Ct-152
[**2130-10-26**] 05:00AM BLOOD PT-24.8* PTT-69.5* INR(PT)-2.4*
Brief Hospital Course:
ICU Course:
Patient was admitted to the ICU for hemodynamic monitoring
post-operatively. He was continued on a beta blocker with
metoprolol 5 mg IV Q6H. Remained hemodynamically stable, and
did not require any nitroprusside or phenylephrine to maintain
BP in target range of MAPs 60-100. His FSBS were monitored, and
he did not develop hypoglycemia. Post-op pain was controlled
with a dilaudid PCA. On POD #1, plan was to restart warfarin.
Plan also to restart heparin gtt 36 hours post-op.Once patient
was hemodynamically stable he was transferred to the floor.
POD 1. Patient was restarted on anticoagulation therapy; Heparin
drip and Coumadin. PTT/INR levels were monitored closely
.Patient was started on clear sips to clear liquids. Patient had
decrease oral intake due to nausea and required several doses of
IV Zofran. His foley catheter was discontinued however he had
postoperative urinary retention and required replacement of
foley catheter. Flomax was also started due to his history of
BPH.
POD 2, Patient was noted to be mildly hypotensive with SBP
90's.His metoprolol was briefly titrated down due to his soft
blood pressures. Patient subsequently reported nausea and
migraine headache, and SBP 130. Of note reported mild left sided
tenderness likely muscular. EKG was performed and there were no
cardiac changes. He was also started on morphine pca and Tylenol
ATC for pain control.
In addition,he was switched back to his home dose metoprolol
tartrate 100 mg [**Hospital1 **] per his cardiologist reccomendations.Of note
he also received an additional dose of Metoprolol to normalize
his blood pressure to his baseline.
By POD 3, patient was subjectively feeling better,and had no
headaches. His nausea had markedly improved and he was advanced
BRAT to regular diet which was tolerated well. His PCA was
discontinued and he was started on oral pain medication. His
foley catheter was also discontinued and he subsequently voided.
Patient will continue on Flomax for a total of five days.PTT
level was therapeutic and his Heparin drip was discontinued. INR
was sub therapeutic and his Coumadin was dosed appropriately.
Patient will have his INR level monitored closely and dosed by
his cardiologist/PCP (Dr.[**Last Name (STitle) 1270**]).
POD 4: Patient was tolerating a regular diet. He was passing
flatus and having bowel movements. His pain was well controlled
with oxycodone 5 mg po q 4 prn pain. His am INR was 3.2. He was
ambulating and feeling well reporting no nausea. Patient was
instructed prior to discharge to return to [**Hospital1 18**] on Saturday to
have his INR and PT drawn for monitoring. He was told to return
to his home coumadin regimen. Patient was voiding appropriately
and was instructed to continue taking Flomax at home until
[**2130-10-29**]. Finally patient was instructed to followup with his
cardiologist regarding coumadin management as an outpatient.
Patient received postoperative discharge teaching and follow-up
instructions. Patient was discharged home in good
condition.Patient and will follow-up with Dr.[**Last Name (STitle) 5182**] for his
post operative appointment.
Medications on Admission:
metoprolol tartrate 100 mg PO BID, dibenzyline 30 mg PO BID,
simvastatin 20mg PO QD, coumadin 6 mg ([**Doctor First Name **],Tu,W,F,Sa), coumadin 9
mg (M,Thurs)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
RX *docusate sodium 100 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
3. Metoprolol Tartrate 100 mg PO BID
Hold for SBP < 90/60 or HR < 50
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Simvastatin 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*3
Capsule Refills:*0
8. Warfarin 6 mg PO DAILY16
coumadin 6mg ([**Doctor First Name **],Tu,W,F,Sa),
9. Warfarin 9 mg PO DAILY16
coumadin 9mg (M,Thurs)
10. Laboratory
Please have PT and INR drawn on [**2130-10-28**] in the am. Please fax
results to [**Last Name (LF) 1270**], [**Name8 (MD) **] MD Fax: [**Telephone/Fax (1) 8474**].
Discharge Disposition:
Home
Discharge Diagnosis:
Left adrenal pheochromocytoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Following your surgery your Coumadin (blood thinner) was
restarted and your INR level were monitored closely. Please have
your INR level checked frequently and follow-up with your
PCP/cardiologist for Coumadin dosing.
You will be prescribed a small amount of the pain medication
please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000 mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication. Continue taking stool
softeners while taking narcotic medications.
Please monitor your incision for signs of infection. If you have
sutures/staples it will stay in place until your first
post-operative visit at which time they can be removed in the
clinic. Please monitor the incision for signs and symptoms of
infection including:increasing redness at the incision, opening
of the incision, increased pain at the incision line, draining
of white/green/yellow/foul smelling drainage, or if you develop
a fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
Continue to walk several times a day.You may gradually increase
your activity as tolerated but clear heavy excercise with your
surgeon.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by your surgeon. If you have any questions
or concerns please call the office.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
NOTE you are to return to [**Hospital1 18**] laboratory on [**2130-10-28**] to have
your PT and INR drawn so that we can monitor your coumadin level
appropriately.
NOTE you experienced difficulty voiding after having the foley
removed and were started on Flomax. You are to continue taking
this medication until [**2130-10-29**].
Follow up with your cardiologist regarding your coumadin levels
and monitoring your ventricular ectopy.
Followup Instructions:
Follow-up with DR. [**Last Name (STitle) 5182**]
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2130-11-3**] at 10:00 AM [**Telephone/Fax (1) 5189**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2130-10-27**]
|
[
"V43.3",
"427.31",
"729.1",
"346.90",
"E878.8",
"427.1",
"272.4",
"227.0",
"788.20",
"V58.61",
"997.5",
"401.9",
"787.02",
"427.32",
"287.5",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"07.29"
] |
icd9pcs
|
[
[
[]
]
] |
7970, 7976
|
3544, 6684
|
303, 325
|
8053, 8053
|
2831, 3521
|
10558, 10965
|
2218, 2505
|
6896, 7947
|
7997, 8032
|
6710, 6873
|
8204, 10535
|
2520, 2812
|
232, 265
|
353, 1515
|
8068, 8180
|
1537, 2032
|
2048, 2202
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,800
| 168,730
|
46357
|
Discharge summary
|
report
|
Admission Date: [**2160-11-4**] Discharge Date: [**2160-11-19**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], MD
.
CHIEF COMPLAINT: Dypsnea
.
REASON FOR MICU ADMISSION: Respiratory Distress.
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Mechanical Ventilation
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname 79627**] is a 64 y.o. M with COPD on oxygen at home 1-2L at
night, schizophrenia, intubated [**1-13**] for COPD flare who
presented to ED for hypoxia. Patient has a home health aid who
visits twice a day and found him to satting in the 60s on RA.
Oxygen applied sats came up 70% PCP called who recommend
transfer to ED. Of note, on [**10-15**] he had bilateral conjunctivitis
and was given erythromycin eye drops.
.
In the ED, initial VS: 98.2 83 131/77 28 98% on RA. He had a gas
7.24 pCO2 93 pO2 46 HCO3 42 BaseXS 8. Sats in 80s on NRB in
ambulance. Tried on Bipap because of somnolence which improved
PCO2 to 80. Mental status also changed He was given
Azithromycin 250 mg Tab 2, MethylPREDNISolone Sodium Succ 125mg
IV, Aspirin (Buffered) 325mg PO daily, Ipratropium Bromide Neb
2.5mL and Albuterol 0.083% Nebs x2. Prior to transfer satting
92% on 3L. CXR wnl. Given 2L fluids.
.
Currently, patient relative vague but felt that cough productive
of sputum and SOB worsening. Notable tachypneic and coughing and
hReported feel sick for couple of weeks with cough. No fever,
chills. No nasal congestion. Denies CP or abdominal pain. He was
AAOx3 upon arrival to floor. Reported thirst. Reports current
smoking.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1) COPD: on home 1.5-2L O2 at night only
2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
3) Schizophrenia
4) Hx GI bleeding
5) Mental Retardation
6) MRSA VAP [**1-13**]
Social History:
Lives in [**Location **] with brother and brother-in-law. On
disability since [**2149**] for mental health issues. Visiting nurse
twice daily. Ongoing tobacco use, in the past as much as 4
packs/day. Denies ongoing EtOH or drug use. No guardian, [**Name (NI) **]
new mental health agency.
Family History:
Non-contributory
Physical Exam:
VS 96.2 94 123/77 22 86% on2L
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, Poor dentition,
dentures
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)
Resonant : , Dullness : bilateral), (Breath Sounds: Diminished:
bilateral, Rhonchorous: bilateral), using accessory muscles,
minimal air movement
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Purposeful, Tone: Normal
Pertinent Results:
EKG: NSR withlate R wave progression, normal axis, normal
intervals, [**Street Address(2) 4793**] elevation in V3-V4 which is new
.
PORTABLE CXR [**11-4**] (WET READ): no acute process
.
SPIROMETRY [**2160-2-26**]:
Mechanics: The FVC is mildly to moderately reduced. The FEV1 and
FEV1/FVC ratio are markedly reduced.
Flow-Volume Loop: Marked expiratory coving with a moderately
reduced volume excursion.
.
Impression:
Severe obstructive ventilatory defect. The reduced FVC is likely
due to gas trapping given the normal TLC measured on [**2150-9-10**].
Compared to that study the FVC has decreased by 1.27 L (-38%)
and the FEV1 has decreased by 0.96 L (-62%).
.
Echo: [**11-5**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
aortic valve leaflets are mildly thickened (?#). The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened.
Compared with the prior study (images reviewed) of [**2159-9-18**],
suboptimal images on current study, but overall findings are
similar with normal left ventricular size and systolic function.
Hypertrophied moderately dilated right ventricle with mildly
depressed systolic function.
.
[**11-7**] CT chest:
1. Emphysema. Bilateral pleural effusion. No PE. Stable lung
nodules. CT
chest followup is recommended in one year to document two-year
stability, if clinically warranted.
2. Ascites.
3. Hypodensity in the right liver lobe, not fully characterized
on the
current scan, and in similar appearance compared to prior study.
If further clinical correlation is needed, ultrasound can be
done.
4. Cystic lesion at the left kidney
.
[**11-7**] CXR
Peribronchial opacification in the right lower lobe persists,
less severe
abnormality on the left has improved. Progression suggests
aspiration,
developing into right lower lobe pneumonia. ET tube is in
standard placement. Feeding tube passes into the stomach and out
of view. No pneumothorax or pleural effusion. Heart size is
normal.
.
[**11-11**] CXR
Continued improvement in the perihilar infiltrates with no new
consolidation or pneumothorax.
.
[**2160-11-19**] 06:00AM BLOOD WBC-12.7* RBC-4.06* Hgb-12.3* Hct-38.6*
MCV-95 MCH-30.2 MCHC-31.8 RDW-13.2 Plt Ct-246
[**2160-11-16**] 05:00AM BLOOD WBC-17.4*# RBC-4.02* Hgb-12.5* Hct-37.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-13.2 Plt Ct-280
[**2160-11-10**] 04:02AM BLOOD WBC-9.1 RBC-4.14* Hgb-12.7* Hct-38.5*
MCV-93 MCH-30.7 MCHC-33.0 RDW-13.7 Plt Ct-214
Brief Hospital Course:
# COPD EXACERBATION: Pt was admitted to the Medical ICU due to
increased dyspnea, productive cough, and tachypnea on
presentation. CXR did not show infiltrate. However, as the
patient had increased work of breathing, altered mental status
and tachypnea, he was intubated on [**11-4**]. ABGs were consistent
with hypercarbic respiratory failure. He was started on high
dose methylprednisolone 125 mg IV q6 hours. He was ruled out for
influenza and was treated initially for HAP with vancomycin /
cefepime. However, this was narrowed to vancomycin after
culture data returned with GPCs in sputum. He completed an 8
day course of Vancomycin and was treated with standing albuterol
and ipratroprium. Bronchoscopy was performed without
complication. The patient was extubated on [**11-11**]. and required
Bipap for most of the day of extubation and day after
extubation. He was weaned to BIPAP overnight only and was
transferred to the floor on oral prednisone, inhalers. His O2
goal is 88-93% which he maintains at 2 L NC. He requires Bipap
on overnight. His baseline respiratory rate is in the mid 30s.
On the medicine floor from [**Date range (1) **], pt was continued on oral
prednisone and received albuterol/atrovent nebs every 6hrs. Pt
was notably tachypneic with minimal exertion but denied
significant worsening in SOB. He maintained mental status at
baseline and required BIPAP overnight as well as intermittently
during the day while napping. Due to concern for increased
wheezing, IV steroids were re-started and should continued for
an additional day ([**11-20**]). He should be monitored during his
wean to oral prednisone and continued on a slow taper as
outlined in the medication regimen. Of note, pt should resume
Advair and Tiotropium inhalers when he is no longer requiring
Albuterol/Atrovent nebs every 6hrs.
# HYPOTENSION: Pt had transient hypotension in the setting of
intubation with succ/etomidate and sedation. Pt was bolused with
IVFs of almost 15 L over his MICU stay and did not require
vasopressor support at any time. There was no clear source for
sepsis and lactate remained within normal limits. Pt was later
diuresed to optimize extubation. Hypotension had resolved and
ACE-Inhibitor was initiated for hypertension. Lisinopril was
well tolerated on medical floor.
# BRADYCARDIA: Pt was notably bradycardic after intubation which
was thought likely due to a vaso vagal repsonse. He was
monitored on telemetry and once extubated, his HR remained in
60-70s.
# EKG CHANGES: No known history of CAD. EKGs in setting of
hypoxia and acute respiratory failure showed V3-V4 with 1mm
elevation. However, he denied chest pain and there was no
enzyme elevation to suggest ACS. Cardiology was consulted about
changes in EKG, which were not thought to be due to ACS. Pt was
continued on Aspirin 81mg daily on discharge.
# SCHIZOPHRENIA / MR: Unclear documentation, but on disability
for mental health. Pt was continued on Zyprexa 7.5 mg po.
Sister is HCP.
Medications on Admission:
From OMR [**2160-9-18**]
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled 2 puffs q 4 hrs prn
ERYTHROMYCIN - 5 mg/gram Ointment - apply thin ribbon of
ointment(s) to affected eye twice a day continue rx for 48 hours
after your symptoms have cleared
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day
HOME OXYGEN 1- 2 LITERS NASAL CANULA AT BEDTIME TO KEEP O2 SAT
ABOVE 94% - (Dose adjustment - no new Rx) - Dosage uncertain
INHALATIONAL SPACING DEVICE [AEROCHAMBER] - Inhaler - use with
inhalers every time
NYSTATIN [MYCOSTATIN] - 100,000 unit/gram Powder - APPLY AS
DIRECTED twice a day
OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 1 Tablet(s) by mouth
every four (4) hours as needed for fever or pain
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day
MULTIVITAMINS WITH MINERALS - Tablet - 1 Tablet(s) by mouth
once a day
WHITE PETROLATUM-MINERAL OIL [EUCERIN] - Cream - APPLY AS
DIRECTED AS NEEDED twice a day FOR DRY SKIN
.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
2. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Methylprednisolone Sodium Succ 125 mg/2 mL Recon Soln Sig:
One (1) Recon Soln Injection Q24H (every 24 hours) for 1 days:
please give last one dose on [**11-20**] then begin slow prednisone
taper on [**11-21**].
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Insulin Lispro 100 unit/mL Solution Sig: 1-10 units
Subcutaneous ASDIR (AS DIRECTED): please adjust per sliding
scale regimen.
10. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: Please start this medication on [**11-21**] through [**11-27**].
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: please start this medication on [**11-28**] through [**12-4**].
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: Please take this medication of [**12-5**] through [**12-11**].
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: Please start this medication on [**12-12**] through [**12-18**],
then stop.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
16. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Severe COPD with Exacerbation
Hypercarbic Respiratory Failure requiring Intubation
Upper Respiratory Illness
Severe Pulmonary Hypertension
Secondary:
Tobacco Dependance
Schizophrenia
Hypertension
Hyperlipidemia
Discharge Condition:
Pt is tachypneic with a respiratory rate in the 30s at baseline.
He gets more tachypneic with exertion and requires 2L NC oxygen
to maintain goal sats of 88-92%. Pt requires BIPAP settings [**1-10**]
at bedside and should be used anytime when sleeping. Pt has a
foley in place and will need to have this removed with follow up
bladder training.
Discharge Instructions:
You were admitted with shortness of breath and low oxygen levels
due to COPD exacerbation. You were intubated briefly and
treated with a course of antibiotics for possible pulmonary
infection though there was no clear pneumonia seen. Your
breathing remains impaired and we have been treated with
steroids and nebulizers to help with recovery to your baseline.
Most importantly, you will be going to pulmonary rehabilitation
to work on improving your respiratory dynamics. It is important
that you stop smoking in order to allow your lungs to heal.
We have made the following changes to your medication regimen.
1. Start Nicotine Patch 21mcg
2. Start Lisinopril 30mg daily
3. Hold Advair inhaled [**Hospital1 **] until you are no longer using
Atrovent Nebulizers every 6hrs (please resume in 2 wks-[**12-3**])
4. Hold Tiotroprium inhaler until you are no longer using
Atrovent every 6hrs (please resume in 2 wks-[**12-3**])
5. Prednisone taper as defined in medication list
If you develop any chest pain, mental status changes, severe
worsening in shortness of breath, increased cough or any other
general worsening in condition, please call your PCP or come
directly to the ED.
Followup Instructions:
Please keep your follow up appointments with Dr. [**First Name (STitle) 1022**]:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2160-12-18**] 10:40
Please talk to Dr. [**First Name (STitle) 1022**] about the incidental pulmonary nodules
seen on CT scan, it was recommended for you to get follow up
imaging in 1 year to monitor for stability of these lesions.
There was another incidental finding of a liver hypodensity, we
recommend that you get a follow up liver ultrasound to monitor
for stability.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
|
[
"401.9",
"514",
"518.84",
"V46.2",
"427.89",
"272.4",
"416.8",
"491.21",
"305.1",
"276.51",
"295.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.23",
"96.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12426, 12497
|
6239, 9237
|
472, 533
|
12762, 13111
|
3523, 6216
|
14343, 15056
|
2565, 2583
|
10633, 12403
|
12518, 12741
|
9263, 10610
|
13135, 14320
|
2598, 3504
|
374, 434
|
561, 2024
|
2046, 2242
|
2258, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
674
| 116,577
|
45526
|
Discharge summary
|
report
|
Admission Date: [**2192-5-16**] Discharge Date: [**2192-5-23**]
Date of Birth: [**2113-12-14**] Sex: F
Service: MEDICINE
Allergies:
Prednisone / Azithromycin / Trilisate / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
78 yo F w/ PMH Afib on coumadin who presents with a "racing
heart". Patient states that she exeprienced palpitatins one day
ago, however was unsure if she was in a. fib. She had an appt
with PCP for neck pain when ECG done showed a. fib with RVR so
she was sent to ED. She denies any chest pain, sob,
palpitations. denies doe. Denies recent fevers or chills,
caugh/n/v.
.
In the ED, 96.9 HR 130 BP 122/76 and 98%RA. she received 325 mg
aspirin and lopressor 5 mg IV X 3 with slowing of her heart rate
to 110s.
.
On transfer to the floor pt c/o neck pain which she states has
been bothering her for several months. She has tried tylenol
with minimal relief. Some relief with local heat and bengay.
Denies any recent trauma.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle, syncope or presyncope.
Past Medical History:
1. Parkinson's disease
2. Congestive heart failure with an ejection fraction of 50-55%
on TEE in [**1-29**]
3. Atrial fibrillation
4. Hypertension
5. Constipation
6. Dizziness
7. Colonic polyps
8. Irritable bowel syndrome
9. Gastritis
10. Hyponatremia
11. Back pain
12. Hearing loss
13. Insomnia
14. Basal cell carcinoma
15. Left bundle-branch block
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Pt cares for her
husband at
home, has [**Name (NI) **] on Wheels, cleaning woman every other week;
husband has aide 4x/week.
Family History:
Her parents died when they were in their 60s, her mother of
renal disease, her father of heart disease.
Physical Exam:
Vitals: T 97.6 HR 65 BP 158/78 RR: 20 100% 2L
Gen: awake, alert, sitting in chair breathing comfortably
HEENT: Clear OP, MMM
NECK: Supple, No LAD, JVP 8-10
CV: RR, NL rate. NL S1, S2. soft sys murmur LLSB
LUNGS: crackles bilaterally [**1-24**] way up.
ABD: Soft, NT, ND. NL BS. No HSM
EXT: trace edema. 2+ DP pulses BL
Pertinent Results:
REPORTS:
.
CHEST (PORTABLE AP) [**2192-5-16**] 1:11 PM
IMPRESSION:
1. Unchanged cardiomegaly, without evidence of pulmonary edema.
2. Probable small bilateral pleural effusions with bilateral
basilar atelectasis.
.
CHEST (PORTABLE AP) [**2192-5-19**] 9:34 AM
Cardiac silhouette is enlarged, and there has been development
of congestive heart failure with perihilar and basilar edema.
Bilateral moderate pleural effusions have increased in size with
adjacent atelectasis.
.
TTE: [**2192-5-21**]:
Conclusions:
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The right
atrium is markedly dilated. The estimated right atrial pressure
is 11-15mmHg. Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferoseptal walls. The remaining segments contract well.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. [Intrinsic function may be
depressed given the severity of tricuspid regurgitation.] 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. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is a small
pericardial effusion without hemodynamic evidence of
compromise/tamponade physiology.
.
Compared with the prior study (images reviewed) of [**2192-1-4**], the
inferior/inferoseptal wall motion abnormality is new, overall
LVEF is more depressed, and the severity of mitral regurgitation
has increased. The severity of pulmonary artery systolic
hypertension is also markedly increased.
.
.
ADMISSION LABS:
[**2192-5-16**] 12:55PM GLUCOSE-102 UREA N-34* CREAT-1.3* SODIUM-138
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-29 ANION GAP-18
[**2192-5-16**] 12:55PM estGFR-Using this
[**2192-5-16**] 12:55PM CK(CPK)-61
[**2192-5-16**] 12:55PM cTropnT-<0.01
[**2192-5-16**] 12:55PM CK-MB-NotDone
[**2192-5-16**] 12:55PM WBC-7.7 RBC-3.60* HGB-11.5* HCT-34.4* MCV-96
MCH-32.0 MCHC-33.5 RDW-15.0
[**2192-5-16**] 12:55PM NEUTS-66.8 LYMPHS-26.2 MONOS-4.7 EOS-0.6
BASOS-1.7
[**2192-5-16**] 12:55PM MACROCYT-1+
[**2192-5-16**] 12:55PM PLT COUNT-454*
[**2192-5-16**] 12:55PM PT-25.5* PTT-33.4 INR(PT)-2.6*
[**2192-5-23**] 06:20AM BLOOD WBC-8.1 RBC-3.43* Hgb-11.1* Hct-32.5*
MCV-95 MCH-32.5* MCHC-34.3 RDW-15.2 Plt Ct-395
[**2192-5-21**] 06:06AM BLOOD Neuts-62.7 Lymphs-27.8 Monos-7.1 Eos-2.0
Baso-0.4
[**2192-5-23**] 06:20AM BLOOD Plt Ct-395
[**2192-5-23**] 06:20AM BLOOD PT-23.1* PTT-150 INR(PT)-2.3*
[**2192-5-22**] 01:00PM BLOOD PT-18.8* PTT-24.9 INR(PT)-1.8*
[**2192-5-21**] 06:06AM BLOOD PT-24.2* PTT-30.4 INR(PT)-2.4*
[**2192-5-23**] 06:20AM BLOOD Glucose-89 UreaN-26* Creat-0.9 Na-141
K-3.7 Cl-97 HCO3-34* AnGap-14
[**2192-5-20**] 05:09AM BLOOD CK(CPK)-94
[**2192-5-19**] 04:35PM BLOOD ALT-9 AST-35 LD(LDH)-193 CK(CPK)-136
AlkPhos-109 Amylase-83 TotBili-0.8
[**2192-5-20**] 05:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-5-19**] 04:35PM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-5-19**] 11:05AM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-5-20**] 05:09AM BLOOD calTIBC-339 VitB12-912* Folate-19.0
Ferritn-33 TRF-261
[**2192-5-19**] 11:28AM BLOOD Type-ART pO2-91 pCO2-58* pH-7.28*
calTCO2-28 Base XS-0
[**2192-5-19**] 11:28AM BLOOD Lactate-2.2*
Brief Hospital Course:
78 yo F with CHF (EF 50%) and a history of Afib who presented
with palpitations due to recurrent Afib.
.
#. Rhythm:
The patient presented in Afib w/RVR. There were no signs of
infection or any complaint of chest pain suggesting ischemia as
etiology for afib recurrance. Had rates 120's-130's on
admission, with stable blood pressure. Initially rate control
was attempted by increasing metoprolol to 75mg [**Hospital1 **], however pt
still had HR's in 110's. Pt was then DC cardioverted, and
remained in NSR. She did not need a TEE prior to cardioversion,
as PCP records were [**Name9 (PRE) 97121**] and INR had largely been therapeutic
in past month. Metoprolol dose was then decreased to home dose
as pt had rate in 70's.
--pt's INR became supratherapeutic, so coumadin was held for
several days, and then re-started once INR was in acceptable
range.
--started sotalol for rhythm control, however pt had prolonging
QTc. Sotalol dose was then decreased from 80mg [**Hospital1 **] to 40mg [**Hospital1 **].
QTc was monitored while on sotalol.
.
#. Pump - EF 40%
-- given renal insufficiency on admission and dry mucous
membranes, lasix and lisinopril were held, however lasix and
lisinopril were later restarted
-- approximately 24 hours after cardioversion, pt c/o SOB and
had hypoxic respiratory failure, which was thought secondary to
post-cardioversion CHF. She required a 100% NRB, nitro gtt, and
was transferred to the CCU for BiPAP. She underwent aggressive
diuresis along with BiPAP, and SOB and O2 requirement greatly
improved. Pt now satting well on 2L NC and returned to the floor
once breathing was stable. She ruled out for MI during this
episode.
.
#. CAD:
no documented history of CAD, though inferior HK on echo
--she was contined on BB, asa
--she was not previously on statin LDL 102 [**2192-1-23**], previously
114. Simvastatin was started during the admission.
#. HTN:
The lasix, metoprolol, and lisinopril were held on admission,
then restarted to her home doses.
.
#. [**Doctor First Name 48**]:
Pt had elevated BUN and creatinine up to 1.3 on admission, came
down to 1.0.
ACEI and Lasix were held on admission, now both have been
re-started
.
#. Nausea + Abdominal distension:
pt complained of this during her episode of SOB. Now resolved.
KUB negative for obstruction. Likely due to constipation. LFTs
WNL.
.
#. Parkinson's Disease - continued Sinemet
.
# Neck pain:
Pt has had chronic neck pain for several months, thought [**2-24**]
arthritis. Has tried ultram and physical therapy in the past
without relief. Pain consult was called, however would need
C-spine MRI prior to any injections, so will continue
conservative management for now and hold off on inpatient
consult. We re-scheduled her outpatient pain appointment (had
appt scheduled for [**5-22**] prior to admission).
.
#. FEN - low-sodium/cardiac diet, replete lytes prn
.
#. Access: PIV
#. PPx: therapeutic INR, bowel regimen, PPI
#. Code: Full
Medications on Admission:
Coumadin 5 mg PO daily
Lasix 20 mg PO daily
Lisinopril 10 mg daily
Toprol XL 50 mg qhs
Sinemet 25-100MG-- 1.5 tablets TID
Coenzyme Q10 400 mg TID
Fosamax 70 mg q weekly
Calcium Citrate With D [**Hospital1 **]
Discharge Medications:
1. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
4. Coenzyme Q10 10 mg Capsule Sig: One (1) Capsule PO tid ().
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
12. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Primary diagnoses:
Afib w/RVR
hypoxic respiratory failure
pulmonary edema s/p cardioversion
Secondary diagnoses:
Parkinson's disease
CHF
HTN
Discharge Condition:
Stable. In sinus rhythm.
Discharge Instructions:
Please seek medical attention immediately if you experiences
chest pain, shortness of breath, palpitations, nausea, vomiting,
sweating, or any other concerning symptoms.
Please take all medications as prescribed. You have been
started on sotalol.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) 19245**] [**Last Name (NamePattern4) 19246**], MD Date/Time:[**2192-5-22**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2192-6-13**] 11:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2192-6-20**] 1:40
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic appointment [**2192-6-7**] at 2:30pm ([**Telephone/Fax (1) 19088**]
|
[
"564.1",
"585.9",
"397.0",
"426.3",
"721.0",
"518.81",
"424.0",
"593.9",
"V58.61",
"332.0",
"403.90",
"427.31",
"564.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
10895, 10947
|
6356, 9291
|
334, 350
|
11133, 11160
|
2576, 4691
|
11457, 12053
|
2106, 2211
|
9551, 10872
|
10968, 11061
|
9317, 9528
|
11184, 11434
|
2226, 2557
|
11082, 11112
|
282, 296
|
378, 1465
|
4707, 6333
|
1487, 1839
|
1855, 2090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,832
| 149,753
|
34962
|
Discharge summary
|
report
|
Admission Date: [**2155-10-23**] Discharge Date: [**2155-11-3**]
Date of Birth: [**2106-9-6**] 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:
Cardiac Catherization
Coronary Artery Bypass Grafting Surgery
History of Present Illness:
Mr. [**Known lastname 79980**] is a 49 year old male with hypertension,
dyslipidemia, and a family history of early stroke who presented
to an OSH with recurrent episodes of chest discomfort. About
three weeks ago, patient reported an episode of chest "pressure"
and "aching" spreading like a band across his upper chest and
throat and slight radiation to both upper arms. Occurred at rest
while he was watching a Red Sox game on TV. Has never had chest
pain like this before. Admitted to nausea and said he felt quite
"sick", but attributed the pain to GERD. Took a baby ASA and
fell asleep - pain had dissipated completely on awakening. He
reports that he does feel similar pain when he exerts himself
and when he is out in the cold, and the pain is always relieved
with rest.
.
He presented to his outpatient PCP on day of admission to
discuss these symptoms. PCP did an EKG in the office whic showed
ST elevations in the inferior leads. Patient was immediately
directed to the nearest ED for [**Last Name (LF) 79981**], [**First Name3 (LF) **] he presented to the
[**Hospital3 **] ED today. At OSH ED, vital signs were 97.6 72
156/85 100% on 2 L NC. He was given metoprolol 5mg IV x3,
aspirin 325mg, and plavix 600mg x1, and transferred to [**Hospital1 18**] for
cardiac cath. Troponin-I was elevated to 0.62. At catherization,
he was found to have 3VD and CABG was planned. No intervention
was performed, and he was taken off his plavix and integrilin
gtt.
Past Medical History:
-hyperlipidemia
-hypertension
-allergic rhinitis
-hyperglycemia
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Liquor distributor to
various liquor chains in [**Location (un) 86**] such as Cappy's.
Family History:
There is a family history of premature coronary artery disease
or sudden death (father had his first stroke at age 50 and had
CAD requiring a CABG in his 70s that was complicated by multiple
CVAs s/p surgery from which his father died.)
Physical Exam:
VS - 99, 102/60, 70SR, 20, 92%RA
Gen: WDWN middle aged male in NAD. AOx3, denies chest pain.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 2 cm sitting upright.
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: diminished left base and crackles to mid lung b/l
Abd: Soft, NTND. No HSM or tenderness. no guarding or RT.
Ext: No c/c/e. No femoral bruits
Pertinent Results:
EKG: [**2155-10-23**] - normal sinus rhythm, slight PR prolongation, o/w
normal intervals, NA, biphasic twaves in V1, no LVH, poor R wave
progression in V1/V2 c/w previous infarct. TWI in inferior leads
not present in EKG from [**2153**] (more biphasic) but present in
[**2155-10-23**] EKGs from OSH. Q-waves in inferior leads similar to
previous EKGs.
2D-ECHOCARDIOGRAM: None
CARDIAC CATH:
R dominant circulation. mild LMCA disease, 70% disease in
proximal LAD, 90% proximal OM1 in LCX. RCA mid total occlusion.
No intervention, CABG planned.
[**2155-11-2**] 06:45AM BLOOD WBC-8.6 RBC-3.04* Hgb-9.1* Hct-25.5*
MCV-84 MCH-29.8 MCHC-35.6* RDW-14.4 Plt Ct-205
[**2155-11-2**] 06:45AM BLOOD Glucose-90 UreaN-20 Creat-1.0 Na-137
K-4.6 Cl-99 HCO3-31 AnGap-12
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] from the [**Hospital3 4107**] emergency
room with ST elevations on his EKG. In the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] he was
started on integrillin, heparin, and loaded with plavix 600MG
PO. Diagnostic catheterization at [**Hospital1 18**] revealed 100% mid RCA
lesion (unable to be crossed with a wire), 100% LAD after D1
with left-to-left collaterals, and a 90% stenosis of his first
obtuse marginal branch. LVEF was 45% on ventriculogram. He was
then admitted, plavix discontinued and he was brought to the OR
on [**2155-10-29**] with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] where he underwent 4-vessel
CABG. See dicatated operative note for full details. After his
surgery he was brought to the cardiac surgical ICU for invasive
monitoring. He required several days of intravenous
Neosynephrine for blood pressure support. On POD 3 he was
transferred to the step down unit and he was started on lasix,
beta-blockers, and ACE-inhibitors. The patient made excellent
progress on the floor. The physical therapy service was
consulted for assistance with post-operative mobility. The
patient made excellent progress, showing good strength and
balance before discharge. Chest tubes and pacing wires were
discontinued without complication. He was diuresed toward his
preoperative weight. By the time of discharge to home on POD 5
the patient was ambulating freely, the wound was healing, and
pain was controlled with oral analgesics.
Medications on Admission:
Metoprolol XL 100 mg PO daily
Flonase 2 sprays IN daily
Vytorin 10/40 mg PO daily
Omeprazole 20 mg PO daily
ASA 325 mg PO daily
Vitamin E 400 U PO daily
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-18**] Tablet,
Sublinguals Sublingual PRN (as needed): please take 1-2 tablets
for chest pain every 5 minutes. if your pain is not releived
within [**1-19**] attempts, please call 911.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Vytorin [**9-/2127**] 10-80 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 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. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
chest pain
coronary artery disease
hypertension
hyperlipidemia
hyperglycemia
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:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr. [**Last Name (STitle) 4469**] in 1 week ([**Telephone/Fax (1) 4475**]) please call for appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2155-11-3**]
|
[
"584.9",
"401.9",
"470",
"E878.2",
"E849.7",
"458.29",
"530.81",
"414.01",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.14",
"88.53",
"99.20",
"00.40",
"37.22",
"38.93",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
7250, 7305
|
3795, 5328
|
331, 395
|
7426, 7433
|
3015, 3772
|
7945, 8271
|
2204, 2442
|
5531, 7227
|
7326, 7405
|
5354, 5508
|
7457, 7922
|
2457, 2996
|
281, 293
|
423, 1888
|
1910, 1976
|
1992, 2188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,799
| 199,813
|
49412
|
Discharge summary
|
report
|
Admission Date: [**2181-7-23**] Discharge Date: [**2181-8-7**]
Date of Birth: [**2120-6-13**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 female involved in a motor vehicle collision. Was the
unrestrained driver without airbag deployment. Had loss of
consciousness and was noted to have a GCS of 13 at and OSH. She
was intubated for airway protection and transferred to [**Hospital1 18**].
Past Medical History:
Tourette's syndrome
Mood disoder, Bipolar
severe COPD on home oxygen
H/o hypercapnic resp failure needing intubation in [**2-4**]
h/o steroid use for COPD exacerbation
HTN
opiate abuse
Social History:
h/o heavy EtOH use, quit in [**2162**]; quit smoking in [**1-/2181**]; h/o
addiction to painkillers (oral), quit 4 years ago and currently
on methadone maintenance; h/o remote cocaine use (intranasal);
no h/o IVDU or smoking crack.
Family History:
father died of lung ca; mother died of CVA/breast ca. Strong
family h/o substance abuse; brother died likely of overdose.
Physical Exam:
On admission:
Afebrile, Vital signs stable
Intubated, sedated
C-collar in place
No significant facial lacerations
RRR
Lungs clear bilaterally, no chest crepitus, no chest wall
deformity
Abdomen soft, nondistended, nontender, no palpable masses, no
bruises or lacerations
No LE deformities
Pertinent Results:
[**2181-7-23**] 01:30PM BLOOD WBC-7.7 RBC-3.40* Hgb-9.3* Hct-28.7*
MCV-85 MCH-27.5 MCHC-32.5 RDW-14.1 Plt Ct-118*
[**2181-7-24**] 02:21AM BLOOD Glucose-176* UreaN-9 Creat-0.8 Na-142
K-4.4 Cl-107 HCO3-31 AnGap-8
[**2181-7-23**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2181-7-23**]:CXR: Left sixth and seventh rib fractures.
[**2181-7-23**]:CT torso Left 6 and 7 lateral rib fractures. Otherwise
no findings of acute trauma
[**2181-7-23**]:CT Head: no traumatic injury
[**2181-7-23**]:CT Cspine: No definite fracture seen.
Mild anterolisthesis of C4 on C5 which is likely on a
degenerative basis,
however, if there is strong clinical suspicion for ligamentous
injury, MRI
would be more sensitive.
[**2181-7-25**]:CT Abd/Pelvis
1. Large subcapsular splenic hematoma (involving greater than
>50% of the splenic capsular surface) with no evidence of active
bleeding, however there has been intermittent bleeding with
blood of varying densities within the hematoma. There has been
recent hemorrhage with high- density blood within this hematoma.
In addition hemoperitoneum is present.
2. Non-displaced fractures of the left fifth and sixth lateral
ribs with no evidence of pneumothorax.
3. Other solid organs are normal.
[**2181-7-25**]:CT head:
IMPRESSION: Mild bifrontal effacement of [**Doctor Last Name 352**]-white matter
differentiation, could be technical, however, in the setting of
trauma, cerebral edema is a differential consideration and
short-term interval followup is recommended.
No evidence of intracranial hemorrhage.
ATTENDING NOTE: The frontal abnormality is likely due to
motion
[**2181-7-31**] CXR: A new round 2 cm wide opacity projects lateral to
the right hilus, and was not present on torso CT on [**7-23**]. If
this is genuinely a lung nodule, it would have to be infectious,
likely a septic embolus. Reticulation at the right lung base
medially is probably mild residual edema, but could be due to
aspiration. There are no findings to suggest pneumonia
elsewhere. The heart is normal size and there is no appreciable
pleural effusion. Vascular deficiency in the upper lungs is
probably a function of centrilobular emphysema. Previous
atelectasis or small pneumonia in the left upper lobe seen on
the torso CT has resolved over the past eight days. Heart size
is normal.
[**2181-8-1**]:CT Abd/Pelv:
1. New right lower lung opacities most likely represent acute
infectious
process or aspiration. Small left lower lung opacity may
represent atelectasis but acute infectious process can not be
excluded
2. Decrease in size of large subcapsular splenic hematoma and
hemoperitoneum.
3. Stable nondisplaced left rib fractures.
[**2181-8-2**]:ECHO
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
70%). 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. 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. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: no vegetations or shunt seen
[**2181-8-4**]: CXR: Two views of the chest are compared to the prior
study from [**2181-7-31**]. There is a nodular density in the right mid
lung zone seen on the prior study. There is patchy airspace
consolidation of the right mid and lower lung zones,
superimposed on interstitial disease. The cardiomediastinal
silhouette is unremarkable.
Microbiology:
[**2181-7-31**] 6:56 pm URINE Source: Catheter.
URINE CULTURE (Final [**2181-8-1**]):
BETA STREPTOCOCCUS GROUP B. 10,000-100,000
ORGANISMS/ML..
[**2181-8-2**] 9:33 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2181-8-3**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2181-8-5**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
All other cultures including Blood cultures negative.
Brief Hospital Course:
The patient was admitted to the Trauma service in the trauma ICU
after initial evaluation and appropriate imaging studies were
performed in the ED. She remained hemodynamically stable
throughout. She was extubated hospital day #2 and transferred to
the surgical floor. She remained well initially, was tolerating
a regular diet, oxygen saturations were maintained and her pain
was controlled for her rib fractures. On the morning of
hospital day #3 however she began complaining of acute and
severe left abdominal pain and was tender to palpation in the
LUQ. A hematocrit at that time revealed acute blood loss anemia
at 16.5. A stat CT revealed a splenic laceration that had not
been evident on her admission imaging. She remained
hemodynamically stable at this time. She was transferred to the
ICU and appropriately transfused. Serial HCTs and abdominal
exams were performed and after an initial transfusion
requirement for 24 hours her HCT stabilized. A total of 3 units
of PRBCs were transfused. The patient was observed on bedrest
in the ICU for another 2 days and then transferred to the floor.
Her diet was advanced and she was allowed to ambulate with
assistance.
She became febrile on [**7-31**] in the p.m. Urine cultures were
obtained, and eventually noted to grow group B Streptococcus. A
CXR on the same day demonstated densities c/w septic emboli
(absent on chest CT done [**7-23**]). She remained intermittently
febrile to as high as 102.6 [**8-1**], and was started on levofloxacin
[**8-1**] p.m. A CT showed patchy opacities as well as a more dense
stellate opacity concerning for a septic embolus. An ID consult
was obtained as she was started on broad spectrum antibiotics.
