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28,604
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52506
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Discharge summary
|
report
|
Admission Date: [**2169-8-16**] Discharge Date: [**2169-8-29**]
Date of Birth: [**2093-4-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
generalized weakness, gait difficulty
Major Surgical or Invasive Procedure:
Right frontal craniotomy with excision of lesion
History of Present Illness:
Mr [**Known lastname **] is a 76 yo male who presents from the onc clinic with
progressive generalized weakness. He reports that he noted a
decline in his functional status about 4 months ago. He began to
feel more fatigued and weak around this time. He notes that it
was about this time that he began to have trouble walking,
getting out of bed, and doing his daily activities. In the last
4 weeks, he notes that his weakness and fatigue has gotten
worse. He reports significant amount of difficulty ambulatingm
and cites episdoes of sinking to the floor and not being able to
get up.
.
He also reports a new tremor, and headache. His headache is
worse in teh mornings and improved with tylenol. He also reports
urinary incontinence, mildly worse from the past, as he has a hx
of prostate ca s/p brachytherapy. He also reports not being able
to make it to the bathroom in time for his BMs. No associated
numbness, tingling, back pain.
.
He also notes a new subcutaenous nodule in his inner right
thigh.
Past Medical History:
1. Melanoma per Dr.[**Name (NI) 22252**] note:
1. Resection of a primary melanoma from the posterior aspect of
his left upper arm [**2150**].
2. Recurrence of disease in the left supraclavicular lymph nodes
in 06/[**2163**].
3. One cycle of biochemotherapy in [**5-/2165**], interrupted due to
development of pancreatitis and severe orthostatic
hypotension. He was continued on single [**Doctor Last Name 360**] DTIC which was
ultimately terminated in [**5-/2165**] because of disease progression
in the left supraclavicular region.
4. Resection of bulky left supraclavicular lymph nodes by Dr.
[**Last Name (STitle) 1837**].
5. Resumption of DTIC, which resulted in stabilization of his
lung metastases.
6. Pulmonary embolus in 06/[**2166**]. This was detected on a
surveillance CT scan but was quite symptomatic. The patient was
treated with heparin and subsequently put on Coumadin.
7. Resection of a right subscapular mass by Dr. [**Last Name (STitle) 519**] and
subsequent radiation therapy to this site.
8. Treatment with the phase 1 reagent RTA-402 (seven cycles)
[**9-/2168**]/[**2168**].
9. Sutent given [**9-/2168**] through [**3-/2169**] and stopped because of
development of subcutaneous metastases.
10. Status post CyberKnife treatment to right infrahilar lymph
nodes 04/[**2168**]. Lymph nodes had nearly occluded right lower lobe
bronchus.
11. Status post removal of subcutaneous scalp nodules by Dr.
[**Last Name (STitle) 1837**] [**2169-5-22**].
2. prostate cancer [**2162**] s/p seed implants c/b radiation
proctitis
3. hypercholesterolemia
4. psoriasis s/p UV tx
5. pancreatitis secondary to chemo [**11-30**] s/p subtotal
pancreatectomy
6. non tension ptx [**11-30**]
8. h/o PE and DVts 10y ago
.
Social History:
divorced, 4 kids, GF=HCP, GF x 34 yeras, retired- president of A
and P food stores, h/o ETOH, sober x 34 years (AA),no tobacco
Family History:
He has two brothers and two sisters. One sister
died of a gynecologic cancer. He is unsure of the type. He has
four children, three sons and one daughter, all in good health.
None of the siblings or his children ever had a diagnosis of
melanoma or other skin cancer.
Physical Exam:
Vitals- Afebrile HR 100 BP 110/60
General- Well appearing male in NAD
HEENT- PERRLA, EOMI, mucous membrane dry
Neck- Supple, no LAD
Pulm- Clear to ascultation
CV- RRR nl s1 s2
Abd- Soft, nontender, nondistended, guaiac negative, good rectal
tone.
Extrem- +palpable nodule in right inner thigh
Neuro- CN II-XII grossly in tact, [**4-1**] muscle strength of UE
flexor/extensors, [**4-1**] bilateral hip flexor/extensors, quads.
Normal sensation to light touch. 2+ brachial reflex, 1+ patellar
reflex, +Intention tremor, no dysmetria, +Rhomberg
.
Pertinent Results:
Admission Laboratories:
[**2169-8-16**] 02:42PM GLUCOSE-230* UREA N-22* CREAT-1.3* SODIUM-137
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2169-8-16**] 02:42PM estGFR-Using this
[**2169-8-16**] 02:42PM ALT(SGPT)-16 AST(SGOT)-14 LD(LDH)-131 ALK
PHOS-118* TOT BILI-0.3
[**2169-8-16**] 02:42PM ALT(SGPT)-16 AST(SGOT)-14 LD(LDH)-131 ALK
PHOS-118* TOT BILI-0.3
[**2169-8-16**] 02:42PM WBC-11.3* RBC-3.85* HGB-13.3* HCT-39.1*
MCV-102* MCH-34.5* MCHC-33.9 RDW-13.0
[**2169-8-16**] 02:42PM PLT COUNT-522*
.
Imaging:
MRI Head [**2169-8-16**]:
1) Irregular enhancing mass of the right frontal lobe is
associated with significant secondary mass effect and subfalcine
herniation. There are small foci of enhancement extending to the
frontal [**Doctor Last Name 534**] of the right lateral ventricle and T2
hyperintensity extending into the corpus callosum. There is
overlying leptomeningeal enhancement, which may represent tumor
extension vs engorged vessels. Given the presence of other
likely metastasis, this mass likely represents metastasis.
However, a glial tumor should be considered in the differential.
Multivoxel spectroscopy of the peritumoral region may help in
the evaluation.
2) Round enhancing mass lesion of the right cerebellum with mild
surrounding edema is consistent with metastatic disease. There
are areas of abnormal enhancement along the folia of cerebellum
which might represent leptomeningeal seeding/engorged vessels.
Continued follow up is recommended.
3) Pathologically enlarged node of the right posterior cervical
space which may represent metastasis.
.
CT Chest/Abdomen/Pelvis:
No significant interval change in size to right lower lobe
pulmonary nodule, right infrahilar dominant mass, and
mediastinal/hilar lymphadenopathy. No new metastatic lesions
identified.
.
EKG [**2169-8-18**]:
Sinus rhythm. Right atrial abnormality. Borderline left axis
deviation.
Possible left anterior fascicular block. Compared to previous
tracing
of [**2169-3-16**] multiple abnormalities as noted persist without major
change.
.
MRI [**8-25**]:
1. Minimal amount of nodular enhancement along the posteromedial
aspect of the right frontal resection cavity which represents
post-surgical changes.
2. Cerebellar mass and right cervical mass again visualized.
Brief Hospital Course:
A/P: 76yo M w/ a PMH of metastatic melanoma p/w FTT and
generalized weakness, now found to have brain metastases and
cerebral edema.
<br>
# BRAIN MASSES: The patient presented with headache and
generalized weakness. He underwent brain MRI on the evening of
admission and was found to have an irregular enhancing mass of
the right frontal lobe measuring 32 x 32 mm in axial dimension
with associated severe cerebral edema and 16 mm sub- falcine
herniation. He was also found to have a round enhancing lesion
of the right cerebellum measures 18 x 16 mm. These lesions were
felt to be consistent with metastatic disease from his known
diagnosis of melanoma. On neurologic exam he was found to have
evidence of diplopia, left sided facial weakness, left sided
pronator drift, left sided upper and lower extremity motor
weakness and difficulty with finger-nose-finger and rapid
alternating movements bilaterally L>R. He was immediately
started on high dose IV dexamethasone for cerebral edema. The
neurosurgical service was consulted who recommended against
starting mannitol for cerebral edema. His neurologic exam was
monitored closely. He showed significant clinical improvement
during his MICU course and on transfer to oncology had
significant improvement in his motor weakness. His headache had
resolved. He continued to have evidence of cerebellar
dysfunction as manifested by difficulty with finger-nose-finger
and rapid alternating movements. He also continued to have a
mild left sided facial droop.
<br>
He underwent a right frontal craniotomy with excision of his
frontal lesion on [**8-23**]. He tolerated the procedure well with no
evidence of residual tumor on post-op MRI. Preliminary path
showed spindle cell tumor. He was set up with an appointment in
the Brain [**Hospital 341**] Clinic, where his cerebellar tumor will be
addressed. He will have his sutures removed 7-10 days post-op.