Sputum cultures eventually grew gram negative rods and yeast.
An echocardiogram to rule out valve endocarditis was negative.
Blood cultures were negative ultimately as well. Infectious
disease recommended changing broad spectrum antibiotis to
levofloxacin and flagyl on discharge until [**8-14**].
She failed multiple voiding trials during the hospitalization
and had to have her foley replaced 3 times. Flomax was
initiated and the foley will continue with removal planned at
rehab.
Physical therapy saw the patient during the hospitalization,
please see PT recs for further care at rehab.
She was on nasal cannula oxygen without desaturations. Home
oxygen is 3 liters/mi
The patient should followup in the acute care surgery clinic in
2 weeks after discharge
Medications on Admission:
paxil 20 ,Ropinirole 0.5,duoneb inhal prn,Singulair 10
,Lisinopril 40,Demadex 20m,Spiriva,Proair prn,Diltiazem er
360,Advair 500-50 [**Hospital1 **],methimazole 10,omeprazole,Methadone 65
daily,aspirin 81,Clonazepam
Discharge Medications:
1. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for sleep.
13. Methadone 10 mg Tablet Sig: 6.5 Tablets PO DAILY (Daily).
14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for increased chest
congestion.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily): d/c when able to
void on own.
18. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
21. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
22. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
23. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
polytrauma from MVC
Splenic laceration
rib fractures
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
see d/c summary. Antibiotics until [**8-14**].
**Psychopharm - [**First Name8 (NamePattern2) 12660**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 103451**]**
Followup Instructions:
F/u with the Acute care surgery clinic in [**1-27**] weeks.
Completed by:[**2181-8-7**]
|
[
"415.12",
"850.5",
"307.23",
"304.00",
"285.1",
"865.01",
"296.80",
"807.02",
"E816.0",
"995.91",
"868.03",
"300.00",
"401.9",
"038.9",
"496",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10998, 11075
|
6085, 8561
|
317, 323
|
11182, 11182
|
1533, 2017
|
11511, 11601
|
1084, 1208
|
8827, 10975
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11096, 11161
|
8587, 8804
|
11318, 11488
|
1223, 1223
|
274, 279
|
351, 610
|
2821, 6062
|
1237, 1514
|
11197, 11294
|
632, 819
|
835, 1068
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,607
| 156,556
|
54860
|
Discharge summary
|
report
|
Admission Date: [**2128-7-22**] Discharge Date: [**2128-8-10**]
Date of Birth: [**2058-6-12**] Sex: F
Service: MEDICINE
Allergies:
Januvia / allopurinol
Attending:[**Last Name (un) 2888**]
Chief Complaint:
OSH transfer for acute on chronic systolic heart failure and
ventricular tachycardia
Major Surgical or Invasive Procedure:
cardiac catheterization lab for epicardial lead placement which
was unsuccesful [**2128-8-3**]
cardiac surgery for Upgrade of VVI-ICD to biventricular-pacer-
ICD with addition of epicardial left ventricular pacing lead
and transvenous atrial lead, cardioversion [**2128-8-4**]
cardioversion on [**2128-8-9**]
History of Present Illness:
70 F history of ischemic cardiomyopathy ([**Hospital1 **]-V ICD placed 2 weeks
ago, EF 30%) presented to OSH on [**2128-7-19**] for acute on chronic
systolic heart failure and ventricular tachycardia.
Pt had recent hosptialization ([**Hospital 931**] hospital--> [**Hospital1 498**])
[**Date range (1) 23794**] for pulmonary edema vs pneumonia requiring intubation,
lasix and ceftriaxone. She was extubated after brief period.
Pt presented back to [**Hospital 931**] hospital on [**7-19**] with
nausea/emesis/ epigastric pain.
V tach: on prsentation to OSH she found to be in V Tach at rate
of 160-170s. She was alert during this time, SBP 80s. Amiodarone
was given but no conversion. She was then cardioverted and
shocked back to NSR. (Despite ICD being in place, it did not go
off.) Last night she was in A fib then converted to sinus. This
morning, she was found to be in V tach again, sp shock then
given amiodarone gtt starting this AM. She remained in NSR since
then.
Acute systolic Heart failure: Pt found to be in pulmonary edema
and was given lasix 60mg PO. Echo at OSH showed on [**7-21**]: EF 30%
(2 weeks ago)--> LVEF [**10-25**] %. Apical akinesis and thinning,
anterior and inferior akinesis and thinning.
During hospitalization, she was hypotensive (SBP 80-90s) with
leukocytosis (WBC 23) and was given vancomycin and zosyn for
broad empiric coverage.
She was transfered to [**Hospital1 18**] for management of CHF and VTach.
In the ambulance to [**Hospital1 18**] she was initialy satting well on 2 L.
However, she suddenly became SOB and required a non-rebreather.
No clear precipitant as EMS reports BP and HR overall stable
during transfer. No episodes of VT. Her arms and legs were cold
with BP in the 80s. On arrival to the CCU, pt looked ill, was in
respiratory distress. She was transitioned to BIPAP 100%. CXR
was performed and showed pulmonary edema. She was given lasix
60mg IV once with minimal UO. She was then given 100mg IV
followed by lasix gtt.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of ankle edema,
palpitations, syncope or presyncope.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
prior MI in [**2096**] (no cabg or cath since then)
A fib
Ischemic cardiomyopathy- LBBB, sp ICD. Baseline EF 20-30% few
weeks ago, now 10%
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
osteoperosis
Gout
Social History:
non smoker, no drugs. married
Family History:
n/c
Physical Exam:
VS: T 98, HR 66 sinus, 97/61, RR 26, 99% non rebreather
GENERAL: resp distress, cold feet and arms, ill appearing
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Cold
feet and hands
PULSES:
Radial 2+ bilaterally
Pertinent Results:
LABS:
On admission:
[**2128-7-22**] 12:01PM WBC-17.6* RBC-3.85* HGB-12.3 HCT-38.6
MCV-100* MCH-32.0 MCHC-31.9 RDW-15.9*
[**2128-7-22**] 12:01PM NEUTS-90.3* LYMPHS-4.6* MONOS-3.4 EOS-1.4
BASOS-0.4
[**2128-7-22**] 12:01PM GLUCOSE-182* UREA N-27* CREAT-1.4* SODIUM-139
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2128-7-22**] 12:01PM CALCIUM-7.9* PHOSPHATE-5.1* MAGNESIUM-2.5
[**2128-7-22**] 11:56AM GLUCOSE-182* LACTATE-3.2* NA+-133 K+-5.7*
CL--105
[**2128-7-22**] 11:56AM O2 SAT-99
[**2128-7-22**] 12:01PM PT-16.2* PTT-27.4 INR(PT)-1.5*
[**2128-7-22**] 12:01PM PLT COUNT-243
[**2128-7-22**] 12:01PM CK-MB-2 cTropnT-0.10*
[**2128-7-22**] 12:01PM ALT(SGPT)-97* AST(SGOT)-109* CK(CPK)-50 ALK
PHOS-80 TOT BILI-0.6
On discharge:
[**2128-8-10**] 06:00AM BLOOD WBC-10.6 RBC-3.34* Hgb-10.6* Hct-33.2*
MCV-99* MCH-31.7 MCHC-31.9 RDW-17.1* Plt Ct-353
[**2128-8-10**] 06:00AM BLOOD PT-30.8* INR(PT)-3.0*
[**2128-8-10**] 06:00AM BLOOD Glucose-90 UreaN-26* Creat-1.4* Na-137
K-4.0 Cl-97 HCO3-33* AnGap-11
IMAGING/STUDIES:
Cardiac Echocardiogram:[**2128-7-23**] [**Hospital1 18**]
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.18 >= 0.29
Left Ventricle - Ejection Fraction: 15% to 20% >= 55%
Left Ventricle - Stroke Volume: 33 ml/beat
Left Ventricle - Cardiac Output: 2.71 L/min
Left Ventricle - Cardiac Index: *1.50 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.40 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 5 < 15
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 13
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave deceleration time: *124 ms 140-250 ms
TR Gradient (+ RA = PASP): 23 to 25 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe
regional LV systolic dysfunction. Estimated cardiac index is
depressed (<2.0L/min/m2). No LV mass/thrombus. No resting LVOT
gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: No AS. No AR.
MITRAL VALVE: Mild (1+) MR. LV inflow pattern c/w restrictive
filling abnormality, with elevated LA pressure.
TRICUSPID VALVE: Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - body habitus.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with anterior, septal and
apical akinesis. There is moderate hypokinesis of the remaining
segments (LVEF = 15-20%). The estimated cardiac index is
depressed (<2.0L/min/m2). No masses or thrombi are seen in the
left ventricle. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The diameters of aorta
at
the sinus, ascending and arch levels are normal. There is no
aortic valve stenosis. No aortic regurgitation is seen. Mild
(1+)
mitral regurgitation is seen. The left ventricular inflow
pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The estimated pulmonary artery systolic
pressure
is normal. There is no pericardial effusion.
IMPRESSION: Severe regional and global left ventricular systolic
dysfunction, most c/w ischemic cardiomyopathy. Mild mitral
regurgitation. Elevated intracardiac filling pressures and low
cardiac index
Other diagnostics:
Chest xray [**2128-7-24**] [**Hospital1 18**]
As compared to the previous radiograph, there is no relevant
change. Borderline size of the cardiac silhouette with left
pleural effusion and subsequent atelectasis. Extent of the
effusion is constant. Minimal atelectasis at the right lung base
but no evidence of interval appearance of focal parenchymal
opacity suggesting pneumonia. Unchanged position and course
of the pacemaker leads.
CARDIAC PERFUSION PERSANTINE [**2128-7-28**] [**Hospital1 18**]
1. Fixed, severe, very large perfusion defect involving the LAD
territory.
2. Increased left ventricular cavity size. Severe systolic
dysfunction with akinesis of the apex, entire distal ventricle
and the entire mid ventricle
[**2128-7-27**] Rest Thalium
IMPRESSION:
1. Severe resting perfusion defect of the apex, entire distal
ventricle and entire mid ventricle, indicating low probability
of recovery of function of these segments after
revascularization. The remaining basal segments have normal
tracer uptake, indicating viability of these segments.
[**7-25**] CT Abdomen with contrast
IMPRESSION:
1. Unchanged appearance of subcapsular splenic hematoma.
2. Bilateral pleural effusions, small amount on the right and
moderate amount on the left.
3. Small non-obstructing stone measuring 5 mm in the lower pole
of the left kidney.
EKG:[**2128-7-30**] Atrial fibrillation with mean rate of 82 beats per
minute. Demand ventricular pacing in a left bundle-branch block
pattern. Compared to the previous tracing of [**2128-7-22**] the rhythm
is now atrial fibrillation which is being tracked by the
pacemaker.
Brief Hospital Course:
70 F with history of ischemic cardiomypathy (EF previously 30%)
sp [**Hospital 3941**] transfered from OSH for V tach and acute on chronic
systolic heart failure.
ACTIVE ISSUES BY PROBLEM:
# Acute on chronic Systolic heart failure: The patient's EF was
30% few weeks prior to admission, then on admission found to be
10%. The acute worsening of systolic function was likely
triggered by Ventricular tahycardia and heart failure. Troponins
were not elevated at OSH making another acute ischemic event
less likely, however given no history of cath but + history of
inferior-posterior MI, it was unclear whether the exacerbation
was due to an ischemic event. -history of infero-posterior MI.
The patient was initially hypotensive and dyspneic on arrival to
CCU. She improved with BiPAP and was able to be weaned down to
face mask after diuresis. Nitroprusside and lasix gtts were
initiated. The patient diuresed nicely, was weaned off nasal
canula oxygen and and was transitioned to torsemide. We also
initiated coreg and captopril to optimize hemodynamics. Patient
agreed to workup of her heart disease and etiology of the CHF
exacerbation, see below in Coronary Artery Disease.
# Arrhythmias: The patient suffered 2 episodes of ventricular
Tachcyardia episodes on day of admission likely from scar from
inferior region. She also has chronic atrial fibrillation and
takes coumadin at home. The coumadin was held (as was heparin
gtt) upon admission due to suspicion of a splenic hematoma on
OSH CT scan (see below). Her ICD was adjusted to fire at 160
bpm instead of 200 (ICD did not fire at OSH because the
threshold was set to the latter). After stabilization of her
splenic hematoma a heparin gtt was initiated with PTT goal of
50-70. Patient was started on amiodarone while in house loading
dose 200 TID for 7 g total, pt was continued 200TID (last day
[**8-1**]), then on [**8-2**] decreased dose to 200 daily for maintenance.
#BiV Placement: The patient went for BiV lead placement for more
efficient squeeze. Patient has a low EF and LBBB and we thought
she would benefit from a BiV palcement. Cardiology tried to
place BiV in the cath lab on [**8-3**] but they were unsuccesful. On
[**8-4**] surgery took her to for Upgrade of VVI-ICD to
biventricular-pacer-
ICD with addition of epicardial left ventricular pacing lead
and transvenous atrial lead and she was also cardioverted at
this time. As a complicaton there was a minor left ventricular
perforation at the
time of the left ventricular lead implant which was oversewn.
Patient was cared for by cardiac surgery for about 24 hours than
transferred to the floors to have continuous care by the CCU
team. Though patient was cardioverted on [**8-4**] she soon after
went back into Afib. Heparin was restarted after surgery with
goal PTT 50-70. She was also on keflex for total of 5 days after
her BiV placement. On [**8-9**] she was cardioverted and she went
back into sinus rythm. She was discharged on coumadin and will
follow up with cardiology in the outpatient setting to discuss
how long she should be on coumadin and if she still is in sinus
rythm.
#Splenic Infarct: CT at OSH showed suspected splenic infarct vs.
hematoma. Repeat CT w/ contrast here confirmed the suspicion
and showed increasing size of lesion. ACS consulted and
recommended to hold heparin/warfarin for Afib and no surgical
indication as not a good surgical candidate. After
rescrutinization of the CT scans, surgery thought patient might
benefit from embolization therapy. Interventional radiology was
consulted and decided no intervention was needed at this time
because the patient's Hcts were stable and not downtrending. We
trended her hematocrits every 6 hours and got another repeat CT
scan which showed stable blood counts and no interval change in
hematoma. Etiology of spleic infarct and hemhorragic
conerversion werent clear however it is likely patient through a
clot from her A-fib which caused splenic infarct then led to
hemhorragic conversion. CT surgery recommended we restart
anticoagulation because of her Afib and we put her back on
heparin drip with goal PTT 50-60.
# Coronary artery disease: Pt has history of ischemic
Cardiomyopathy due to history of MI in past. She has refused
cardiac catheterization in the past. Given the documented MI in
the past, it was postulated that ongoing coronary artery disease
was the possible culprit for the CHF exacerbation/VTach. She
underwent a viability study on [**7-27**] which showed Severe resting
perfusion defect of the apex, entire distal ventricle and entire
mid ventricle, indicating low probability of recovery of
function of these segments after revascularization. The
remaining basal segments have normal tracer uptake, indicating
viability of these segments. On [**7-28**] we got cardiac perfusion
persantine showing fixed, severe, very large perfusion defect
involving the LAD territory and Increased left ventricular
cavity size. Severe systolic dysfunction with akinesis of the
apex, entire distal ventricle and the entire mid ventricle.
Patient was not a candidate for revascularization in cath lab
because the scans indicated that this damage was old.
#C diff: Pt presented with an elevated WBC 19 with predominant
polys. A C.Diff assay came back positive, and the patient was
treated with Metronidazole in house. Last day of flagyl was
[**2128-8-5**]. After the biV patient was on C-surgery floor and they
restarted her home colchicine for gout. She subesquently had
diarrhea differtnial was from starting the colchicine vs Cdif.
She was restarted again on flagyl an told to continue for
another 14 days.
# Acute renal failure: Cr 1.4 initialy at OSH then improved to
1.1 , now 1.4 and has been stable for a few days. Unknown true
baseline. Differential: pre-renal in setting of CHF and low
intravascular volume, AIN in setting of penicillin antibiotics
at OSH, ATN (preceeded by pre-renal), foley in so less likely
obstruction and post-renal. Renal vein thrombus and renal artery
clot also possible in pt with known A fib and ?splenic infarcts
in the past. Given her exposure to contrast on the first CT
abdomen in house, contrast nephropathy was the likely culprit
for her [**Last Name (un) **] though pre-renal CHF was also likely a cause. She
was treated with supportive therapy including titration of BP
meds and strict monitoring of her I/Os. Her Cr was at 1.4 at
time of admission. It is possible this is her new baseline.
# Diabetes type 2:
Patient was on Insulin sliding scale.
TANSITIONAL ISSUES.
#CHF: will follow up with cardiologist
#Diarrhea: being treated for recurrent Cdif with flagyl. If
patient develops cdiff again she should get PO vanco
#Arrythmias: patient has history of Afib and was cardioverted
while in house and went into sinus but she is at high risk for
converting back to Afib and this should be followed up by
cardiologist in outpatient setting. She was sent home on
coumadin and discussion should be made at folllow up about how
long she should be on it.
#Splenic hematoma: it appeared stable while she was here however
this should be followed up in outpatient setting by her PCP
#BiV placement: patient will follow up with Dr [**Last Name (STitle) **] who performed
the surgery for BiV lead placement
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Alendronate Sodium 70 mg PO QSUN
2. Anucort-HC *NF* (hydrocorTISone Acetate) 25 mg Rectal as
needed rectal pain
3. Carvedilol 6.25 mg PO BID
4. Colchicine 0.6 mg PO BID
5. Fluocinonide 0.05% Ointment 1 Appl TP [**Hospital1 **]
6. Furosemide 60 mg PO DAILY
7. GlipiZIDE 5 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Jantoven *NF* (warfarin) 5 mg Oral daily
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Lisinopril 5 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. Vagifem *NF* (estradiol) 25 mcg Vaginal 2 times per week
14. Lantus *NF* (insulin glargine) 70 units Subcutaneous daily
15. Spironolactone 25 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Estroven Regular Strength *NF* (mv,Ca,min-FA-herbal no.159)
one tab Oral daily
18. Aspirin 81 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Vitamin D 400 UNIT PO DAILY
21. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Alendronate Sodium 70 mg PO 1X/WEEK ([**Doctor First Name **])
2. Aspirin EC 81 mg PO DAILY
3. Carvedilol 25 mg PO BID
hold for SBP < 100, HR < 60
RX *carvedilol 25 mg one tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
4. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Anucort-HC *NF* (hydrocorTISone Acetate) 25 mg Rectal as
needed rectal pain
6. Simvastatin 20 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
10. Cholestyramine 4 gm PO BID Duration: 1 Weeks
RX *cholestyramine (with sugar) 4 gram one packet by mouth twice
a day Disp #*14 Packet Refills:*0
11. Digoxin 0.125 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg one tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*2
12. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg two tablet(s) by mouth daily Disp #*60
Tablet Refills:*2
13. Vagifem *NF* (estradiol) 25 mcg Vaginal 2 times per week
14. Vitamin D 400 UNIT PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. GlipiZIDE 5 mg PO BID
17. Lantus *NF* (insulin glargine) 30 units SUBCUTANEOUS DAILY
Please go back up on your dose if your blood sugar is high
18. Fluocinonide 0.05% Ointment 1 Appl TP [**Hospital1 **]
19. Jantoven *NF* (warfarin) 1 mg Oral daily
RX *warfarin 1 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
20. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 12 Days
RX *metronidazole 500 mg one tablet(s) by mouth three times a
day Disp #*36 Tablet Refills:*0
21. Outpatient Lab Work
Please check INR and Chem-7 on [**2128-8-13**] with results to Dr. [**Last Name (STitle) 26237**]
at Phone: [**Telephone/Fax (1) 26268**]
Fax: [**Telephone/Fax (1) 112087**]
ICD 9: 427.31
22. Estroven Regular Strength *NF* (mv,Ca,min-FA-herbal no.159)
0 tab ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
VNA of Southern [**Hospital1 1559**] Co.
Discharge Diagnosis:
Acute on chronic systolic CHF
Atrial Fibrillation
Diabetes Mellitus
Hypertension
Coronary Artery Disease
Dyslipidemia
C difficile Colitis
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 10595**],
It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 **]. You were admitted with congestive
heart failure and a dangerous heart rhythm called ventricular
tachycardia. You were started on amiodarone to treat this rhythm
and it is now gone. We attempted to place another pacer lead in
your heart through the veins but needed to place it surgically
instead. You tolerated this procedure well and it seems that
your heart is pumping better. We have adjusted your medicines to
keep the fluid off that we have removed during your stay. Your
weight at discharge is 145 pounds and you need to keep your
weight here to prevent fluid overload. Please weigh yourself
every day and call Dr. [**Last Name (STitle) 91348**] if your weight increases more than
3 pounds in 1 day or 5 pounds in 3 days. You should also follow
a low sodium diet as we discussed. You are on warfarin
(coumadin) to prevent a stroke resulting from the atrial
fibrillation. Please continue to take this medicine. Dr. [**Last Name (STitle) 26237**]
will monitor the blood levels and tell you how much to take.
.
Followup Instructions:
.
Department: CARDIAC SURGERY
When: THURSDAY [**2128-9-2**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] A
Address: [**Street Address(2) 47528**], [**Location (un) **],[**Numeric Identifier 47529**]
Phone: [**Telephone/Fax (1) 26268**]
Appointment: Friday [**2128-8-13**] 2:00pm
Name: [**Last Name (LF) 73863**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Street Address(2) 112088**] [**Apartment Address(1) 37164**], [**Location (un) **],[**Numeric Identifier 112089**]
Phone: [**Telephone/Fax (1) 112090**]
*The office is working on a follow up appointment for your
hospitalization with your cardiologist. It is recommended you be
seen within 2 weeks of discharge. The office will contact you at
home with an appointment. If you have not heard within 2
business days please call the office at the above number.
.
Name: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: [**Hospital3 **]-Cardiology
Address: [**Doctor Last Name **] North ACC 4th Fl, [**Hospital1 1559**], MA
Phone: [**Telephone/Fax (1) 112091**]
Appt: [**9-1**] at 1pm
|
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icd9cm
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[
[
[]
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[
"35.72",
"38.91",
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"38.97",
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|
[
[
[]
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241, 327
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703, 3153
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4405, 5128
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20915, 21059
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3453, 3488
|
3197, 3263
|
3504, 3535
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,018
| 103,349
|
40538
|
Discharge summary
|
report
|
Admission Date: [**2190-8-2**] Discharge Date: [**2190-8-12**]
Date of Birth: [**2109-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2190-8-3**] Urgent coronary artery bypass grafting x3 with left
internal mammary artery to left anterior descending coronary;
reverse saphenous vein single graft from the aorta to the first
diagonal coronary artery; reverse saphenous vein single graft
from the aorta to the first obtuse marginal coronary artery.
History of Present Illness:
This is an 81 year old male with a history of paroxysmal Atrial
Fibrillation who was recently admitted to OSH with chest pain.
Cardiac workup included a nuclear stress test that showed no
evidence of ischemia. He was discharged with planned follow up
with Cardiology in 2 weeks. However, he again had left sided
chest pain associated with a racing heart rate and presented to
the OSH ED. At that time he was cardioverted to NSR. Further
cardiac workup included cardiac angiogram that revealed
multivessel coronary artery disease. He presents to [**Hospital1 18**] for
further evaluation of coronary artery revascularization.
Past Medical History:
Coronary Artery Disease
Past Medical History:
Paroxysmal Atrial Fibrillation
Hypertension
Hypercholesterolemia
Gastro intestinal bleed (while on heparin)
Toxic-metabolic encephalopathy
ETOH withdrawal
Pilonidal cyst.
Past Surgical History:
s/p Appendectomy [**1-26**]
lumbar diskectomy [**2188**]
Social History:
Lives with: wife-[**Name (NI) **]
Contact: [**Name (NI) **](wife) Phone # [**Telephone/Fax (1) 88767**]
Occupation: retired construction worker
Cigarettes: yes [x] last cigarette [**2175**] Hx: 40 pack year hx
Other Tobacco use: denies
ETOH: none in last 6 months. Previously daily beers and shot
Family History:
Premature coronary artery disease - none
Physical Exam:
Pulse: 56 SB Resp: 16 O2 sat: 99 % RA
B/P Left: 132/77
Height: 69 inches Weight: 83.3 kg
General: Pleasant cooperative no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anteriorly
Heart: RRR [x] Irregular [] Murmur [] grade
Abdomen: Soft[x] non-distended[x] non-tender[x] + bowel
sounds[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Alert and oriented x3 nonfocal, unable to assess gait on
bedrest s/p cath
Pulses:
Femoral Right: mynx closure Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: + bruit Left: no bruit
Pertinent Results:
Admission labs:
[**2190-8-2**] 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-8-2**] 09:30PM PT-12.2 PTT-40.9* INR(PT)-1.0
[**2190-8-2**] 09:30PM PLT COUNT-159
[**2190-8-2**] 09:30PM WBC-5.6 RBC-3.64* HGB-11.1* HCT-32.6* MCV-90
MCH-30.6 MCHC-34.1 RDW-14.4
[**2190-8-2**] 09:30PM %HbA1c-5.4 eAG-108
[**2190-8-2**] 09:30PM ALBUMIN-3.6 CALCIUM-10.0 PHOSPHATE-2.4*
MAGNESIUM-2.1
[**2190-8-2**] 09:30PM CK-MB-2 cTropnT-<0.01
[**2190-8-2**] 09:30PM LIPASE-61*
[**2190-8-2**] 09:30PM ALT(SGPT)-11 AST(SGOT)-20 LD(LDH)-185
CK(CPK)-42* ALK PHOS-86 AMYLASE-144* TOT BILI-0.3
[**2190-8-2**] 09:30PM GLUCOSE-104* UREA N-23* CREAT-1.4* SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**2190-8-2**] 10:45PM CK-MB-2 cTropnT-<0.01
[**2190-8-2**] 10:45PM CK(CPK)-36*
[**2190-8-3**] Intra-op TEE
PREBYPASS
No mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the left
atrial appendage. No thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is moderately dilated. The descending thoracic
aorta is mildly dilated. There are complex (>4mm) atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trace mitral regurgitation
is seen.
An epiaortic scan was performed which confirmed dilated aorta
with no significant atheromatous disease at canullation or cross
clamp location.
POSTBYPASS
Biventricular systolic function remains normal. The study is
otherwise unchanged from prebypass.
Discharge Labs:
[**2190-8-12**] 06:15AM BLOOD WBC-6.6 RBC-3.31* Hgb-9.7* Hct-29.5*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.6 Plt Ct-284
[**2190-8-11**] 06:23AM BLOOD WBC-7.5 RBC-3.61* Hgb-10.6* Hct-31.4*
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.5 Plt Ct-256
[**2190-8-9**] 06:50AM BLOOD WBC-5.3 RBC-3.27* Hgb-9.7* Hct-28.9*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.9 Plt Ct-201
[**2190-8-12**] 06:15AM BLOOD PT-19.4* INR(PT)-1.8*
[**2190-8-11**] 06:23AM BLOOD PT-16.5* PTT-29.9 INR(PT)-1.5*
[**2190-8-9**] 06:50AM BLOOD PT-16.3* PTT-30.4 INR(PT)-1.4*
[**2190-8-8**] 06:55PM BLOOD PT-21.8* INR(PT)-2.0*
[**2190-8-12**] 06:15AM BLOOD Glucose-85 UreaN-23* Creat-1.6* Na-142
K-4.2 Cl-106 HCO3-28 AnGap-12
[**2190-8-11**] 06:23AM BLOOD Glucose-96 UreaN-24* Creat-1.5* Na-141
K-4.1 Cl-104 HCO3-27 AnGap-14
[**2190-8-8**] 04:16AM BLOOD Glucose-91 UreaN-29* Creat-1.4* Na-144
K-3.5 Cl-106 HCO3-28 AnGap-14
[**2190-8-7**] 05:15AM BLOOD Glucose-83 UreaN-32* Creat-1.5* Na-142
K-3.4 Cl-105 HCO3-30 AnGap-10
[**2190-8-12**] 06:15AM BLOOD Mg-2.1
[**2190-8-10**] Chest x-ray:
As compared to the previous radiograph, there is no relevant
change. Minimal pericardial air inclusion might be present at
the level of the aortopulmonary window. Unchanged left rib
fractures and area of mild pleural thickening might have
increased in extent. Unchanged size of the cardiac silhouette.
Pre-existing retrocardiac atelectasis is improving. Unchanged
unremarkable right lung. No pulmonary edema. No evidence of
pneumonia.
Brief Hospital Course:
Following the routine pre-operative workup, the patient was
brought to the Operating Room on [**2190-8-3**] where the patient
underwent coronary bypass grafting with Dr. [**Last Name (STitle) 914**]. Please see
the operative note for details, in summary he had:
Urgent coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary; reverse
saphenous vein single graft from the aorta
to the first diagonal coronary artery; reverse saphenous vein
single graft from the aorta to the first obtuse marginal
coronary artery. His bypass time was 62 minutes, with a
crossclamp of 46 minutes. Of note, 4.5cm Ascending Aortic
Aneurysm was noted on intra-op TEE. The patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring on
Propofol and phenylephrine infusions. He remained
hemodynamically stable in the immediate post-op period, woke
from anesthesia neurologically intact and was extubated. He
remained hemodynamically stable, was weaned from vasopressor
support and on POD1 was transferred from the ICU to the stepdown
floor for continued care and recovery. The patient was begun on
diuretics at that time as well. All chest tubes, invasive lines
and epicardial pacing wires were removed per cardiac surgery
protocol and without complication. He had intermittent atrial
fibrillation/flutter for which Amiodarone and Warfarin were
started. Warfarin was dosed for a goal INR between 2.0 - 2.5.
Amiodarone was titrated per Atrius cardiology. The patient
worked with the physical therapy service for assistance with
strength and mobility. By the time of discharge on
postoperative day nine, the patient was ambulating with
assistance, the wound was healing and pain was controlled with
Percocet. There was very minimal sternal drainage and PO
antibiotic was changed to a one week course of Keflex. The
patient was discharged to rehabilitation at [**Hospital **] Health Care
in good condition, he is to follow up with Dr [**Last Name (STitle) 914**] on
[**2190-8-31**] @1:45PM. Cardiology followup appt. was also arranged at
[**Location (un) 2274**] [**Location (un) 38**]. The cardiac surgery office will also arrange a
chest CT scan with contrast in approximately one year time to
re-evaluate his dilated ascending aorta. At discharge, he was in
a normal sinus rhythm with rate in the 60's.
Medications on Admission:
Nitroglycerin SL prn
Colace 100 mg [**Hospital1 **]
Ferrous Sulfate 325 mg daily
Imdur 30 mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 20 mg daily
ASA 81 mg daily
Omeprazole 20 mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily) for 1 weeks: hold for K+ >4.5.
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 1 weeks.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: then drop to 1 tab(200mg) daily until
followup with cardiologist.
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate for goal INR between 2.0 - 2.5. Daily dose may vary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care center
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Paroxysmal Atrial Fibrillation/Flutter
Hypertension
Hypercholesterolemia
Dilated Ascending Aorta
Chronic Renal Insufficiency
Mild Postop Sternal Drainage(improved)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, with assistance
Sternal pain managed with Percocet
Sternal Incision - healing well, no erythema, minimal drainage
Edema: trace bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call 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 A Fib
Goal INR 2.0-2.5
First draw day after discharge from hospital
****Please arrange for coumadin/INR follow up prior to discharge
from rehab
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] Date/Time:[**2190-8-31**] @1:45PM [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 88768**] [**Name (STitle) 42388**] [**2190-8-20**] @ 11:00 AM
[**Location (un) 38**] [**Hospital1 **] Medical Assoc.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 17465**] in [**4-20**] 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 A Fib
Goal INR 2.0-2.5
First draw day after discharge from hospital
****Please arrange for coumadin/INR follow up prior to discharge
from rehab****
***Cardiac surgery office will arrange chest CT scan in
approximately one year to evaluate ascending aortic aneurysm***
Completed by:[**2190-8-12**]
|
[
"414.01",
"403.90",
"272.0",
"585.9",
"427.32",
"411.1",
"V15.82",
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"447.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
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icd9pcs
|
[
[
[]
]
] |
10191, 10252
|
6265, 8682
|
319, 637
|
10495, 10679
|
2792, 2792
|
11553, 12529
|
1948, 1991
|
8930, 10168
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10273, 10474
|
8708, 8907
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10703, 11530
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4779, 6242
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1553, 1612
|
2006, 2773
|
269, 281
|
665, 1291
|
2808, 4763
|
1359, 1530
|
1628, 1932
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,326
| 149,062
|
26067
|
Discharge summary
|
report
|
Admission Date: [**2119-5-12**] Discharge Date: [**2119-5-31**]
Date of Birth: [**2055-10-21**] Sex: F
Service: SURGERY
Allergies:
Meperidine / Iodine
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Exploratory Laparotomy/Lysis of adhesions, and right
hemicolectomy.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 64713**] is a 63 year-old female
with a history of CAD status post MI in [**10/2118**], status post
stents X3 (last on [**2119-4-14**]) currently on ASA and Plavix, atrial
fibrillation no longer on Coumadin given a history of
life-threatening lower GI bleed in [**11/2118**] (at which time
Coumadin was discontinued and Plavix was initiated), also with
CHF and PVD, who presents from home with a 1-day history of
"dark stools". Of note, she was admitted to [**Hospital1 18**] in [**11/2118**]
with a lower GI bleed while on Coumadin and ASA. At that time,
endoscopy was remarkable for EGD with mild gastritis (negative
H. pylori), and C-scope with multiple diverticula and polyps,
with a blood clot seen at the hepatic flexure with diverticula
and polyps underneath without active bleeding. A tagged RBC scan
was positive for tracer uptake at the hepatic flexure, but an
angiogram was negative, and an intervention was not performed.
ASA and Plavix were subsequently restarted.
*
She now reports that she started having marroon-colored stools
at night before admission. She subsequently had 10 other BMs
with marroon-colored stools and bright red blood mixed in. She
notes that she feels the urge to move her bowels, and does not
have bleeding in between. She had transient abdominal discomfort
in the LLQ, which lasted 30 minutes and spontaneously resolved.
She is currently pain free. She reports mild shortness of
breath, without chest pain. She had transient lightheadedness
last night, now improved. No recent fever or chills, no other
complaints.
*
In ED, T 98.1, HR 82, BP 168/66, RR 18, Sat 99% on RA. DRE per
ED notes with melena and bright red blood. She declined an NG
lavage. She was given Protonix 40 mg IV X1. She remained
hemodynamically stable while in the ED, and was admitted to 11R.
There, she had 2 other bloody BMs. Orthostatic vitals showed a
mild increase in HR (currently on BB).
Past Medical History:
--LGIB: Admitted to [**Hospital1 **] [**2118-12-1**] with massive LGIB while on
coumadin and plavix after NSTEMI and A.fib. s/p >20 units pRBCs
during this admission. s/p multiple colonoscopies, bleeding
scans -->diverticular bleed, localized bleed to hepatic
flexture, unable to perform intervention. Now stable. Off
coumadin due to lifethreatening LGIB.
--MYOCARDIAL INFARCTION [**2118-11-15**] NSTEMI with peak CK 204 and
Trop 0.17, s/p coronary catheterization on [**11-16**] received 2
drug-eluting stents to LCx and D1.
--ATRIAL FIBRILLATION Developed PAF during admission for NSTEMI
[**10-31**] converted to sinus rhythm with beta blocker,
anticoagulated with coumadin s/p massive LGIB. Now off coumadin.
--ANEMIA [**2118-12-12**] Hemolytic Anemia - unclear etiology after
extensive inpatient w/up. Initially thought to be delayed
transfusio reaction given 20+ units transfused [**12-29**] LGIB. Blood
bank w/up however negative. Heme consult placed, negative for
G6PD deficiency, other causes. Currently stable.
--FIBROMYALGIA Longstanding history - takes Percocet 7.5/325 120
tabs per month
--HYPERTENSION H/o hypertensive crisis - admitted [**2118-11-15**] with
hypertensive crisis and pulmonary edema. Renal U/S negative for
obstruction [**2118-12-12**]. Followed by renal. Currently under better
control - some degree of permissive hypertension given
elevated creatinine.
--BREAST CANCER s/p R mastectomy ~20 years ago
--CONGESTIVE HEART FAILURE EF 35-40% 3+ TR or 1+ MR, e/a 0.45
--PERIPHERAL VASCULAR DISEASE s/p bifem bypass
--? PATENT FORAMEN OVALE: conflicting echo readings [**10-31**]
--h/o ENDOCARDITIS h/o questionable step viridans endocarditis
--h/o RIGHT ATRIAL LESION (THROMBUS VS. VEGETATION) seen on ECHO
[**11-15**] and [**2118-11-16**]. Not present [**12-2**] and not present on TEE
intraoperatively
Social History:
h/o tobacco, quit 3 years ago, minimal etoh, no illicits; lives
alone, no close family or friends, has a daughter who lives in
[**Name (NI) 26692**]
Family History:
heart disease of unclear etiology
Physical Exam:
T 98.9 P 90 BP 128/64 R 20 SaO2 95
GEN: In NAD, pleasant African-american female.
HEENT: Anicteric, MMM.
NECK: JVP not elevated.
RESP: CTAB, without adventitious sounds.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur appreciated.
GI: BS NA. Abdomen soft, mild RUQ tenderness without rebound or
guarding.
DRE: Bright red blood, no stool.
EXT: Warm, without edema.
Pertinent Results:
[**2119-5-27**] 09:40AM BLOOD WBC-23.8* RBC-3.55* Hgb-10.3* Hct-31.0*
MCV-87# MCH-28.9 MCHC-33.1 RDW-16.3* Plt Ct-502*
[**2119-5-31**] 06:19AM BLOOD WBC-10.2 RBC-3.13* Hgb-8.7* Hct-27.1*
MCV-86 MCH-27.8 MCHC-32.1 RDW-17.0* Plt Ct-548*
[**2119-5-30**] 06:15AM BLOOD PT-30.1* PTT-31.0 INR(PT)-3.2*
[**2119-5-30**] 06:15AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2119-5-29**] 05:43AM BLOOD ALT-24 AST-39 AlkPhos-73 TotBili-0.3
[**2119-5-24**] 11:09PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2119-5-24**] 05:15PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2119-5-24**] 08:12AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2119-5-26**] 8:53 am SWAB Site: ABDOMEN Source: abdomem.
GRAM STAIN (Final [**2119-5-26**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2119-5-30**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD #1. MODERATE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
GRAM NEGATIVE ROD #3. RARE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 8 I
MEROPENEM------------- 1 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Preliminary):
ANAEROBIC GRAM NEGATIVE ROD(S). BETA LACTAMASE
POSITIVE.
FURTHER IDENTIFICATION TO FOLLOW.
[**2119-5-27**] 9:42 pm URINE
**FINAL REPORT [**2119-5-29**]**
URINE CULTURE (Final [**2119-5-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2119-5-28**] 12:08 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2119-5-28**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2119-5-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
Pt was admitted to the [**Hospital Unit Name 153**] for close monitoring given concern
for her brisk LGI bleed. She remained hemodynamically stable
with slight decreases in her hematocrit. She underwent a
tagged RBC scan which was not revealing in terms of her bleeding
source. She was transfused to maintain her hct >28 given her
h/o CAD. Unfortunately, due to her recent stent placement, her
ASA and Plavix had to be continued. GI was consulted who
recommended transfusions as needed, and prep for c-scope. Her
c-scope was finally performed on [**5-15**] which did not show any
active bleeding, but with diffuse diverticulosis throughout her
entire colon, and multiple polyps. It was thought that likely
one of her diverticula bled, but it was unclear exactly in what
location. Gen [**Doctor First Name **] had been consulted to assist with possible
surgical intervention, but given lack of localization, it was
felt that short of performing a total colectomy, it would be
prudent to wait for the next bleeding episode to decide on which
portion of the colon to remove. Pt remained hemodynamically
stable with stable hematocrits and she was transferred to the
floor on [**5-14**]. Pt stayed hemodynamically stable with stable hct
for ~18 hours, then pt started having marroon colored stools
again and hct began to drop requiring more PRBC. Bleeding scan
was done on [**5-17**] showing GI bleeding, beginning at approximately
40 minutes, most likely at the hepatic flexure of the colon.
The pt was evaluated by surgery and taken to OR [**5-18**] for a R
hemicolectomy due to persistent bleeding and transferred to the
recovery room in good condition.
On [**5-18**], patient developed chest pain and shortness of breath.
ECG revealed no acute changes and cardiac enzymes were negative.
TEE revealed the left atrium is markedly dilated and elongated.
No mass/thrombus is seen in the left atrium or left atrial
appendage. The right atrium is moderately dilated. There is a
prominent eustachain valve and chiari network which appears
thicker than usual, but othewise, no abnormal masses,
vegetations, or thrombi are seen in the right atrium or right
atrial appendage. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. The interatrial septum bows prominently into the
right atrium, suggesting elevated left atiral pressures. There
is severe left ventricular hypertrophy, but the infeior wall is
somewhat thinner (1.5 cm vs over 2 cm for other walls). There is
mild regional left ventricular systolic dysfunction. Overall
left ventricular systolic function is mildly depressed at
45-50%. Resting regional wall motion abnormalities include
moderate infeior hypokinesis. The remaining left ventricular
segments contract normally, although the posteior wall is poorly
visualized. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace central aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral central regurgitation is
seen. [**Last Name (un) **] vena contracta measures less than 4 mm. Pt was
continued on her anticoagulation medications.