<br>
# MENTAL STATUS CHANGES: The patient presented with mental
status changes which he described as increased ability to "do
anything." He was noted on exam to have a flat affect and
difficulty with concentration. It was felt that his
presentation was likely secondary to his metastastic disease,
specifically his large frontal lobe lesion with associated
edema. He had no localizing symptoms of infection. His
electrolytes were within normal limits. His urinalysis and
culture were normal. His RPR was non-reactive. He was
continued on his home doses of donepazil, fluoxetine and
clonazepam. His mental status significantly improved after
starting on steroids and was close to baseline at time of
transfer.
<br>
# MELANOMA: The patient reports a new subcutaneous mass on his
thigh and possibly his neck which likely represent metastatic
disease. He has no been on treatment for the past several
months and has known metastatic disease in his lung and
subcutaneous tissue. MRI of the brain performed on admission
showed evidence of new lesions in the brain. He underwent CT of
the chest/abdomen and torso which showed evidence of a
previously known pulmonary lesion but no knew lesions. MRI of
the spine to evaluate further for metastatic disease was
deferred during his MICU course but may be considered during
this hospitalization given that on presentation the patient
noted some mild bowel incontinence (but in the setting of
diarrhea). He will see Dr. [**Last Name (STitle) 519**] as an outpatient to have his
thigh lesion evaluated.
<br>
# 2ND DEGREE HEART BLOCK: The patient has a history of
Wenckebach phenomenon. On admission the patient was noted to be
in this rhythm on telemetry. He was asymptomatic and
hemodynamically stable. His was monitored on telemetry and did
not have any concerning events. His electrolytes were monitored
closely and repleted and all nodal agents were held.
<br>
# HYPERLIPIDEMIA: He was continued on his home dose of
atorvastatin.
<br>
# ANEMIA: On admission the patient had evidence of a mild
macrocytic anemia with an MCV of 101 and hematocrit of 37.3
which is approximately his baseline. B12 and Folate were normal
on this admission as were iron studies. Reticulocyte count was
1.2 which is slightly decreased in the setting of anemia. The
etiology of his anemia is unclear. [**Name2 (NI) **] further workup was
pursued.
<br>
# PULMONARY EMBOLUS: The patient has a remote history of
pulmonary embolus for which he is on coumadin. On admission his
INR was supratherapeutic and his coumadin was held in the
setting of the likely need for surgical intervention for his
brain lesions. Neurosurgery was consulted who recommended
against the urgent reversal of his anticoagulation.
<br>
# ARF: On admission the patient's creatinine was 1.3. After
fluid hydration it had decreased to 0.8 which is his baseline.
It was felt that his acute renal failure was thus of prerenal
etiology secondary to dehydration.
<Br>
# CODE: FULL - confirmed in clinic on admission
<br>
# DISPO: Discharged to rehab.
Medications on Admission:
1. Fluoxetine 40mg daily
2. Coumadin 5mg daily
3. Klonopin 0.5mg daily
4. Aricept 10mg daily
5. Lipitor 20mg daily
6. Multivitamin daily
7. Vitamin C
8. Vitamin B complex
9. Vitamine E
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Hold for sedation. Do
not exceed 4g Tyelenol a day.
Disp:*60 Tablet(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
8. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**]
Drops Ophthalmic QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
Charwell House
Discharge Diagnosis:
Metastatic melanoma to brain
Discharge Condition:
Neurologically stable. Slight left pronator drift but otherwise
intact strength.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up for suture removal in 10 days post-operatively: on or
around [**9-2**] (or have them removed at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] if you are
still there).
You have an appointment in the Brain [**Hospital 341**] Clinic scheduled as
follows:
1. MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-9-25**] 2:05
2. Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2169-9-25**] 4:00
Finally, have an appointment with Dr. [**Last Name (STitle) 519**] in the cutaneous
oncology clinic for evaluation of your thigh lesion at 10:30 am
on [**2169-8-30**]; phone [**Telephone/Fax (1) 19462**].
Completed by:[**2169-8-29**]
|
[
"V10.82",
"348.5",
"197.0",
"198.89",
"V58.61",
"584.9",
"191.1",
"426.13",
"198.4",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51",
"01.59",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
12595, 12636
|
6506, 11472
|
357, 408
|
12708, 12790
|
4198, 6483
|
14164, 14903
|
3349, 3618
|
11717, 12572
|
12657, 12687
|
11498, 11694
|
12814, 14141
|
3633, 4179
|
280, 319
|
436, 1442
|
1464, 3188
|
3204, 3333
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,773
| 139,496
|
4347
|
Discharge summary
|
report
|
Admission Date: [**2118-11-11**] Discharge Date: [**2118-11-15**]
Date of Birth: [**2071-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
intermittent chest pain, diaphoresis and SOB that resolved with
rest over the past month
Major Surgical or Invasive Procedure:
CABGx3
History of Present Illness:
47 yo male with know history of CAD and prior PTCA of LAD and
RCA in 8/[**2107**]. He had a repeat atherectomy of the LAD in 11/94.
Has had medical mgmt. and was running six days a week until 2
years ago. He had a normal ETT in [**8-1**], and a negative stress
echo in [**10-30**]. He began to develop anginal symptoms again about
one month ago. He had a + ETT and was referred for cath at
[**Hospital1 18**].
Past Medical History:
remote ETOH abuse
elev. chol.
anxiety
cluster headaches
CAD (PTCA LAD and RCA)
Social History:
works as NStar technician
married with 2 children
smoked for 15 years, then quit for 8 years. Now smokes one ppd X
2 years.
States he quit drinking 18 years ago ( wife not sure this is
true), may still be drinking
Family History:
mother had CABG
father had congenital heart abnormality
Physical Exam:
97 T, SR 56, 130/70, 98% RA sat, RR 22
PERLA , EOMI, normocephalic, atraumatic
RRR S1S2, no m/r/g , no JVD or carotid bruits
R fem drsg, 2+ DP/PT/radials
no varicosities
CTA bilat.
abd, soft, NT, ND, + BS, no HSM
[**6-2**] strengths, MAE, non focal neurologically
Pertinent Results:
[**2118-11-11**] 09:00AM BLOOD WBC-5.8 RBC-4.45* Hgb-12.7* Hct-38.1*
MCV-86 MCH-28.5 MCHC-33.3 RDW-13.7 Plt Ct-156
[**2118-11-15**] 06:20AM BLOOD WBC-6.2 RBC-2.77* Hgb-8.0* Hct-23.2*
MCV-84 MCH-29.0 MCHC-34.6 RDW-13.6 Plt Ct-144*
[**2118-11-15**] 10:40AM BLOOD Hct-24.2*
[**2118-11-11**] 09:00AM BLOOD Neuts-60.1 Lymphs-28.6 Monos-6.2 Eos-4.9*
Baso-0.3
[**2118-11-11**] 09:00AM BLOOD PT-12.0 PTT-27.8 INR(PT)-1.0
[**2118-11-15**] 06:20AM BLOOD Plt Ct-144*
[**2118-11-11**] 09:00AM BLOOD Glucose-131* UreaN-22* Creat-0.9 Na-139
K-3.8 Cl-105 HCO3-26 AnGap-12
[**2118-11-15**] 06:20AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-138
K-4.1 Cl-102 HCO3-28 AnGap-12
[**2118-11-11**] 09:00AM BLOOD ALT-21 AST-19 AlkPhos-55 Amylase-79
TotBili-0.1
[**2118-11-11**] 09:00AM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
[**2118-11-11**] 09:00AM BLOOD Triglyc-58 HDL-71 CHOL/HD-2.5 LDLcalc-96
Brief Hospital Course:
Admitted on [**11-11**] for cath which revealed: 95% LM, LAD mild prox
dz, CX/OM1 50%, small RCA 80% EF 60%. Refered to Dr. [**Last Name (STitle) **] for
urgent CABG, and taken to the OR for CABG x3 (LIMA to LAD, SVG
to OM, SVG to PDA). Transferred to CSRU in stable condition on
titrated neosynephrine and propofol drips. Extubated early the
next day and was on ativan for protection from possible post-op
delirium given his uncertain ETOH history.Remained on neo and
started diuresis on POD #1. He was alert and oriented and
hemodynamically stable. Was encouraged to increase his pulm.
toilet and neo weaned off on POD #2 and chest tubes were
removed. On POD #3, he was transfused one unit PRBCs for Hct of
25.2, and then transferred to the floor. Beta blockade continued
with lopressor. He completed a level 5 with PT on POD #4. His
Hct was 24 and the patient was given the option of transfusion,
but he declined it, so iron will be given postoperatively for
one month. Tobacco cessation was also discussed with the
patient, but he declined the use of a nicotine patch at this
time. He is discharged to home with VNA services today in stable
condition.