Because pt's HR was >100 and she was in atrial fibrillation,
cardiology was called to see the patient. Pt was started on a
diltiazem drip and beta blocker for rate control. Pt's H&H was
stable throughout the hospital course and she did not require
the need for blood transfusion. Pt again had chest pain and
shortness of breath [**5-24**]. ECG again showed no acute changes and
cardiac enzymes were negative. At the time of discharge, pt's
HR was adequately maintained in the 80s on PO Toprol and PO
diltiazem.
Pt was started on sips 2 days post-operatively and and she was
started on TPN. Diet was slowly advanced. However on [**5-24**], pt
vomited and an NG was placed which drained 6 liters. Pt was
restarted on clears [**5-26**] and her diet was gradually advanced to
a regular diet. TPN was discontinued [**5-28**].
On [**5-27**], pt had WBC of 23 and a wound infection was discovered.
Her abdominal wound was opened up in 2 places and drained pus.
Wet to dry dressings three times a day were done to treat the
wound infection. On discharge, pt had WBC of 10.2 and wound was
no longer draining and had granulation tissue
Medications on Admission:
MEDICATIONS ON ADMISSION:
ASA 325 mg PO QD
Plavix 75 mg PO QD
Percocet prn
Norvasc 10 mg PO QD
Sertraline 25 mg PO QD
Imdur 60 mg PO QD
Ambien prn
Lipitor 80 mg PO QD
Toprol 100 mg PO QD
HCTZ 25 mg PO QD
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. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO QAM (once a day
(in the morning)).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO HS (at bedtime).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
Disp:*30 Tablet(s)* Refills:*0*
7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Metoprolol 10 mg IV Q4H:PRN
hold SBP < 100, HR < 60
9. Diltiazem 10 mg IV Q6H:PRN prn HR>100
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebule
Inhalation Q6H (every 6 hours) as needed.
Disp:*30 Solutions* Refills:*0*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebule
Inhalation Q6H (every 6 hours) as needed.
Disp:*30 Solutions* Refills:*0*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
14. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
16. Colace 50 mg Capsule Sig: [**11-28**] Capsules PO every 4-6 hours as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
17. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
Right colonic bleeding secondary to colon cancer
Post operative ileus
Atrial Fibrillation with rapid ventricular response
Acute Blood loss anemia
Post Op Wound Infection
HTN
Depression/Anxiety
Discharge Condition:
stable
Discharge Instructions:
Call your doctor if you experience fever, chills,
lightheadedness, dizziness, chest pain, palpitations, shortness
of breath, severe abdominal pain, nausea/vomiting, or bleeding
from abdominal wound.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Call [**Telephone/Fax (1) 2359**]
for appointment.
|
[
"153.6",
"786.59",
"V45.82",
"560.1",
"998.59",
"401.9",
"300.00",
"V10.3",
"562.10",
"196.2",
"997.4",
"568.0",
"285.1",
"729.1",
"427.31",
"211.3",
"428.0",
"682.2",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"54.59",
"86.04",
"96.07",
"88.72",
"45.93",
"45.23",
"38.93",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
14105, 14208
|
7424, 11816
|
308, 378
|
14445, 14454
|
4837, 6727
|
14701, 14825
|
4400, 4435
|
12072, 14082
|
14229, 14424
|
11869, 12049
|
14478, 14678
|
4450, 4818
|
241, 270
|
435, 2363
|
6766, 7401
|
2385, 4217
|
4233, 4384
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,464
| 121,677
|
11132
|
Discharge summary
|
report
|
Admission Date: [**2152-3-25**] Discharge Date: [**2152-4-9**]
Date of Birth: [**2077-1-9**] Sex: F
Service: Medical Intensive Care Unit, Green Team
HISTORY OF PRESENT ILLNESS: This is a 75-year-old female
with a history type 2 diabetes mellitus (on oral
hypoglycemics) and a 3-vessel coronary artery bypass graft in
[**2151-9-20**] who was admitted to [**Hospital1 190**] on [**2152-3-25**] with a 4-day history of
nausea, mild emesis, and a cough productive of clear white
sputum. She also complained of abdominal pain over those
preceding days which was not clearly defined by her son who
was giving most of the medical history.
On the night prior to admission, she developed worsening
shortness of breath and a question of chest pain. She
originally presented to [**Hospital 1474**] Hospital where she was
hypertensive at 220/120, and tachycardic to 110, with a
respiratory rate of 40, and an oxygen saturation of 87%. She
was treated for congestive heart failure with diuretics
without a good response. Her creatinine was also found to be
elevated to 2.5 from her baseline of 1.2. She progressively
deteriorated, requiring intubation for hypoxic respiratory
failure. She was transferred to [**Hospital1 190**] after receiving ceftriaxone and erythromycin.
A pulmonary artery catheter revealed a wedge of 12 and a
cardiac output of 6, with pulmonary artery pressures of 38/8.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus; on oral hypoglycemics, none of
which were changed prior to admission.
2. Coronary artery disease; status post coronary artery
bypass graft times three in [**2151-9-20**].
3. Hypertension.
4. No history of significant renal insufficiency (per her
primary care doctor).
MEDICATIONS ON ADMISSION: Her medications as an outpatient
included glyburide, nifedipine, Colace, potassium, Lasix,
Glucophage, Lopressor, and aspirin.
ALLERGIES: She had no known drug allergies.
SOCIAL HISTORY: She was not an alcohol user.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 97.9, heart rate was
58, blood pressure was 170/60, respiratory rate were assist
control 600 X 18, 100% FIO2, and 5 positive end-expiratory
pressure. She was saturating 96% on those settings. Central
venous pressure was 14. Her wedge pressure was 25 with a
pulmonary artery pressure of 50/25. Cardiac output was 5.5.
Cardiac index was 2.9. Systemic vascular resistance was
1860. In general, she was sedated but did follow some
commands despite being intubated. Her heart was regular and
without murmurs. Her lung examination revealed rales
laterally. Her abdomen was soft with decreased bowel sounds.
The abdomen was nontender and nondistended. Her rectal
examination revealed guaiac-negative stool in the vault with
no mass. Her extremities were without edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories on admission revealed white blood cell count was
19.5, hematocrit was 27, creatinine was 2.8, and glucose was
155. Her bicarbonate was 20 with an anion gap of 13.
Amylase was 1100. Alkaline phosphatase was 130. AST was 17
and ALT was 7. Total bilirubin was 0.8. Lactate was 1.7.
INR was 1.4.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient's entire
hospital course was in the Intensive Care Unit where she was
being treated for pancreatitis, hypoxic respiratory failure
(felt to be secondary to acute respiratory distress
syndrome), renal failure, and hypoglycemia.
1. HYPOXIC RESPIRATORY FAILURE ISSUES: This started at
[**Hospital 1474**] Hospital, and she continued to progress with
worsening failure despite aggressive ventilatory support.
She required increasing levels of positive end-expiratory
pressure and progressive bilateral infiltrates on chest
x-ray.
A bronchoscopy was performed during her hospitalization which
revealed normal airways, but culture revealed Pseudomonas for
which she was treated. Legionella antigen was negative. She
underwent a thoracentesis on [**2152-4-5**]; removing 800 cc
of transudative fluid without any improvement in her
respiratory status.
It was the acute respiratory distress syndrome was felt to be
secondary to her pancreatitis that caused her eventual
demise.
2. PANCREATITIS ISSUES: The etiology of this was unclear.
She had no stones. She had no history of alcohol use and was
not on any new medications or culprit medications for this.
Her triglycerides were never elevated. She was covered
empirically with antibiotics and received computed tomography
scans during her hospitalization at the time of fevers which
revealed no drainable fluid collections.
3. RENAL FAILURE ISSUES: The patient's renal failure was
felt to be secondary to acute tubular necrosis in the setting
of relative hypotension that she experienced right after
presenting to [**Hospital 1474**] Hospital.
She did have an intermediate syndrome revealing a FENa of
less than 1%. SPEP was negative. UPEP did not show any
monoclonal spikes. She was hydrated aggressively with
alkalized fluid with some improvement in her creatinine
clearance; however, this never returned back to normal.
4. HYPOGLYCEMIC ISSUES: Her hospital course was complicated
by hypoglycemia which was felt to be secondary to persistent
sulfonylurea affect in the setting of her acute renal
failure. Her cortisol stimulation test was negative.
The patient's Intensive Care Unit course was long with
persistent hypoxic respiratory failure secondary to acute
respiratory distress syndrome which precluded any possibility
for meaningful recovery. A tracheostomy was not pursued, as
her respiratory status continued to deteriorate.
After a discussion with the [**Hospital 228**] health care proxy (her
son [**Name (NI) **] [**Name (NI) 35883**]), critical care support was withdrawn, and
the patient expired on [**2152-4-9**].
DISCHARGE DIAGNOSES: (Discharge diagnoses included)
1. Pancreatitis.
2. Acute respiratory distress syndrome.
3. Renal failure.
4. Coronary artery disease.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 8167**]
MEDQUIST36
D: [**2153-3-22**] 14:35
T: [**2153-3-24**] 04:56
JOB#: [**Job Number 35884**]
|
[
"577.0",
"507.0",
"584.9",
"410.71",
"401.9",
"250.82",
"518.81",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"96.04",
"96.72",
"38.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5885, 6266
|
1757, 1931
|
3252, 5863
|
195, 1406
|
1428, 1730
|
1948, 3217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,552
| 160,230
|
48086
|
Discharge summary
|
report
|
Admission Date: [**2137-12-9**] Discharge Date: [**2137-12-10**]
Date of Birth: [**2060-10-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
tachypnea
Major Surgical or Invasive Procedure:
bronchoscopy, intubation
History of Present Illness:
77 F w/ PMH of parkinson's and SLE, with history of resp
failure, s/p trach which has been getting downsized. Today the
pt was going to have a T-tube placed. Prior to procedure, trach
was found to be decanulated. IP bronched her to remove
granulation tissue. Following the bronch/extubation she
developed bronchospasm. She had to be re-intubated and was
therefore double dosed with succinylcholine. She was extubated
again and was tachypnic to 33 and thus felt to require ICU
monitoring.
.
In the ICU, pt reports breathing is comfortable. She is having
[**2137-6-27**] back pain consistent with her chronic back pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
SLE, Parkinson's disease
Atrial fibrillation/aflutter
Paralysis agitans
Episodic hypertension during previous hospitalizations
H/O respiratory failure requiring tracheostomy placement
Tracheal and subglottic stenosis
Glaucoma, blind in R eye
Social History:
Patient lives at [**Hospital **] Rehabilitation and Nursing Center.
Denies any history of tobacco, alcohol, or illit drug use. She
is originally from [**Country **] and worked at [**Company 22916**] Corporation in
[**Location (un) 86**]. Daughters [**Name (NI) **] lives in [**Location 686**] and [**Doctor First Name **] in
[**Location (un) 101401**], FL.
Family History:
non-contributory
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: tegaderm applied to neck, supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
ejection murmur at apex
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
A. Labs
[**2137-12-10**] 02:57AM BLOOD WBC-12.1*# RBC-4.16* Hgb-11.3* Hct-34.0*
MCV-82 MCH-27.1 MCHC-33.1 RDW-15.4 Plt Ct-196
[**2137-12-10**] 02:57AM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3*
[**2137-12-10**] 02:57AM BLOOD Glucose-112* UreaN-15 Creat-1.0 Na-144
K-3.5 Cl-105 HCO3-27 AnGap-16
[**2137-12-10**] 02:57AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.6
B. Radiology
CT TRACHEA ([**12-10**]):
1. Focal area of narrowing of the trachea just at the level of
the thoracic inlet to be 9 x 7 mm in diameter, 71 mm2, with no
significant change during dynamic expiration. The rest of the
trachea is unremarkable.
2. Local collection in the area adjacent to the right upper
mediastinum that might represent local pneumothorax. No evidence
of fluid collection in the area demonstrated to suggest
infectious origin of this finding.
3. Areas of ground-glass opacity in the lungs are concerning for
infection/aspiration.
4. Cardiomegaly, moderate. Small amount of pericardial effusion.
Brief Hospital Course:
77 yo female with PMH tracheostomy [**1-22**] respiratory failure,
subglottic stenosis, Parkinson's and SLE who is s/p rigid
bronchoscopy on [**12-9**] for removal of granulation tissue who
required ICU admission for observation due to tachypnea post
extubation.
Bronch revealed mild TBM and recidual tracehal stenosis. She has
a tegaderm covering her stomal opening, which will stay in place
for now. She had normal oxygen saturations throughout her ICU
stay. A CT airway was done to evaluate for tracheal stenosis,
which showed tracheal and subglottic stenosis as noted above.
In terms of Atrial Fibrillation, Currently in sinus rhythm.
Maintained on metoprolol. INR was 1.3 on [**12-10**]. Warfarin was
being held pre-procedure and was restarted on [**12-10**].
Healthcare proxy : [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 101402**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(daughter) [**Telephone/Fax (1) 101403**]
Medications on Admission:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): One drop in R eye [**Hospital1 **].
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): One drop in R eye at bedtime.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for Constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for Constipation.
9. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for GI upset.
10. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO Q6 ().
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Metoprolol Tartrate 75 mg Tablet PO BID
15. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
16. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
17. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation three times a day.
18. Acetylcysteine 10 % (100 mg/mL) Solution Sig: Two (2) mL
Miscellaneous three times a day: give with duoneb.
19. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation Q2HR as needed for
shortness of breath or wheezing.
20. Acetylcysteine 10 % (100 mg/mL) Solution Sig: [**12-22**] mL
Miscellaneous as needed as needed for mucous plugging.
21. Tube Feeding
Jevity 1.5 TF
22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
four (4) hours as needed for pain, fever.
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) drop to RIGHT
EYE Ophthalmic twice a day.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for GI upset.
8. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
13. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
14. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation three times a day.
15. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: please check daily INR while being restarted on warfarin
post-procedure.
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
17. Tube Feeds
Tube Feeding Jevity 1.5 TF
18. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at
bedtime: One drop in R eye at bedtime. .
19. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every 2 hours as needed
for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Tracheal and subglottic stenosis
SECONDARY DIAGNOSIS:
Lupus
Parkinson's disease
Atrial fibrillation/aflutter
Episodic hypertension during previous hospitalizations
H/O respiratory failure requiring tracheostomy placement
Glaucoma, blind in R eye
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You initially came to [**Hospital1 18**] for placement of a T tube, but prior
to this your tracheostomy had come out. The interventional
pulmonologist did a bronchoscopy to remove excess tissue. When
this happened, you had some airway spasming and a breathing tube
had to be replaced. When the breathing tube was taken out, you
were breathing fast and had to come to the ICU for overnight
monitoring. There were no further complications and you are
being discharged back to your rehab facility. A CT scan of your
airways showed mild tracheal stenosis.
The following changes were made to your medications:
1. Please reSTART your coumadin at 3mg every night. Daily INR
should be checked until back at your goal INR of [**1-23**].
2. STOP acetylcysteine inhalation.
Followup Instructions:
Please follow up with the interventional pulmonologists within 1
MONTH
Dr. [**Last Name (STitle) **] (extension [**Telephone/Fax (1) 7769**] or [**Telephone/Fax (1) 56721**])
[**Hospital1 18**] main number: [**Telephone/Fax (1) 2756**]
You will be also followed by a physician at [**Name9 (PRE) **] Health Care.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"427.31",
"332.0",
"519.19",
"519.02",
"427.32",
"369.60",
"288.60",
"365.9",
"710.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
8638, 8711
|
3665, 4662
|
316, 342
|
9020, 9020
|
2671, 3642
|
9999, 10407
|
2115, 2133
|
6769, 8615
|
8732, 8732
|
4688, 6746
|
9211, 9976
|
2148, 2652
|
1010, 1458
|
267, 278
|
371, 991
|
8806, 8999
|
8751, 8785
|
9118, 9187
|
1480, 1724
|
1740, 2099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,531
| 116,333
|
24127
|
Discharge summary
|
report
|
Admission Date: [**2141-7-29**] Discharge Date: [**2141-7-30**]
Date of Birth: [**2083-5-14**] Sex: F
Service: MEDICINE
Allergies:
Lorazepam / Ultram
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
endoscopy [**2141-7-30**]
Placement of left femoral central venous catheter [**2141-7-30**]
History of Present Illness:
This was a 58F with history of seizure disorder, BPAD, frontal
and cerebellar atrophy but no prior history of liver disease or
GIB who presented to the ED by ambulance after a syncopal
episode at home. She reported having taken zolpidem and then
walked to the kitchen. Unclear actual mechanism of fall as
patient unable to remember but noted to have blood on her face,
which was attributed to striking her face on the sink as she
fell. EMS reported observing two possible focal seizures with
fixed gaze and arm posturing with incontinence. She has a
history of seizures with tramadol in the past but had not taken
this in some time.
In the ED she had a SBP in the 50s in triage while awake and
mentating. 18g IV placed and she received 4L NS with improvement
of SBP to 80-90s. She had an episode of stool incontinence with
a melena. NG lavage with 1L fluid showed copious coffee grounds
that cleared followed by bright red blood. At that point lavage
was stopped. Labs notable for Hct 31.7 from a distant baseline
of 38 in [**2135**] and a Cr 1.7 from baseline of 1.1. Head CT was
without acute change. She received 1 unit pRBCs in the ED and
was started on pantoprazole drip after an 80 mg bolus. A second
unit of pRBC's was started just prior to transfer to the ICU. .
After arrival to the ICU the patient when asked more about her
history noted decreased appetite with early satiety x1 month as
well as epigastric pain, which she attributed to her diabetes
and reportedly improved with sugar. Her husband endorsed at
least one episode of emesis a day, but he was not sure if this
was bloody. She endorsed occasional falls, which were a
longstanding issue. Of note, patient did endorse taking
meloxicam daily for arthritis pain. She denied any abdominal
pain at time of arrival to the ICU and denied any heartburn,
chest pain, F/C, dizziness, or dysuria.
Past Medical History:
- Type II DM (not on meds)
- HTN
- HL
- Insomnia
- Chronic Gait instability with falls
- Cerebellar atrophy
- Frontal atrophy
- Bipolar disorder
- Seizure disorder (not on meds)
- Osteoarthritis
- Cervical Spondylosis
Social History:
Retired. Lives separately from husband [**Name (NI) 4468**]. History of
smoking. She denied any EtOH or drug use.
Family History:
Father with diabetes
Physical Exam:
At admission:
VS: T 96.9 ??????F, HR 65, BP 107/62, RR 23, O2 Sat 100% on RA
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: Nl S1 and S2, RRR, no M/R/G, peripheral pulses
at radials and DP's present and normal
Respiratory / Chest: Clear to auscultation bilaterally with
equal chest expansion bilaterally
Abdominal: Soft, Non-tender, normoactive bowel sounds, mild
tenderness with deep palpation of the epigastrum and RUQ
Extremities: Warm and well perfused with no lower extremity
edema appreciated
Skin: Warm
Neurologic: Alert and oriented *3. Responding to questions
appropriately.
Child-like affect.
Pertinent Results:
===================
LABORATORY RESULTS
===================
At Admission:
WBC-13.4* Hgb-10.9* Hct-31.7* MCV-91 RDW-12.9 Plt Ct-349#
----Neuts-60.4 Lymphs-31.9 Monos-4.7 Eos-2.3 Baso-0.7
Glucose-167* UreaN-37* Creat-1.7* Na-137 K-4.6 Cl-97 HCO3-23
PT-12.7 PTT-19.8* INR(PT)-1.1 Lipase-70*
Calcium-10.3 Phos-4.8*# Mg-2.4
Lactate-2.6*
Prior to demise:
WBC-9.7 RBC-1.28*# Hgb-4.1*# Hct-12.1*# MCV-94 RDW-14.3 Plt
Ct-86*
---PT-28.1* PTT-150* INR(PT)-2.7*
Glucose-105* UreaN-13 Creat-0.5 Na-147* K-3.2* Cl-129* HCO3-8*
Calcium-3.5* Mg-1.2*
ABG: Temp-35.6 pO2-79* pCO2-49* pH-6.98* calTCO2-12*
Lactate-7.1*
Hct Trend:
[**2141-7-29**] 02:30AM Hgb-10.9* Hct-31.7*
[**2141-7-29**] 10:30AM Hgb-10.9* Hct-31.9*
[**2141-7-29**] 03:30PM Hct-30.2*
[**2141-7-29**] 09:50PM Hct-26.9*
[**2141-7-30**] 02:30AM Hct-25.9*
[**2141-7-30**] 03:44AM Hgb-4.1*# Hct-12.1*#
============================
RADIOLOGY AND OTHER RESULTS
============================
EKG [**7-29**]:
NSR at 60bpm. LAD, poor R wave progression. TWI in V1, TWF in
V2-V3. No prior for comparison.
CT head [**7-29**]
FINDINGS: There is no evidence of acute intracranial hemorrhage,
discrete
masses, mass effect or shift of normally midline structures. The
ventricles
and sulci are prominent which is not typical for the patient's
age, however it is unchanged since [**2134-5-3**]. There is
pronounced cerebellar atrophy
bilaterally. No acute fractures are identified. Bilateral
mastoid and
paranasal sinuses are clear.
IMPRESSION: No acute intracranial pathology.
CXR [**7-29**]
PORTABLE AP CHEST RADIOGRAPH: Prominence of the right hilum and
upper
mediastinum may represent technique and rotated position. Both
lungs are
clear with no focal consolidation, pleural effusion or
pneumothorax.
Recommend a repeat PA and lateral chest radiograph for further
evaluation.
The study and the report were reviewed by the staff radiologist.
Upper Endoscopy [**2141-7-30**]:
Impression: Immediately upon entering the esophagus there was a
large amount of active bleeding obscuring the view. At approx
45cm there was an area without any blood, ?if this was
peritoneum, reflecting a massive perforation. Procedure aborted,
surgical team at the bedside.
Otherwise normal EGD to unknown
Brief Hospital Course:
58F with history of seizures and bipolar disorder presenting
with syncope, hypotension, melena and coffee grounds on lavage.
Patient was admitted to the medical ICU for concern of
hematemasis. She was started on a pantoprazole drip and NSAIDs
were held. 2 large PIV were placed. As Hct's were initially
stable and hemodynamics were stable, endoscopy was initially
defered until [**7-31**].
At approximately 2:30am on [**7-30**], patient became
unresponsiveness, hypotensive, with hematemesis. Palpable
pulse, anesthesia called for intubation and then Code Blue
called. ETT and OGT and oropharynx with copious blood. PEA
arrest. 2 rounds epi, chest compressions, L groin cordis placed
by surgery, NS wide open and PRBC running. Regained pulse after
~10-15 minutes down time with MAPs >60.
Massive transfusion protocol activated, GI, surgery, IR
consulted. R groin Aline placed by MICU attending. Liters of
blood continuing pour from OGT and oropharynx. Hypoxemia
requiring FiO2 1.0 and PEEP 10 for sats > 90, CXR with ETT in
place, no PTX, no obvious free air. acidosis pH 6.85 Ca <
assay, PTT>150, INR 5, Progressive massive abdominal
distention. Received 22 U PRBC 6 FFP 4 Plt.
GI arrived for endoscopy, concerning for perforation; surgery /
anesthesia planned to take pt to the OR. While preparing
patient for transfer, Aline tracing dampened, pulse initially
not palpable ?????? then thready. Repeat episode of massive
hemoptysis around yankauer / OGT, decorticate posturing.
Decision made at bedside to not initiate CPR and cease further
resuscitative efforts; discussed with surgery, nursing, medical
housestaff. Communicated with her husband the severe nature of
her illness and that further resuscitation would not be
performed. PRBC/pressors/Vent D/c??????d and patient died shortly
thereafter.
Medications on Admission:
Medications:
- lisinopril 5mg daily
- atenolol 25mg daily
- niacin 500mg daily
- aspirin 81mg daily
- ambien 10-20mg QHS
- Calcium-Vit D
- Mobic 15mg daily
- Fish Oil 1000mg caps daily
.
Allergies:
Lidocaine
Lorazepam
Ultram
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"784.7",
"272.4",
"345.90",
"296.80",
"285.1",
"721.0",
"780.52",
"787.03",
"715.90",
"531.50",
"780.2",
"781.2",
"331.9",
"401.9",
"250.00",
"796.3",
"578.1",
"E935.9",
"873.22",
"507.0",
"578.0",
"E885.9",
"427.5",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7891, 7900
|
5760, 7587
|
292, 385
|
7952, 7962
|
3479, 5737
|
8019, 8030
|
2681, 2704
|
7863, 7868
|
7921, 7931
|
7613, 7840
|
7986, 7996
|
2719, 3460
|
238, 254
|
413, 2289
|
2311, 2531
|
2547, 2665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,769
| 112,099
|
15504
|
Discharge summary
|
report
|
Admission Date: [**2160-10-16**] Discharge Date: [**2160-11-18**]
Date of Birth: [**2092-2-20**] Sex: F
Service: Surgery
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 44935**] is a
68-year-old primarily Russian-speaking female who has been
diagnosed with myeloproliferative disorder several years ago.
The patient has been closely followed by her primary care
physician, [**Name10 (NameIs) **] she also has a hematologist/oncologist. The
patient has undergone radiation treatment for her
splenomegaly several years ago. The spleen has recently
increased in size, and the patient has been somewhat
symptomatic.
The patient's comorbidities included coronary artery disease
(with a myocardial infarction in [**2153**]) as well as a history
of hypertension. In addition, she had a left-sided
nephrectomy and breast carcinoma with a left-sided mastectomy
in [**2148**].
The patient presented to General Surgery for a possible
surgical solution of her splenomegaly due to her
myeloproliferative disorder. The patient received all of her
previous treatments at outside facilities. The patient was
consequently scheduled for an elective open splenectomy by
the General Surgery staff.
On [**2160-10-16**], the patient underwent open splenectomy
by Dr. [**Last Name (STitle) **]. The procedure was without any
complications. The estimated blood loss was approximately
600 cc, and the patient received one unit of packed red blood
cells. Please see the full Operative Report for details.
PAST MEDICAL HISTORY:
1. Myeloproliferative disorder.
2. Coronary artery disease.
3. Status post myocardial infarction in [**2153**].
4. Hypertension.
5. Breast carcinoma; status post left-sided mastectomy in
[**2148**].
PAST SURGICAL HISTORY:
1. Left-sided mastectomy for breast carcinoma in [**2148**].
2. Status post left-sided nephrectomy.
3. Status post eye surgery.
MEDICATIONS ON ADMISSION:
1. Hydroxyurea 500 mg p.o. q.d.
2. Ambien 10 mg p.o. q.h.s. as needed.
3. Trazodone 50 mg p.o. as needed.
4. Lopressor 50 mg p.o. b.i.d.
5. Allopurinol 300 mg p.o. q.d.
6. Norvasc 5 mg p.o. q.d.
7. Prilosec.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed alert and oriented, in no apparent distress. An
elderly, primarily Russian-speaking, female. Temperature was
98.4, blood pressure was 142/74, heart rate was 78,
respiratory rate was 17, oxygen saturation was 97% on room
air. Head, eyes, ears, nose, and throat examination was
within normal limits. No signs of lymphadenopathy. Full
range of motion in the neck. No carotid bruits were
detected. Cardiovascular examination revealed a regular rate
and rhythm. No murmurs, rubs, or gallops. Pulmonary
examination revealed clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. An enlarged
spleen extending below the umbilicus was palpable in the left
upper quadrant. Bowel sounds were present. Chest
examination revealed the site of prior mastectomy.
Extremities were warm and well perfused. No signs of edema.
HOSPITAL COURSE: Given the history of myeloproliferative
disorder and significant splenomegaly, a surgical
intervention was undertaken. On [**2160-10-16**], the
patient underwent open splenectomy. The procedure was
without any complications with an estimated blood loss of
approximately 600 cc. Please see the full Operative Report
for details.
The patient was extubated successfully and transferred to the
Postanesthesia Care Unit in stable condition. She was
originally made nothing by mouth and was adequately
resuscitated with intravenous fluids. She was transfused
with one unit of packed red blood cells in the operating
room.
She was placed on a beta blocker and subcutaneous heparin.
Her pain was adequately controlled. She was placed on
prophylactic antibiotics.
The patient maintained a low-grade fever and remained
somewhat tachycardic. She was further resuscitated with
fluids given her low urine output. A nasogastric tube was
placed. Her postoperative hematocrit was 34.2 with a white
blood cell count of 11.
Given the symptoms of nausea, a KUB of the abdomen was
obtained which showed diffuse dilatation of the small bowel
and colon; consistent with postoperative ileus.
On postoperative day three, the patient was noted to be
hypotensive, and she was noted to have her hematocrit
decrease from 36 to 21.2. At that point, she was taking
aspirin.
The patient was quickly taken to the operating room on
[**2160-10-19**] for exploratory laparotomy and evaluation
of the bleed. Intraoperatively, the patient was found to be
coagulopathic, but no discrete source of the bleed was found.
The patient was transfused with several units of packed red
blood cells as well as platelets. Several liters of blood
were aspirated from the abdomen.
Before the exploratory laparotomy, she was found to have an
INR of 4.3. She had been on Lovenox and Coumadin. After the
exploration, the patient was transferred to the Intensive
Care Unit. A central line was placed. The patient remained
intubated. Her hematocrit was increased with several
transfusions. Her urine output remained adequate. She was
maintained on intravenous fluids. Several blood cultures
were taken which showed no growth.
The patient was extubated on postoperative day five and two.
Total parenteral nutrition was started given that the patient
had been without any oral intake for several days. She
continued to have a low-grade fever. The patient was
consequently transferred to the regular floor on
postoperative day six and three.
The Nutrition Service was consulted, who followed the patient
throughout her hospitalization.
An electrocardiogram performed at the time showed a sinus
rhythm, and no change compared to the baseline tracing
available.
The patient continued to be coagulopathic even without
receiving any Coumadin or other anticoagulation products.
Her wound remained clean, dry, and intact. There was some
abdominal distention noted. She was started on clear
liquids, and her diet was very slowly advanced; which she
tolerated well.
Given the persistent elevated temperatures and distended
abdomen, a computed tomography of the abdomen was performed
on [**2160-10-25**]. There was no evidence of abscess.
However, diffuse ascites were noted. In addition, bilateral
pleural effusions were noted; which were associated with
atelectasis at both lung bases. A successful
ultrasound-guided paracentesis of the ascites was performed
on [**2160-10-25**]. The patient would have several such
paracentesis procedures. Cultures were obtained from the
fluid which showed no microorganisms; only polymorphonuclear
leukocytes. In addition, the white blood cell count in the
fluid was low and not suggestive of any infection. The
patient was consequently placed on Unasyn for empiric
coverage. The patient also had several urine cultures
obtained which grew Escherichia coli as well as
Corynebacterium species. In addition, her sputum grew yeast.
As perviously mentioned, her blood cultures grew nothing.
The patient continued to be diuresed. Her hematocrit
remained stable; although, she continued to be anemic, and at
some point required more blood.
The patient was consequently restarted on Coumadin. In
addition, the Renal Service was consulted given the ascites;
with the specific question of whether ascites were from a
renal etiology and also the significance of proteinuria which
was noted on routine urinalysis.
In addition, the CAT scan that was obtained on [**2160-10-25**] showed evidence of portal vein thrombosis which was
confirmed by the ultrasound. It was thought that the
significant ascites that seemed to reaccumulate after
therapeutic paracenteses were due to the portal vein
thrombosis and not renal failure. The patient's creatinine
did increase slightly but then returned back to the patient's
baseline of approximately 1.5.
On [**2160-10-27**], the patient appeared to have a
relatively sudden onset of chest discomfort as well as
tachypnea. There was no nausea, vomiting, or diaphoresis.
She appeared to be tachypneic with a respiratory rate of
approximately 35, but her blood pressure and heart rate were
stable, and her oxygen levels remained the same. A arterial
blood gas was obtained at that time which showed a pH of
7.53, PO2 of 75, and PCO2 of 19, with a base excess of -3,
and total CO2 of 16. She ruled out for a myocardial
infarction by cardiac enzymes, and her lung scan was low
probability of any pulmonary embolism. A venous ultrasound
of the lower extremities was also negative for any clots.
Given these symptoms, the patient was again admitted to the
Intensive Care Unit for closer monitoring. She was continued
on Unasyn and intravenous heparin. She continued to make
adequate urine. She remained on beta blocker. Her
electrocardiogram showed no changes. However, the chest
x-ray did show left lower lobe consolidation.
The patient remained stable and was transferred out of the
Intensive Care Unit to the regular floor. She continued to
be coagulopathic with an INR of 2.6 on [**2160-10-30**]. She
was also noted to have a white blood cell count of 48 and a
platelet count of approximately 2 million. Her liver
function tests were elevated; consistent with portal vein
thrombosis seen on the CAT scan and ultrasound.
The Hematology/Oncology Service was consulted given the
elevated white blood cell count and platelets. The patient
was restarted on Hydroxyurea. Her white blood cell count and
platelet count decreased slowly with this medication. In
addition, the patient underwent one round of plasmapheresis
which she tolerated well. While on Hydroxyurea, the
patient's white blood cell count decreased significantly and
was noted to be 0.4 several days later. Consequently,
Hydroxyurea was stopped. The patient was placed on
neutropenic precautions. Hydroxyurea was discontinued. The
patient was place G-CSF (growth factor) to which she
responded well, and G-CSF was discontinued several days
later.
The Renal Service continued to follow the patient, and they
thought that her proteinuria was secondary to a nephrotic
syndrome. They recommended further diuresis and oral fluid
restriction.
The patient continued to improve, and her ascites decreased
significantly toward the end of her hospitalization. She was
making significant urine. Her liver function tests improved
and were essentially normal. She was continued on Coumadin
with a stable regimen of 2.5 mg toward the end of her
hospitalization. She continued to tolerate an oral diet
without any difficulties. The staples were removed on
postoperative day 18.
While the patient was on neutropenic precautions; secondary
to a low white blood cell count, she was maintained on
cefepime intravenously which was discontinued when the
neutropenic precautions were removed. Her lower extremity
edema decreased significantly as well.
DISCHARGE DISPOSITION: The patient continued to improve
significantly and was discharged to home on [**2160-11-18**].
PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories
upon discharge were as follows: White blood cell count was
7.9 and hematocrit was 27.8 (differential with 70%
neutrophils), platelet count was 389. INR was 2.2.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Myeloproliferative disorder.
2. Status post open splenectomy; complicated by
intra-abdominal bleed, status post re-exploration and
aspiration of intra-abdominal bleed.
3. Portal vein thrombosis.
4. Anemia.
5. Coagulopathy.
6. Hypertension.
7. Coronary artery disease.
MEDICATIONS ON DISCHARGE:
1. Coumadin 2.5 mg p.o. q.d.
2. Potassium chloride 20 mEq p.o. b.i.d. (while the patient
is taking lasix).
3. Lasix 80 mg p.o. b.i.d.
4. Lisinopril 5 mg p.o. q.d.
5. Ambien 5 mg p.o. q.h.s. as needed (for insomnia).
6. Colace 100 mg p.o. b.i.d.
7. Allopurinol 200 mg p.o. q.d.
8. Protonix 40 mg p.o. q.d.
9. Lopressor 75 mg p.o. b.i.d.
10. Artificial Tears one to two drops as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to take 2.5 mg of Coumadin q.d., and she
was to see her primary care physician (Dr. [**Last Name (STitle) 44936**] in
approximately two to three days for an INR check and any
adjustment of Coumadin. The INR goal is approximately 2.5;
but one needs to be careful given the history of coagulopathy
with this patient.
2. The patient was to follow up with her
hematologist/oncologist (Dr. [**First Name8 (NamePattern2) 565**] [**Last Name (NamePattern1) **]) in approximately
one week.
3. The patient was to follow up with her surgeon (Dr.
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]) in approximately two to three weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2160-11-18**] 15:32
T: [**2160-11-18**] 16:11
JOB#: [**Job Number 19921**]
cc:[**Hospital6 44937**]
|
[
"789.5",
"286.9",
"238.7",
"452",
"998.11",
"276.1",
"997.5",
"288.0",
"581.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.71",
"38.91",
"99.15",
"54.12",
"38.93",
"41.5",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10977, 11101
|
11427, 11706
|
11733, 12137
|
1924, 3062
|
3080, 10953
|
12170, 13141
|
1766, 1898
|
11322, 11406
|
11116, 11307
|
171, 1516
|
1538, 1743
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,412
| 106,061
|
53121
|
Discharge summary
|
report
|
Admission Date: [**2195-1-9**] Discharge Date: [**2195-1-13**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 14129**] was admitted on
[**2195-1-9**] to the Medical Intensive Care Unit.
He is an 81-year-old white male with chronic obstructive
pulmonary disease who was admitted to the Medical Intensive
Care Unit with a pneumothorax, status post a bronchoscopy
with multiple biopsies on [**1-9**].
The patient had been in his usual state of health until one
month prior to admission. He had been admitted to [**Hospital **]
Hospital with a chronic obstructive pulmonary disease
exacerbation. A chest computed tomography at that time
revealed new significant right upper lobe mass which was
worrisome for bronchoalveolar carcinoma. The patient had
multiple small nodules in the past which have been biopsied
showing macronodular pulmonary amyloid. Computed tomography
also showed a left-sided pneumothorax that was not treated at
that time.
At bronchoscopy on [**1-9**], multiple biopsies were taken.
He had acute shortness of breath five minutes prior to the
end of the procedure and required nebulizers. He received
albuterol times three and Atrovent times one with
improvement, and a subsequent x-ray revealed a large
right-sided pneumothorax. The pneumothorax was noted and
attempted conservative management with nebulizers and
high-flow oxygen. At that point, he failed conservative
treatment, and a right-sided chest tube was placed for
respiratory distress. The lung was reinflated, and he was
again made comfortable. His shortness of breath was
resolved.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Macronodular pulmonary amyloidosis diagnosed in [**2194-1-4**].
3. New pulmonary nodule in the right upper lobe.
4. Peripheral vascular disease; status post bilateral
vascular surgery.
5. Abdominal aortic aneurysm measured at 4.4 cm X 2.4 cm.
6. Hypercholesterolemia.
7. History of atrial fibrillation.
8. History of an anterior neck mass.
9. Lupus anticoagulation.
MEDICATIONS ON ADMISSION:
1. Albuterol 2 puffs four times per day.
2. Atrovent 2 puffs four times per day.
3. Lipitor 40 mg p.o. q.d.
4. Aspirin.
5. Digoxin 0.25 mcg p.o. q.d.
6. Quinidine 324 mg p.o. times two b.i.d.
7. Serevent two times per day.
8. Lasix 10 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: One son and two daughters. [**Name (NI) **] works at a
dry cleaning shop. He quit tobacco in [**2148**] after 50 pack
years. Occasional alcohol. No intravenous drug abuse.
FAMILY HISTORY: No history of pulmonary disease.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 97.4, blood pressure was 128/60,
heart rate was 72, respiratory rate was 20, oxygen saturation
was 90% on face mask and 95% on room air. In no acute
distress. Spoke in complete sentences. Lungs revealed
bilateral breath sounds were equal. Poor inspiratory effort.
Moved air in all fields. Cardiovascular examination revealed
a regular rate and rhythm. No murmurs, rubs, or gallops.
The abdomen was soft, nontender, and nondistended. Active
bowel sounds. Extremities revealed no clubbing, cyanosis, or
edema.
RADIOLOGY/IMAGING: A chest x-ray on [**1-13**] at 7 a.m.
showed no pneumothorax.
HOSPITAL COURSE:
1. PULMONARY SYSTEM: Status post bronchoscopy complicated
by a pneumothorax. The pneumothorax was initially attempted
conservatively, but conservative treatment failed and a
right-sided chest tube was subsequently required to relieve
respiratory distress. The chest tube resolved the
pneumothorax, and the patient's respiratory distress was much
improved. He was continued on his outpatient chronic
obstructive pulmonary disease medications including
albuterol, Atrovent, and Serevent.
On [**1-12**], the chest tube was switched from suction to
water seal. Again, no pneumothorax developed. At 4 p.m. on
[**1-12**], the patient stood up and the chest tube was
accidentally discontinued. An occlusive Vaseline gauze
dressing was applied with minimal air leak.
A subsequent chest x-ray revealed no reaccumulation of the
pneumothorax but some subcutaneous air. The patient was
maintained on oxygen over the course of the next night
without any respiratory distress or other symptoms. A chest
x-ray on the morning of discharge revealed no reaccumulation
of the pneumothorax. The patient had been stable for greater
than 24 hours status post the discontinuation of the chest
tube.
The preliminary pathology results on the bronchoscopy
specimens revealed a resolving pneumonia and amyloid. No
evidence of bronchoalveolar carcinoma.
2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was
maintained on his Atrovent, albuterol, and Serevent without
any problems.
3. CARDIOVASCULAR SYSTEM: The patient was cardiovascularly
stable throughout his hospital stay with the exception of
some hypertension at the time of bronchoscopy. At the time
of discharge, the patient had been hemodynamically stable for
greater than 48 hours. He was restarted on his home
medications of digoxin and quinidine on [**2195-1-12**]. He
also was maintained on Lasix.
4. FLUIDS/ELECTROLYTES/NUTRITION: The patient was
maintained on a regular diet. Electrolytes and laboratories
were stable.
5. PROPHYLAXIS: The patient had been getting out of bed and
moving consistently. He was taking an oral diet. He was
only requiring Pneumo boots while in bed.
6. HYPERCHOLESTEROLEMIA: The patient was continued on
Lipitor.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was discharged to home.
MEDICATIONS ON DISCHARGE:
1. Percocet one tablet p.o. q.4-6h. for pain as needed.
2. Albuterol 2 puffs four times per day.
3. Atrovent 2 puffs four times per day.
5. Lipitor 40 mg p.o. q.d.
6. Aspirin.
7. Digoxin 0.25 mcg p.o. q.d.
7. Quinidine 324 mg p.o. times two b.i.d.
8. Serevent two times per day.
9. Lasix 10 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 217**] as
indicated by Dr. [**Last Name (STitle) 217**] to the patient.
2. Return to the Emergency Department if any shortness of
breath, fevers, chills, chest pain, or any other questions or
concerns.
DISCHARGE DIAGNOSES: Right-sided pneumothorax.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], M.D. [**MD Number(1) 36858**]
Dictated By:[**Last Name (NamePattern1) 9126**]
MEDQUIST36
D: [**2195-1-13**] 18:22
T: [**2195-1-17**] 00:16
JOB#: [**Job Number 109429**]
|
[
"515",
"277.3",
"496",
"517.8",
"512.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.27",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
2592, 3313
|
6328, 6636
|
5691, 6005
|
2085, 2380
|
3331, 5560
|
6038, 6306
|
5575, 5665
|
128, 1616
|
1638, 2059
|
2397, 2574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,350
| 196,145
|
16289
|
Discharge summary
|
report
|
Admission Date: [**2104-3-20**] Discharge Date: [**2104-3-24**]
Date of Birth: [**2051-10-27**] Sex: F
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Transient ischemic attack.
HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old
nondiabetic white female with laryngeal cancer involving left
neck treated with chemotherapy and radiation therapy was
scheduled for excision of a left anterior cervical lymph node
the week of admission by Dr. [**Last Name (STitle) 46439**] at [**Hospital3 **]. On
the morning of scheduled admission, while at home, the
patient experienced left handed clumsiness picking up a pill.
She also felt she was speaking like she was drunk. She went
to see her primary care physician that same morning where a
left facial droop was noted and a left upper extremity
pronator drift was seen.
The patient is admitted to the [**Hospital3 **] on [**2104-3-17**].
She was started on intravenous heparin after symptoms had
already resolved. Noncontrast CT on [**3-10**] was negative.
Carotid ultrasound showed right internal carotid artery
stenosis - progression from 60 to 69% previously to 80 to
89%. MRA showed a 1 cm long proximal right ICA stenosis of
80%. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46440**] discussed the patient with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and the patient was transferred from [**Hospital3 **]
to [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Squamous cell carcinoma of the larynx and left side of
neck. Chemotherapy and radiation therapy finished [**2103-11-6**].
2. Left cervical lymphadenopathy, scheduled for excision by
Dr. [**Last Name (STitle) 46439**].
3. History of asymptomatic carotid bruit.
4. Gastroesophageal reflux disease.
5. Pneumonia.
6. Depression/anxiety.
PAST SURGICAL HISTORY:
1. G tube and Port-A-Cath placed [**2103-8-6**] at [**Hospital3 9683**].
2. Repair of left foot fracture.
3. Cervical disc "titanium" approximately five years ago at
[**Hospital **] Hospital.
4. Appendectomy.
5. Tonsillectomy.
6. C section.
FAMILY HISTORY: No diabetes. Father had lung cancer.
Mother had heart disease. Mother had a stroke.
SOCIAL HISTORY: The patient currently is living with her
daughters. [**Name (NI) **] husband died several months ago secondary to
complications of a fall. She smokes approximately a half a
pack of cigarettes a day. She does not drink alcohol.
ALLERGIES: Novocaine.
MEDICATIONS ON ADMISSION FROM [**Hospital1 **]:
1. Heparin intravenous at 900 units per hour.
2. Sialagen 5 mg po t.i.d.
3. Protonix 40 mg po q.d.
4. Lipitor 10 mg po q.d.
5. Zoloft 100 mg po q.d.
6. Colace 100 mg po b.i.d.
7. Percocet one to two tabs q 4 hours prn.
8. Ambien 5 to 10 mg po q.h.s. prn.
PHYSICAL EXAMINATION: Vital signs temperature 98.8. Pulse
80. Respirations 16. Blood pressure 118/78. O2 saturation
96% on room air. General, alert, cooperative white female in
no acute distress. Skin warm and dry. No rashes. HEENT
sclera anicteric. Pupils are equal, round and reactive to
light. Teeth in good repair. No lesions. Neck range of
motion within normal limits. No lymphadenopathy or
thyromegaly. Carotids palpable. No bruits. Breast
examination not done. Chest x-ray lungs clear bilaterally,
Port-A-Cath in left upper chest. Heart regular rate and
rhythm without murmur. Abdomen soft. Bowel sounds present,
nontender. No masses or hepatosplenomegaly. G tube in
epigastric area. Rectal examination deferred. Extremities
equally warm. No lesions. Pulse examination carotid and
radial pulses 2+ bilaterally. Abdominal aorta not palpable.
Femoral pulses 1+ bilaterally. Popliteal pulses 2+
bilaterally. Right dorsalis pedis pulse 2+. Right posterior
tibial pulse and left dorsalis pedis pulse and posterior
tibial pulses dopplerable. Neurological examination cranial
nerves II through XII intact. No facial droop. Speech
fluent.
ADMISSION LABORATORIES: White blood cell 5.2, hemoglobin
12.5, hematocrit 37.0, platelets 165,000. PT 12.3, PTT 53.3
(heparin at 900 units per hour), INR 1.0, sodium 139,
potassium 4.0, chloride 100, CO2 26, BUN 15, creatinine 0.8,
glucose 121. Calcium 8.1, phosphate 4.4, magnesium 1.9,
ionized calcium 1.19.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] on [**2104-3-20**] from [**Hospital3 **].
Her intravenous heparin was continued. She was given a
loading dose of 300 mg of Plavix and then started on a 30 day
course of 75 mg of Plavix q.d. Aspirin 325 mg po q.d. was
also started on admission. The MRI/MRA was reviewed by Dr.
[**Last Name (STitle) **]. The stroke service and the neurosurgical service
was consulted.
On [**2104-3-21**] the patient had an arch/cerebral angiogram and
placement of a right internal carotid artery stent following
angioplasty by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1132**]. At the end of the
procedure the patient was neurologically intact.
By the end of postoperative day number one the patient
developed sudden hypotension with a hematocrit drop from 37
to 26.5. She was transferred to the Surgical Intensive Care
Unit for further treatment. Her abdomen was soft with mild
right lower quadrant tenderness. There were no masses felt.
The groin puncture site was clean, dry and intact. There was
no hematoma. The patient was resuscitated with a total of 3
units of packed red blood cells and crystalloid. No
pressors were used. She had no electrocardiogram changes.
The intravenous heparin was stopped. Aspirin and Plavix were
continued. Serial hematocrit checks were done. At the time
of discharge the patient's hematocrit stabilized at 40.4.
She remained neurologically intact.
The patient was discharged home on [**2104-3-24**]. She was to
follow up with Dr. [**Last Name (STitle) **] in the office in two weeks. She
was to follow up with Dr. [**Last Name (STitle) 1132**] in the office in one month.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po q.d.
2. Aspirin 325 mg po q.d.
3. Lipitor 10 mg po q.d.
4. Sertraline 100 mg po q.d.
5. Protonix 40 mg po q.d.
6. Pilocarpine 10 mg po t.i.d.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home.
PRIMARY DIAGNOSES:
1. Symptomatic right internal carotid artery stenosis.
2. Right internal carotid artery angioplasty and stent on
[**2104-3-21**].
SECONDARY DIAGNOSES:
1. Blood loss anemia status post transfusion.
2. Status post CA of the larynx and left neck.
3. Left cervical lymphadenopathy, excision to be done by
local surgeon at a future date.
4. Gastroesophageal reflux disease.
5. Depression/anxiety.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2104-6-18**] 12:41
T: [**2104-6-18**] 12:49
JOB#: [**Job Number 46441**]
|
[
"300.00",
"530.81",
"311",
"785.6",
"V10.21",
"433.11",
"V17.3",
"458.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
2111, 2198
|
5991, 6159
|
4287, 5968
|
1846, 2094
|
6393, 6896
|
2805, 4269
|
168, 196
|
225, 1457
|
1479, 1823
|
2215, 2782
|
6184, 6372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,137
| 102,280
|
30237
|
Discharge summary
|
report
|
Admission Date: [**2106-9-23**] Discharge Date: [**2106-9-28**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 67 yo male with PMH of EtOH cirrhosis with HCC s/p
OLT on [**2104-8-22**] p/w acute onset SOB last night. He was watching
TV
when he suddenly epxerienced difficulty breathing that continued
worsen and he went to the hospital in [**Hospital3 **] where he was
found
to have pulmonary edema and increased creatinine to 4. He was
subsequently transported to [**Hospital1 18**]. Patient reports chest
tightness, but denies any chest pain, nausea, vomiting, fevers,
chills. He felt well prior to the episode and had a regular day
at work. He denies any changes in the amount of his urine output
or the urine color. He had no blood transfusions since the last
admission here on [**2106-9-8**]. He denies hematemasis or
hematochezia.
Of note: Patient was admitted to us on [**2106-9-8**] for low
hematocrit
of 19 and stayed overnight. He was transfused 3units of PRBCs on
that admission. The transplant hepatology, transplant
nephrology,
hematology and cardiology services were consulted at that time.
The hematology service determined that patient does not have any
hematologic abnormality that could explain his chrnically low
hematocrit. Patient did not have a work-up to r/o GI bleed as he
refused. There was no need for hemodialysis at that time. His
transplanted liver has been functioning well.
Past Medical History:
- liver transplant ([**2104-8-22**])
- EtOH cirrhosis, diagnosed 06/[**2103**].
- HCC
- Anemia
- Essential thrombocytosis
- Prior complications of ascites, malnutrition,
- portal [**Year (4 digits) **] with grade 2 esophageal varices.
Peritonitis [**7-18**], Duodenitis [**7-18**], Grade I rectal varices
- grade 2 esoph varices and gastritis by EGD [**3-/2106**]
- failure to thrive s/p PEG
- ? pancreatic insufficiency
- CAD
[**2104-7-1**] with
coronary angiography that showed inferolateral akinesis and
substantial lateral hypokinesis. 50% LAD lesion. Circumflex was
occluded distally. The right coronary artery had 40% stenosis
during his hospitalization recently in [**Month (only) 956**] with pneumonia
associated with diarrhea, malnutrition, hyperkalemia, and renal
insufficiency.
ECHO [**3-22**], EF 19%
- 2+ MR
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs. Stopped EtOH in 6/[**2103**].
Family History:
Non contributory
Physical Exam:
O2 saturation 95% on 50% humidified face mask
gen: catechtic man, slightly pale, labored breathing, otherwise
stable, AAOx3, mental status not altered
heent: ncat, mmm, eomi, nonicteric sclera, perrl
[**Year (4 digits) **]: diffuse crackles in the base and mid right lung and in the
base of left lung
cv: RRR, no m/r/g appreciated
abd: thin, NT/ND, NBS, PEG tube in place (not using), incision
well healed
extr: trace b/l ankle edema
neuro: cn 2-12 intact grossly
Pertinent Results:
[**2106-9-23**] 11:04AM BLOOD WBC-16.8*# RBC-3.52* Hgb-8.9* Hct-29.7*
MCV-84 MCH-25.3* MCHC-30.0* RDW-16.0* Plt Ct-990*
[**2106-9-23**] 11:04AM BLOOD Neuts-88.1* Lymphs-9.7* Monos-1.5*
Eos-0.6 Baso-0.2
[**2106-9-23**] 11:04AM BLOOD PT-12.7 PTT-32.5 INR(PT)-1.1
[**2106-9-23**] 11:04AM BLOOD Glucose-89 UreaN-82* Creat-4.6*# Na-146*
K-5.8* Cl-120* HCO3-12* AnGap-20
[**2106-9-23**] 11:04AM BLOOD ALT-7 AST-15 CK(CPK)-43 AlkPhos-54
TotBili-0.3
[**2106-9-23**] 04:54PM BLOOD proBNP->[**Numeric Identifier **]
[**2106-9-23**] 11:04AM BLOOD Albumin-2.9* Calcium-8.1* Phos-5.9*
Mg-2.6
[**2106-9-23**] 10:43AM BLOOD Type-ART FiO2-50 pO2-90 pCO2-24* pH-7.30*
calTCO2-12* Base XS--12 Intubat-NOT INTUBA
[**2106-9-28**] 04:31AM BLOOD WBC-6.2 RBC-2.68* Hgb-6.9* Hct-22.1*
MCV-82 MCH-25.6* MCHC-31.1 RDW-15.1 Plt Ct-965*
[**2106-9-28**] 04:31AM BLOOD Glucose-109* UreaN-82* Creat-4.6* Na-143
K-4.2 Cl-116* HCO3-16* AnGap-15
[**2106-9-28**] 04:31AM BLOOD ALT-4 AST-11 AlkPhos-49 TotBili-0.2
[**2106-9-28**] 04:31AM BLOOD Calcium-7.3* Phos-4.0 Mg-1.8
[**2106-9-27**] 05:26AM BLOOD rapmycn-5.4
CXR:
Study Date of [**2106-9-23**] 10:02 AM Worsening pleural effusions and
confluent bilateral perihilar opacities are consistent with
pulmonary edema.
Study Date of [**2106-9-28**] 12:16 AM In comparison with the study of
[**9-27**], there is continued moderate left pleural effusion and
smaller right effusion. Bibasilar atelectatic changes are seen.
No evidence of acute focal pneumonia or vascular congestion.
RENAL U.S. PORT Study Date of [**2106-9-23**] 11:15 AM
IMPRESSION: Echogenic kidneys, the appearance of which is
suggestive of
diffuse parenchymal disease. No hydronephrosis. Two tiny left
renal cyst.
Echocardiography [**2106-9-23**] 11:00 AM
IMPRESSION: Dilated left ventricle with severe regional systolic
dysfunction, c/w CAD. Normal right ventricular systolic
function. Mild to moderate mitral regurgitation. Mild pulmonary
[**Month/Day/Year **].
Compared with the prior study (images reviewed) of [**2106-3-18**],
mitral regurgitation severity has slightly diminished and RV
regional wall motion abnormalities have resolved. The other
findings are similar.
ECG Study Date of [**2106-9-23**] 12:30:32 PM
Sinus rhythm. Left ventricular hypertrophy. Anteroseptal ST-T
wave changes may be due to left ventricular hypertrophy or
ischemia. Low QRS voltage in the limb leads. Compared to the
previous tracing of [**2106-7-31**] the ST-T wave changes are now
involving lead V4 which may be due to lead placement. Otherwise,
no significant change.
Brief Hospital Course:
The patient was admitted to the surgical ICU. He was diagnosed
with acute CHF exacerbation with pulmonary edema and acute renal
failure. An echo and a renal ultrasound were done (see
results). The nephrology team was consulted for assistance with
diurese. Over the course of his ICU stay he received IV lasix
boluses, then a lasix gtt with good effect. He progressively had
decreasing oxygen requirements. His renal function stabilized
as well. Transplant hepatology was consulted with no further
recommendations. His blood pressure medications were increased
as he had slightly elevated blood pressures during his stay as
he neared discharge.
He was ambulating, tolerating a regular diet, and was breathing
comfortably on room air with SaO2 of 100% on discharge to home.
Medications on Admission:
1. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) ml
Injection once a week: On Mondays.
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO DAILY
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
7. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
8. Testosterone 2.5 mg/24 hr Patch 24 hr
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
10. Ferrous Sulfate 325 mg (65 mg Iron) (1) tab PO TID (3 times
a
day).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID
13. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Aspirin 81 mg Tablet
15. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
16. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
17. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
14. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) Injection
once a week.
15. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
17. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
18. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please call if you experience fevers, chills, shortness of
breath, chest pain, dizziness, sputum production, or cough.
Please weigh yourself daily and call if you notice significant
weight gain over a short time period.
Followup Instructions:
Call the transplant center. Followup should be arranged for you
in 1-2wks
|
[
"577.8",
"584.9",
"486",
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"428.0",
"572.3",
"416.8",
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"456.21",
"V58.65",
"V10.07",
"414.01",
"456.8",
"571.2",
"276.2",
"V11.3",
"238.71",
"V42.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9658, 9664
|
5899, 6680
|
333, 340
|
9743, 9750
|
3326, 5876
|
10019, 10097
|
2808, 2826
|
7918, 9635
|
9685, 9722
|
6706, 7895
|
9774, 9996
|
2841, 3307
|
274, 295
|
368, 1678
|
1700, 2523
|
2539, 2792
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
483
| 173,729
|
30788
|
Discharge summary
|
report
|
Admission Date: [**2116-5-30**] Discharge Date: [**2116-6-14**]
Date of Birth: [**2116-5-30**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] was the 2.375 kg product of a 35-
[**2-26**] week gestation born to a 23-year-old, G2, P1, now 2,
mother. Prenatal screen: O negative, antibody negative, RPR
nonreactive, rubella immune, hepatitis surface antigen
negative, GBS unknown. Mother receive RhoGAM at 28 weeks.
PAST MEDICAL HISTORY FOR MOTHER: Notable for chronic
hypertension, tobacco use, Factor V Leiden heterozygosity.
FAMILY HISTORY: Negative.
SOCIAL HISTORY: Notable for cigarette use but negative for
alcohol during pregnancy. Father of baby is involved.
This pregnancy complicated by thin lower uterine segment,
full fetal survey within normal limits at 16 weeks. Underwent
repeat cesarean section under spinal anesthesia. No
intrapartum fever or other clinical evidence of
chorioamnionitis. Intrapartum antibiotics were given only
intraoperatively. Rupture of membranes occurred at delivery
yielding clear amniotic fluid. Infant was vigorous at
delivery, was orally and nasally suctioned, dried, and a
supplemental flow of O2 was administered. Apgars were 8 at
one minute and 8 at five minutes. Infant was transferred to
the newborn intensive care unit.
DISCHARGE EXAM: Active with good tone. Anterior fontanel
open and flat. Pink, well perfused. No murmurs auscultated.
Comfortable in room air. Breath sounds clear and equal.
Tolerating enteral feedings with a soft abdominal exam.
Active bowel sounds. Moving all extremities.
HISTORY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory: [**Known firstname **] was admitted to the newborn intensive
care unit, placed on cannula briefly with progressive
grunting, flaring and retracting. Chest x-ray revealing
transient tachypnea of the newborn versus respiratory
distress syndrome. Infant was placed on CPAP.
He remained on CPAP for a total of 72 hours at which time
he transitioned to nasal cannula O2. He remained on nasal
cannula O2 until [**6-6**] at which time he transitioned to
room air and has been stable in room air since that time.
He has not required methylxanthine therapy and he has had
no documented episodes of apnea and bradycardia.
2. Cardiovascular: [**Known firstname **] has an audible murmur. Cardiac
workup was within normal limits. EKG was normal. Chest x-
ray showed normal cardiac silhouette, pre and post ductal
sats within normal limits and 4 extremity blood pressures
within normal limits. Murmur felt to be PPS in quality.
3. Fluids/Electrolytes: Birth weight 2.375 kg, discharge
weight is 2390g; discharge head circumference was 32.5
cm, length was 46 cm. Infant was initially started on 80
cc per kilo per day. Enteral feedings were initiated on
day of life #3. Full enteral feedings were achieved by
day of life #8. He is currently ad lib feeding Similac 24-
calorie, taking in adequate amounts.
4. GI/GU: Peak bilirubin was, on day of life #3, 11.8/0.3,
responded nicely to phototherapy, and his most recent
bilirubin was 8.5/0.3 on [**6-6**].
5. Hematology: The patient's blood type is O positive,
direct Coombs' negative. Initial hematocrit was 46.8.
6. Infectious disease: CBC and blood culture obtained on
admission. CBC was benign. Blood culture remained
negative at 48 hours at which time ampicillin and
gentamicin were discontinued. Infant is currently
receiving Nystatin ointment to a monilial rash in his
diaper area.
7. Neuro: Infant has been appropriate for gestational age.
8. Sensory: Hearing screen was performed with automated
auditory brainstem responses and the infant passed.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD, telephone number
([**Telephone/Fax (1) 65233**].
CARE RECOMMENDATIONS: Continue ad lib feeding Similac 24-
calorie.
MEDICATIONS: Not applicable.
Car seat position screening was performed for a 90-minute
screening and the infant passed. State newborn screen was
sent most recently on [**6-6**]. Initial screening was done on
[**6-1**] with an elevated 17-OHP, with repeat screen requested.
IMMUNIZATIONS RECEIVED: Infant received hepatitis B vaccine
on [**6-9**].
DISCHARGE DIAGNOSES:
1. Premature infant born at 35-3/7 weeks.
2. Respiratory distress syndrome.
3. Rule out sepsis with antibiotics.
4. Hyperbilirubinemia.
5. Monilial rash.
6. PPS murmur.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], MD [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2116-6-13**] 19:49:20
T: [**2116-6-14**] 11:21:45
Job#: [**Job Number 72893**]
|
[
"V30.01",
"765.28",
"769",
"778.8",
"V05.3",
"774.2",
"782.1",
"V50.2",
"765.15",
"747.3",
"V29.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"64.0",
"93.90",
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
3818, 3974
|
591, 602
|
4416, 4853
|
3997, 4395
|
1633, 3770
|
1336, 1606
|
3785, 3794
|
619, 1319
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,624
| 153,123
|
38185
|
Discharge summary
|
report
|
Admission Date: [**2112-5-16**] Discharge Date: [**2112-5-18**]
Date of Birth: [**2035-3-14**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
weakness and difficulty with speech
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Code Stroke
Called: 4:54am
At Bedside: 4:59am
CT scan obtained: 5:03
NIHSS: 5
Outside 3 hour window, no TPA given
HISTORY OF PRESENT ILLNESS:
Ms. [**Known lastname **] is a 77 yo right handed woman with a history of
squamous cell cancer who presents as a code stroke.
According to her son, the patient was watching TV this evening
around midnight when he noted a left facial droop, robotic
speech
and left sided weakness. He felt as though the face/speech
symptoms where improving and so he did not call EMS at that
time.
However, when he attempted to get her up at around 4AM, he noted
that she continued to have difficulty ambulating and her speech
was again slurred. He called 911 and the patient was brought to
[**Hospital1 18**]. Upon arrival, a Code stroke was called. NIHSS at the
time
of arrival was 5. She was quickly scanned and a right MCA
territory infarct was identified. She was given a full dose
aspirin.
Currently, the patient reports feeling well. She states that
she
didn't even know anything was wrong with her at the time of
symptom onset and that her son pointed it out. She denies any
recent illness and infact, she was out walking briskly the day
prior. She has no headache, neck pain, changes in vision,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. She denied difficulties producing or comprehending
speech. She reports no focal weakness, numbness, parasthesiae.
No bowel or bladder incontinence or retention. She enied
difficulty with gait.
On general review of systems, the patient denied recent fever or
chills, cough, shortness of breath, chest pain/palpitations,
nausea, vomiting, or diarrhea. She denies dysuria. All other ROS
were negative.
Past Medical History:
- Squamous Cell Cancer (Right neck, 4.5cm, never further
evaluated per patient preference, diagnosed [**2107**])
- Invasive ductal carcinoma in R breast, diagnosed in [**2107**], work
up as above
- Incidental RML nodule 5cm in size, no further work up
- HL
- Asthma
Social History:
Lives with Son, used to smoke. Quit smoking 16 years ago.
Independent in ADLs and iADLs.
Family History:
No family history of stroke, tremor, negative in
detial.
Physical Exam:
on admissions:
T 97.9 BP 145/86 HR 85 RR 20 98 O2%
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormailites, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: distant, regular rate and rhythm, No murmurs
appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x to month, location. She is
able
to relate history. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
dysarthric. There was no evidence of apraxia, there was slight
neglect of the left side of the cookie theft image. Registered
[**2-24**] and recalled [**2-24**] at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Visual fields full to
confrontation. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI with 6 beats nystagmus on right gaze. Normal
saccades.
V: Facial sensation intact to light touch.
VII: left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue with rightward deviation
-Motor: Normal bulk, increased tone on left. Left pronator
drift.
No rigidity. Action tremor present, Right>Left.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5- 5 5 5 5 5 5 5 5 4+ 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. Extinguishes on left
to DSS.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R -- TRACE -- 0 0
Plantar response was extensor bilaterally.
-Coordination: + intention tremor, Slow [**Doctor First Name **] on left
Exam at discharge:
Bilateral crackels posteriorly.
A/Ox3, MOYB intact, Language intact, impaired calculation, no
apraxia or neglect. Impersistence.
CN: L temporal VF cut, L UMN facial weakness.
Motor: LUE [**2-26**] at D/Tri/WE and [**1-29**] at FEs. LLE [**1-29**] at IP/H, 4-/5
TA.
Reflexes: [**Hospital1 **]/Tri/Patella L > R, but no spread. Toe upgoing on
Left.
Ext. to Double simult. stimulation. FNF intact on R.
Pertinent Results:
Labs on admission:
[**2112-5-16**] 05:08AM BLOOD WBC-7.5 RBC-4.79 Hgb-14.2 Hct-42.7 MCV-89
MCH-29.7 MCHC-33.2 RDW-13.4 Plt Ct-220
[**2112-5-16**] 05:08AM BLOOD Neuts-62.8 Lymphs-29.9 Monos-5.6 Eos-1.4
Baso-0.3
[**2112-5-16**] 05:08AM BLOOD PT-11.8 PTT-22.6 INR(PT)-1.0
[**2112-5-16**] 05:08AM BLOOD Glucose-133* UreaN-18 Creat-0.8 Na-142
K-3.8 Cl-105 HCO3-24 AnGap-17
[**2112-5-16**] 08:39AM BLOOD ALT-12 AST-22 LD(LDH)-165 AlkPhos-97
TotBili-0.5
[**2112-5-16**] 05:08AM BLOOD CK(CPK)-34
[**2112-5-16**] 01:24PM BLOOD CK(CPK)-47
[**2112-5-17**] 04:35AM BLOOD CK-MB-2 cTropnT-<0.01
[**2112-5-17**] 04:35AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
[**2112-5-16**] 08:39AM BLOOD Cholest-225*
[**2112-5-16**] 08:39AM BLOOD %HbA1c-5.1 eAG-100
[**2112-5-16**] 08:39AM BLOOD Triglyc-170* HDL-40 CHOL/HD-5.6
LDLcalc-151*
[**2112-5-16**] 08:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Studies:
CTA head and neck:
IMPRESSION:
1. The findings suggest an acute embolus within the distal M1
segment of the right middle cerebral artery, associated with a
small infarct within the anterior right frontal lobe and a much
broader area of tissue at risk
encompassing just under 50% of the right middle cerebral artery
territory.
2. Multifocal atherosclerosis as detailed.
3. 3.4 cm right submandibular space mass, which may represent a
pathologic
lymph node. There is associated asymmetric thickening of the
tongue base on the right and the findings are concerning for an
oropharyngeal tumor such as squamous cell carcinoma with an
adjacent metastatic node. ENT consultation and direct inspection
are recommended.
4. Biapical scarring with what may represent nodular
consolidation within the visualized lung apices, which should be
correlated with a dedicated chest CT.
Perfusion findings were appropriately identified by the on-call
radiology
resident and communicated to the clinical service at the time of
study, and the additional findings of the right neck mass were
discussed with the
managing neurology service, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**], at the time of
dictation at
10:30 hours on [**2112-5-16**].
MRI brain [**5-18**]:
IMPRESSION:
1. Acute/subacute right middle cerebral artery distribution
infarct involving
portions of the corona radiata, likely secondary to occlusion of
small
penetrating arteries. Equivocal area of subacute infarct within
the left
centrum semiovale.
2. The acute changes are superimposed upon sequelae of chronic
microvascular
white matter ischemic disease with old hemorrhagic lacunar
infarct within the right lentiform nucleus.
ECHO: [**5-17**]
The left atrium is mildly dilated. The left atrium is elongated.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: No intracardiac source of embolism identified.
Normal global biventricular systolic function. Technically
suboptimal to exclude focal wall motion abnormality
CXR: [**5-18**]: No focal consolidation (preliminary)
CT head [**5-18**]: Evolution of known infarction, no evidence of
hemorrhage (preliminary)
Brief Hospital Course:
77 yo right handed woman with a history untreated squamous cell
malignancy in the right neck as well as invasive R breast ductal
carcinoma since [**2107**], RML lung nodule (none of these were
evaluated per patient preference), who presented with sudden
onset of left sided facial droop as well as dysarthia and
unsteadiness when standing.
On initial examination, she was noted to have minimal left
neglect and left facial droop and mild UMN L hemiparesis with
extiction to DSS on LEFT. CT Perfusion showed occlusion of the
M2 but her symptoms were already improving (speech and attention
were nearly normal at evaluation). She was outside the time
window for tPA.
MRI of brain revealed acute/subacute right middle cerebral
artery distribution infarct involving portions of the corona
radiata as well as equivocal area of subacute infarct within the
left centrum semiovale superimposed of chronic microvascular
white matter ischemic disease with old hemorrhagic lacunar
infarct within the right lentiform nucleus.
A1C was normal and LDL was 150. She was started on simvastatin.
ECHO showed no evidence for source of thrombus or PFO/ASD.
Unfortunately, her L sided hemiparesis progressed to exam as
listed above.
CT head was repeated on [**5-18**] to assess for hemorrhagic
transformation and showed evolution of the known infarct without
any evidence of hemorrhage.
Further evaluation of malignancies was brought up with patient
and son, neither of them felt that they would desire further
evaluation.
She had a 2L NC requirement, CXR showed no focal consolidation
or acute process.
No evidence of CHF. Oxygen requirement was thought likely due
to longstanding COPD and atelectasis.
She was noted to have a UTI and was started on BACTRIM on [**5-18**]
for a total of 7 day course. Urine culture at [**Hospital1 18**] is pending
and will require follow up.
For pain control patient was started on standing tylenol with
moderate to good relief and lidocaine patches for b/l knee pain.
She had tolerated oxycodone in the past, however this was
withheld given recent stroke to avoid clouding of MS exam.
She was stared on Lovenox for secondary stroke prevention in
setting of known malignancy.
Patient is DNR/I.
Medications on Admission:
Albuterol PRN
Tylenol PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 doses: total of 6 doses, 2
given in the hospital.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day).
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
10. HydrALAzine 10 mg IV Q6H:PRN SBP>180
11. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Right MCA 2 occlusion with subsequent stroke, likely
embolic.
Secondary: Hyperlipidemia, Breast Cancer, Right neck squamous
cancer (neither cancer is staged due to patient preference)
Discharge Condition:
Neurological exam notable for:
A/Ox3, MOYB intact, Language intact, impaired calculation, no
apraxia or neglect. Impersistence.
CN: L temporal VF cut, L UMN facial weakness.
Motor: LUE [**2-26**] at D/Tri/WE and [**1-29**] at FEs. LLE [**1-29**] at IP/H, 4-/5
TA.
Reflexes: [**Hospital1 **]/Tri/Patella L > R, but no spread. Toe upgoing on
Left.
Ext. to Double simult. stimulation. FNF intact on R.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a new stroke. You had a blood
vessel occlusion on the right side of your brain, that caused
weakness and difficulty with some parts of your thinking because
of that.
It was felt that your stroke was due to both, atherosclerotic
disease as well as hypercoagulability due to your breast and
head and neck cancer (for which you have refused further
evaluations and treatment).
This is consistent with your prior wishes.
The following changes were made to you medications:
- Started on Simvastatin 40mg daily
- Started on Lovenox twice daily
- Started on Tylenol 650mg every six hours
- Lidocaine patches to both knees
You were discharged to rehabilitation facility.
Followup Instructions:
NEUROLOGY: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2112-7-19**] 1:30
PCP: [**Name10 (NameIs) 357**] call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1355**], to arrange an
appointment after your discharge from rehabilitation, [**Telephone/Fax (1) 85165**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2112-5-19**]
|
[
"493.20",
"289.81",
"438.20",
"173.4",
"174.9",
"434.11",
"599.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12498, 12568
|
9117, 11344
|
318, 325
|
12805, 13212
|
5299, 5304
|
13972, 14485
|
2476, 2535
|
11421, 12475
|
12589, 12784
|
11370, 11398
|
13236, 13949
|
3616, 4859
|
2550, 3107
|
4874, 5280
|
243, 280
|
496, 2063
|
5319, 9094
|
3122, 3599
|
2085, 2353
|
2369, 2460
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,554
| 177,915
|
16925
|
Discharge summary
|
report
|
Admission Date: [**2113-1-8**] Discharge Date: [**2113-1-10**]
Date of Birth: [**2049-1-12**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
[**2113-1-8**] Cardiac catheterization, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2
[**2113-1-10**] Cardiac catherterization
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 1557**] is a 63 year-old
physician with hypertension who presented to the ED today for
chest pain. He is relatively active at baseline and runs on the
treadmill three times weekly without difficulty. About 2 weeks
ago, he had an episode of mild exertional chest pain while
running in the cold which resolved with rest. There was no
recurrence. However, this morning at 5:30am he developed
midsternal chest pain initially [**3-2**] increasing to [**7-30**]
radiating down both arms (not to neck or back), and accompanied
by nausea. He initially attributed this to GERD and took
antacids without improvement. His wife then called EMS. EMS gave
him ASA 325mg and nitro SL x 3 with decrease in pain to [**3-2**]. He
remained hemodynamically stable.
.
On ED arrival, VS were 98 155/89 61 18 99%3L. EKG reviewed STEMI
anterolateral ST elevations with reciprocal changes inferiorly.
Code STEMI was called. He was loaded with Plavix and started on
a heparin gtt. He was then taken emergently to the cath lab,
reportedly pain-free. He was found to have a long, 80% mid-LAD
lesion as well as a 70% hazy OM1. TIMI 3 flow in all vessels and
patient pain-free but the significant anterior ST elevations
persisted on ECG so DES were placed to both his mid-LAD and OM1.
Patient started on integrillin. Post-procedure EKG shows
improved but persistent anterolateral ST elevations. He is
transferred to the CCU for monitoring. Nitro gtt is being
weaned.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for minimal sensation of
chest pressure, about [**1-31**]. No dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
GERD
Hypothyroidism
BPH
Elevated PSA with negative prostate bx in [**2108**]
Right proximal fifth metatarsal fracture in [**2106**]
Social History:
-Tobacco history: Quit smoking 40 years ago (~10 pack-year
history)
-ETOH: ~1 bottle wine/month
-Illicit drugs: None
Family History:
His father died at age [**Age over 90 **] (cause unknown). His mother has CAD
s/p 3-vessel CABG at age 75, died of colon cancer. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
On CCU admission:
VS: T=98 BP=112/67 HR=69 RR=11 O2 sat=98% 2L NC
GENERAL: WDWN Caucasian male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R femoral site with
small hematoma, minimally TTP, no bruit
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
Admission:
[**2113-1-8**] 08:40AM BLOOD WBC-8.8 RBC-4.74 Hgb-14.3 Hct-40.9 MCV-86
MCH-30.0 MCHC-34.8 RDW-14.1 Plt Ct-257
[**2113-1-8**] 08:40AM BLOOD Neuts-54.9 Lymphs-35.1 Monos-6.2 Eos-3.1
Baso-0.7
[**2113-1-8**] 08:40AM BLOOD PT-14.6* PTT-150* INR(PT)-1.3*
[**2113-1-8**] 08:40AM BLOOD Glucose-134* UreaN-31* Creat-1.2 Na-139
K-3.8 Cl-103 HCO3-29 AnGap-11
[**2113-1-8**] 08:40AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1
[**2113-1-8**] 01:24PM BLOOD %HbA1c-5.6 eAG-114
Enzymes:
[**2113-1-8**] 08:40AM BLOOD CK(CPK)-150
[**2113-1-8**] 04:32PM BLOOD CK(CPK)-790*
[**2113-1-8**] 09:59PM BLOOD CK(CPK)-697*
[**2113-1-9**] 04:59AM BLOOD CK(CPK)-538*
[**2113-1-10**] 05:52AM BLOOD CK(CPK)-675*
[**2113-1-8**] 08:40AM BLOOD CK-MB-6
[**2113-1-8**] 08:40AM BLOOD cTropnT-<0.01
[**2113-1-8**] 04:32PM BLOOD CK-MB-84* MB Indx-10.6* cTropnT-1.89*
[**2113-1-8**] 09:59PM BLOOD CK-MB-71* MB Indx-10.2* cTropnT-1.65*
[**2113-1-9**] 04:59AM BLOOD CK-MB-48* MB Indx-8.9*
[**2113-1-10**] 05:52AM BLOOD CK-MB-49* MB Indx-7.3* cTropnT-1.62*
Discharge:
[**2113-1-10**] 05:52AM BLOOD WBC-13.4* RBC-4.60 Hgb-14.1 Hct-38.8*
MCV-84 MCH-30.6 MCHC-36.3* RDW-14.2 Plt Ct-216
[**2113-1-10**] 05:52AM BLOOD PT-13.2 PTT-23.6 INR(PT)-1.1
[**2113-1-10**] 05:52AM BLOOD Glucose-105* UreaN-20 Creat-1.1 Na-136
K-4.3 Cl-103 HCO3-24 AnGap-13
[**2113-1-10**] 05:52AM BLOOD Calcium-9.2 Phos-2.3* Mg-2.2
.
Micro: MRSA SCREEN (Final [**2113-1-10**]): No MRSA isolated.
.
Imaging:
PCXR: IMPRESSION: Normal cardiomediastinal silhouette.
.
TTE: The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with mild hypokinesis of the distal half of the
anterior and distal septal and apex. The apex is not aneurysmal
and the remaining segments contract well (LVEF >50%). The
estimated cardiac index is normal (>=2.5L/min/m2). No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size is normal. with borderline normal free wall
function. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
CONCLUSIONS: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (mid-LAD distribution). Mild
pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2106-7-9**], there is now mild hypokinesis of the
distal anterior, septal, and apical segments with LVEF 50%.
There is now mild pulmonary artery hypertension.
.
Cardiac Cath:
[**1-8**]:
1. Selective coronary angiography in this right dominant system
revealed
two vessel disease. The LMCA was normal. The LAD had an 80%
mid vessel
stenosis. The LCx had a hazy 70% stenosis in the first obtuse
marginal
branch. The RCA was without significant disease.
2. Limited resting hemodynamics showed normal left sided filling
pressures with central aortic pressure of 122/74 with a mean of
95 mmHg.
3. Successful PTCA and stenting of mid LAD with 2.5x28mm Promus
drug
eluting stent postdilated proximally to 2.75mm.
4. Successful PTCA and stenting of OM1 with 3.0x23mm Promus drug
eluting
stent postdilated with 3.0mm balloon.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Anterior STEMI
3. Successful PCI of LAD with DES.
4. Successful PCI of OM1 with DES.
.
[**1-10**]:
1. Limited selective coronary angiography of this right dominant
system revealed no angiographically apparent obstructive
coronary artery
disease. The LMCA had no angiographically apparent disease. The
LAD had
a patent stent with a 30% mid-stent irregularity with a 60%
lesion at
the origin of the jailed diagonal with normal flow. The Lcx had
a patent
OM stent. The RCA was no engaged.
2. Limited hemodynamics showed normotension
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Patent stents in LAD and OM1.
3. Normotension.
Brief Hospital Course:
63yo M with HTN who p/w CP at rest, found to have STE in
anterior precordial leads, now s/p cath showing LAD and LCx
disease, but no definitive culprit lesion and s/p placement of 2
DES, pain free but with persistent ST elevations, improved
compared to prior.
.
# CORONARIES: Pt. with history and ECG changes concerning for
STEMI with no known CAD. Now s/p [**1-8**] cath with placement of
DES x2, though no definitive culprit lesion. Integrillin gtt was
continued 18h post [**1-8**] cath. Nitro gtt was initially weaned
but pt. developed CP again once off nitro gtt, so restarted
without much improvement. Pt. had further episodes of CP and was
taken back to the cath lab which showed patent stents and stable
disease. Nitro gtt was off post [**1-10**] cath. Atorvastatin 80mg
was started. ASA 325mg was started and transitioned to 81mg [**Hospital1 **]
at discharge. Plavix 75mg was started and should be continued
for at least 1 year. Atenolol was stopped and patient was
discharged on metoprolol succinate 50mg daily. Given allergy to
[**Name (NI) 8213**], pt. also discharged on low dose valsartan. A1c <6%. ECG
showed improved but persistent ST elevations at discharge, CP
free. Echo as below.
.
# PUMP: Beta blockade as above. TTE showed LVEF of >50% with
mild regional left ventricular systolic dysfunction with mild
hypokinesis of the distal half of the anterior and distal septal
and apex. No overload on exam throughout admission.
.