SR 80, T 97.8, 107/64, RR 18, 95% RA sat., wt. 72.2 kg (pre-op
70 kg)
Medications on Admission:
ASA 325 mg daily
lipitor 20 mg daily
valium 5 mg prn ( uses 2-3 times/mo.)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Ferrous Gluconate 324 (36) mg Tablet Sig: One (1) Tablet PO
twice a day for 1 months.
Disp:*60 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
9. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p CABG x3(LIMA->LAD, SVG->OM, SVG->PDA)
CAD,^chol,anxiety, ETOH abuse, cluster headaches.
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and d ry. OK to shower, no bathing or
swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
no lifting greater than 10 pounds for 10 weeks
may not drive for one month
Followup Instructions:
wound clinic in 2 weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-3**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2118-11-15**]
|
[
"V17.3",
"272.0",
"300.00",
"414.01",
"305.1",
"V11.3",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.56",
"88.53",
"36.15",
"37.22",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4989, 5047
|
2462, 3689
|
412, 421
|
5183, 5190
|
1566, 2439
|
5467, 5652
|
1209, 1267
|
3814, 4966
|
5068, 5162
|
3715, 3791
|
5214, 5444
|
1282, 1547
|
284, 374
|
449, 860
|
882, 962
|
978, 1193
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,558
| 113,424
|
269
|
Discharge summary
|
report
|
Admission Date: [**2120-9-26**] Discharge Date: [**2120-10-9**]
Date of Birth: [**2080-8-6**] Sex: M
Service: Plastic Surgery
REASON FOR ADMISSION: The patient was transferred from [**Hospital3 418**] Hospital via med-flight, status post [**2080**]5 feet
out of a tree with extensive facial fractures.
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
gentleman who fell 25 feet four hours prior to arrival at
[**Hospital1 69**] after an intermediate
stop at an outside Emergency Department ([**Hospital3 417**]
Hospital) who intubated the patient for airway protection and
life-flighted him to the trauma unit here.
PAST MEDICAL HISTORY: The patient's past medical history on
presentation was negative (per report). The patient was
intubated.
REVIEW OF SYSTEMS: Review of systems was negative.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood
pressure on arrival was 137/81. His heart rate was in the
80s. He was intubated at 99%. His pupils were equal, round,
and reactive to light and accommodation. There was blood in
his nares. A mobile hard palate was appreciated, and he had
three lacerations on the left cheek. His tympanic membranes
were clear. He had a chin laceration as well. He was placed
in a cervical collar. No obvious deformity was appreciated.
His lungs were clear to auscultation bilaterally. His
abdomen was soft, nontender, and nondistended. A left upper
quadrant abrasion was noted. His peritoneum was
guaiac-negative. His prostate was okay. His extremities
revealed a left shoulder contusion. Pulses were found in all
distal extremities and in all upper extremities. He moved
all extremities spontaneously. His back and spine revealed
there was no deformity. He was on a back board on
presentation. His [**Location (un) 2611**] Coma Scale on presentation was 7.
PAST MEDICAL HISTORY: Further information was obtained from
the family regarding the patient's past medical history of
hypertension, high cholesterol, and gastroesophageal reflux
disease.
MEDICATIONS ON DISCHARGE: His medications were [**Doctor First Name **] and
Lipitor.
ALLERGIES: He had an allergy to PROTONIX (from which he got
a rash).
SOCIAL HISTORY: Occasional alcohol. A nonsmoker.
PERTINENT LABORATORY VALUES ON PRESENTATION: His
laboratories on presentation revealed his white blood cell
count was 13.8, his hematocrit was 37.7, and his platelets
were 245. His sodium was 144, potassium was 4.2, chloride
was 108, bicarbonate was 24, blood urea nitrogen was 19,
creatinine was 0.8, and blood glucose was 155. His amylase
was 59. His prothrombin time was 12.7, partial
thromboplastin time was 18.4, and his INR was 1.1.
Toxicology screen was negative. Gas was 7.34/45/92/28 with a
base deficit of -1. The patient was on synchronized
intermittent mandatory ventilation at 700, 50% FIO2, and a
positive end-expiratory pressure of 5.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative.
A pelvic x-ray was negative.
A computed tomography of the abdomen and pelvis was negative.