# Insomnia/Anxiety: Pt. understandably anxious surrounding
events, reports taking triazolam prn at home. He was started on
Ambien 5mg QHS Prn insomnia and Lorazepam 0.5mg PO prn anxiety,
which he required throughout his admission. He was asked to
follow up with his PCP for continuing prescriptions for
benzodiazepines.
.
# GERD: stable, continued famotidine [**Hospital1 **] and started GI cocktail
prn for symptomatic relief.
.
# Hypothyroidism: stable, continued home levothyroxine.
.
# Transitional issues:
- may need benzo prescription for anxiety
- titrate beta blocker, [**Last Name (un) **]
- TTE to follow up post STEMI
Medications on Admission:
1. Atenolol 25mg PO QHS
2. Ambien 5mg PO prn insomnia
3. Levothyroxine 125mcg PO daily
4. Pepcid 20mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*62 Tablet(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*31 Tablet(s)* Refills:*2*
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
[**Month (only) 116**] take up to 3 tabs, 5 minutes apart, then go to emergency
room if still having pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
7. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*31 Tablet(s)* Refills:*2*
8. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*31 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*11*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for chest pain and found to have a heart
attack. You were taken to the cardiac catheterization lab where
two drug-eluting stents were placed. As you had chest pain
afterwards with persistent EKG abnormalities, you were taken
back to the catheterization lab where you were found to have no
changes from prior. You had no further chest pain.
.
The following changes were made to your medications:
- Start aspirin 81mg twice a day
- Start Plavix 75mg daily for at least a year
- Stop atenolol
- Start metoprolol succinate 50mg daily
- Start simvastatin 80mg daily
- Start valsartan 80mg daily
- Start nitroglycerin sublingual tabs, 1 tab every 5 minutes
when having chest pain up to 3 tabs. If you are still having
chest pain after 3 tabs, go to your local emergency room.
.
Do not stop your Aspirin or Plavix without first discussing with
your cardiologist.
Followup Instructions:
Department: [**State **]When: TUESDAY [**2113-1-17**] at 11:45 AM
With: [**First Name8 (NamePattern2) 8741**] [**Doctor Last Name **], (works with Dr [**Last Name (STitle) 2903**] MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
.
Dr. [**Last Name (STitle) 696**] had no open appointment slots for 8 weeks, which we
felt was too long for you to wait to be seen. You can make an
appointment to follow up with him after the appointment below.
.
Department: CARDIAC SERVICES
When: THURSDAY [**2113-2-9**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"410.11",
"300.00",
"414.01",
"401.9",
"244.9",
"530.81",
"600.00",
"416.8",
"780.52",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"00.46",
"88.55",
"00.41",
"36.07",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
11766, 11772
|
8431, 10363
|
280, 423
|
11850, 11850
|
4199, 7711
|
12900, 13740
|
2999, 3243
|
10676, 11743
|
11793, 11829
|
10532, 10653
|
8317, 8408
|
12000, 12877
|
3258, 4180
|
2616, 2684
|
235, 242
|
451, 2506
|
11865, 11976
|
2715, 2848
|
10386, 10506
|
2528, 2596
|
2864, 2983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,269
| 127,560
|
39635
|
Discharge summary
|
report
|
Admission Date: [**2180-8-21**] Discharge Date: [**2180-8-22**]
Date of Birth: [**2112-10-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Chief Complaint: diarrhea
Reason for MICU transfer: hypotension with GI bleed
Major Surgical or Invasive Procedure:
Arterial Line Placement
Central Venous Catheter Placement Attempt x 4
Intubation and Mechanical Ventilation
Blood transfusion
Intraosseous Line Placement
History of Present Illness:
67M w/ hx metastatic lung cancer, COPD, erosive gastritis p/w
hypotension and diarrhea, possible blood per rectum. States for
the past several days he felt faint, weak, and fatigued.
Yesterday his symtoms worsened and he also experienced several
episodes of ?bloody diarrhea. No N/V, no CP or abdominal pain.
No fever, chills, dysuria. Complains of continued LLE pain c/w
chronic pain. Also some ?SOB. [**Name (NI) 1094**] sister states that pt was
on toilet and she caught him while he was trying to get up.
Called [**Hospital1 **], SOB on the phone. Sister was with him
and stated he was too weak to walk or get down stairs. She
called 911.
Patient presented to the [**Hospital1 18**] ED by ambulance. On arrival at
[**Hospital1 18**] he was noted to be hypotensive and triggered. ED vitals:
97.2, 102, 70/40-->repeat 95/47, 16, 100%. He had heme postive,
brown stool w/ no gross blood. Recent HCT 31.8 on [**2180-7-31**]
(Atrius), and patient was found to have HCT of 19, ordered 2
units PRBCs, but did not yet get. Given 100mg hydrocortisone IV
as stress-dose steroids because pt is on steroids. BPs have
been mostly in the 100s-110s. Unclear if pt has had recent EGD
or colonoscopy, none in our system, did have recent EGD for
gallstone pancreatitis, but pt does reportedly have erosive
gastritis, diverticulitosis, and has had rectal and colonic
polyps. Also recent history of peri-anal zoster, now on
Valtrex. Patient was given 2L NS in ED, bedside U/S NML, and
had CT abdomen (oral, no IV contrast). GI paged and aware, but
did not yet see patient.
Most recent set of ED vitals: 97.7, 95, 118/46, 19, 100%RA.
On arrival to the MICU, pt was mentating well, still c/o some
dizziness, no CP, no stool since arrived to ED.
Past Medical History:
-Metastatic Lung Cancer (see below)
-Chronic Obstructive Pulmonary Disease
-Anemia (chemo and CKD)
-Erosive Gastritis (secondary to NSAID use)
-Psoriasis and Psoriatic Arthritis
-Hypertension
-Osteoarthritis
-Peripheral Vascular Disease (s/p LE bypass)
-Diverticulosis
-Hypercholesterolemia
-AAA repair in [**2171**]
-Left total knee replacement in [**2173**]
-Left L4/L5 spine surgery in [**2138**], reported as a discectomy;
and severe lumbar DJD
-Gallstone pancreatitis
-Rectal and colonic polyps
-ECHO [**4-/2179**]: L atrium mildly dilated; otherwise essentially NML
w/ EF 60%
-ECG [**4-/2179**]: normal sinus rhythm, Qwaves V1-V2
Social History:
-Divorced, two children
-Lives with sister, independent in ADLs
-Tobacco: quit 8 years ago
-ETOH: 1-2 drinks weekly at most, had 2 beers last night
-Illicits: None
Family History:
-Mother had some type of cancer. No family hx of pancreatitis.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.5, BP: 99/47, P: 93, R: 17, O2: 100% RA
General: Alert, oriented, no acute distress, rash on face, arms
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, holosystolic
murmur, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Rectal: Melena, guaiac +
Ext: no edema
Neuro: CNII-XII intact
Discharge Exam: expired
Pertinent Results:
[**2180-8-21**] 12:55AM BLOOD WBC-10.9# RBC-2.23*# Hgb-5.8*# Hct-19.4*#
MCV-87 MCH-26.0* MCHC-29.8* RDW-17.2* Plt Ct-482*#
[**2180-8-21**] 12:55AM BLOOD Neuts-81.9* Lymphs-11.5* Monos-5.8
Eos-0.5 Baso-0.2
[**2180-8-21**] 12:55AM BLOOD Glucose-169* UreaN-47* Creat-1.9* Na-138
K-4.1 Cl-104 HCO3-24 AnGap-14
[**2180-8-21**] 12:55AM BLOOD Albumin-2.4* Calcium-7.7* Phos-2.5*
Mg-1.3*
[**2180-8-21**] 05:40PM BLOOD WBC-17.5*# RBC-3.29* Hgb-9.6*# Hct-28.5*
MCV-87 MCH-29.1 MCHC-33.7 RDW-15.0 Plt Ct-333
[**2180-8-21**] 05:40PM BLOOD Mg-2.5
[**2180-8-21**] 12:55AM BLOOD ALT-10 AST-16 AlkPhos-91 TotBili-0.1
Brief Hospital Course:
67M w/ hx metastatic lung cancer, COPD, erosive gastritis who
presented with diarrhea and GI bleed with admission Hct of 19.
He was initially admitted to the ICU for close monitoring,
during which time he was transfused 2 units of pRBCs. He
remained hemodynamically stable. GI was consulted who planned to
complete an EGD. However as the day progressed, patient became
increasingly hypotensive with sBPs in 60s. Vascular surgery
consulted for concern aortoenteric fistula. Patient became too
unstable to CT scan. Plan was made to pursue EGD more urgently
to rule out upper GI bleed. Patient was intubated in preparation
of EGD. Prior EGD, family meeting was held to explain the
patient's poor condition. After speaking to the HCP, he was kelp
full code until she could arrive to be at this bedside Just
prior to EGD, patient's BPs dropped and he ultimately went
pulseless. Resuscitative measures were initiated with chest
compressions. Patient received 1mg of epinephrine and ROSC was
established. Massive transfusion protocol was commensed. He then
remained on maximal BP support and was started on epinephrine
gtt. He remained profoundly hypotensive despite maximal
vasopressor support and massive transfusion. Family meeting was
held and focus was shifted to comfort oriented care. Patient
passed on [**2180-8-21**] at 2145. Family declined autopsy.
Medications on Admission:
- dexamethasone
- folic acid?
- lorazepam 1 mg as needed for insomnia or for nausea
- omeprazole 20 mg capsule, delayed release(DR/EC) [**Hospital1 **]
- ondansetron 8 mg tablet ODT every 8 hours as needed for nausea
- oxycodone 5 mg tablet every 4 hours as needed for pain
- prochlorperazine maleate 10 mg tablet every 6 hours as needed
- simvastatin 80 mg daily (pravastatin?)
- Alleve
- Zometa
- imatinib 100 mg daily
- Tarceva (erlotinib)
- Valtrex
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2180-8-22**]
|
[
"729.5",
"197.0",
"518.81",
"272.0",
"276.52",
"285.21",
"785.59",
"338.29",
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"V15.82",
"162.3",
"585.3",
"535.40",
"285.1",
"696.0",
"427.5",
"E935.9",
"196.1",
"053.9",
"403.90",
"443.9",
"496",
"198.5",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.60",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6348, 6357
|
4458, 5812
|
384, 539
|
6408, 6417
|
3832, 4435
|
6473, 6511
|
3171, 3236
|
6316, 6325
|
6378, 6387
|
5838, 6293
|
6441, 6450
|
3276, 3788
|
3804, 3813
|
282, 346
|
567, 2313
|
2335, 2973
|
2989, 3155
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,704
| 195,219
|
49368
|
Discharge summary
|
report
|
Admission Date: [**2180-10-4**] Discharge Date: [**2180-10-11**]
Date of Birth: [**2122-7-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 58 year old woman with scoliosis, chemo related
cardiomyopathy that has since resolved, metastatic breast CA s/p
first dose of monthly faslodex who initially presented to the
[**Hospital1 18**] on [**10-4**] with shortness of breath, hypotension and new
anemia / thrombocytopenia.
.
Upon arrival to the ED, temp 98.6, HR 91, BP 84/53, RR 22, and
pulse ox 91% on room air. Her labs were notable for
transaminitis, thrombocytopenia with Plt 24. CTA chest
demonstrated no pulmonary embolus and known liver and bony mets.
She received zosyn.
.
She was tranferred to the [**Hospital Unit Name 153**] the patient underwent an
echocardiogram and CTA of the chest, both of which were
unrevealing for significant cause of the patients hypotension
and SOB. The patient's hypotension was easily corrected with
holding her home antihypertensives and fluid repletion. The
patient had new LFT abnormalities, thrombocytopenia, elevated
INR, hemolytic anemia and these were thought to be related to
chronic DIC related to the patient's malignancy. She was given
1 unit PRBC but did not require any other blood products. Given
her anemia she was ruled out for babesia with parasite smears.
The patient's breathing stabalized and she was transferred back
to a regular floor
Review of systems:
(+) Per HPI.
(-) Denies pain, fever, chills, night sweats, weight loss,
headache, sinus tenderness, rhinorrhea, congestion, cough,
shortness of breath, chest pain or tightness, palpitations,
nausea, vomiting, constipation, abdominal pain, change in
bladder habits, dysuria, arthralgias, or myalgias.
Past Medical History:
# CHF: seen every 6 months by Dr.[**First Name (STitle) 2031**] at [**Hospital **].
# Breast Ca: on [**9-14**] started faslodex (Estrogen Receptor
Antagonist) monthly
# Osteoporosis
# ? GERD/Esophageal Spasms
# Scoliosis
Social History:
The patient lives at home with her husband who work from home.
Family History:
Non-contributory
Physical Exam:
VS: T 98.0 HR 91 BP 124/71 RR 20-24 O2 94% on 3L NC
GEN: NAD, AOX3
HEENT: MMM OP clear, JVP 8cm
CARD: RRR, widely split S2, SEM at the LUSB
PULM: CTAB, scoliosis
ABD: soft, NT, ND, no masses or organomegaly
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Pertinent Results:
Discharge Labs: [**2180-10-11**]
WBC-8.9 RBC-4.01* Hgb-11.4* Hct-32.9* MCV-82 MCH-28.5 MCHC-34.8
RDW-16.8* Plt Ct-20*
Fibrino-124*
Glucose-76 UreaN-23* Creat-0.9 Na-140 K-4.5 Cl-104 HCO3-26
AnGap-15
ALT-146* AST-219* LD(LDH)-2620* AlkPhos-333* TotBili-1.0
Calcium-10.1 Phos-3.3 Mg-2.0
Hapto-<20*
.
Micro:
[**2180-10-4**] Blood culture x 2: No growth, final
[**2180-10-4**] Urine culture: No growth, final
.
Studies:
[**2180-10-6**] Liver U/S: 1. Numerous echogenic small lesions in both
lobes of the liver, measuring up to 0.5 cm concerning for
metastatic disease.
2. A number of cystic lesions in the liver in both lobes.
3. No evidence of hepatic or portal vein thrombosis.
[**2180-10-5**] Echo: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Diastolic function could not be assessed. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of mild (1+) 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.
IMPRESSION: Normal regional and global biventricular systolic
function. Mild mitral regurgitation. Moderate pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2180-9-20**], the
pulmonary artery systolic pressures can be estimated on the
current study (and are moderately elevated).
[**2180-10-4**] CTA: 1. No evidence of pulmonary embolus or thoracic
aorta dissection. 2. Trace pericardial effusion. 3. 3mm right
middle lobe pulmonary nodule. Recommend follow-up chest CT in 12
months to assess for stability. 4. Diffuse osseous metastatic
disease again seen. 5. Multiple hypodense intrahepatic lesion,
some of which represent cysts,
Brief Hospital Course:
Impression / Plan: 58 year old woman with scoliosis, chemo
related cardiomyopathy that has since resolved, metastatic
breast CA s/p first dose of monthly faslodex who initially
presented to the [**Hospital1 18**] on [**10-4**] with shortness of breath,
hypotension and new anemia / thrombocytopenia.
.
# Shortness of breath: Restrictive lung disease likely due to
lymphangitic spread of tumor vs pulmonary fibrosis. After
extensive work up the patient was put on Prednisone 60mg by
mouth with a plan to do a slow taper and follow up in pulmonary
clnic. She was also started on Bactrim prohylaxis, Ca/Vit D.
.
# Chronic DIC: The patients platelet count and HCT stabalized
during this admission but remained low. The patient has close
follow up with her Oncologist who will follow these values.
.
# Abnormal LFTs: Likely [**2-14**] to liver mets. They were elevated
but stable before discharge.
.
#Metastatic Breast CA: Her oncologist will follow this issue.
The patient was started on lovenox.
Medications on Admission:
Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for insomnia.
Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO
every 4-6 hours as needed for pain.
Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily ().
Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a day.
Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for nausea.
Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing. Disp:*1 inhaler* Refills:*0*
Carvedilol
Lisinopril
Digoxin
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
6. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily ().
7. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a day.
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea.
9. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
10. Oxygen
Please provide continued O2, 2L nasal canula.
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*12 Tablet(s)* Refills:*2*
13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 38 days: 60mg [**10-12**]- [**10-14**], 50mg [**Date range (1) 90497**], 40mg
[**Date range (1) 96745**], 30mg [**Date range (1) 103410**], 20mg [**Date range (1) 41492**], 10mg
[**Date range (1) 22749**].
Disp:*130 Tablet(s)* Refills:*0*
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 60 syringes* Refills:*2*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
16. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] oxygen company
Discharge Diagnosis:
Primary:
Pneumonitis
Restrictive lung disease
Secondary:
Breast cancer
Discharge Condition:
Stable vitals, afebrile.
Discharge Instructions:
You were admitted to the hospital for shortness of breath. A CT
scan was negative for pneumonia, pulmonary embolism, or fluid in
your lungs. You underwent pulmonay function testing (PFTs) which
showed restrictive abnormalities of your lungs. This was thought
to be possibly due to a pneumonitis or inflammation of the
lungs, and a trial of steroids was attempted. Fortunately, the
steroids significantly improved your symptoms. You will be
discharged home on oxygen.
We have made the following changes to your medications:
Prednisone 60mg by mouth from [**2180-10-12**] - [**10-14**]
Prednisone 50mg by mouth from [**2180-10-15**] - [**10-21**]
Prednisone 40mg by mouth from [**Date range (1) 96745**]
Prednisone 30mg by mouth from [**Date range (1) 103410**]
Prednisone 20mg by mouth from [**Date range (1) 41492**]
Prednisone 10mg by mouth from [**Date range (1) 22749**]
Then stop taking Prednisone after [**11-18**]
Take Lovenox 30mg subcutaneously every 12 hours
Sulfameth/Trimethoprim DS 1 TAB by mouth Monday, Wednesday,
Friday
Vitamin D 400 UNIT by mouth DAILY
Continue taking the Colace and Senna as needed for constipation.
Please follow up at the appointments listed below.
If you experience chest pain, shortness of breath, fevers,
please call your PCP or come to the emergency room.
Followup Instructions:
You have an appointment with Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-10-18**] 10:30
You have an appointment with Provider: [**Name10 (NameIs) 706**]
Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2180-12-20**] 9:30
You have an appointment with Provider: [**Name10 (NameIs) 706**]
Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2180-12-20**] 10:00
You have an appointment with Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **]. Phone:
[**Telephone/Fax (1) 3393**] Date/Time: [**2180-10-18**] 10:30am.
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2180-11-1**] 11:30
You will see the pulmonologist after this appointment.
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**] Date/Time: [**2180-10-18**] 10:00am. Phone
[**Telephone/Fax (1) 13341**]
Dr. [**Last Name (STitle) 2036**] will follow your blood work and discuss any further
test.
Completed by:[**2180-10-16**]
|
[
"285.9",
"287.5",
"198.5",
"458.9",
"428.0",
"V10.3",
"428.22",
"515",
"518.89",
"276.51",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.91"
] |
icd9pcs
|
[
[
[]
]
] |
8514, 8580
|
4708, 5702
|
336, 343
|
8696, 8723
|
2614, 2614
|
10070, 11194
|
2303, 2321
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8601, 8675
|
5728, 6645
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8747, 9242
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2630, 4685
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2336, 2595
|
9271, 10047
|
1661, 1962
|
277, 298
|
371, 1642
|
1984, 2207
|
2223, 2287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,144
| 108,988
|
33652
|
Discharge summary
|
report
|
Admission Date: [**2133-8-22**] Discharge Date: [**2133-8-25**]
Date of Birth: [**2084-6-11**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Penicillins / Food Extracts / Latex / Lovenox /
Demerol / Wellbutrin / nsaids
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
epigastric pain and hematemesis x 2
Major Surgical or Invasive Procedure:
PSH: lap RNYGB [**2129**], Lap appy, soft palate surgery, right ankle
surgery
History of Present Illness:
49 y/o man with hx lap roux en y gastric bypass in [**2129**] and hx
marginal ulcer who presents with vomiting blood x 2 since 7pm
[**2133-8-21**]. Per patient, he ate normal breakfast and then had
nausea and decreased appetite during day. He had sudden onset
bright red vomit mixed with clots x 2, associated with light
headedness and left upper quadrant moderate pain. Of note, he
recently completed a course of PO steroids for respiratory
illness. He denies tobacco or NSAID use, and last ETOH 3 weeks
ago.
Past Medical History:
HTN, asthma, GERD, dyslipidemia, PVD, restless leg syndrome,
back pain, shingles, OSA
Social History:
He denies tobacco or recreational drug usage and drinks wine
occasionally (2 to 3 times/wk). He has 1 to 2 cups of coffee
daily and a 12-ounce diet soda occasionally. He is employed as
a real estate broker. He is married and lives with his wife,
age 44. They have no children.
Family History:
Father age 75 with heart disease & hyperlipidemia. Mother age
74 with cancer and asthma. Brother at 48 with hyperlipidemia &
obesity. Twin brother age 48 with obesity. Paternal
grandmother deceased with diabetes.
Physical Exam:
General: Awake, alert, oriented x 3
CV: RRR
Puml: CTAB
Abd: Soft, non-tender, distention hard to assess [**2-26**] size
Extrem: WWP, 2+ radial and DP pulses
Neuro: No focal deficits
Pertinent Results:
[**2133-8-23**] 12:00AM GLUCOSE-83 UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2133-8-23**] 12:00AM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2133-8-23**] 12:00AM WBC-10.0 RBC-3.97* HGB-11.5* HCT-35.3* MCV-89
MCH-29.0 MCHC-32.6 RDW-13.3
[**2133-8-23**] 12:00AM PT-11.4 PTT-33.6 INR(PT)-1.1
Brief Hospital Course:
The patient presented to the [**Hospital1 18**] ED on [**2133-8-22**] with abdominal
pain and hematemesis x 2. Hct on admission was 36, CXR with no
pneumoperitoneum,
CT with remnant thickened (not dilated or fluid filled) - likely
chronic gastritis and duodenitis - consistent with hx of PUD.
Patient was hemodynamically stable and admitted for further
observation
Neuro: The patient was alert and oriented throughout the
hospitalization
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored, hct trended
down to 31.9 on [**2133-8-24**] for a one-time read, all other hct > 33,
with discharge hct 37.5.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: He was initially NPO until EGD completed to confirm
no UGI bleed, after which he was advanced to stage 3, and well
tolerated. Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 4
diet. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Fluticasone 50 2 sprays [**Hospital1 **], FLOVENT 110 [**Hospital1 **], Roxicet prn,
prednisone 5 (finished 5 day course last w), pantoprazole 40
[**Hospital1 **], Carafate prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache
RX *8 HOUR PAIN RELIEVER 650 mg 1 tablet(s) by mouth every six
(6) hours Disp #*64 Tablet Refills:*0
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *Prevacid SoluTab 30 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Sucralfate 1 gm PO QID
RX *Carafate 1 gram/10 mL 10 mL by mouth four times a day Disp
#*1 Bottle Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg/5 mL 5 mL by mouth every six (6) hours
Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain and hematemsis x 2 with EGD showing no active
bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory ?????? Independent.
Discharge Instructions:
You were admitted to the Bariatric Surgery Service at [**Hospital1 1535**] after presenting on [**2133-8-22**] with
abdominal pain and hematemesis x 2.
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, bloody emesis, chest
pain, shortness of breath, severe abdominal pain, severe nausea
or vomiting, severe abdominal bloating, or any other symptoms
which are concerning to you.
Diet: Stay on Stage 4 as tolerated.
Medication Instructions:
Resume your home medications.
1. If you take prescription pain medications, these medications
will make you drowsy and impair your ability to drive a motor
vehicle or operate machinery safely. You MUST refrain from such
activities while taking these medications.
2. You should begin/continue taking a chewable complete
multivitamin with minerals.
3. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
Normal activity as tolerated
Followup Instructions:
Department: BARIATRIC SURGERY
When: [**2133-9-9**] 9:45AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Best Parking: [**Hospital Ward Name 23**] Garage
Weight Loss Surgery Center
[**Hospital1 69**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
[**Location (un) 830**]
[**Location (un) 86**] , [**Telephone/Fax (1) 47701**]
|
[
"578.0",
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"789.06",
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"493.90",
"443.9",
"327.23",
"534.90",
"V45.86",
"530.81",
"V12.71",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4497, 4503
|
2234, 3718
|
383, 463
|
4617, 4617
|
1867, 2211
|
5878, 6285
|
1432, 1650
|
3946, 4474
|
4524, 4596
|
3744, 3923
|
4773, 5245
|
1665, 1848
|
308, 345
|
491, 1007
|
5270, 5855
|
4632, 4749
|
1029, 1116
|
1132, 1416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,312
| 133,613
|
20274
|
Discharge summary
|
report
|
Admission Date: [**2122-5-12**] Discharge Date: [**2122-5-15**]
Date of Birth: [**2061-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
admitted for VT ablation
Major Surgical or Invasive Procedure:
1. VT ablation
2. Endotracheal intubation
History of Present Illness:
59 y/o man with hx. AMI in [**2094**] with resulatant apical aneurysm
and VT, EF 17%, s/p amio, ICD with ATP pacing, VT ablation [**2119**],
admitted for repeat VT ablation [**3-13**] recurrent shocks on [**2122-4-22**]
who had only non-clinical VT inducible in the EP lab today, and
this was poorly tolerated hemodynamically. He underwent multiple
shocks to get out of this rhythm and was hypotensive, beleived
[**3-13**] myocardial "stunning" of multiple shocks. He was started on
neosynephrine for BP support, and left intubated, admitted to
the CCU for monitoring overnight. Plan is to start ASA, Warfarin
s/p ablation attempt and given apical aneurysm. Device was
reprogrammed to previous settings.
Past Medical History:
AMI [**2094**], as above
DM
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. The patient resides
in [**Country 2451**], but works in [**State 2690**] part of the year. He stays with his
brother, [**Name (NI) **] [**Name (NI) 54432**] in [**State 2690**].
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 105/59 mm Hg while seated. Pulse was 83
beats/min and regular, respiratory rate was 12 breaths/min.
Intubated, sedated.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 7 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2122-5-12**] 07:20PM PLT COUNT-254
[**2122-5-12**] 07:20PM WBC-11.9* RBC-4.95 HGB-15.4 HCT-44.5 MCV-90
MCH-31.0 MCHC-34.5 RDW-13.2
[**2122-5-12**] 07:20PM CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2122-5-12**] 07:20PM estGFR-Using this
[**2122-5-12**] 07:20PM GLUCOSE-159* UREA N-16 CREAT-0.8 SODIUM-133
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-13
[**2122-5-12**] 10:17PM LACTATE-1.1
[**2122-5-12**] 10:17PM TYPE-ART PO2-118* PCO2-36 PH-7.40 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED
.
IMAGING/STUDIES:
[**2122-5-12**] FOCUSED TRANS-THROACIC ECHOCARDIOGRAM: The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is severely depressed. There is no pericardial
effusion.
.
[**2122-5-14**] CARDIAC CATHETERIZATION: COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD was
occluded in the proximal segment. The LCx had no angiographic
evidence of flow-limiting disease. The RCA had an 80% stenosis
in the mid, small posterolateral branch. 2. Resting
hemodynamics revealed elevated right and left sided filling
pressure with a RVEDP of 17 mmHg and a mean PCWP of 30 mmHg.
There was moderate pulmonary arterial hypertension with PA
pressure of 56/33 mmHg. Systemic arterial pressure was normal at
130/84 mmHg. There was no transaortic valve gradient on
pullback of the catheter from the LV to the aorta. FINAL
DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Marked
elevation of filling pressures. 3. Moderate pulmonary arterial
hypertension.
Brief Hospital Course:
Mr. [**Known lastname 54433**] is a 59 year old male with a past medical history of
acute myocardial infarct approximately 30 years ago with an EF
of 10 %, VT with ICD and ATP who was transferred to the CCU
after attempted VT ablation. In the VT lab, patient required
multiple shocks, became hypotensive post-procedure, was admitted
to the CCU for monitoring.
.
1. VENTRICULAR TACHYCARDIA: The patient has had multiple
episodes of V-TACH. He underwent VT ablation, but his VT was not
induced. He did develop unstable VT in the EP lab requiring
multiple shocks. He became hypotensive after the procedure
requiring pressor support and fluid resuscitation. He was
quickly weaned off of pressors upon arrival to the CCU. He
remained intubated until the day after his procedure. He
continued to have intermittent episodes of VT recorded on
telemetry. However, he did not require further defibrillation by
his ICD. He was started on anti-coagulation therapy for known
apical aneurysm and post-VT ablation and this should be
continued for 2 months. He is returning to [**Location (un) 36413**] for 2 weeks
where Dr. [**First Name (STitle) 9723**] will follow his INR. He will then return to [**Country 2451**]
where his PCP will monitor his INR.
.
2. CHF: The patient has poor cardiac ejection fraction at
baseline. He did experience moderate symptoms of volume overload
after being volume resuscitated for hypotension. He responded
well to diuresis and tolerated self-extubation well. His home
medication regimen was re-started when the patient was deemed
hemodynamically stable.
.
3. CAD: The patient underwent cardiac catheterization during
this admission to evaluate for a potential ischemic source of
his VT. Cardiac catheterization demonstrated 80% lesion in the
RCA and total occlusion of the proximal LAD. No intervention was
performed. He was continued on ASA and beta-blocker. The patient
would likely benefit from monitoring of his lipid profile and
the addition of a statin product to his medical regimen. It is
unclear whether he has received lipid lowering therapy in the
past.
.
4. DM II: The patient was managed with sliding scale insulin. He
was instructed to restart his home dose of Glyburide upon
discharge.
Medications on Admission:
Carvedilol, Captopril, Lasix, Spirinolactone, Digoxin, ASA,
Glyburide
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: As directed Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day:
Please start taking this medication in 7 days after discharge
(Saturday [**2122-5-23**]).
Disp:*30 Tablet(s)* Refills:*0*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day) for 3 days.
Disp:*6 syringe* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*0*
9. Diabetes medication - Glyburide
Please resume your pre-hospitalization glyburide dose.
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Ventricular tachycardia
2. CHF
.
Secondary:
1. DM II
2. Ischemic cardiomyopathy
3. CAD
Discharge Condition:
Good. Tolerating PO. Afebrile. No oxygen requirement.
Discharge Instructions:
You were admitted to hospital for ventricular tachycardia
ablation. You experienced a complication of your procedure and
required volume resuscitation and breathing assistance.
.
Please return to the ER or call your doctor if you experience
any of the following symptoms: fever > 100.4, SOB, palpitations,
chest pain, weakness, dizziness or any other concerning
symptoms.
.
Please take all medications as prescribed.
.
Please follow up with all appointments as instructed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere
to 2 gm sodium diet. Fluid Restriction: 1.5L per day
Followup Instructions:
1. Please call Dr.[**Name (NI) 54434**] office on Monday morning. They have
been informed that you will be arriving in [**Location (un) 36413**] on Saturday.
You have been provided with a prescription to have blood work
checked twice weekly for 3 weeks. Please have your blood checked
on Monday [**2122-5-18**] at Dr.[**Name (NI) 54434**] office ([**0-0-**]). Goal INR
[**3-14**].
2. Please follow up with your doctor within one week of
returning to [**Country 2451**]. He should check your PT/PTT/INR twice weekly
and adjust your warfarin dose for a goal INR of [**3-14**].
3. You will require anti-coagulation with warfarin for 2 months.
4. Lipid profile should be monitored by the patient's doctor.
[**Month (only) 116**] benefit from statin therapy.
|
[
"428.0",
"V45.02",
"414.8",
"412",
"416.9",
"427.0",
"458.29",
"414.01",
"E878.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"37.34",
"88.56",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
8119, 8125
|
4619, 6841
|
340, 384
|
8267, 8323
|
2950, 4596
|
8979, 9736
|
1487, 1569
|
6961, 8096
|
8146, 8246
|
6867, 6938
|
8347, 8956
|
1584, 2931
|
276, 302
|
412, 1117
|
1139, 1168
|
1184, 1471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,768
| 194,302
|
4907
|
Discharge summary
|
report
|
Admission Date: [**2141-3-28**] Discharge Date: [**2141-4-20**]
Date of Birth: [**2073-9-24**] Sex: M
Service: BLUE SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old
male with metastatic rectal cancer who presented with nausea,
vomiting, abdominal pain times 36 hours, pain at the lower
abdominal area but no radiation, slightly improved with
nausea and vomiting times four, large amounts, nonbilious,
colostomy with no output and no gas times 24 hours.
PAST MEDICAL HISTORY:
1. Metastatic rectal cancer , status post abdominoperineal
resection in [**2126**], status post chemotherapy and radiotherapy.
2. Status post right ureteral stents.
3. CABG times five in [**2135**],
4. Diabetes type 2.
5. Benign prostatic hypertrophy.
6. Hypertension.
7. Hypercholesterolemia.
8. DVT.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Albuterol.
2. Atrovent.
3. Fentanyl patch 25 q. three days.
4. Flonase.
5. Glyburide 15/5.
6. Lasix 40 q.o.d., 20 q.o.d.
7. Lipitor 20 q.d.
8. Nitroglycerin p.r.n.
9. Oxycodone 5 q. three to four hours.
10. Coumadin.
11. Toprol 50 q.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: On
admission, the patient was afebrile. The vital signs were
stable. General: The patient was alert, in no acute
distress. Lungs: Clear to auscultation bilaterally. Heart:
Regular rate and rhythm. Abdomen: Positive bowel sounds,
soft, slightly distended, nontender. The ostomy was pink
with parastomal hernia. No evidence of obstruction above
fascial level. Neurologic: Within normal limits.
LABORATORY DATA: White count 9, hematocrit 36, platelets
301,000. The first set of cardiac enzymes was negative.
Chest x-ray showed no free air.
KUB showed air-fluid levels.
HOSPITAL COURSE: The patient was taken to the Operating Room
for an exploratory laparotomy, lysis of adhesions and repair
of the parastomal hernia with Vicryl mesh. The patient
tolerated the procedure without complications. The patient
had a fever spike on postoperative day number two with
increased pulmonary secretions, desaturations to 85%. The
patient was felt to have had a perioperative aspiration event
and was placed on antibiotics. The patient continued to have
respiratory distress and was transferred to the Intensive
Care Unit.
He had problems with agitation and respiration, ultimately
needing reintubation. The patient had an episode of atrial
fibrillation on postoperative day number three which
eventually corrected with Amiodarone. The patient continued
to have blood pressure and respiratory issues. It was
eventually controlled and he was weaned off the ventilator.
He was extubated on postoperative day number ten.
The patient continued to have issues with agitation and
pulling out his nasogastric tube numerous times. The patient
failed a swallowing evaluation.
He was eventually transferred to the floor on postoperative
day number 14. A Dobbhoff feeding tube was placed. In
discussion with the family, it was decided that the patient
would benefit from a PEG placement which was done by
Interventional Radiology on postoperative day number 16. The
patient's tube feedings were started and eventually the TPN
was weaned off. The patient was able to pass air into his
ostomy bag on postoperative day number 19. There was stool
in the bag on postoperative day number 21.
The patient was felt to be ready for discharge to a
rehabilitation facility. The patient is to follow-up with
Dr. [**First Name (STitle) 2819**], to be scheduled through his office.
DISCHARGE MEDICATIONS:
1. Fentanyl patch q. three days.
2. Albuterol.
3. Flovent.
4. Tylenol 650 mg p.o. q. four to six hours p.r.n. through
his tube.
5. Sliding scale insulin.
6. Colace.
7. Continue on tube feeds.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To a rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post exploratory laparotomy, lysis of adhesions with
repair of parastomal hernia for small bowel obstruction and
parastomal hernia
2. Hypovolemia
3. Aspiration Pneumomia
4. Metastatic Rectal Cancer
5. Delayed Bowel Function
6. Acute Delirium
7. Malnutrition
6. Coronary Artery Disease
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 02-915
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2141-4-19**] 08:02
T: [**2141-4-19**] 20:20
JOB#: [**Job Number 20448**]
|
[
"197.0",
"427.31",
"263.9",
"198.89",
"569.69",
"197.7",
"560.81",
"507.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"54.59",
"46.43",
"89.64",
"38.93",
"43.11",
"96.6",
"96.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3829, 3888
|
3607, 3807
|
3909, 4419
|
1807, 3584
|
906, 1176
|
1191, 1789
|
518, 883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,806
| 102,831
|
3366
|
Discharge summary
|
report
|
Admission Date: [**2158-12-7**] Discharge Date: [**2158-12-12**]
Date of Birth: [**2113-11-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
female, being anticoagulated with Coumadin, status post
mitral valve replacement, #27 Carbomedics in [**2151**]. She
presented to the Emergency Department with one day history of
abdominal pain and bright red blood per rectum. The patient
usually takes 7 mg of Coumadin during the week days and 9 mg
of Coumadin on the weekends, as per husband who administers
her medications. Reportedly, she had an INR of 3.2 ten days
prior to admission. One day prior to admission, the patient
started having crampy abdominal pain, mostly in the left
lower quadrant. Pain was non radiating but progressively
worsened in intensity. Since the beginning of the abdominal
pain, the patient reports having passed three bloody bowel
movements with visible clots in the toilet. The patient
denies fevers, chills, sweats or any other systemic symptoms.
PAST MEDICAL HISTORY: Rheumatic heart disease with mitral
stenosis and mitral regurgitation, status post mitral valve
replacement in [**2151**], with 27 mm Carbomedics mitral valve
(mechanical). Asthma. Hypercholesterolemia. Anxiety. Panic
disorder. History of poly substance abuse, including alcohol
and cocaine. [**Location (un) 15587**] disease.
PAST SURGICAL HISTORY: Mitral valve replacement in [**2151**] as
mentioned above. Tubal ligation.
ALLERGIES: The patient reports allergic reaction to
Penicillin and aspirin.
MEDICATIONS AT HOME:
Lipitor 20 mg p.o. q. day.
Coumadin regular home regimen of 7 mg on week days and 9 mg
p.o. q. day on weekends, although the history is not clear
whether the patient had been taking mostly 9 mg p.o. q. day
prior to admission.
Zyprexa 5 mg p.o. q h.s.
Clonidine 0.1 mg p.o. q h.s.
Trazodone 150 mg q h.s.
Proventil MDI inhaled twice a day.
Calcium, Vitamin D and Vitamin C.
SOCIAL HISTORY: Significant for prior abuse of cocaine and
alcohol. The patient reports continuing one pack per day
history of smoking.
PHYSICAL EXAMINATION: Temperature of 98.4; heart rate of 94;
blood pressure of 105/86; respiratory rate of 16; 96% on room
air. The patient was alert and oriented times three and not
in apparent distress. HEAD, EYES, EARS, NOSE AND THROAT:
Within normal limits. Cardiovascular examination: Regular
rate and rhythm with S1 and S2, 3/6 systolic murmur,
consistent with history of mitral valve replacement.
Respiratory examination: Clear to auscultation bilaterally.
Abdominal examination with bowel sounds soft, diffusely
tender. Abdomen with worse pain and tenderness in the left
lower quadrant with rebound and guarding. There was no
rigidity. Extremities were warm and well perfused without
edema.
LABORATORY DATA: White blood cell count of 10.2; hematocrit
of 41.9; platelets of 202. PT was 100; PTT was 82.3 with INR
of 112.3. Chemistries were 143, potassium of 3.6; chloride
105; C02 of 27; BUN of 10 and creatinine of 0.6; glucose of
125. AST was 59; ALT was 28; alkaline phosphatase was 83;
Total bilirubin was 0.4; amylase 71 and lipase of 37.
Urinalysis showed large amounts of blood in the urine.
CT scan of the abdomen showed a 10 cm segment of the proximal
sigmoid colon with low attenuation signal within the sigmoid
wall. There were also several small diverticula noted within
the sigmoid colon. There was minimal stranding in the
adjacent fat and trace amount of free fluid within the
pelvis. These readings were consistent with intramural
hemorrhage of the sigmoid colon.
HOSPITAL COURSE: Because of the significantly elevated INR
of 112.3, the patient was urgently given two units of FFP, 10
mg of Vitamin K p.o., and one dose of Factor VII, (2,400
units) while in the Emergency Department. The patient was
followed closely with serial hematocrit checks and serial INR
checks. The gastrointestinal service and the surgery service
were called for urgent consultation. It was decided that the
patient should be admitted to the surgical Intensive Care
Unit for management of the anticoagulation.
Within a span of six hours of the treatment for the elevated
INR while in the Emergency Department, the patient's INR came
down to a level of 2.2 and, in the next two hours, the INR
dropped down to 0.6. Given the mechanical valve, the patient
was urgently started on heparin drip without a loading bolus.
The patient was started on 18 units per kg per hour which
translates to 800 units per hour, with a goal PTT of 60 to
80. However, the patient's PTT rose up to 120 after six
hours of treatment on heparin drip at 800 units per hour and
the heparin was held for one hour and restarted at 700 units
per hour. Serial check of the PT, PTT and hematocrit with
subsequent adjustment in the heparin drip stabilized the
patient at an acceptable PTT level, within the goal of 60 to
80 and the hematocrit remained stable. (It should be noted
that while the patient had a hematocrit of 41.9 on admission,
recheck of the hematocrit nine hours later showed hematocrit
of 34.8 and, with proper resuscitation, the patient's
hematocrit dropped to 30.5 on hospital day number two and
this was monitored in the Intensive Care Unit and the
hematocrit remained stable and increased slightly while being
observed in the Intensive Care Unit. Thus, the hematocrit
was deemed to be stable and there were no suspicions that the
patient was continuing to bleed.)
At the end of hospital day number two, with documented
evidence of stable hematocrit as explained above, and proper
anticoagulation on heparin drip, the patient was transferred
to the floor. While on the floor, the patient was maintained
n.p.o. because she had not passed flatus during the two days
of her hospital stay to that point. There was a question
whether or not the sigmoid intramural hematoma may be causing
an obstruction. It was thought to possibly be causing an
obstruction.
The patient underwent a Hypaque enema on hospital day number
five to rule out obstruction and the Hypaque enema did not
show any obstructing lesion. Given the stable nature of the
patient, the patient was started on p.o. which she tolerated
without any difficulty and without any episode of bright red
blood per rectum. The patient's Coumadin had been held for
three days by hospital day number five and, in discussion
with the patient's primary care physician, [**Name10 (NameIs) **] the
[**Hospital3 **] at which the patient is followed up,
the patient was restarted on Coumadin of 7 mg. The patient's
INR which had drifted down to 0.6 with the quick reversal at
the Emergency Department on the day of admission, slowly
increased with the depletion of the Factor VII infusion which
had been given on hospital day number one. On the day of
discharge, on hospital day number six, the INR was 2.5. The
patient was discharged home with Coumadin schedule of 7 mg
p.o. q h.s. during week days and the weekends. The patient
was instructed to follow-up on the day after discharge at the
[**Hospital3 **] for check of the INR. On the day of
discharge, the patient was tolerating a regular diet, without
any difficulty, without any episodes of bright red blood per
rectum.
DISCHARGE CONDITION: Discharged to home.
DISCHARGE DIAGNOSES:
Sigmoid hematoma, secondary to over anticoagulation, status
post mitral valve replacement.
DISCHARGE MEDICATIONS:
The patient is to continue all her preadmission medications
as ordered by her primary care physician, [**Name10 (NameIs) 151**] the exception
of Coumadin and the patient is to take 7 mg p.o. q h.s.
daily.
FOLLOW-UP: The patient is to be seen at the [**Hospital1 346**] [**Hospital3 **] on the day
after discharge, on [**2158-12-13**] for check of her INR.
The patient is to see Dr. [**First Name (STitle) 452**], gastroenterologist in four
weeks for sigmoidoscopy and is to call for an appointment
date and time. The patient is to see Dr. [**Last Name (STitle) 1888**] of
Gastrointestinal surgery in six weeks for surgical consult
and will call his office for appointment date and time. The
patient needs to see her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
within the next one or two weeks. The patient can follow-up
with Dr. [**Last Name (STitle) **] as needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2158-12-13**] 08:24
T: [**2158-12-13**] 20:29
JOB#: [**Job Number 15588**]
|
[
"V43.3",
"493.90",
"790.92",
"V58.61",
"398.90",
"578.9",
"272.0",
"733.00",
"300.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
7257, 7278
|
7299, 7391
|
7414, 8605
|
3620, 7235
|
1585, 1959
|
1409, 1564
|
2120, 3602
|
162, 1029
|
1052, 1385
|
1976, 2097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,969
| 177,266
|
3180
|
Discharge summary
|
report
|
Admission Date: [**2152-4-25**] Discharge Date: [**2152-5-1**]
Date of Birth: [**2086-10-5**] Sex: F
Service: NEUROLOGY
Allergies:
Imdur
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
HA, Loss of Coordination
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 65 yo woman with a h/o Infiltrating ductal breast
cancer (Stage II) s/p right mastectomy and 4 cycles chemo also
with CAD s/p CABG who presents with 5 days of "excruciating"
headache and lack of coordination. Patient notes that she was
working on a computer five days ago when she had an acute onset
of severe, constant headache localized to the top of her head.
She notes that she has not had a similar headache before, noting
that it was the worst headache of her life. She tried Tylenol
and Motrin with no improvement. She notes that the HA worsens
when standing and when bending over. She notes that since the
headache, she has been veering to the left and walking into
objects on the left despite being able to see them.
On the day of admission, she was bending over and lost her
balance and was not able to get back into position on her own.
She was, therefore, brought to the [**Hospital1 18**] ED by her daughter.
She denies N/V/D, photophobia, phonophobia, visual changes,
hearing changes, fevers, chills, weight loss, dysuria, vertigo,
dysarthria, aphasia, dysphagia, weakness, numbness, and
incontinence but notes night sweats for the last 5 days.
Past Medical History:
Infiltrating ductal breast cancer (Stage II) diagnosed in [**11-3**]
- right mastectomy for a 3.7cm breast tumor which was grade III
and ER negative, PR negative, and Her2/neu negative. Has
finished four cycles of Taxotere and Cytoxan.
CAD with CABG years ago and prior to that stents which she says
were removed with the CABG,
Hypertension
Hypercholesterolemia
Congestive heart failure
DM Type II (last Hgb A1c 6.2 in [**12-3**])
H.pylori
Esophageal webbing
Ovarian cyst
Social History:
Patient is married and lives with her husband who has diabetes
and is disabled in [**Location (un) 669**]. She has four children in their 50's.
One of her daughter's has been helping her at home since she
has not been able to cook or take care of herself. She owns a
travel agency. Patient quit smoking cigarettes 11 years ago,
but smoked a half pack a day for 20 years. She denies alcohol
use or illegal drug use. She feels safe at home. Her health
care proxy is her daughter [**Name (NI) 6177**] [**Name (NI) 5903**]. Her home number is
[**Telephone/Fax (1) 14958**].
Family History:
The patient denies family history of malignancies in her uterus,
breast, colon, ovary, or cervix. Grandmother and Grandfather
both had diabetes, otherwise everyone is healthy.
Physical Exam:
T- 97.8 BP- 150/90 HR- 81 RR- 19 O2Sat 98 RA
Gen: 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
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
and
appropriate affect. Oriented to person, place, and says [**2152-4-10**]
for date. Attentive, says [**Doctor Last Name 1841**] backwards x 4, but then says its
hurting her head. Attentive with exam. Speech is fluent with
normal comprehension and repetition; naming intact. No
dysarthria. [**Location (un) **] intact. Registers [**2-28**], recalls [**2-28**] in 1
minute. No right left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Left field cut. Could not see discs secondary to
cataracts. Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Hearing intact to finger rub bilaterally. Palate elevation
symmetrical. Traps normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift. No asterixis
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 * * 5 * 4+ * * 5 * 5 *
L 5 5 5 * * 5 * 4+ * * 5 * 5 *
* Patient had severe exacerbation of headache on motor testing,
so portions were deferred.
Sensation: Intact to light touch and cold throughout. Perhaps
some extinction to DSS but only one out of three tries.
Reflexes:
+1 and symmetric throughout BUE. Absent knees and ankles.
Toes up bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based, mildly unsteady and wobbles twice. Does not
seem to veer to one side.
Romberg: deferred as patient's headache was exacerbated by
standing and could not comply.
Pertinent Results:
[**2152-4-25**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2152-4-25**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2152-4-25**] 03:00PM URINE RBC-0 WBC-[**3-1**] BACTERIA-FEW YEAST-FEW
EPI-[**6-6**] TRANS EPI-[**3-1**]
[**2152-4-25**] 03:00PM URINE HYALINE-0-2
[**2152-4-25**] 11:26AM PT-12.1 PTT-23.0 INR(PT)-1.0
[**2152-4-25**] 10:06AM GLUCOSE-116* UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-20* ANION GAP-21*
[**2152-4-25**] 10:06AM CALCIUM-10.3* PHOSPHATE-4.4 MAGNESIUM-2.2
[**2152-4-25**] 10:06AM WBC-11.9* RBC-4.29 HGB-12.3 HCT-37.2 MCV-87
MCH-28.6 MCHC-33.0 RDW-16.1*
[**2152-4-25**] 10:06AM NEUTS-86.3* LYMPHS-8.8* MONOS-3.2 EOS-1.5
BASOS-0.2
CTH: [**4-25**]: IMPRESSION:
1. Multiple high-attenuation foci in bilateral cerebral
hemispheres. Differential diagnosis includes hemorrhagic,
hypervascular or adenocarcinomatous metastases.
2. There is a 6.8 mm leftward subfalcine herniation with early
uncal herniation.
MRI brain: [**4-26**]:
FINDINGS: There is extensive metastatic disease with multiple
rounded rim- enhancing lesions in all lobes of the brain. The
largest lesions include: A 1 x 0.9 cm mass at the left frontal
vertex, 2 x 1.6 cm mass in the right parietal lobe, 1.6 x 1.4 cm
mass in the right lentiform nucleus, 1.3 x 1.2 cm mass in the
right temporal cortex, 1.9 x 1.7 cm mass in the left cerebellar
hemisphere, and 1.5 x 1.2 cm mass in the right cerebellar
hemisphere, as well as multiple subcentimeter lesions. There is
moderate vasogenic edema, with severe extensive edema in the
right frontal and parietal lobes surrounding the right parietal
and right lentiform nucleus lesions. Mass effect and effacement
of the right lateral ventricle as well as subfalcine herniation
with 9 mm of leftward midline shift are stable from prior CT.
The suprasellar cisterns are poorly visualized and there is
distortion of the interpeduncular cistern. Nearly all of the
lesions demonstrate hypervascularity and hemorrhage.
IMPRESSION: Innumerable hypervascular and hemorrhagic metastases
throughout the cerebral and cerebellar hemispheres with
extensive edema in the right frontal and parietal lobes and
evidence of subfalcine and early uncal herniation.
CXR: [**4-26**]: Left lower lobe mass as described highly suspicious
for metastatic spread.
Brief Hospital Course:
Pt did well during stay. Pt started on decadron 4 Q6hrs. With
question of worsening diplopia, pt'd decadron was increased to 4
Q4hrs. Pt had whole brain radiation started on [**4-26**] (with goal
10 days of treatment). Neuro oncology evaluated her and will
follow her in brain tumor clinic (Dr. [**Last Name (STitle) 724**].Pt with diplopia
worse with lateral gaze to either direction suggestive of
bilateral VIth nerve palsies. Pt was given patch with relief.
Her headache significantly improved with analgesia and steroids.
Pt was evaluated by physical therapy who felt that she would
initially benefit from rehab, however her exam improved and she
was felt to be safe to go home with home PT and OT.
Medications on Admission:
Allopurinol - 100 mg Tablet - 2 (Two) Tablet(s) daily
Amlodipine [Norvasc] - 5 mg Tablet - 1 daily
ATORVASTATIN CALCIUM - 80MG daily
Clopidogrel [Plavix] - 75 mg Tablet - once daily
Colchicine - 0.6 mg Tablet - 1 (One) Tablet(s) by mouth once a
day as needed for pain
Furosemide - 20 mg Tablet - 1 Tablet(s) by mouth once a day
Insulin Glargine [Lantus] - 100 unit/mL Solution - 20 units HS
Insulin Lispro [Humalog] sliding scale
Levothyroxine [Levoxyl] - 100 mcg Tablet - 1 (One) Tablet(s) by
Lisinopril - 40 mg Tablet - 1 Tablet(s) by mouth daily
Metoprolol Tartrate - 50 mg Tablet - 2 Tablet(s) by mouth qam
and
Nitroglycerin - 0.4 mg Tablet, Sublingual - 1 (One) Tablet(s)
Aspirin - (Prescribed by Other Provider) - 325 mg Tablet - 1
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 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. Insulin Regular Human Injection
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Dexamethasone 4 mg Tablet Sig: Four (4) Tablet PO Q4H.
Disp:*120 Tablet(s)* Refills:*1*
Discharge Disposition:
Home with Service
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
breast cancer
multiple brain lesions - likely metastatic breast cancer
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
please follow up with primary care provider and primary
oncologist.
please follow up with Dr. [**Last Name (STitle) 724**] in ([**Telephone/Fax (1) 6574**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 10662**]
Date/Time:[**2152-6-20**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-9-27**] 10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2152-9-27**]
10:00
Please follow up with Dr. [**Last Name (STitle) 724**] ([**Telephone/Fax (1) 6574**]. His office will
contact you with appointment.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
|
[
"V45.81",
"197.0",
"348.4",
"428.0",
"431",
"198.3",
"378.54",
"V10.3",
"250.00",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
10329, 10412
|
7376, 8086
|
291, 298
|
10527, 10536
|
4942, 7353
|
10842, 11526
|
2614, 2792
|
8878, 10306
|
10433, 10506
|
8112, 8853
|
10560, 10819
|
2807, 3162
|
227, 253
|
326, 1505
|
3705, 4923
|
3201, 3689
|
3186, 3186
|
1527, 2006
|
2022, 2598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,728
| 190,229
|
2965
|
Discharge summary
|
report
|
Admission Date: [**2144-10-26**] Discharge Date: [**2144-11-6**]
Date of Birth: [**2113-8-27**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Codeine / Rifampin
Attending:[**First Name3 (LF) 14197**]
Chief Complaint:
Infected knee prothesis
Major Surgical or Invasive Procedure:
[**10-26**]-Explantation tibial component L knee arthroplasty,
explantation antibiotic spacer, L prixmal femur debridement,
Irrigation and debridment of L lower extremity
[**10-29**]-Complex open reduction internal
fixation of left pathologic subtrochanteric periprosthetic
femur fracture.
History of Present Illness:
31F with h/o osteosarcoma of femur as a teenager, s/p resection
and mult surgeries, c/b infection, who underwent a 8 hour
operation to remove her of femoral antibiotic spacer and the
tibial component of previous endoprosthesis, and place a of new
femoral and tibial antibiotic spacer.
Operative course: EBL = 1.5-2 L. Required Neo intraop to
maintain her BP. Transfused 2 units PRBC's and 6L crystalloid.
Post op: Continued to have borderline BP in PACU post op (SBP
60-80, with MAP in 50's), therefore, neo was restarted with
increase in MAP to 60s. HR was tachy in 100s-110s. Extubated
without complication, quickly weaned to room air. Transferred to
the [**Hospital Unit Name 153**] for further monitoring and evaluation of hypotension.
.
Regarding her osteosarcoma: Tumor initially removed and replaced
with prosthesis at age 13; this eventually failed. In [**Month (only) 404**]
[**2143**] she underwent replacement; complicated by coag-neg staph
infection of her distal femur. Treated through this infection
with 10 weeks with vanco and started on minocycline suppression.
She developed recurrent infection 6 weeks after stopping therapy
with coag-neg staph. Her prosthesis was removed at that time
with washout and placement of vanco-impregnanted cement,
followed by 8 weeks of vanco.
One week after stopping abx (approx 2 weeks PTA) she had
recurrent pain with elevated ESR and CRP; aspiration showed 4000
WBC with poly predominance, cultures grew coag-neg staph. She
was restarted on Vanco at that time. She was brought to the OR
on the day of admission for removal of the remainder of the
prosthesis, vanco cement, and for placement of spacer
impregnated with tobra (per ID).
Past Medical History:
Osteoscarcoma L distal femur,
Depression
H/O EtOH abuse
H/O cocaine
H/O tobacco use: quit [**2-5**]; prev smoked 10 cigarettes a day
H/O CHF: echo [**2142**]: EF = 30%, repeat echo with ACE-I: Normal EF
ANXIETY
Allograft prosthetic composite left distal femur (fracture
allograft) used for limb salvage reconstruction for osteosarcoma
left distal femur [**2127-5-14**]. History of alcohol and cocaine
abuse, history of Adriamycin, a history of abnormal Pap smear.
Social History:
Unemployed. Currently living with her mom who
lives in the area and has plans to move to the [**State 4565**] area
after her surgery. She is divorced. Tobacco: Ten cigarettes a
day x15 years. Alcohol: As stated above. Drugs: As stated
above.
Family History:
Mother with osteoporosis and arthritis. Father
with hypertension. Siblings: Brother with bipolar disorder.
Physical Exam:
VS:AFVSS
Gen: Sitting in bed, anxious, not acutely distressed
HEENT: MMM but lips dry. EOMI.
PULM: CTA in all fields
CV: RRR, tachy, no M/R/G
ABD: +BS, soft, NT/ND. EXT:
triceps. PICC in place without erythema or tenderness.
LLE: in LLE brace
RLE: no c/c/e.
Pertinent Results:
[**2144-10-26**] 04:45PM BLOOD WBC-11.4*# RBC-3.07*# Hgb-8.3*#
Hct-24.6*# MCV-80* MCH-27.1 MCHC-33.8 RDW-14.1 Plt Ct-244
[**2144-10-26**] 04:45PM BLOOD PT-13.8* PTT-28.3 INR(PT)-1.2*
[**2144-10-26**] 04:45PM BLOOD Fibrino-161
[**2144-10-26**] 09:17PM BLOOD Glucose-130* UreaN-15 Creat-0.6 Na-138
K-4.1 Cl-108 HCO3-27 AnGap-7*
[**2144-10-27**] 08:43AM BLOOD ALT-17 AST-37 CK(CPK)-1295* AlkPhos-39
TotBili-0.4
[**2144-10-26**] 09:17PM BLOOD Calcium-8.1* Phos-4.9* Mg-1.2*
[**2144-10-29**] 10:20AM BLOOD VitB12-471 Folate-13.1
[**2144-10-29**] 10:20AM BLOOD TSH-0.98
[**2144-10-26**] 02:59PM BLOOD Glucose-101 Lactate-2.0 Na-138 K-3.8
Cl-104
[**2144-10-26**] 02:59PM BLOOD Hgb-9.7* calcHCT-29
[**2144-10-26**] 02:59PM BLOOD freeCa-1.08*
FEMUR (AP & LAT) LEFT PORT [**2144-10-27**] 2:09 PM
FEMUR (AP & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORT
Reason: ? alignment
[**Hospital 93**] MEDICAL CONDITION:
31 year old woman POD1 s/p resection/spacer placement
REASON FOR THIS EXAMINATION:
? alignment
LEFT FEMUR AND LEFT LOWER LEG, FOUR VIEWS
HISTORY: Post-operative day 1 status post resection and spacer
placement.
FINDINGS: Extensive post-operative changes of the left lower
extremity are seen. There has been removal distal femoral
allograft and placement of a methylmethacrylate spacer as well
as removal of the tibial component of a constrained total knee
prosthesis and placement of a methylmethacrylate spacer
replacing the proximal articular surface of the tibia. The
intramedullary rod within the proximal tibial shaft is still
present. Two cerclage wires are seen in this region. No
immediate complication is noted following surgery. Soft tissue
drains and skin staples are seen.
UNILAT UP EXT VEINS US LEFT [**2144-10-27**] 1:14 PM
UNILAT UP EXT VEINS US LEFT
Reason: Thrombus of left upper extremity.
[**Hospital 93**] MEDICAL CONDITION:
31 year old woman s/p removal of hardware from femur, found to
have PE, LUE swelling.
REASON FOR THIS EXAMINATION:
Thrombus of left upper extremity.
CLINICAL HISTORY: 31-year-old female status post removal of
hardware from femur, found to have questionable PE. Evaluate for
left upper extremity thrombus.
LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
son[**Name (NI) **] of the left internal jugular, subclavian, axillary,
brachial, cephalic and basilic veins are performed. Normal
waveform, compressibility, augmentation, and flow is
demonstrated. No intraluminal thrombus is identified. Note is
made of a PIC catheter coursing from the basilic vein into the
subclavian vein.
IMPRESSION: No evidence of left upper extremity DVT.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2144-10-27**] 12:20 AM
CTA CHEST W&W/O C&RECONS, NON-
Reason: CTA-- assess for PE
Field of view: 32 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
31 year old woman with 31 year old woman s/p major orthopedic
surgery today, and several major recent ortho surgeries, now
hypotensive post op. Has L arm pain/edema, has chronic PICC in L
arm.
REASON FOR THIS EXAMINATION:
CTA-- assess for PE
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 31-year-old female status post several major
recent orthopedic surgeries, now with hypertensive postop.
Patient with left arm pain and edema. Evaluate for pulmonary
embolus.
COMPARISON: None.
TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the
chest from the thoracic inlet to the upper abdomen. Multiplanar
reformatted images were obtained.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Respiratory motion
somewhat limits sensitivity for detection of pulmonary embolus
within the subsegmental pulmonary arteries. Apparent filling
defect is identified within the left lower lobe subsegmental
pulmonary artery on axial images (series 2, image 69), which is
not confirmed on multiplaner reformatted images and likely
represents partial volume averaging. No central or segmental
pulmonary embolus is identified. The thoracic aorta maintains a
normal contour without evidence of dissection.
The lungs are clear, without evidence of mass, nodule or
consolidation. Minimal atelectasis is seen within the dependent
portions of the lung. No pleural or pericardial effusion is
detected. The heart and great vessels are within normal limits.
A left subclavian central venous catheter is present with tip in
the distal SVC. No axillary or central lymphadenopathy is
appreciated. Limited views of the upper abdomen are
unremarkable.
BONE WINDOWS: No suspicious lytic or sclerotic lesion is
identified.
IMPRESSION: Limited sensitivity for detection of subsegmental
pulmonary embolus given respiratory motion. Apparent filling
defect is seen within the left lower lobe subsegmental pulmonary
artery on axial images, not clearly identified on multiplanar
reformatted images and likely represent partial volume
averaging. No conclusive evidence of PE.
FEMUR (AP & LAT) LEFT [**2144-10-28**] 6:44 PM
FEMUR (AP & LAT) LEFT
Reason: r/o femur fracture, please perform on long cassette
[**Hospital 93**] MEDICAL CONDITION:
31 year old woman w/ h/o osteosarcoma, now s/p TKR revision [**1-3**]
infection with new onset pain in left upper leg
REASON FOR THIS EXAMINATION:
r/o femur fracture, please perform on long cassette
LEFT FEMUR, THREE VIEWS.
INDICATION: History of osteosarcoma.
FINDINGS: Comparison to [**2144-10-27**]. There is a new fracture of
the residual aspect of the proximal left femur with malalignment
of the intramedullary rod and methylmethacrylate spacer compared
to the immediate previous exam. Spacer itself is intact. Clips
are noted in the soft tissues. Drains are in place. Soft tissues
are diffusely atrophic.
IMPRESSION:
Fracture of the residual aspect of the proximal left femur with
malalignment of the long intramedullary rod and
methylmethacrylate spacer, new compared to the previous exam
from [**2144-10-27**].
Brief Hospital Course:
A/P: 31F w/ history of h/o osteosarcoma of femur s/p resection
and mult surgeries c/b infection, POD 3 from hardware
removal/washout/tobra spacer placement initially admitted to
[**Hospital Unit Name 153**] with post op hypotension, now POD 0 s/p ORIF of proximal
femur again with post-op hypotension.
.
#) ORIF: POD 0 with hypotension post-op. Intra-op blood loss
approx 1L. Patient s/p 1 unit PRBCs and 3L NS IVF resuscitation.
Patient did not require pressors during this episode of
hypotension.
- Transfuse 2 more units of PRBCs
- Resume lovenox this afternoon at prophylaxis dose
- continue pain control w/ dilaudid PCA, appreciate pain recs
- f/u Ortho recs
- non weight wearing LLE
.
#) Post- op Fever: Likely secondary to atelectasis as patient
with no other localizing symptoms on history or exam.
- will check Blood and urine cultures, tylenol prn
.
#) Hypotension: Patient reports baseline BP 100/50. Current SBP
90-110. Most likely hypovolemic s/p surgery from inadequate
fluid resusitation.
- check post-tranfusion Hct
- Continue fluid boluses prn symptomatic hypotension
.
#) Infected Hardware/Osteomyelitis: s/p washout and removal of
all hardware with placement of tobra impregnated spacer on
[**10-27**].
ID team following, antibiotic regimen per ID. Needs at least 8
wks abx, then plan for prosthesis in ~12 weeks.
- Dapto 360 mg IV Q24H, Levo 500 mg q24
- f/u ID team recs
.
#) L arm pain: post op, now resolved. Per ortho and PACU nursing
staff, likely [**1-3**] muscle spasm after prolonged surgery. However,
given PICC, and PE at risk for DVT, has mild edema.
- negative U/S for DVT
.
#) Depression/Anxiety: chronic. Aleviated somewhat when mother
present. Medical work-up for depression negative.
-continue sertaline, ativan
- SW consult ordered
- psych consulted, appreciate recs
.
.
#)FEN: IVF prn symptomatic hypotension. Advance diet as
tolerated. Follow/replete lytes PRN
.
#)PPX: Pneumoboots, Lovenox, bowel regimen
.
#)Access: PICC (L) and PIV (R)
.
#)Code: Full
.
Communication: pt and mother - [**Name (NI) 402**] [**Telephone/Fax (1) 14198**]
Dispo: to floor, ortho service
**** after being transferred to the orthopaedic service the
patient was transferred to the floor in stable condition.
Throughout the rest of her hostpial course the patient's vitals
remained stable. The patient was seen and evlauated thorughout
her course by the pain mgt team, physica therapy and Infectious
disease. Her course on the floor was complicated by difficulty
with pain control. Her epidural was d/c on POD #5 After a few
days of being on the IV PCA after being transferred to the floor
she was switched to PO pain medications and her pain was
tolerable. Prior to discharge the patient was tolerating po,
her pain was well controlled, and she was cleared by PT.
Alsp, prior to being discharge her PICC line that was placed on
[**10-8**] was changed due to concerns that her PICC line was not
appropriately flushing/drawing. Her PICC line was changed
without event
Medications on Admission:
aspirin 81 mg qday
Calcium + Vit D 500 mg qday
Fluconazole 100 mg Tablet qday while on Vanco
Guaifenesin [**Hospital1 **] PRN
Hydromorphone 4-8 mg q4H PRN up to 8 tabs qday
Lorazepam 1 mg TID PRN
Magnesium 84 mg [**Hospital1 **]
Multivitamin w/ minerals
Miralax 17 g qday PRN
Sertraline 100 mg qday
Valacyclovir 500 mg Tablet [**Hospital1 **] x 3days when active lesion
Vancomycin
Flonase
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q 3-4 H PRN ().
Disp:*120 Tablet(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
5. Tizandine Sig: One (1) 2 mg tab three times a day.
6. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO see tapered dose below: -4
tabs three times a day x 3 days
- 4 tabs two times day x 3 days
- 2 tabs two times a day x 3 days
- 1 tab two times a day times 3 days
-1 tab once a day x 3 days.
Disp:*81 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Daptomycin 500 mg Recon Soln Sig: 360mg Recon Solns
Intravenous Q24H (every 24 hours) for 8 weeks.
Disp:*54 Recon Soln(s)* Refills:*0*
8. Rifabutin 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily) for 8 weeks.
Disp:*54 Capsule(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 8 weeks.
Disp:*54 Tablet(s)* Refills:*0*
10. heparin flushes Sig: One (1) 10U/3cc every twenty-four(24)
hours.
Disp:*25 * Refills:*2*
11. saline flushes Sig: One (1) 5 cc once a day.
Disp:*25 * Refills:*2*
12. Outpatient Lab Work
laboratory monitoring required
weekly CBC, BUN/Cr, LFTs, CPK to be faed to [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] in [**Hospital **]
clinic at [**Telephone/Fax (1) 432**].
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**]
13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
17. Magnesium Oxide 140 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
Disp:*4 syringe* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
L lower extremity osteomyelitis
Discharge Condition:
stable
Discharge Instructions:
1. Non-weight bearing Left Lower extremity
2. Lovenox
3. Abx: per ID protocol- Levaquin, Daptomycin, Rifabutin
4. weekly labs- per ID recs
5. dressing changes PRn, may leave the incision open to air if
more comforable
Physical Therapy:
Non-weight bearing Left Lower extremity
Treatments Frequency:
administration of daptomycin as ordered 360mg IV q 24 (recon
soln)
PICC line care-- normal saline flushes, heparin flushes once
daily
Followup Instructions:
-Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 14200**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2144-11-12**] 10:30-- Ortho
-Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2144-11-12**] 4:00- opthalmology
-Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1670**] [**Last Name (un) 1671**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2144-11-17**] 12:00-- Psych
- Pain management Clinic-- [**2144-11-26**] 11:00AM in [**Hospital1 18**] [**Hospital Ward Name **]
[**Hospital Ward Name 1950**] Building level 5
- [**2144-11-18**] 11:00a ID,[**Doctor Last Name **]
LM [**Hospital Unit Name **], BASEMENT
ID WEST (SB)
-Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Completed by:[**2144-11-6**]
|
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"V10.81",
"428.0",
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icd9cm
|
[
[
[]
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[
"79.35",
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"77.85",
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"84.57"
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icd9pcs
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[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,992
| 154,174
|
30758
|
Discharge summary
|
report
|
Admission Date: [**2139-9-15**] Discharge Date: [**2139-9-23**]
Date of Birth: [**2069-5-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Chest pain
Tuberculosis rule-out
Acute cerebral infarct
Headache
End Stage Renal Disease
Pulmonary Edema
Type II Diabetes Mellitus
Anxiety
Major Surgical or Invasive Procedure:
tPA adminsistration
History of Present Illness:
70 year old man with a history ESRD, on HD T-Th-Sat, DM, HTN,
CAD s/p IMI with DES in [**2136**] recent stress shows reversible
defect in inferior wall but overall improved per cardiologist.
Complained of cough and left sided chest pain, he was then
having a cough productive of [**Doctor Last Name 352**] and white sputum, he did have
drenching night sweats, unable to tell if he had weight loss.
Followed for latent TB infection by Dr. [**Last Name (STitle) 724**], had been treated
with INH, but while being treated was exposed to his son so
there was a question of whether he could be treated or not. Dr.
[**Last Name (STitle) **] did feel like he was adequetely treated for TB. The CP was
constant, sharp, and pleuritic, made worse with climbing stairs,
similar to angina, EKG showed LVH with early repol abnormality,
no signs of acute ischemia, was ruled out for MI. With cough,
night sweats, questionable history of TB, decided he needed to
be ruled out for TB. On CXR had a LLL infiltrate. Was in sbps in
180s upon arrival, gave his home meds because they didn't think
this was urgency and he was 160 systolic prior to HS. They were
going to start CTX/Azithro after HD the next morning. Around
[**9-16**] in AM at 8am, intern spoke with him via interpreter, said
his CP was improved, and his headache was improved (longstanding
and worse on HD days), and so at that time moving all his
extremities, no focal deficits, then had bedside HD after exam,
and nurse noted that he was moving his extremities, then came in
around 9:20 for AM rounds found to have flaccid LUE paralysis,
left nasal-labial fold flattening. CODE STROKE called, taken to
head CT, showed right MCA perfusion defect with "penumbra", but
no evidence of bleed. BP was 210 systolic. So he was admitted to
the NSICU and started TPA. Wheeled him to the MICU but was
turned away because no respiration bed. Gave 10 x 2 brought his
BP down to 177 systpolic, at 1115 pushed TPA on the floor, neuro
attending at bedside, pushed continuous infusion. By the time
back to room, still aphasic but starting to move his LUE before
starting TPA. Then confirmed FULL CODE with family, transferrred
to TSICU under neuro team. Remains aphasic and still has LUE
weakness, but is moving it, still has nasolabial fold flattening
on the left. They did see a R carotid stenosis. No a fib on EKG.
In Neuro ICU, patient started to speak slowly, so hopefully more
dysarthria as opposed to enunciating rather than true aphasia.
Put the order in for an MRI given his cypher stent, but he has
an unusual intracranial circulation, he is a vasculopath, has
all the risk factors for large vessel disease, ?embolic
phenomena, so getting a TTE with bubble study. But now anxious
and associating HD with stroke unfortunately, need to reiterate
that with him. Currently, 98 73 147/56 (required 10 of
labetolol and hydralazine IV this morning for 170s) 15 982L.
He did pass speech and swallow. He was transferred to the
medical floor for continued stabilization before discharge to
home with PT.
Past Medical History:
ESRD -CKD stage 5 on hemodialysis.
DM2
CAD s/p drug-eluting stent [**3-/2136**]
Hyperlipidemia
HTN
Anemia
Latent TB treated with INH [**3-/2136**]/[**2136**]
Chronic HA
Social History:
Immigration from Bolivia in [**2134-12-1**]. Has completed high
school and is currently married. Quit drinking approximately 4
years ago, however, has history of some heavier alcohol abuse.
He is a nonsmoker and has no tattoos. Has 8 children, 6 of whom
live in the area and are heavily involved in patient's health
care.
Family History:
Sister died from diabetes complications
6 siblings alive with hypertension
8 living children with various problems including diabetes,
obesity, and fatty liver
Physical Exam:
Admission Exam:
V/S: 97.6F, 180/100, 80, 16, 92-93%/RA
Gen: NAD, lying in bed comfortably
Head/Neck: NC/AT, no scleral icterus, no oropharyngeal lesions,
neck supple
Cardiovascular: RRR, continuous systolic-diastolic murmur
Pulmonary: Equal air entry bilaterally
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, thrill at L upper arm AVF
Discharge Exam:
VS: 97.0F, 167/64, 63, 18, 97%/RA
GENERAL: Comfortable, NAD
HEENT: NCAT, sclerae anicteric, PERRLA, MMM, OP clear, neck
supple
HEART: RRR, [**3-8**] continuous systolic-diastolic murmur, no rubs or
gallops.
LUNGS: CTAB, no r/r/w, good air movement, resp unlabored
ABDOMEN: +BS, soft, NT/ND, no guarding
EXTREMITIES: WWP, thrill at LUE AV fistula, slightly more
swollen L arm without pitting edema or rubor/calor/dolor, no
c/c/e, 2+ peripheral pulses.
NEURO: Awake, speaking in short sentences, persistent left NLF
droop, smile asymmetric with drooping on L side, symmetric
eyebrow raise and palate elevation, Strength 4+/5 and equal b/l
and distally. LT intact bilaterally. [**Doctor First Name **] continues to be slowed
on left compared to right. Can ambulate to bathroom without
assistance.
Pertinent Results:
# CBC with Diff:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] WBC-7.5 RBC-3.45* Hgb-12.2* Hct-33.6*
MCV-98 MCH-35.3* MCHC-36.2* RDW-15.1 Plt Ct-219
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] Neuts-78.3* Lymphs-13.9* Monos-4.6
Eos-2.2 Baso-1.0
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] WBC-6.5 RBC-3.21* Hgb-10.9* Hct-32.4*
MCV-101* MCH-33.9* MCHC-33.6 RDW-14.9 Plt Ct-232
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] WBC-6.2 RBC-3.17* Hgb-10.8* Hct-31.3*
MCV-99* MCH-34.0* MCHC-34.5 RDW-14.8 Plt Ct-218
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] WBC-7.5 RBC-3.20* Hgb-11.1* Hct-32.0*
MCV-100* MCH-34.7* MCHC-34.8 RDW-14.8 Plt Ct-239
[**2139-9-18**] 07:35AM [**Month/Day/Year 3143**] WBC-4.6 RBC-3.29* Hgb-10.9* Hct-31.9*
MCV-97 MCH-33.1* MCHC-34.2 RDW-14.7 Plt Ct-188
[**2139-9-19**] 08:24AM [**Month/Day/Year 3143**] WBC-3.6* RBC-3.22* Hgb-11.0* Hct-30.9*
MCV-96 MCH-34.1* MCHC-35.5* RDW-14.5 Plt Ct-202
[**2139-9-20**] 07:35AM [**Month/Day/Year 3143**] WBC-3.7* RBC-3.27* Hgb-11.2* Hct-31.7*
MCV-97 MCH-34.2* MCHC-35.3* RDW-14.8 Plt Ct-180
[**2139-9-21**] 05:55AM [**Month/Day/Year 3143**] WBC-3.9* RBC-3.10* Hgb-10.6* Hct-30.1*
MCV-97 MCH-34.1* MCHC-35.2* RDW-14.8 Plt Ct-220
[**2139-9-22**] 07:47AM [**Month/Day/Year 3143**] WBC-4.3 RBC-3.31* Hgb-11.3* Hct-32.2*
MCV-97 MCH-34.1* MCHC-35.2* RDW-15.3 Plt Ct-224
[**2139-9-23**] 06:15AM [**Month/Day/Year 3143**] WBC-5.3 RBC-3.40* Hgb-11.8* Hct-33.5*
MCV-99* MCH-34.7* MCHC-35.2* RDW-15.4 Plt Ct-251
# [**Month/Day/Year **] Chemistry:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] Glucose-86 UreaN-59* Creat-10.2*# Na-143
K-5.0 Cl-97 HCO3-27 AnGap-24*
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] Calcium-9.1 Phos-5.6* Mg-2.7*
[**2139-9-15**] 11:21AM [**Month/Day/Year 3143**] Lactate-1.2 K-4.7
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] Glucose-130* UreaN-70* Creat-10.9* Na-140
K-5.2* Cl-95* HCO3-28 AnGap-22*
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-6.4* Mg-2.6
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] Glucose-138* UreaN-53* Creat-9.4*# Na-138
K-4.5 Cl-93* HCO3-30 AnGap-20
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] Calcium-8.7 Phos-5.3* Mg-2.3
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] Glucose-98 UreaN-57* Creat-10.6*# Na-141
K-4.6 Cl-95* HCO3-26 AnGap-25*
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] Albumin-4.3 Calcium-9.0 Phos-6.8* Mg-2.4
Cholest-158
[**2139-9-18**] 07:35AM [**Month/Day/Year 3143**] Glucose-73 UreaN-27* Creat-7.4*# Na-141
K-4.4 Cl-93* HCO3-37* AnGap-15
[**2139-9-18**] 07:35AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-5.9* Mg-2.2
[**2139-9-19**] 08:24AM [**Month/Day/Year 3143**] Glucose-147* UreaN-39* Creat-9.7*# Na-137
K-4.0 Cl-91* HCO3-32 AnGap-18
[**2139-9-19**] 08:24AM [**Month/Day/Year 3143**] Calcium-9.1 Phos-6.7* Mg-2.3
[**2139-9-20**] 07:35AM [**Month/Day/Year 3143**] Glucose-85 UreaN-17 Creat-5.9*# Na-138
K-4.4 Cl-92* HCO3-35* AnGap-15
[**2139-9-20**] 07:35AM [**Month/Day/Year 3143**] Calcium-9.7 Phos-4.7*# Mg-2.1
[**2139-9-21**] 05:55AM [**Month/Day/Year 3143**] Glucose-79 UreaN-27* Creat-7.7*# Na-136
K-4.5 Cl-91* HCO3-35* AnGap-15
[**2139-9-21**] 05:55AM [**Month/Day/Year 3143**] Calcium-9.5 Phos-5.6* Mg-2.1
[**2139-9-22**] 07:47AM [**Month/Day/Year 3143**] Glucose-77 UreaN-39* Creat-9.7*# Na-136
K-5.0 Cl-91* HCO3-32 AnGap-18
[**2139-9-22**] 07:47AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-6.3* Mg-2.3
[**2139-9-23**] 06:15AM [**Month/Day/Year 3143**] Glucose-83 UreaN-24* Creat-6.7*# Na-133
K-4.4 Cl-89* HCO3-34* AnGap-14
[**2139-9-23**] 06:15AM [**Month/Day/Year 3143**] Calcium-9.3 Phos-4.5# Mg-2.2
# Cardiac Biomarkers:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-15**] 06:45PM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.05*
# Liver function tests:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] CK(CPK)-58
[**2139-9-15**] 06:45PM [**Month/Day/Year 3143**] CK(CPK)-52
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] CK(CPK)-52
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] CK(CPK)-57
[**2139-9-16**] 07:59PM [**Month/Day/Year 3143**] CK(CPK)-75
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] ALT-14 AST-23 CK(CPK)-81 AlkPhos-93
TotBili-0.3
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] Triglyc-101 HDL-43 CHOL/HD-3.7 LDLcalc-95
# U/A:
[**2139-9-15**] 01:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2139-9-15**] 01:00PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein->600
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
[**2139-9-15**] 01:00PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
# Sputum studies:
[**2139-9-16**] 5:28 am SPUTUM Source: Induced.
GRAM STAIN (Final [**2139-9-16**]):
[**11-24**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2139-9-16**]):
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final [**2139-9-17**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2139-9-17**] 10:54 am SPUTUM Source: Induced.
GRAM STAIN (Final [**2139-9-17**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2139-9-17**]):
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final [**2139-9-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Log-In Date/Time: [**2139-9-18**] 5:53 am
SPUTUM Source: Induced.
GRAM STAIN (Final [**2139-9-18**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2139-9-18**]):
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final [**2139-9-21**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2139-9-19**] 8:55 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2139-9-21**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
# MRSA Screen:
[**2139-9-16**] 12:47 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2139-9-18**]): No MRSA isolated.
# [**Month/Day/Year **] Cultures:
[**2139-9-15**] 12:05 pm [**Month/Day/Year 3143**] CULTURE Site: ARM X2.
**FINAL REPORT [**2139-9-21**]**
[**Month/Day/Year **] Culture, Routine (Final [**2139-9-21**]): NO GROWTH.
# [**2139-9-15**] EKG:
Normal sinus rhythm at a rate of 80. Right bundle-branch block.
Mild
prolongation of the Q-T interval. Left ventricular hypertrophy.
There are
diffuse non-specific ST-T wave changes throughout. Clinical
correlation is
suggested.
# [**2139-9-15**] CXR:
IMPRESSION: Mild pulmonary edema with bilateral small pleural
effusions and atelectasis.
# [**2139-9-16**] EKG:
Normal sinus rhythm. Right bundle-branch block. Non-specific
ST-T wave
changes, all of which are unchanged compared with the previous
tracing.