CONCISE SUMMARY OF HOSPITAL COURSE: The diagnosis at the
time of presentation was loss of consciousness and maxillary
fracture. The patient was admitted to the Trauma Surgical
Intensive Care Unit. Cervical spine films, cervical collar,
ACT, tetanus, antibiotics, and a Plastic Surgery was
initiated.
Plastic Surgery saw the patient the same evening. They
arrived to find the patient sedated. The patient was
intubated and sedated. Facial laceration of 5 cm and a chin
laceration were sutured. Open mandible fracture, midline and
open palate, and ecchymosis of the left eye. Tympanic
membranes were clear bilaterally. No septal hematoma was
appreciated. Facial bones were palpated. Stepoff was noted
at palate.
At this juncture, two coronal computed tomography scans were
initiated for evaluation of facial fractures. Oral and
Maxillofacial Surgery was initiated. An Ophthalmology
consultation was initiated. The patient was placed on
clindamycin and sutures of laceration for repair.
On postoperative day one, the patient continued to be
hemodynamically stable. His respiratory system was clear.
His abdomen was soft with positive bowel sounds. Socially,
his wife was updated on his status, as an Intensive Care Unit
resident, and the patient was stable.
On hospital day two, officially the cervical spine was
cleared. The patient was evaluated by the Plastics
attending. Le Fort I and Le Forte II palatal fracture. The
plan was for open reduction/internal fixation of facial
fractures after cervical spine clearance.
On hospital day two, Ophthalmology came by. On computed
tomography, there was already apparent, with a lateral
orbital fracture nondisplaced with no evidence of globe
rupture. The left lateral orbital wall fracture. Consensual
pupil reflexes were intact.
On hospital day three, the patient continued to be stable.
He did spike a temperature with a temperature maximum of 101
degrees Fahrenheit. Urine cultures were initiated which
turned out to be negative.
On hospital day four, tube feeds were started. The patient's
temperature maximum was 101.2 degrees Fahrenheit. The
patient remained stable and intubated.
On hospital day five, the patient continued to be stable. No
events of significance. The patient was made nothing by
mouth at midnight with a plan to take the patient to the
operating room on hospital day six.
The patient was taken to the operating room for open
reduction/internal fixation of multiple facial fractures.
Please see the Operative Report. The patient tolerated the
procedure well. The patient was stable postoperatively with
a patent airway and was kept intubated overnight. His head
was elevated. The patient was placed in a maxillary
mandibular fixation.
On postoperative day one, hospital day seven, the patient
continued to do well. The patient did spike a temperature to
103.1 degrees Fahrenheit. In addition to clindamycin, the
patient was placed on levofloxacin.
On hospital day seven, postoperative two, the patient
continued to be intubated secondary to facial edema. A
Dobbhoff tube was placed, and tube feeds were once again
started. Maxillary computed tomography scan was taken again,
and with input of Oral and Maxillofacial Surgery, the
condylar displacement was once again evaluated and judged to
be stable. Further evaluation will be determined through
Oral and Maxillofacial Surgery. The patient's hematocrit, on
hospital day seven, required a transfusion of 2 units of
packed red blood cells with further hematocrit levels being
ascertained. Input was once again given by Oral and
Maxillofacial Surgery. All fractures were reduced. The
patient was stable from a Plastic Surgery perspective;
however, he remained intubated due to facial edema. Tube
feeds were advanced.
On [**2120-10-5**] there was decreasing facial edema. The
sutures in the cheek were removed. The sutures under the
chin were removed subsequently. The patient was in an
extubation trial. The patient was appropriate and followed
commands. The patient was extubated on hospital day ten,
postoperative day four. The patient continued to do well.
He was transferred to the floor. The facial swelling was
decreasing. As the patient was transferred to the floor, he
continued to improve. However, there was some question as to
when the patient was out of bed and was evaluated by Physical
Therapy; there was some question as to some unsteadiness on
his feet. His Romberg sign was negative; however, that
coupled with his mechanism injury prompted a head computed
tomography which was negative for mass effect or for any old
or new bleeds. The patient continued to improve.
On hospital day 12, the patient was given a Panorex. His
Foley catheter was discontinued. On hospital day 13, the
patient was evaluated by Nutrition and given instructions on
what kilocalories were needed to meet the patient's needs.
The patient would need 9 cans to 10 cans of Boost per day.
The patient continued to do well and was cleared by Neurology
as to a normal neurologic examination. The patient was
cleared by Physical Therapy to be able to go home with a cane
for assistance until he regained stability in ambulation.