# [**2139-9-16**] CT Brain Perfusion
IMPRESSION:
1. No acute intra- or extra-axial hemorrhage.
2. Relatively small geographic region of abnormally increased
mean transit
time, without definite corresponding decreased relative cerebral
[**Name2 (NI) **] volume,
in the superior right frontal lobe, representing acute ischemic
(penumbra) in
the superior division, right MCA territory; there is no similar
region
elsewhere.
3. Unremarkable intracranial circulation; specifically, no
stenosis or
occlusion of the right MCA and its branches or the right ICA
terminus.
4. Atherosclerotic disease, involving particularly the left
carotid bulb and
proximal ICA with at least 65% diameter stenosis at its origin.
5. Evidence of CHF with bilateral pleural effusions.
# [**2139-9-17**] TTE
Conclusion:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Doppler parameters
are indeterminate for left ventricular diastolic function. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Indeterminate indices to assess diastolic dysfunction. No
pathologic valvular abnormality seen.
# [**2139-9-17**] CXR:
FINDINGS: In comparison with the study of [**9-15**], there is
increasing
opacification at both bases with poor definition of the
hemidiaphragms
consistent with pleural effusions and compressive atelectasis.
The degree of pulmonary vascular congestion is more prominent,
though some of this could reflect the AP supine rather than PA
technique.
# [**2139-9-17**] Non Con Head CT
IMPRESSION:
Residual IV contrast limits optimal evaluation for subtle
hemorrhage.
1. New focal hypodense area with loss of [**Doctor Last Name 352**]-white
differentiation in the
right frontal lobe corresponding to the previously seen
perfusion abnormality representing either evolving ischemia or
infarction.
2. No large area of hemorrhage in this area or elsewhere within
limitation of this study. No new edema, mass effect, or shift in
midline structures.
# [**2139-9-18**] TTE Bubble Study
Findings:
No evidence suggestive of an atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
# [**2139-9-18**] MRI Head
IMPRESSION:
1. Acute infarct in the right posterior frontal lobe involving
the precentral gyrus which is unchanged.
2. No evidence of acute intracranial hemorrhage or new infarct.
3. Changes of chronic small vessel ischemic disease.
4. Arachnoid cyst versus a prominent cisterna magna in the
posterior fossa.
Brief Hospital Course:
ASSESSMENT: 70 yo Spanish-speaking RHM with h/o ESRD, CAD s/p
drug-eluting stent placed [**3-/2136**], DM2, HTN, HL, and latent TB
initially presented on [**2139-9-15**] with c/o CP, productive cough and
night sweats, admitted for MI rule out hospital course c/b
right-sided acute cerebral infarct s/p tPA on [**9-16**], initially
with motor weakness, left sided facial droop and expressive
aphasia, now with symmetric strength and no facial droop but
persistent expressive aphasia.
# Acute Cerebral Infarct: While in dialysis on [**2139-9-16**] pt was
found around 09:20 to have new speech difficulty and LUE flaccid
weakness. A Code Stroke was called and CTA showed small
frontoparietal increased MTT/perfusion deficit. He was
administered tPA starting at approximately 11:15 on [**9-16**]. He was
then transfered to the TICU for frequent neuro checks given risk
of bleed post-tPA. Passed speech and swallow on [**2139-9-17**].
Continued to improve on the medical floor, with equal strength
and sensation distally. TTE showed no ASD or PFO. Cardiology had
low suspicion for any left atrial thrombus or appendage
abnormality, so TEE was recommended for outpatient. Neuro aware
of left ICA. LDL is 95, so started a statin to obtain less than
70. Followed daily by neurology. Antihypertensives were
uptitrated as necessary to bring BP within goal SBP 140-180.
Patient was placed on Aspirin 325 mg per neuro recs because they
felt plavix was not a good medication for him.
Treatment Course:
- Captopril 12.5 mg PO TID x1 day
- Captopril 37.5 mg PO TID x3 days
- Lisinopril 40 mg PO DAILY x2 days
- Metoprolol tartrate 25 mg PO BID x3 days
- Carvedilol 25 mg PO BID x3 days
- Hydralazine 10-15 mg IV Q6H PRN SBP>180
- Atorvastatin 80 mg daily x6 days
- Aspirin 325 mg PO/NG DAILY x7 days
- Frequent neuro checks with monitoring for headache as
indication of possible hemorrhagic conversion or cerebral edema
- Continuous monitoring by telemetry
- Maintained normothermia
- Risk Factor Assessment with Lipid panel
# Headache: pt has h/o chronic HA with HD along with dizziness
and ear ache. [**Month (only) 116**] have h/o migraine but due to language barrier
it is described simply as HA. Associated with nausea and
vomiting. Varies from [**3-12**] to [**10-10**] in severity.
- Acetaminophen dose to 1000 mg PO Q6H prn pain
- Ibuprofen 600 mg PO Q8H prn pain
- Odansetron 4 mg IV Q8H:PRN nausea/vomiting
- Elevated HOB to 30 degrees
- Monitored closely for concurrent neurological findings
- Pt sent with a prescription for Tramadol for break through
headache pain
# No TB infection, ruled out after neg AFBx3 and neg
concentrated smear. Has been followed for latent TB infection by
Dr. [**Last Name (STitle) 724**] and previously treated with INH. Resolved.
# ESRD: has a LUE fistula, after TPA did have more swelling of
his LUE ?less mobile, non pitting edema, so don't believe there
is a clot but something to monitor as an outpatient. Dialysis
on T, Tr, Saturday.
- Monitored by daily Cr, urine output, electrolytes
# No current chest pain on discharge, ruled out for MI with flat
CK-MB and TpnT. Resolved.
# Pulmonary Edema: Likely [**3-4**] fluid overload on admission CXR,
now resolved. Sats stable, lung sounds clear.
# DM 2:
- Pt placed on Insulin SS with goal <150. BG very well
controlled during this admission.
# Anxiety: Pt has increased anxiety following stroke, especially
around HD, now resolved.
- Pt given Lorazepam 0.5 mg IV PRN anxiety pre-HD.
# Consults:
- PT evaluations for walking stairs, showering without assitance
- Nutrition evaluations for poor PO intake, treated with
appetite stimulant Megace
- Social work consults for discharge home with services
Transitional Issues:
1. Pt still needs a TEE for a better look at possible atrial
pathology which may have caused this stroke. Cardiology did not
feel that this procedure had to be done in house and that he was
very low risk for having anything that would change our
management. For this reason he was set up with cardiology as an
outpatient to get this TEE.
2. Pt will need close neurology follow up to follow neuro
deficits and continue to reduce his risk of further stroke.
3. Pt will need close PCP follow up to follow up on new
medications, medication refills, ongoing neuro deficits, stroke
risk reduction etc.
Medications on Admission:
Medications (verified):
metoprolol 25mg po BID
renagel 800mg nine tablets po TID with meals
ASA 81mg po daily
vitamin B complex one tab daily
fluticasone proprionate one spray in each nostril daily
lidocaine cream, apply to fistula as directed prior to
hemodialysis
prozac _____ (unknown dose)
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
5. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: Fifteen
(15) mL PO once a day.
Disp:*1 bottle* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
9. Outpatient Occupational Therapy
10. Outpatient Physical Therapy
11. Outpatient Speech/Swallowing Therapy
12. lidocaine 4 % Cream Sig: One (1) application Topical once a
day as needed for prior to dialysis: PRN for dialysis.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cerebral Infarct
Headache
End Stage Renal Disease
Pulmonary Edema
Type II Diabetes Mellitus
Anxiety
Anemia
Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 72838**],
You were admitted to the hospital with chest pain which has
resolved. Unfortunately, while you were here you had a stroke
that affected the right side of your brain (and consequently the
left side of your body). You were given a medication that helps
to dissolve clots and helps people improve following a stroke.
Over the few days following the stroke you improved dramatically
and your motor muscle function appears to be back to baseline.
As we discussed, the reason for the stroke was secondary to
years of high cholesterol, diabetes, high [**Known lastname **] pressure, and
dialysis that lead to hardening of the arteries, leading to a
blockage. The key to your recovery lies in your new medications
including aspirin, atorvastatin, and new [**Known lastname **] pressure agents.
Further, you will benefit from outpatient physical therapy,
occupational therapy, and speech therapy. We have set you up
with primary care, cardiology and neurology appointments below.
Additionally, while you were here we tested you for tuberculosis
and all of our tests were negative, indicating that you do not
have this infection.
The following changes were made to your medications:
STOP Metoprolol
STOP Fluticasone
CHANGE Vitamin B complex vitamins to B complex with Vitamin C
and Folic Acid, 1 capsule by mouth daily
CHANGE Aspirin from 81 mg daily to 325 mg daily
START Atorvastatin 80 mg by mouth once daily
START Carvedilol 25 mg by mouth twice daily
START Lisinopril 20 mg by mouth twice daily
START Megace 600 mg by mouth once daily
START Tramadol 50 mg by mouth every 6 hours as needed for
headache
Thank you for allowing us to participate in your care. We wish
you a speedy recovery.
Followup Instructions:
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23903**]
Location: [**Hospital6 28009**]
Address: [**Street Address(2) 33773**], [**Location (un) **],[**Numeric Identifier 4544**]
Phone: [**Telephone/Fax (1) 17826**]
Appointment: Friday [**2139-10-2**] 2:30pm
Department: CARDIAC SERVICES
When: MONDAY [**2139-10-12**] at 10:40 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2139-11-18**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***We are working on a sooner appt for you and the office will
call you at home when a sooner appt becomes available.***
|
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1,602
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25492
|
Discharge summary
|
report
|
Admission Date: [**2103-8-12**] Discharge Date: [**2103-8-20**]
Date of Birth: [**2047-8-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
56 year old male with h/o EtOH abuse/narcotic dependence, CAD
s/p MI, HTN initially transferred from [**Hospital3 **] to
[**Hospital1 18**] [**2103-8-12**] for concern of AAA rupture vs ischemic bowel. The
pt reports 2-3 days of diffuse abdominal pain prior to
admission, associated with N/V (no hemetemesis), [**10-15**] unable to
describe character, exacerbating/relieving factors. (+)
anorexia. No diarrhea, BRBPR, fevers, chills, chest pain,
shortness of breath. His brother visited him, noted he was "not
acting right" and was diaphoretic and called EMS -> [**Hospital1 63695**]. There, he was noted to be bradycardic (HR 40s) for
which he received 0.5 mg atropine X 1. He was hypertensive with
sbp 180s and a nitro gtt was started. He was noted to be
acidotic (7.062/72.1/100) with acute renal failure (Cr 5.3) and
CK 3000. Reportedly, his NG lavage revealed ~ 100 cc maroon
blood and his rectal exam showed gross blood. He received 2u
PRBC and was emergently intubated and transfered to [**Hospital1 18**] for
further management. Given reports that he had fallen 2 days
earlier (the patient does not recall this event), the patient
was evaluated by trauma surgery. He underwent extensive CT
imaging (head, neck, chest, abdominal, pelvis), which was most
notable for ileal thickening. He was extubated this a.m., and,
given no clear surgical cause was found, he is being transferred
to medicine for further management.
Past Medical History:
PMHx:
1) CAD: h/o MI
2) Narcotic dependence
3) h/o cluster headaches
4) HTN
5) s/p appendectomy
6) s/p knee surgery
7) h/o left hip dislocation s/p closed reduction [**2-10**]
8) ? cancer: diagnosed in [**State 108**], told he had 4 months to live.
Social History:
Pt reports drinks ~ 1 drink/month, however per his brother he is
a heavy drinker. Denies other drug use. (+) tobacco [**2-8**] ppd X 40
yrs. He lives alone on disability.
Family History:
3 brothers, mother, father with DM and CAD. Mother died at age
67 yrs of MI, father died at 77 yrs of MI, brother had MI in his
40s
Physical Exam:
PE:
Gen:awake, in NAD, restless in bed
HEENT: no cervical LAD, no JVD appreciated
Cardiac: RRR, no MRG
Pulm: CTAB in all lung fields, no WRR
Abd: non-tender, non-distended, soft, + BS throughout
Ext: no C/C/E in bilateral LE
Neuro: oriented x 1 only, awake, answers questions, but confused
Pertinent Results:
[**8-12**] CT chest/abd/pelvis without contrast: Right hilar LAD, small
bilateral pleural effusion, no focal lungs consolidation,
thickening in distal ileum (infectious vs ischemic), limited
oral contrast reaching bowel, although no clear evidence of
obstruction, small amt of free fluid around liver/spleen.
.
[**8-12**] Head CT: No ICH, fracture
.
[**8-12**] CT C-spine: mild degenerative changes in mid cervical spine
w/o fracture
.
[**8-12**] CXR: no acute cardiopulmonary abnormality.
EKG on admission [**8-12**]- TWI and 1 mm depressions in II, III, and
aVF
EKG on [**8-13**]- TWI and ST depressions resolved, NSR, normal
intervals
Brief Hospital Course:
1) GI bleeding: given report of (+) lavage, concern for UGI
process. Potential UGI sources include PUD, varices, gastritis,
[**Doctor First Name 329**]-[**Doctor Last Name **] tear, gastroenteritis. Also some reports of rectal
bleeding at OSH (though guiac neg to date here), could be c/w
hemmorrhoid, polyp, colon CA, ischemic bowel, diverticuli, IBD.
- 2 large bore IVs
- transfuse for hct > 30 given hx CAD, hct stable over
admission, no signs of active bleeding, no transfusion necessary
- daily hct check
- GI consult --> they will performed EGD and Colonoscopy --> EGD
revealed duodenitis and gastritis. A colonoscopy revealed a
hyperplastic polyp 20
cm from the anal verge
- guaiced all stools- negative
.
2) Pneumonia- RLL PNA on CXR, fever resolved, satting well on RA
on the floor. Pt's hypoxia also probably has a component of
Emphysema
- Albuterol and Atrovent Nebs PRN
- Levofloxacin, Flagyl PO Day 4 -> discharged on 1 more week
Levo, 10 days Flagyl
- Advair started for component of COPD
.
3) Anisocoria- probably long-standing from old injury- pt. has
no sx of HA, normal Neuro exam
- monitor pupils, monitor for signs of HA, changes in Neuro exam
-> no changes over admission
.
4) EtOH Withdrawal
- Diazepam tapered and then d/ced for auto-taper, pt. did
exhibit any further signs of withdrawal on the floor
- Thiamine, Folate
.
5) Acute Renal Failure- resolved with IVF, most likely [**2-7**]
Rhabdomyolysis, Cr 4.4 on admission -> 0.6 in discharge
- Urine eos negative
- US Abd --> no hydronephrosis
- monitored lytes
.
6) Troponin Leak- most likely [**2-7**] demand ischemia
- held ASA until UGIB is investigated
- lipids WNL
- TTE --> LVEF > 55%, no WMA, no AR, trace MR
- continued metoprolol
.
7) C diff- may explain Abd pain on presentation, no diarrhea
over admission
- PO Flagyl day 4 -> discharged with 10 more days for 2 week
course
.
8) Prophy-
- Thiamine, Folate
- Hep SC
- Pantoprazole
.
9) Access- 2 large bore IVs
.
10) Code- full code
.
Discharge Disposition:
Home
Discharge Diagnosis:
C difficile colitis, Gastritis, Pneumonia, Acute Renal Failure
(resolved)
Discharge Condition:
Good- Acute renal failure has resolved, breathing comfortably on
room air, with no more episodes of upper or lower GI bleeding.
No fevers for 1 week.
Discharge Instructions:
Please take all medications as prescribed.
Please follow up with Dr. [**First Name (STitle) **] on [**2103-9-7**].
We gave you a prescription for Levaquin, which is an antibiotic
for Pneumonia. You should take it as directed for 7 more days.
We gave you a prescription for Flagyl, which is an antibiotic
for an infection in your intestine called C difficile colitis.
You should take it as directed for 10 more days.
Please continue your normal medications prescribed by Dr.
[**First Name (STitle) **], including your Atenolol, HCTZ and Accupril for your
blood pressure, and your Advair inhaler for your Emphysema.
Please call Dr [**First Name (STitle) **] or go to the ER if you have chest pain,
shortness of breath, cough up blood, have blood in your stool,
are making significantly less urine than usual, or have any
other symptoms that concern you.
Followup Instructions:
Please follow up with your Primary Care Doctor, Dr. [**First Name (STitle) **]. You
have an appointment scheduled with him on [**Last Name (LF) 2974**], [**9-7**]
at 1:30. You can call his office at [**Telephone/Fax (1) 63696**] if you need to
change the appointment. Dr. [**First Name (STitle) **] should check your Creatinine
to watch your kidney function and follow up on the results of
the biopsies the GI Doctors took of your stomach and your Colon.
Completed by:[**2103-9-10**]
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73,648
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1620+55302+55303
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2123-8-31**] Discharge Date: [**2123-9-6**]
Service: MEDICINE
Allergies:
Sulfonamides / Xanax / Tetracyclines / Erythromycin / Tetanus
Antitoxin / Morphine / Isosorbide
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
retroperitoneal bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 7796**] is a [**Age over 90 **]F with a PMH s/f critical aortic stenosis s/p
recent valvuloplasty in [**7-/2123**] who presented to [**Hospital3 4107**]
with right groin pain. The patient was admitted [**Date range (2) 9390**]
for complaints of dyspnea. A cardiac catheterization was
performed to determine the etiology. After evaluation of the
coronary arteries showed no culprit lesion that was amenable to
PCI, the team proceeded with an aortic balloon valvulotomy, as
they felt the dyspnea was likely secondary to her critical AS.
At the conclusion of the case it was noted that patient was
forming a massive right groin hematoma. She was transiently
hypotensive, and required three units of pRBCs, fluids,
dopamine, and neosynephrine. She was able to be weaned off
within 30 minutes.
.
At [**Hospital3 4107**] the patient was noted to be hypotensive. She
was started on peripheral dopamine, transfused 2 units of blood,
and transferred to the [**Hospital1 18**] for further evaluation. In the ED
initial vitals were HR 106, BP 88/56, RR 20, O2 Sat 85% 3L.
Patient was maintained on neosynephrine and weaned off dopamine
with resolution of tachycardia. CT scan was obtained and patient
was admitted to CCU.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Cardiac History:
<i>CABG:</i> [**2111-3-18**]
LIMA to LAD, SVG to RCA, SVG to OM
<i>Percutaneous coronary intervention:</i> [**2117-2-1**]
Anatomy: Right dominant system. Native three vessel coronary
artery disease. Widely patent SVG-OM, SVG-RCA, and LIMA-LAD.
Intervention: Successful rotational atherectomy, PTCA, and stent
of the LMCA and proximal circumflex artery was performed with a
1.75 mm Rotaburr and a 4.0 x 18 mm Bx Velocity Hepacoat
postdilated to 4.5 mm
<i>Pacemaker/ICD:</i> Generator change in [**2121-4-2**]
[**Company 1543**] EnRhythm dual chamber pacemaker in DDI mode indicated
for tachy-brady syndrome
<br>
<i>Other Past History:</i>
1) Severe osteoarthritis s/p knee replacement
2) tachy-brady syndrome
3) Bronchectasis/COPD
4) TIAs
5) Duodenal ulcer
6) s/p TAH and BSO
7) Cholecystectomy in [**2111-9-25**] for crescendo biliary colic
8) Bilateral mastectomies
9) Cystocele
10) Rectocele repairs
11) Tonsillectomy as a child
12) History of peptic ulcer disease
13) Deep venous thrombosis in her right leg after childbirth
14) Bilateral cataract surgery
Social History:
Social history is significant for approximately a 10 pack-year
smoking history with last use during World War II. There is no
history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T=98 BP= 122/58 HR= 7 RR= 20 O2 sat= 100% 2L NC
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
slihtly pale, Dry MM
NECK: Supple with JVP of [**7-4**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2, oud high pitched systolic crescendo
decrescendo murmur, mid peaking with soft S2 at RUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits, right inguinal tenderness with
no palpable mass or thrill. Distal pulses (+) with doppler in
DP/PT.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+
Left: Carotid 2+ Femoral 2+
At time of discharge, physical exam was notable for marked
abdominal tenderness on the right side of the abdomen, rales in
the lower lung fields, and pitting edema of the ankles: right
greater than left
Pertinent Results:
[**2123-9-5**] 05:25AM BLOOD WBC-8.1 RBC-2.94* Hgb-8.9* Hct-25.5*
MCV-87 MCH-30.1 MCHC-34.7 RDW-16.9* Plt Ct-370
[**2123-9-4**] 05:04AM BLOOD WBC-8.1 RBC-2.94* Hgb-9.0* Hct-25.4*
MCV-87 MCH-30.6 MCHC-35.4* RDW-17.4* Plt Ct-349
[**2123-9-3**] 04:30AM BLOOD WBC-9.8 RBC-2.99* Hgb-9.1* Hct-25.6*
MCV-86 MCH-30.3 MCHC-35.4* RDW-17.5* Plt Ct-323
[**2123-9-2**] 05:15AM BLOOD WBC-13.5* RBC-2.94* Hgb-9.1* Hct-25.2*
MCV-86 MCH-31.1 MCHC-36.3* RDW-17.6* Plt Ct-298
[**2123-9-1**] 04:50AM BLOOD WBC-16.0* RBC-3.38* Hgb-10.2* Hct-28.4*
MCV-84 MCH-30.1 MCHC-35.9* RDW-17.6* Plt Ct-285
[**2123-9-1**] 04:50AM BLOOD Glucose-139* UreaN-51* Creat-2.3* Na-137
K-4.2 Cl-99 HCO3-26 AnGap-16
[**2123-9-2**] 05:15AM BLOOD Glucose-106* UreaN-54* Creat-2.1* Na-141
K-3.9 Cl-102 HCO3-27 AnGap-16
[**2123-9-3**] 04:30AM BLOOD Glucose-114* UreaN-47* Creat-1.7* Na-135
K-4.0 Cl-99 HCO3-27 AnGap-13
[**2123-9-4**] 05:04AM BLOOD Glucose-108* UreaN-38* Creat-1.6* Na-139
K-4.3 Cl-100 HCO3-30 AnGap-13
[**2123-9-5**] 05:25AM BLOOD Glucose-104 UreaN-31* Creat-1.5* Na-137
K-4.4 Cl-100 HCO3-31 AnGap-10
[**2123-9-5**] 05:25AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.7
Brief Hospital Course:
[**Age over 90 **] year old woman with CAD s/p CABG, critical aortic stenosis
s/p valvulotomy, presenting with right groin pain, hypotension
and respiratory distress, found to have a large right groin
hematoma requiring a total of 3 transfusions at [**Hospital3 **]
and 9 transfusions at [**Hospital1 18**]. On day of discharge, Hct had been
stable for 3 days. Shortness of breath had imprvoed to the
point that pt could lie supine without supplemental O2. And ARF
resolved with Creatinine back to baseline of 1.5.
.
# BLOOD LOSS/ HEMATOMA/ HYPOTENSION: Hct stable at 25 for 3 days
prior to discharge. No interval change on serial abdominal CT
scans during hospital stay. Pt's blood pressure is tolerating
Beta blocker at time of discharge. Restarting ACE inhibitor is
deferred to pt's PCP. [**Name10 (NameIs) **] was discontinued indefinitely and
ASA was reduced to 81mg qd given the extent of the RP bleed.
.
# CORONARIES: Last cardiac catheterization with patent LIMA and
SVG grafts. Native vessels with discrete lesions of mid LAD, OM1
and distal circumflex, as well as diffuse RCA disease. S/P BMS
to LM and LCx. Also with known 50% left subclavian artery
stenosis. On Statin.
-- Bare metal Stents placed [**2117-2-1**], safe to discontinue [**Month/Day/Year 4532**]
-- continue ASA at 81 mg qd and continue statin
.
# PUMP: Last EF slightly improved to 45% with inferior akinesis,
mild AR and severe AS. Also 2+ MR and 2+ TR
-- Re-start home dose Lasix 20 mg [**Hospital1 **]
-- defer restarting Ace-i to primary care
.
# RHYTHM: At baseline sinus rhythm with left bundle branch
block. Pacemaker in place for tachy-brady syndrome
-- Pt noted to be in atrial flutter for 30 seconds overnight (no
symptoms reported), given that this was an isolated event and
that the pt has a contraindication to anticoagulation, coumadin
was not started.
.
# ACUTE ON CHRONIC RENAL FAILURE: Creatinine today 1.5, within
baseline 1.3 - 1.6. Improved with resolved hypotension.
.
# Pneumonia: Retrocardiac opacity discovered on CXR. Treat
Levofloxacin for 10 days (until [**2123-9-12**]). Increased dose to 750
mg q48 hr based on improving renal function. So far negative
blood cultures. Patient afebrile.
.
# Guaiac positive stool: Stool brown/green in colour per nurse.
No bright red blood. Not acutely bleeding. Should be followed up
as outpatient.
.
Medications on Admission:
Mavik 4mg daily
Astelin 137mcg two sprays each nostril [**Hospital1 **]
Aspirin 325 mg daily
Clopidogrel 75 mg daily
Actonel 35mg weekly
Iron-vitamin C 100-250mg tabs
Cephalexin 250mg every other day
Protonix 40mg daily
Combivent inhaler
Vitamin E 200 units daily
Acapella
Furosemide 20mg [**Hospital1 **]
MVI
Mevacor 40mg daily
NTG patch 0.2mg/hr patch daily
Mucinex 600mg [**Hospital1 **]
Colace
Amlodipine 5mg daily
Claritin 10mg daily
Flonase 50mcg two sprays daily
Pulmicort 180mcg/inhalation [**Hospital1 **]
Metoprolol succinate 25mg daily
Atrovent nasal spray [**Hospital1 **]
Discharge Medications:
1. Azelastine 137 mcg Aerosol, Spray Sig: [**11-25**] Nasal [**Hospital1 **] (2
times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Iron-Vitamin C 100-250 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day.
6. Vitamin E 200 unit Capsule Sig: One (1) Capsule PO once a
day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
9. Mevacor 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Loratadine 10 mg Tablet Sig: One (1) Tablet PO QD ().
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
18. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for with meals.
19. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO q48h: to
be taken until [**2123-9-12**] to complete 10 day course.
20. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: hold for SBP less
than 110 and pulse less than 60.
21. Tylenol Arthritis 650 mg Tablet Sustained Release Sig: [**11-25**]
Tablet Sustained Releases PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Aortic Stenosis
Congestive Heart Failure
Iatrogenic Retroperitoneal Bleed
Acute Renal Failure
Discharge Condition:
medically stable for discharge
Discharge Instructions:
Dear Ms. [**Known lastname 7796**],
You were transferred to [**Hospital1 **] [**First Name (Titles) 767**] [**Last Name (Titles) 2519**] because you developed a significant bleed during the
procedure which was performed to open your aortic valve. This
bleed required transfusion of 3 units of blood at [**Hospital1 2519**] and the transient use of pressors to maintain your
blood pressure. You had two admissions to [**Hospital1 18**] during which
you received a total of 9 blood transfusions. At the time of
discharge, your hematocrit levels had been stable for three
days. Your kidney function which had also been been impaired
during your hospitalization was back at baseline at the time of
discharge.
You were evaluated by vascular surgery regarding surgical
intervention for your bleed and they determined that the risks
outweighed the benefits.
The shortness of breath you are currently experiencing is a
combination of your congestive heart failure and aortic
stenosis--working with your cardiologist to optimize the heart
medicines you are on will likely make you feel better.
You should return to the hospital if your breathing becomes more
difficult or if you become increasingly lightheaded and weak.
These may be signs of additional blood loss.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please make appointments with Dr. [**Last Name (STitle) 9391**] and with your Primary
Care Physician [**Name Initial (PRE) 176**] 2 weeks of discharge from the hospital.
Please note the following appts which you already had prior to
you hospitalization:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2123-9-30**] 10:30
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2123-9-30**] 11:00
Completed by:[**2123-9-5**] Name: [**Known lastname 1264**],[**Known firstname **] L Unit No: [**Numeric Identifier 1265**]
Admission Date: [**2123-8-31**] Discharge Date: [**2123-9-6**]
Date of Birth: [**2032-10-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Xanax / Tetracyclines / Erythromycin / Tetanus
Antitoxin / Morphine / Isosorbide
Attending:[**First Name3 (LF) 1266**]
Addendum:
NON-CONTRAST CT OF THE ABDOMEN AND PELVIS [**2123-9-2**]
HISTORY: [**Age over 90 **]-year-old woman with retroperitoneal bleed status
post cardiac
catheterization. Evaluate for interval changes.
COMPARISON: CT abdomen and pelvis, [**2123-8-31**].
TECHNIQUE: MDCT-acquired axial images from the lung bases to the
pubic
symphysis were displayed with 5 mm slice thickness without the
administration
of intravenous contrast. Coronal and sagittal reformatted images
were
generated.
FINDINGS: The large right retroperitoneal hematoma extending
along the right
lateral abdomen along the right pericolic gutter is unchanged in
size, and
slightly more heterogeneous appearance, consistent with
evolution of blood
products. The collection measures 18 cm (craniocaudal) x 12 cm
(transverse) x
7.4 cm (AP). A fluid component is again seen superolaterally.
The hematoma remains intimately associated with the right
external iliac
vessels of the pelvis. Vascular integrity cannot be assessed on
this non-
contrast study. The calcified right external iliac artery and
the vein again
course through the lower aspect of the hematoma.
Evaluation of abdominal viscera for focal lesions is limited
without the use
of intravenous contrast. Pneumobilia within the liver is
unchanged. The
patient is status post cholecystectomy. The spleen and adrenal
glands are
unremarkable. The pancreas is largely fatty replaced. There is
no
hydronephrosis. As noted on the prior study, a 9-mm exophytic
lesion arises
from the right mid kidney. Focal dilation of the infrarenal
aorta measures up
to 3.7 cm in diameter. Extensive vascular calcifications involve
the
abdominal aorta, mesenteric vessels, pancreatic, and splenic
arteries.
There are no abnormally dilated loops of bowel. There is no
abdominal free
air or mesenteric or retroperitoneal lymphadenopathy. There is
colonic
diverticulosis without evidence of inflammatory change.
NON-CONTRAST CT OF THE PELVIS: As noted above, the
retroperitoneal hematoma
extends into the right pelvis. Pelvic loops of bowel are
unremarkable. There
is no free pelvic fluid. There is a Foley catheter within the
urinary
bladder, and air, likely related to instrumentation. A
fat-containing right
inguinal hernia is unchanged.
LUNG BASES: As noted on prior studies, the patient is status
post median
sternotomy. Pacemaker wires and cardiomegaly are unchanged. The
heart is
enlarged. There is no pericardial effusion. Ground-glass
opacities at the
lung bases are unchanged.
BONE WINDOWS: Multilevel degenerative changes of the lower
thoracic and
lumbar spine are unchanged.
IMPRESSION:
1. Large retroperitoneal hematoma, stable in size, with
increased
heterogeneity, consistent with evolution of blood products.
Hematoma extends
to right inguinal region. Vascular evaluation not possible due
to noncontrast
examination.
2. 9 mm right renal lesion not completely characterized on this
noncontrast
study. Further evaluation with ultrasound could be performed
when clinical
status permits.
3. 3.7 cm abdominal aortic aneurysm unchanged.
CXR [**2123-9-3**]
REASON FOR EXAM: [**Age over 90 **]-year-old woman with severe AS, retrocardiac
infiltrate,
and pulmonary edema. Please assess for interval change.
Since yesterday, interstitial edema has slightly decreased.
Retrocardiac
opacity persists but decreased. There is no other overall
change.
The study and the report were reviewed by the staff radiologist.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1267**] TCU
[**Name6 (MD) **] [**Last Name (NamePattern4) 1268**] MD [**MD Number(2) 1269**]
Completed by:[**2123-9-5**] Name: [**Known lastname 1264**],[**Known firstname **] L Unit No: [**Numeric Identifier 1265**]
Admission Date: [**2123-8-31**] Discharge Date: [**2123-9-6**]
Date of Birth: [**2032-10-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Xanax / Tetracyclines / Erythromycin / Tetanus
Antitoxin / Morphine / Isosorbide
Attending:[**First Name3 (LF) 1266**]
Addendum:
Patient was observed overnight after additional studies were
obtained per patient request. No acute process was found as
outlined in addendum below. She had right lower extremity edema
which was slightly increased compared with baseline (site of
saphenous vein harvesting). She underwent ultrasound which was
inconclusive for DVT given large pelvic hematoma (with blunted
waveforms). Recommendations by radiology included CT venogram to
evaluate for DVT, if clinically indicated. After extensive
discussion with patient, her son and her daughter, this study
was not pursued as she is not a candidate for anticoagulation
(if DVT was present) given recurrent severe bleeding after
valvuloplasty and patient would not pursue IVC filter if DVT was
detected, given multiple catheterization related bleeding
complications.
Patient discharged to nursing home with physical rehabilitation.
.
Lasix dose was decreased to 20mg daily prior to discharge (from
20mg [**Hospital1 **]).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1267**] TCU
[**Name6 (MD) **] [**Last Name (NamePattern4) 1268**] MD [**MD Number(2) 1269**]
Completed by:[**2123-9-6**]
|
[
"428.0",
"285.1",
"V45.82",
"486",
"403.90",
"424.1",
"584.9",
"V45.01",
"585.9",
"V43.65",
"998.12",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
18436, 18629
|
5805, 8154
|
324, 331
|
10913, 10946
|
4653, 5782
|
12361, 16793
|
3422, 3504
|
8790, 10697
|
10796, 10892
|
8180, 8767
|
10970, 12338
|
3519, 4634
|
263, 286
|
359, 2135
|
2157, 3236
|
3252, 3406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,791
| 131,389
|
3540
|
Discharge summary
|
report
|
Admission Date: [**2152-12-3**] Discharge Date: [**2152-12-6**]
Date of Birth: [**2106-6-1**] Sex: M
Service: O-Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old man
with a history of renal cell carcinoma that is widely
metastatic, status post multiple rounds of Il-2, who was
admitted to the Medical Intensive Care Unit on [**2152-12-3**] for an upper gastrointestinal bleed.
Mr. [**Known lastname 1968**] was recently admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] on [**2152-10-28**] until [**2152-11-6**]
after he had a large upper gastrointestinal requiring 28
units of packed red blood cells and 23 units of fresh frozen
plasma. His bleed was due to esophageal and gastric varices
secondary to portal vein compression by metastatic tumor.
During the hospital stay, the patient had complications
including transient intubation, development of an aspiration
pneumonia, transient acute renal failure secondary to dye
induced nephrotoxicity, and an increased alveolar arterial
gradient in the setting of deep vein thrombosis, status post
a failed attempted at an inferior vena cava filter placement
due to concern for pulmonary embolism.
After discharge, the patient was in a compensated state of
health until [**2152-12-1**], when he had an episode of
bloody emesis times one. The next day, he had a second
episode of hematemesis and presented to [**Hospital **] Hospital. He
was subsequently transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] and admitted to the Intensive Care Unit.
The patient initially had borderline hemodynamic instability
with a heart rate in the 100s and a blood pressure of 98/42.
His presenting hematocrit was 18. His initial INR was 1.4.
Intravenous octreotide was started and emergent
esophagogastroduodenoscopy was performed which revealed grade
IV esophageal varices that were banded. He received a total
of eight units of packed red blood cells and fresh frozen
plasma.
PAST MEDICAL HISTORY: Metastatic renal cell carcinoma,
diagnosed in [**2139**], status post right nephrectomy with a round
of Il-2 in [**2141**]. The patient then underwent a right
pulmonary nodule resection with another round of Il-2 in
[**2143**]. He then had recurrence in [**2149**] and underwent Il-2
again. In [**2151**], he had a fourth course of Il-2; after he
failed that, he was started on thalidomide in [**2152-5-2**]. This
was accompanied by progression of disease. At that point, he
suffered a number of complications, including biliary
obstruction by tumor in [**2152-4-2**], status post a stent in
[**2152-7-2**] and status post stent revision in [**2152-10-2**].
Another complication included portal vein compression
proximal to the liver, complicated by portal hypertension,
portal hypertensive gastropathy with gastric varices and
esophageal varices. Another complication included deep vein
thrombosis and pulmonary embolism.
MEDICATIONS ON ADMISSION: Propranolol 50 mg p.o.b.i.d.,
Xanax 0.5 mg p.o.b.i.d., Oxycontin 20 mg p.o.q.d., Ativan
p.r.n., and oxycodone p.r.n.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a machinist who is married
with two children. He does not smoke or drink.
FAMILY HISTORY: Family history is negative for renal cell
carcinoma.
PHYSICAL EXAMINATION: On physical examination, the patient
was a visibly jaundiced man in no acute distress with scleral
icterus. He had flat neck veins. His lungs were clear to
auscultation bilaterally. His heart rate was tachycardiac
with no murmur, rub or gallop. His abdomen was soft,
nontender, with normal bowel sounds, it was distended and had
a draining tube in the right side which was clean, dry and
intact. Extremities were without edema. Neurologic
examination was nonfocal.
LABORATORY DATA: On presentation, white blood cell count was
7, hematocrit 18, platelet count 141,000 and INR 1.4. Chest
x-ray and KUB were negative.
HOSPITAL COURSE: Mr. [**Known lastname 1968**] was admitted to the Intensive
Care Unit, where he received eight units of packed red blood
cells and fresh frozen plasma. He underwent
esophagogastroduodenoscopy which revealed grade IV varices in
the mid and lower esophagus, status post banding times five.
He also had portal hypertensive gastropathy with gastric
varices. He also had stigmata of recent bleeding.
The patient was started on an octreotide drip and Protonix.
His hematocrit stabilized at around 31 and he had no further
episodes of bleeding, namely, hematemesis or melena. His
bilirubin was increased on presentation and peaked at 8.4
during his stay. He had a stent revision with a larger stent
placed and the old stent removed on [**2152-12-3**]. This
resulted in better bile drainage and a drop in his bilirubin
to 6.9 at the time of discharge. His hematocrit stabilized
at around 31 with a discharge hematocrit of 30.6. The
patient was able to ambulate well by the time of discharge,
and felt well.
CONDITION AT DISCHARGE: Improved.
DISCHARGE STATUS: The patient was discharged to home to
follow up with his oncologist, Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES:
Metastatic renal carcinoma.
Gastric and esophageal varices, status post upper
gastrointestinal bleed.
DISCHARGE MEDICATIONS:
Propranolol 40 mg p.o.b.i.d.
Xanax 0.5 mg p.o.b.i.d.
Oxycontin 20 mg p.o.q.d.
Oxycodone p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], M.D. [**MD Number(1) 16215**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2152-12-12**] 18:51
T: [**2152-12-15**] 13:08
JOB#: [**Job Number 16217**]
|
[
"572.3",
"V10.52",
"197.8",
"456.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
3401, 3455
|
5306, 5409
|
5432, 5795
|
3104, 3276
|
4121, 5139
|
3478, 4103
|
5154, 5285
|
167, 2124
|
2147, 3077
|
3293, 3384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,828
| 174,119
|
52981
|
Discharge summary
|
report
|
Admission Date: [**2128-5-31**] Discharge Date: [**2128-6-5**]
Date of Birth: [**2056-12-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Estolate / Xylocaine
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo woman with metastatic breast cancer to spine, femur p/w
acute dyspnea. Pt was in USOH until this afternoon, when she
developed sudden dyspnea @ 3pm. She was not exerting herself
during this period. She reports sitting in a chair at the time
of onset. Pt's caregiver [**Name (NI) 653**] her daughters. The pt was
hesitant to go to the hospital without her daughters. However,
she became progressively more dyspneic over the next hour and
EMS was called. Of note she had recent admit [**Date range (1) 40693**] for
dyspnea, thought to be [**1-23**] PNA (and a possible aspiration
event), treated with cefpodoxime/flagyl.
.
On arrival to the [**Name (NI) **], pt was initially afebrile (though
eventually spiked to 101.6), BP 180s/110s, hr 120s-140s, rhonchi
on exam, given ntg slx1, started on nitro gtt and given lasix 40
mg iv X1 (UOP 750cc). Pt initially placed on BIPAP, but was
weaned off to a NRB. However, while getting CT, as below, pt
transiently required BIPAP, which was again taken off before
being transferred to [**Hospital Ward Name 516**]. Otherwise w/u in the ED
included: EKG ST @128 bpm, lad, twi I, avl, std v4-6. CXR:
Perihilar vascular congestion, cephalization of the pulmonary
vasculature. CTA negative for PE or consolidation, though
evidence of pulmonary edema and large bilateral pleural
effusions as well as increased right hilar lymphadenopathy. CT
abd showed multiple liver metastases (new since [**1-28**]),
increasing bilateral adrenal thickening - mets vs hypertrophy,
small amount of ascites, mild anasarca. CT head checked in case
of the need for anti-coagulation, showed mass at R cranial
vertex. Labs sig for wbc 15.5, hct 32.2, plt 492, Na 126, cl 87,
ck 155, ck-mb 4, tpn 0.02. BNP 4491. Other than nitro and lasix,
pt given asa 325 mgx1, levoflox 750 mg x1, vanc 1 gm x1, tylenol
650 pr, dilaudid 1 mg x1, oxycontin 280 mg x1.
Past Medical History:
Onc history: Left breast cancer diagnosed in [**2124-6-20**] with
three positive nodes and underwent lumpectomy followed by
Cytoxan and Adriamycin. In [**2126-3-22**] she was diagnosed with a
vetebral metastatic lesion and at the same time was also
diagnosed with colorectal cancer for which she underwent
excision. Has also been on gemtricitabine. Right pathologic
proximal femur fracture s/p ORIF [**2128-4-8**], s/p XRT
-Goiter with hypothyroidism
-Hypertension
-Anxiety disorder
-Lymphedema left arm
-Rectal cancer
Social History:
lives alone with caregiver during day, former tob and etoh, 2
daughters
Family History:
Father died at 73 of coronary artery disease and mother died at
97.
Physical Exam:
Temp 95.3 oral
BP 122/66
Pulse 82
Resp 16
O2 sat 99% 6 L NC
Gen - anxious, but no acute distress
HEENT - extraocular motions intact, anicteric, mucous membranes
moist
Neck - no JVD, no cervical lymphadenopathy
Chest - rales throughout
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - trace edema b/l. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3
Skin - No rash
Pertinent Results:
EKG ST @128 bpm, lad, twi I, avl, std v4-6.
.
[**2128-5-31**] 05:30PM BLOOD WBC-15.5*# RBC-3.42* Hgb-10.3* Hct-32.7*
MCV-96 MCH-30.1 MCHC-31.4 RDW-21.4* Plt Ct-492*#
[**2128-6-5**] 12:02AM BLOOD WBC-9.6 RBC-3.24* Hgb-10.3* Hct-30.6*
MCV-94 MCH-31.7 MCHC-33.7 RDW-20.0* Plt Ct-370
[**2128-5-31**] 05:30PM BLOOD Neuts-63 Bands-4 Lymphs-13* Monos-18*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1*
[**2128-6-1**] 04:25AM BLOOD PT-14.0* PTT-26.0 INR(PT)-1.2*
[**2128-5-31**] 05:30PM BLOOD Glucose-252* UreaN-9 Creat-0.8 Na-126*
K-4.4 Cl-87* HCO3-24 AnGap-19
[**2128-6-5**] 12:02AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-127*
K-4.4 Cl-89* HCO3-26 AnGap-16
[**2128-6-5**] 12:02AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-127*
K-4.4 Cl-89* HCO3-26 AnGap-16
[**2128-5-31**] 05:30PM BLOOD CK(CPK)-155*
[**2128-6-1**] 12:03AM BLOOD ALT-13 AST-81* CK(CPK)-215* AlkPhos-348*
Amylase-30 TotBili-0.3
[**2128-6-1**] 04:25AM BLOOD CK(CPK)-178*
[**2128-6-1**] 12:03AM BLOOD Lipase-9
[**2128-5-31**] 05:30PM BLOOD CK-MB-4 proBNP-4491*
[**2128-5-31**] 05:30PM BLOOD cTropnT-0.02*
[**2128-6-1**] 12:03AM BLOOD CK-MB-8 cTropnT-0.18*
[**2128-6-1**] 04:25AM BLOOD CK-MB-8 cTropnT-0.16*
[**2128-6-3**] 02:28AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.4
[**2128-6-4**] 12:04AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4 Cholest-190
[**2128-6-5**] 12:02AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.3
[**2128-6-4**] 12:04AM BLOOD Triglyc-132 HDL-60 CHOL/HD-3.2
LDLcalc-104
[**2128-6-2**] 05:41AM BLOOD Osmolal-259*
[**2128-6-1**] 04:25AM BLOOD CEA-29*
[**2128-6-1**] 12:03AM BLOOD CA27.29-77*
[**2128-5-31**] 05:42PM BLOOD Lactate-2.5*
[**2128-6-1**] 01:10AM BLOOD Lactate-1.3
.
[**5-31**] CT Head w/o Contrast:
NON-CONTRAST HEAD CT: There is a hyperdense ill-defined 3.2 x
1.9 cm mass at the right frontovertex that appears to be
extra-axial in location with slight mass effect on the subjacent
cortex and minimal subfalcine herniation (approximately 5 mm of
midline shift). No other intracranial mass is identified.
[**Doctor Last Name **]-[**Known lastname **] matter differentiation is preserved and there is no
evidence of acute hemorrhage or major vascular territorial
infarct. No hydrocephalus. A 1 cm destructive osseous lesion at
the right frontal calvarium is seen (2:11), likely a metastasis.
There is also a well-defined lytic lesion of the left parietal
calvarium, at the vertex (2:26) which may represent a prominent
arachnoid granulation, or could represent metastasis in this
patient with extensive metastatic breast cancer. The visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Hyperdense extra-axial mass at the right cranial vertex may
represent dural metastasis or meningioma. There is minimal mass
effect and 5 mm of subfalcine herniation. No evidence of
intracranial hemorrhage or major vascular territorial infarct.
2. Destructive osseous lesion at the right frontal calvarium is
likely a metastatic lesion.
3. Possible metastasis versus prominent arachnoid granulation at
the left parietal vertex.
Findings were conveyed to the ED dashboard at the time of the
exam, and discussed with the MICU team.
NOTE ADDED IN ATTENDING REVIEW: Unusual constellation of
findings, as above. Given the known extensive metastatic
disease, including epidural involvement in the lumbar spine, the
right craniovertex extra-axial lesion, which crosses the midline
and may breach the superior sagittal sinus, likely represents a
dural metastasis. However, incidental meningioma remains a
possibility as these may occur with increased frequency in
patients with breast cancer.
The well-defined, scalloped left parietovertex lesion is most
suggestive of an incidental "giant" pacchionian (arachnoid)
granulation. The lytic "punched out" lesion, in the region of
the right pterion, has a most unusual appearance. This includes
peripheral low-attenuation (measuring negative [**Doctor Last Name **], suggestive of
fat) as well as central stippled calcification or ossification,
with no associated soft tissue component. This could represent
an unrelated hemangioma or, less likely (given the
calcification), epidermoid. However, lytic breast metastasis
with residual bone fragments, remains a concern.
If further evaluation is necessary (unclear, given current
clinical scenario), comparison with any previous cross-sectional
study, as well as MRI (including post-contrast, fat-suppressed
sequences) may be of help.
.
[**5-31**] CTA and CT torso
TECHNIQUE: Multidetector helical scanning of the chest, abdomen
and pelvis was performed prior to and following the
administration of IV contrast (130 cc IV Optiray). Coronal,
sagittal and multiple oblique reformats were performed of the
chest as well as coronal and sagittal reformats of the abdomen
and pelvis.
CTA OF THE CHEST: There is no evidence of pulmonary embolism.
The heart is moderately enlarged with no evidence of pericardial
effusion. There is no evidence of aortic dissection. Large
mediastinal and hilar lymph nodes are noted including a 2 x 2.7
cm pretracheal lymph node (3A:29), and two right hilar lymph
nodes measuring up to 1.5 cm each. The bronchi are patent to the
subsegmental level. Diffuse perivascular ground-glass
opacification of the lungs is consistent with pulmonary edema.
There are moderate bilateral pleural effusions, measuring simple
fluid density, with associated atelectasis. No definite
consolidations are seen. Geographic airspace opacity along the
left upper lobe is relatively unchanged since [**2128-1-22**] and
consistent with post-radiation changes. No pathologically
enlarged axillary lymph nodes are seen.
CT OF THE ABDOMEN: Multiple enhancing masses are seen within the
liver, new since [**2128-1-22**] and consistent with metastases
from patient's known metastatic breast cancer. The largest
lesions include a 3 x 2.5 cm lesion in the right lobe (3B:107).
A 2.7 x 2.5 cm lesion of the inferior and posterior aspect of
the right lobe (3B:123) and an ill-defined 3 x 3 cm lesion in
the inferior aspect of the left lobe (3B:116). The adrenal
glands are thickened bilaterally, increased since [**2128-1-22**],
also concerning for metastases. The spleen, pancreas and
gallbladder are unremarkable. A non-enhancing exophytic cyst of
the left kidney is again noted. The kidneys enhance and excrete
contrast normally. The aorta is of normal caliber throughout.
Intra- abdominal small and large bowel loops are unremarkable.
Increased stranding within the mesentery and soft tissues
consistent with anasarca. Duodenal diverticulum is again noted.
CT OF THE PELVIS: The patient is status post sigmoid resection.
Post-surgical changes of the anastomotic site are stable with no
extraluminal air identified. This area is not well distended to
evaluate for recurrence. No free fluid or lymphadenopathy within
the pelvis. Foley catheter is seen within the bladder.
BONE WINDOWS: Again seen are diffuse sclerotic metastases
throughout the lumbar spine and pelvis with a stable L1
compression fracture status post vertebroplasty.
Multiplanar reformats confirm the above findings.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate pulmonary edema and bilateral pleural effusions.
3. Increasing mediastinal and right hilar lymphadenopathy.
4. Stable radiation changes in the left upper lobe.
5. Progression of disease with new liver metastases and
bilateral adrenal enlargement suggestive of metastasis.
6. Diffuse osseous metastases with no evidence of new fractures.
7. Anasarca.
.
[**5-31**] CXR
FINDINGS: The patient is in lordotic and slightly leftward
rotated position. A right central venous catheter is identified
with tip overlying the expected region of the distal SVC. There
is mild cephalization of the pulmonary vasculature which may be
consistent with mild pulmonary edema. There is a stable
appearing dextroscoliosis of the thoracolumbar spine. There is a
right-sided pleural effusion which is unchanged in size. There
is no evidence of a right pleural effusion. The sclerotic
appearance of several lower thoracic vertebral body is stable
corresponding to sclerotic metastasis on prior studies.
IMPRESSION:
1. Perihilar congestion and cephalization of the pulmonary
vasculature consistent with congestive heart failure.
2. Blunting of the left costophrenic angle is consistent with
either effusion or atelectasis and is stable.
3. Again identified is sclerotic foci and vertebroplasty
material from patient's known metastatic disease to the spine.
.
[**6-1**] CXR
Moderately severe pulmonary edema and small-to-moderate pleural
effusions, right greater than left, have increased since [**5-31**]. Mild cardiac enlargement has increased. Tip of the right
subclavian line projects over the superior cavoatrial junction.
No pneumothorax.
.
[**6-2**] MRI Brain
HEAD MRI
TECHNIQUE: Multiplanar T1, T2, diffusion-weighted, and
post-gadolinium sequences were obtained.
FINDINGS: An 8 x 9 mm ring-enhancing lesion is present within
the right occipital lobe with an adjacent 9 x 10 mm more
homogeneously enhancing lesion within the left occipital lobe,
both consistent with metastatic disease. Additionally, a
previously identified dural-based mass, predominantly located at
the cranial right-sided vertex with midline extension to involve
the left- sided vertex appears to have mild amount of
homogeneous enhancement in association with thickening of the
dura and dural enhancement, also suggestive of a dural
metastatic lesion. Two osseous lesions, one within the inner
table of the right frontal bone with extension to an extradural
location and the second within the posterior high vertex of the
parietal bone with inner table erosion and adural extension are
also likely consistent with osseous metastatic disease.
Increased T2 and FLAIR signal abnormalities within the cerebral
periventricular deep [**Known lastname **] matter are compatible with chronic
small vessel infarction. There is no evidence of hydrocephalus,
shift of normally midline structures, or acute infarct. No
abnormal areas of restricted diffusion are identified
surrounding the parenchymal lesions. There is mild mucosal
thickening of the maxillary sinuses bilaterally, likely
inflammatory in origin.
IMPRESSION:
Findings most consistent with bilateral occipital, subdural, and
osseous right frontal and left parietal metastatic lesions.
Coincident meningiomas accounting for the vertex dural lesions
is an alternative diagnosis.
.
[**6-3**] MRI spine:
FINDINGS: There are areas of low signal identified predominantly
in C2, C4, C5, T1, T2, and T3 vertebral bodies indicative of
sclerotic metastasis. There is no evidence of spinal cord
compression or epidural mass identified. There is no evidence of
intrinsic spinal cord signal abnormalities. Multilevel
degenerative changes are seen from C3-4 to C6-7 without spinal
stenosis.
IMPRESSION: Sclerotic metastatic disease in the visualized
cervical vertebral bodies without epidural mass or spinal cord
compression. No evidence of intrinsic spinal cord signal
abnormalities.
THORACIC SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the thoracic spine were obtained. Comparison was made
with the previous MRI examination of [**2127-6-23**].
FINDINGS: Again diffuse sclerotic metastasis is seen in the
thoracic vertebral bodies. As seen on the previous lumbar spine
MRI of [**2128-3-7**], there is a pathologic fracture of L1 vertebra
visualized with retropulsion. There is mild spinal stenosis seen
at that level.
In the thoracic region at T9 and T10 level, mild epidural soft
tissue changes are seen with mild-to-moderate spinal stenosis.
There is no obvious spinal cord compression seen on the T2 axial
images, however. There is no evidence of intrinsic spinal cord
signal abnormalities seen.
IMPRESSION: Bony metastatic disease with low signal intensities
indicative of sclerosis. Chronic pathologic fracture of L1 with
retropulsion and mild spinal stenosis which appears to be
secondary to epidural disease at T9 and T10 level which can be
better evaluated with gadolinium-enhanced MRI if clinically
indicated. No spinal cord compression seen.
.
[**6-1**] ECHO:
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is
0-5mmHg. Left ventricular wall thickness and cavity size are
normal. There is focal hypokinesis of the distal half of the
inferior wall. The remaining segments contract well. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-23**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2128-4-20**], new
regional left ventricular systolic dysfunction is now seen c/w
CAD and the severity of mitral regurgitation has increased. The
estimated pulmonary artery systolic pressure is lower. A large
left pleural effusion is similar (was present but not reported).
CLINICAL IMPLICATIONS:
Based on [**2127**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
A/P: 71 yo woman with metastatic breast cancer to spine, femur
p/w acute dyspnea
.
Dyspnea: Pt with evidence of pulmonary edema on exam/imaging,
responsive to nitro gtt in the ED. Elevated bnp. No evidence of
PE despite risk factors. No clear PNA but underlying parenchymal
changes, fever, bandemia. In regards to trigger for flash pulm
edema, CEs positive for NSTEMI with rate related changes on ECG.
No baseline LV dysfunction or valvular disease on recent echo
but new murmur concerning for MR. [**First Name (Titles) **] [**Last Name (Titles) 10718**] appeared to occur
in setting of significant HTN, ? related to medication effect
(missed toprolXL, recently started on ritalin).
- Her dyspnea had resolved by discharge. It appeared to have
been caused by ? flash pulmonary edema in the setting of
hypertension and NSTEMI. Unclear which precipitated which but
her blood pressure was well-controlled on dishcarged and she had
no further episodes while in-house.
.
NSTEMI: Troponin elevated but trending down, at risk for CAD
given left chest wall XRT, h/o hypertension. Not a candidate for
heparin/IIbIIIa inhibitors given CNS pathology. Started on
aspirin, continued on beta blockade, nitro gtt overnight. Nitro
gtt stopped prior to transfer from ICU to OMED.
- she was continued on metoprolol and this was increased w/ goal
HR < 70
- lisinopril was also started prior to d/c
- Dr. [**Last Name (STitle) 30938**] was emailed and she will follow-up with him as an
outpatient
.
HTN: [**Month (only) 116**] have missed her toprol dose on the day of admission.
BP initially controlled with nitro gtt but this was weaned
before she was transferred to OMED and her BP was
well-controlled w/ toprol and the additional of lisinopril.
.
leukocytosis/fever: ? pulm source, no other localizing s/s.
Blood sent/urine sent and negative. Cont levoflox for empiric 7
day course (day 1=[**5-31**]). Also given new MR murmur and indwelling
portacath concern for endocarditis, she had a TTE that was not
concerning for endocarditis although it did show slightly
worsened MR.
.
metastatic breast CA: Recently began treatment with Velban
[**2128-5-7**]. Now with evidence on imaging concerning for mets to
head, new mets to liver and elsewhere in abd. She was given the
news of the spread of her disease and an MRI was performed of
her brain and spine. She started whole brain radiation while
inpatient ([**6-3**]) and will continue this as an outpatient per Dr.
[**Last Name (STitle) **].
- prednisone taper per Dr. [**Last Name (STitle) **].
.
s/p ORIF of right pathologic femur fracture: Pt recently
discharged home from rehab. Has been ambulating with walker.
Plan for ortho f/u as out-pt. C/S PT/OT.
.
hypothyroidism: cont home synthroid
.
anxiety: cont home ativan
.
ppx: ppi, BR, pneumoboots, holding heparin given brain mets
.
FEN: HH diet, replete lytes
.
acccess: PIV, port
.
comm: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/HCP, [**Telephone/Fax (1) 109222**]
(work)/[**Telephone/Fax (1) 109223**] (cell)
.
FULL CODE
Medications on Admission:
Oxycontin 280 mg q8h.
oxycodone 20 mg - 30 mg q3h. p.r.n.
Colace prn
Senna prn
Ativan 1 mg q4h prn
ritalin 2.5 mg daily
levothyroxine 25 mcg daily
ibuprofen prn
sertraline 50 mg daily
toprol 12.5 mg daily
omeprazole 20 mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Seven (7)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
3. Oxycodone 5 mg Tablet Sig: 20-30 mg PO Q3H (every 3 hours) as
needed for pain.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety or insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*2*
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
15. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
16. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): through [**6-9**], then 1 tab 3 times per day through [**6-16**],
then 1 tab 2 times per day through [**6-24**] then per Dr. [**Last Name (STitle) 724**].
Disp:*100 Tablet(s)* Refills:*0*
17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-23**]
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 INH* Refills:*0*
18. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: place patch, remove after 12
hours. Wait 12 hours before placing the next patch.
Disp:*30 patches* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
NSTEMI
Pulmonary Edema
HTN
Urinary Tract Infection
SIADH
Metastatic Breast Cancer
Hypothyroidism
Anxiety
Discharge Condition:
Hemodynamically stable. Ambulatory with a walker.
Discharge Instructions:
You were admitted with shortness of breath from pulmonary edema.
The pulmonary edema was likely caused by high blood pressure, a
small heart attack and worsening of your mitral valve function.
It is very important that you have good blood pressure control
(goal <120/80). You should also follow a low-fat, low
cholesterol, low-salt diet.
.
Please seek medical attention immediately if you develop fever,
chills, nausea, vomiting, shortness of breath, chest pain or any
other concerning symptoms.
.
We made some changes to your medicines.
We stopped your Ritalin.
We increased your toprol dose to 25 mg per day.
We added a blood pressure medication call lisinopril to your
regimen.
You will take an antibiotic called levofloxacin for two more
days.
A steroid was added to your regimen for the lesions in your
brain. Please follow the schedule that we have written out for
you on how to take the steroids.
We added a lidoderm patch to your regimen for your pain.
We gave you an inhaler to use when you have shortness of breath.
Followup Instructions:
1) You are scheduled to have radiation therapy on [**5-19**] and
[**6-9**] at 10:00 am. Dr. [**First Name8 (NamePattern2) 324**] [**Last Name (NamePattern1) **]. Tel ([**Telephone/Fax (1) 8082**].
.
2) You have an appointment w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (Neuro-Oncology) on
[**2128-6-21**] at 2:00 pm. Tel ([**Telephone/Fax (1) 6574**].
.
3) You have an appointment with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] (cardiology)
on [**2128-6-24**] at 10:40 am. Tel ([**Telephone/Fax (1) 10085**].
.
Then following appointments are already scheduled for you:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3260**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2128-6-18**] 10:00. This appointment will also be with
Oncologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2128-6-18**]
10:30
|
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"486",
"428.0",
"401.9",
"V10.3",
"244.9",
"707.03",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
22428, 22486
|
16806, 19856
|
315, 322
|
22635, 22687
|
3426, 5091
|
23763, 24832
|
2871, 2940
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|
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|
22711, 23740
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2955, 3407
|
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|
268, 277
|
350, 2223
|
5100, 16523
|
2245, 2766
|
2782, 2855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,394
| 125,104
|
29863
|
Discharge summary
|
report
|
Admission Date: [**2147-2-3**] Discharge Date: [**2147-2-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
EEG
PICC line placement
History of Present Illness:
(History based on accounts of patient's daughter,
daughter-in-law, home caregiver, EMS and OSH records)
Ms. [**Known lastname **] is an 85 year old woman with a history of atrial
fibrillation (not on coumadin), hypertension, DVT's, and colon
CA 7 years ago, who was found unresponsive lying on her right
side on the day of presentation by a neighbor. She lives alone
and has a neighbor who is her nurse-caregiver several mornings a
week. Ms. [**Known lastname **] was last seen normal about 12 hours before
she was found. Her daughter-in-law reportedly called her the
evening prior and there was no answer, and called her again in
the morning, became concerned, and notified her neighbor, who
called EMS. Ms. [**Known lastname **] was found lying on her right side next
to her recliner with her right arm and leg entangled in the
chair. She had some edema overlying her right scalp and her
right arm and leg were also edematous. She was not responsive,
not talking or following commands, and not moving her right side
as well as the left. She was brought to the [**Hospital 5871**] Hospital
ED, where she arrived at 1:17 p.m. There her initial blood
pressure was recorded as 67/45, HR 130, RR 24, T 100.8 axillary.
Blood glucose was 317. Due to her somnolence she was
intubated, for which she received lidocaine, rocuronium,
etomidate, succinylcholine, ativan 4 mg and fentanyl 100 mcg at
about 2 p.m. She was also given NS IV with improvement in her
blood pressure. On exam there prior to intubation she was noted
to have left gaze deviation and "withdrawal with all four
extremities." Labs were significant for a wbc of 18.5, INR of
1.32, and UA with 37 wbc. CK was elevated at 863, MB fraction
was pending. She was then transferred to [**Hospital1 18**].
Upon arrival at 5 p.m. she was afebrile, with BP 220/110, HR
109, RR 20. She had received no sedation since 2 p.m., but was
not responsive to voice, and did not move her right side as well
as the left. Neurosurgery was consulted and she received 1 gram
Dilantin, 50g Mannitol, 10 mg Decadron, and ultimately required
a labetalol drip to control her blood pressures. She had a
CT/CTA of the head which revealed acute subarachnoid and
intraparenchymal hemorrhage in the left frontal, parietal, and
temporal lobes. There was evidence of edema with sulcal
effacement on the left and 2 mm of midline shift. CTA was not
suspicious for a mass lesion. She received propofol 10 mg at 6
p.m. for the CT but has had no sedating medications since then,
without any improvement in her mental status. When it was
determined that Neurosurgery would not be admitting her, the
Neurology service was consulted, 3 hours after the patient's
arrival to the ED.
Ms. [**Known lastname **] has not been feeling well for several weeks,
sometimes not getting out of bed in the morning. Her family are
not aware of any specific recent illnesses, although her
daughter thinks she may have had a mild heart attack two weeks
ago. Her daughter reports that she has been falling a lot
lately, and hitting her head. It sounds like she loses
consciousness with the falls, as she once said she woke up after
falling down the stairs and didn't recall that she had fallen.
Review of systems: Not definitively known per nurse or
daughter.
Past Medical History:
Receives her primary care through [**Hospital3 2358**], Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- Hypertension, not taking her HCTZ recently due to side
effects, baseline blood pressure 160-180
- Diabetes
- Atrial fibrillation, not on coumadin
- DVT's in both legs - per daughter was hospitalized at [**Name (NI) 1774**] in
past, was on heparin but they had to stop it (she doesn't know
why)
- Colon cancer 7 years ago, s/p surgical resection; has not had
follow-up colonoscopies
- Does not go for mammograms
- Cataracts
- Daughter says she was told she could never have any surgery
because of a pinched nerve or blood vessel in her head
Social History:
Lives alone, daughter-in-law and daughter closely involved.
Neighbors include a nurse who is her caregiver, and her partner
who is Ms. [**Known lastname **] lawyer. [**Name (NI) **]
history of tobacco, alcohol, drug use.
Daughter: [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) 20608**] [**Telephone/Fax (1) 71418**]
Family History:
Not contributory.
Physical Exam:
Exam on presentation to neurology service:
T 99.8 HR 90's BP 160/80 RR 19 Pulse Ox 99%
General appearance: 85 year old woman intubated in NAD
HEENT: Wearing C-spine collar
CV: Irreg irreg, distant heart sounds, no gallops or murmurs
audible
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender
Extremities: Bilateral pitting edema in LE's with abrasions
scattered over right LE
Mental Status: Intubated, not sedated. Eyes closed. No
spontaneous eye opening, no eye opening to voice or sternal rub.
Grimaces to sternal rub. Does not follow commands but per
daughter squeezes her left hand to command for her.
Cranial Nerves: Pupils are equal, round and reactive to light
3>2. Does not blink to threat on right. Left gaze preference,
can get eyes to midline but not past. Unable to assess OCR due
to C-spine collar. Corneals present bilaterally. Difficult to
assess facial symmetry due to ETT, grimaces bilaterally to nasal
tickle, maybe a bit less on the right. Does not cough/gag on
ETT.
Motor System: Tone flaccid in right arm, less so in legs,
paratonia with rigidity in left arm. Rarely spontaneously
moves left arm but not purposefully. Able to wiggle fingers
with left arm, withdraws to noxious stimuli. No movement of
right arm, grimaces but does not move with noxious. Weakly
withdraws both legs to noxious, left a bit more vigorously than
right. No spontaneous movement of legs.
Reflexes: Deep tendon reflexes are 2+ and symmetric in the upper
extremities, 2+ at the patellae, absent at the Achilles. No
clonus. Plantar responses are extensor bilaterally. No
[**Doctor Last Name 937**].
Sensory: Responds to noxious stimuli in all four extremities as
above.
Coordination, Gait: Could not assess
On discharge, appears comfortable. Opens eyes spontaneously but
not interactive. Does not follow or fixate.
Pertinent Results:
###LAB RESULTS###
At [**Hospital 5871**] Hospital:
abg 7.41/20.5/435/19.1/-4.1
PT 15.2, INR 1.32, PTT 24
18.5>15.8/45.5<244
89seg, 1 band, 10 lymph
136 98 17 <271
4.2 20 1.6
Ca 8.2
UA sg 1022, 37 wbc, ket 15, gluc 500
AT [**Hospital1 18**]
[**2147-2-3**] 8:10p
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
ColorStraw AppearClear SpecGr1.012 pH 5.0 UrobilNeg
BiliNeg LeukNeg BldSm NitrNeg ProtNeg GluTr KetNeg
RBC 0-2 WBC6-10 BactMany YeastNone Epi0
[**2147-2-3**] 7:10p
137 104 19 242 AGap=18
3.7 19 1.2
estGFR: 43/52 (click for details)
CK: 775 MB: 10 MBI: 1.3 Trop-T: 0.06
Ca: 6.6
ALT: 17 AP: 76 Tbili: 1.5 Alb: 3.0
AST: 34 LDH: Dbili: TProt:
[**Doctor First Name **]: 49 Lip: 54
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
MCV 78
13.1 > 12.7 < 170
37.4
N:85.6 Band:0 L:6.5 M:6.5 E:0.8 Bas:0.5
PT: 14.2 PTT: 24.0 INR: 1.3
###MICROBIOLOGY###
[**2147-2-3**] 8:10 pm URINE Site: CATHETER
URINE CULTURE (Final [**2147-2-6**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
PREVIOUSLY REPORTED AS SULFA X TRIMETH SENSITIVE,
[**2147-2-6**], 9:30AM.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- R
[**2147-2-5**] 4:57 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2147-2-5**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2147-2-7**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). RARE GROWTH.
[**2147-2-14**] 10:04 am SPUTUM Source: Induced.
GRAM STAIN (Final [**2147-2-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2147-2-17**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
ESCHERICHIA COLI. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
BETA STREPTOCOCCUS. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
STAPH AUREUS COAG +
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
###IMAGING###
EKG: Afib, Twave flattening, NSST changes
CTA HEAD W&W/O C & RECO [**2147-2-3**]:
FINDINGS: There is a large hypodense area in the territory of
the left MCA involving the temporal as well as frontoparietal
regions. There is associated intraparenchymal hemorrhage. The
findings are most consistent with hemorrhagic conversion of an
infarct. There is no herniation present.
The CTA demonstrates that the left vertebral artery is dominant.
The internal carotid arteries appear normal. Their origins are
not visualized. There are areas of atherosclerosis within the
cavernous portions of both internal carotid arteries. The
basilar artery is small. There is a fetal origin to both
posterior cerebral arteries. There is a suggestion of an area
of stenosis in the P2 segment of the right posterior cerebral
artery. Both posterior inferior cerebellar arteries are
present.
Both middle and anterior cerebral arteries appear normal. There
are no
aneurysms.
The volume rendered images of the circle of [**Location (un) 431**] demonstrate
inferior
displacement of the distal and middle cerebral artery branches
on the left due to the mass effect from the intraparenchymal
hemorrhage infarct.
No filling defects are noted.
IMPRESSION: Hypodensity in the territory of the left middle
cerebral artery with areas of intraparenchymal hemorrhage. The
CTA does not demonstrate any evidence of an aneurysm or filling
defects.
CT C-SPINE W/O CONTRAST [**2147-2-3**]:
FINDINGS: There is no evidence of acute fracture. Evaluation
of the
prevertebral soft tissues is limited by endotracheal tube.
There is
exaggerated lordosis of the cervical spine with relative
widening of the
anterior disc spaces seen at C3-4 and C4-5 levels. CT does not
provide
intrathecal detail comparable to MRI, however, the thecal sac
appears grossly intact. Degenerative changes noted within the
cervical spine.
IMPRESSION:
1. No evidence of acute fracture. Exaggerated cervical
lordosis with
relative widening of the anterior disc spaces at the C3-4 and
C4-5 levels.
Ligamentous injury cannot be excluded and if clinically
indicated, MR could be helpful for further evaluation.
2. Degenerative changes noted within the cervical spine.
EEG [**2147-2-4**]: This is an abnormal EEG due to the suppressed
background
and intermittent low voltage frontal alpha activity. The
anteriorly
predominant intermittent alpha activity may represent an alpha
coma,
although this is usually more persistent. The low voltage
suppressed
background suggests a severe encephalopathy, which may be seen
with
infections, toxic metabolic abnormalities, medication effect or
ischemia. No epileptiform features were noted. A repeat study
would be
beneficial to better assess the posterior background rhythm and
to
assess for interval change.
CT T-spine: No fracture or malignment within the thoracic spine.
CT L-spine: 1. No fracture or malalignment within the lumbar
spine.
2. 1.5 cm nonobstructing left proximal ureteral stone. 3.
Atherosclerosis.
Head CT [**2-4**]: 1. No significant mass effect or evidence of
herniation.
2. Stable or slight interval increase in left frontoparietal
temporal acute intraparenchymal hemorrhage with acute adjacent
subarachnoid blood.
3. Slight interval worsening in surrounding edema.
MR [**Name13 (STitle) 2853**] [**2147-2-4**]: There is no abnormal bone marrow edema.
There is no disc edema. There is minimal prevertebral soft
tissue edema along the entire cervical spine. This could be due
to ligamentous sprain. In addition, mild edema is also noted
within interspinous ligament posteriorly to C3-4 and 5. Again,
this could indicate ligamentous strain. The craniocervical
junction is normal. The cervical spine alignment is also
preserved.
At C4-5, there is a tiny central disc protrusion indenting the
ventral thecal sac causing no significant spinal canal
narrowing.
IMPRESSION: No evidence of disc or bone marrow edema.
Prevertebral interspinous ligament edema could indicate
ligamentous strain. No abnormal signal within the cord or
spinal canal stenosis.
MR brain with contrast [**2147-2-4**]: FINDINGS: The MRV does not
demonstrate any evidence of venous sinus thrombosis.
There is a large area of slow diffusion associated with the
large left
frontoparietal hematoma. These findings are most consistent
with hemorrhagic infarct. An additional acute infarct is noted
within the left posterior inferior cerebellar artery territory.
There is no associated hemorrhage within this infarct.
There are moderate amounts of confluent periventricular white
matter T2
hyperintensity consistent with moderate amounts of chronic
microvascular
ischemic change. No enhancing masses are identified. Areas of
increased
signal on the post-gadolinium images were present on the
pre-gadolinium axial T1 imaging.
There is no midline shift or herniation. There is fluid within
the paranasal sinuses as well as both mastoid air sinuses due to
intubation.
IMPRESSION: Hemorrhagic left middle cerebral artery territory
infarct.
Additional acute infarct within the posterior inferior cerebral
artery
territory on the left.
LENIs bilateral [**2147-2-6**]: No evidence of any DVT in either lower
extremity
CXR [**2-13**]: Endotracheal tube and nasogastric tube are in standard
positions. Cardiac silhouette is mildly enlarged, and there is
new slight engorgement of the pulmonary vascularity accompanied
by perihilar haziness. Moderate left and small right pleural
effusions have developed. Left retrocardiac opacity may reflect
a combination of atelectasis and effusion, but underlying
infectious process is not excluded in the appropriate setting.
Brief Hospital Course:
85 year old woman with history of afib not on coumadin,
hypertension, dvt's, colon cancer, multiple recent falls with
possible LOC, now found unresponsive with left intraparenchymal
and subarachnoid hemorrhage. Exam revealed right sided weakness,
left gaze preference and decreased blink to threat from the
right. Possible etiology for bleed included hypertension,
amyloid angiopathy, contusion/fall, underlying mass or
hemorrhagic emoblic infarct. Also, given the history of recent
falls, question was raised of possible seizure activity.
Hospital course is listed below by system. Notably, on [**2-21**], by
the family's decision, the goals of care were changed to comfort
measures only. All antibiotics and antihypertensives were
discontinued, all IVs removed, and no further labs or vital
signs were taken. Her cervical collar was removed but kept at
bedside to replace for any movements that might cause neck pain
without a collar in place. She was started on sublingual ativan
and morphine as needed, scopolamine and levsin for secretions,
and a suppository for constipation as needed.
Hospital course:
Neuro: Left intracranial hemorrhage was most likely secondary
to hemorrhagic conversion of emoblic stroke. Patient was
evaluated by neurosurgery, and received mannitol, decadron and
dilnantin. Head CTA was negative for aneurysm or vascular
malformation. An MRI brain showed again left MCA hemorrhagic
infarct and an additional acute infarct with in the left PICA
territory further supporting the etiology of emoblic phenomenon.
EEG initally showed slowing with alpha bursts concerning for
alpha coma but no epileptiform activity; repeat showed findings
consistent with encephalopathy, still no epileptiform activity.
CT spine was negative for fracture and MR [**Name13 (STitle) 2853**] showed
prevertebral interspinous ligament edema that could indicate
ligamentous strain. As a result, she was placed in a hard
collar.
CV: Acute myocardial infarction was ruled out. HbAIC and
fasting lipid panel were sent, and aspirin held. Her heart rate
and BP were controlled with a beta blocker and PRN hydralazine.
Pulm: Patient was extubated without difficulty.
ID: She had leukocytosis and gram stain of sputum positive for
coag positive staph aureus and E. coli. She was started on
empiric antibiotics (vancomycin and cefepime).
ENDO: Treated initially with ISS then started on glyburide [**Hospital1 **].
PPX: Treated with PPI, sc heparin, lipitor, bowel regimen, SSI.
Medications on Admission:
Hydrochlorothiazide 1 daily
Lisinopril 10 mg [**Hospital1 **]
Lopressor 50 mg [**Hospital1 **]
Glyburide 1.25 mg daily
?"sanctura 10 mg daily"
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: [**5-21**] mgs PO Q1-2H
() as needed for discomfort.
2. Lorazepam 0.5 mg Tablet Sig: 0.5-2 mg PO Q4-6H (every 4 to 6
hours) as needed: sublingual.
3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for secretions.
4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q4H (every 4 hours) as needed for
secretions.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Left intraparenchymal hemorrhage with associated subarachnoid
hemorrhage
Pneumonia
Hypertension
Atrial fibrillation with rapid ventricular rate
Hypokalemia
Discharge Condition:
Unresponsive to voice; not interactive. Opens eyes spontaneously
but does not fixate or track.
Discharge Instructions:
Take medications as needed for comfort.
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"431",
"V12.51",
"276.8",
"430",
"599.0",
"V66.7",
"250.00",
"486",
"427.31",
"786.03",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20269, 20342
|
16871, 17967
|
291, 356
|
20542, 20639
|
6637, 16848
|
20727, 20846
|
4731, 4751
|
19557, 20246
|
20363, 20521
|
19389, 19534
|
17985, 19363
|
20663, 20704
|
4766, 5166
|
3622, 3669
|
223, 253
|
384, 3602
|
5415, 6618
|
5181, 5399
|
3691, 4360
|
4376, 4715
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,722
| 173,443
|
38960
|
Discharge summary
|
report
|
Admission Date: [**2195-4-17**] Discharge Date: [**2195-4-20**]
Date of Birth: [**2153-8-17**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41F otherwise healthy had syncopal episode, fell from standing,
+ LOC, sustained left occipital fracture extending to skull
base; intubated for agitation.
Past Medical History:
Denies
Family History:
Noncontributory
Physical Exam:
PSYCH: [x] All Normal
[ ] Mood change [ ] Other
________________________________________________________________
PHYSICAL EXAM:
Temp: 96 HR: 102 BP: [**2172-12-18**] RR: 20 O2 Sat: 100%
OT intubation. CMV/AC 100% (698x18) PEEP 5
GENERAL: Intubated and sedated
HEENT: 3 mm pupils bilateral, reactive to light
Left occipital laceration approx 3cm
Collar neck
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT [ ] No cheat crepitus
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
___________________________________________________________
Pertinent Results:
[**2195-4-17**] 08:20PM GLUCOSE-110* UREA N-10 CREAT-0.6 SODIUM-140
POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-23 ANION GAP-12
[**2195-4-17**] 08:20PM CALCIUM-7.8* PHOSPHATE-2.6* MAGNESIUM-2.0
[**2195-4-17**] 08:20PM WBC-9.4 RBC-3.40* HGB-11.0* HCT-32.1* MCV-95
MCH-32.4* MCHC-34.3 RDW-13.3
[**2195-4-17**] 08:20PM PLT COUNT-196
[**2195-4-17**] 03:19AM cTropnT-< 0.01
[**2195-4-16**] 11:00PM cTropnT-<0.01
[**2195-4-16**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
IMAGING:
[**2195-4-16**] CT head left occipital fracture extending to skull
base; no ICH
[**2195-4-16**] CT c-spine Free air in soft tissues surrouding trachea
at glottis/subglottis
[**2195-4-16**] CXR no acute processes
[**2195-4-16**] Bronch no tracheal trauma
Brief Hospital Course:
She was admitted to the trauma service. There was concern for
pharyngeal air related to her intubation and she underwent a
Barium esophagram which showed no evidence of esophageal
perforation. A syncope workup was also done; the ECHO was
essentially normal with only borderline pulmonary artery
systolic hypertension, EF was normal. The carotid studies
demonstrated normal carotid systems bilaterally.
Her skull fracture was evaluated by Neurosurgery and no acute
intervention was warranted. The temporal bone fracture was
evaluated by ENT, no acute intervention; she will need to follow
up as an outpatient in [**Hospital **] clinic.
She did have some pain control issues associated ith hr
occipital fracture and was prescribed Fioricet and Oxycodone
which helped.
She was evaluated by Physical therapy and is being recommended
for home with services.
Medications on Admission:
Denies
Discharge Medications:
1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-13**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
outpatent PT
Discharge Diagnosis:
s/p Fall/Syncopal episode
Occipital skull fracture
Post-concussive syndrome
Hemotympanum
Right temporal bone fracture
Discharge Condition:
Mental Status: Clear and coherent w/ concussive symptoms.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted after having a fainting episode; you sustained
an occipital (back of the head) skull fracture. You also
susatined an injury to the membrane inside of your ear which has
cauesed you to expeirence intermittent dizziness and extra eye
movments not related to seizure activity. Your injuries did not
require any operations, you were admitted to the hospital for
close observation. The neurosurgery team has recommended that
you avoid all contact sports for 8 weeks.
During your hospital stay you were evaluated for possible causes
of syncope (fainting). Your echocardiogram showed borderline
pulmonary hypertension (you should follow-up with your primary
care physician, [**Name10 (NameIs) **] this is not a cause of syncope). The
ultrasound of your carotid arteries was negative for any clots
or other abnormalities. You should see your primary care
physician after discharge for genral physical exam.
You were provided with a booklet that describes/discusses head
injuries and some of the common symptoms and warning signs.
Followup Instructions:
Follow in 2 weeks with Dr. [**Last Name (STitle) 1837**], ENT for further
evalaution of your inner ear; call [**Telephone/Fax (1) 41**] for an
appointment.
Follow up in 2 weeks with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Cognitive
Neurology for your head injury and post-concussive symptoms.
Please call [**Telephone/Fax (1) 6335**] for an appointment.
Follow up with your PCP [**Last Name (NamePattern4) **] [**12-13**] weeks for a general physical.
You may follow up with Dr. [**Last Name (STitle) **], Neurosurgery if there are any
concerns related to your skull bone fracture. The neurosurgeons
have indicated that you will not need to follow up but if there
are concerns please call [**Telephone/Fax (1) 1669**] if you need to be seen.
Completed by:[**2195-4-29**]
|
[
"389.00",
"780.2",
"310.2",
"801.52",
"E888.9",
"801.02",
"385.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4351, 4395
|
2941, 3798
|
304, 310
|
4556, 4556
|
2139, 2918
|
5830, 6636
|
540, 557
|
3855, 4328
|
4416, 4535
|
3824, 3832
|
4761, 5807
|
716, 2120
|
256, 266
|
338, 494
|
4571, 4737
|
516, 524
|
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