Occupational Therapy cleared the patient from a neurologic
perspective as well.
DISCHARGE DISPOSITION: It was deemed that the patient would
be appropriate to go home on [**2120-10-9**] after his
continued improvement.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Oral and
Maxillofacial Surgery regarding maxillomandibular fixation.
2. The patient was instructed to follow up with Plastic
Surgery regarding his facial fractures.
CONDITION AT DISCHARGE: The patient was discharged on
[**2120-10-9**] in stable condition.
MEDICATIONS ON DISCHARGE: Discharge medications included
resuming his home medications.
DISCHARGE DIAGNOSES:
1. Complicated facial fractures (Le Forte I and Le Forte
II).
2. Mandibular fracture.
3. Lateral and orbital wall fracture.
4. Status post open reduction/internal fixation of facial
fractures.
5. Status post fall from a height of 20 feet.
[**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], M.D. [**MD Number(2) 2613**]
Dictated By:[**Name8 (MD) 2614**]
MEDQUIST36
D: [**2120-10-8**] 19:52
T: [**2120-10-9**] 08:28
JOB#: [**Job Number 2615**]
|
[
"873.41",
"272.0",
"873.44",
"802.32",
"802.4",
"530.81",
"E884.9",
"802.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"86.59",
"96.6",
"76.76",
"76.78",
"76.74",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8362, 8478
|
8931, 9444
|
8847, 8910
|
8511, 8737
|
3095, 8338
|
8752, 8820
|
795, 1848
|
350, 645
|
1871, 2038
|
2213, 3065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,300
| 165,327
|
28161
|
Discharge summary
|
report
|
Admission Date: [**2135-5-11**] Discharge Date: [**2135-6-5**]
Date of Birth: [**2070-10-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
admit for liver transplant evaluation
Major Surgical or Invasive Procedure:
endoscopy
colonoscopy
paracentesis
History of Present Illness:
64 M h/o alcoholic cirrhosis diagnosed [**9-24**], course c/b
encephalopathy, ascites, +SBP and GIB with known varices, who
presents for expedited transplant evaluation.
.
Pt hospitalized [**9-24**] for increasing abdominal girth, found to
have hepatic encephalopathy, GIB. He was started on diuretics,
lactulose, rifaximin, and nadolol, then found to have +SBP.
.
~[**2-20**] mo ago an indwelling abdominal catheter was placed for
fluid drainage. He was seen at [**Hospital1 18**] hepatology clinic [**2135-5-9**]
for evaluation for liver transplant, and [**1-21**] multiple apparent
admission at OSH for encephalopathy and recurrent ascites, he is
being admitted today to expedite transplant evaluation
.
ROS is negative for f/c/ns/ha/dysphagia/cp/abd
pain/n/v/hemetemesis, melena, brbpr, diarrhea, constipation.
weight has been stable over past 2-3 months per pt.
.
+SOB occasionally, but states able to climb flight of steps
without cp/sob, is limited by "weakness in legs." no
orthpnea/pnd.
Past Medical History:
alcoholic cirrhosis - dx [**9-24**], last drink [**9-24**].
h/o SBP
h/o grade 1,2,3 varices with prior GI bleed
h/o CAD s/p 1v CABG, mechanical AVR [**2126**]
DM2 - initially treated with metformin, pt not treated since
[**9-24**].
?h/o hepatitis - +while in army, no intervention ([**2090**])
h/o blood transfusions x 3 ([**2126**]).
Social History:
married, lives with wife in [**Name2 (NI) 68443**], MA. 2 sons, retired
[**Name2 (NI) 68444**] manager. 2ppd x 40yrs, quit 20yrs ago. Drank at least 6
pack per day since age 15. per wife, drinking 1 quart vodka
daily for past 2-3 years. quit [**9-24**]. denies IVDU.
Family History:
F. d. at 72yrs with h/o CAD, s/p MI. M d. [**MD Number(2) 68445**] with colon ca
Physical Exam:
VS: 99.1 98.3 85/51 (85/51 - 87/41) 88 18 97%RA fsbs 113
GEN: nad.
HEENT: PERRL, anicteric, OP clear, MMM , no jvd.
CV: regular, +click, 2/6 SEM loudest at RSB, ?radiates to
carotids, normal s1, s2, no r/g.
Resp: CTA B, no r/r/w.
Abd: +BS, mildly distended, +fluid wave, nontender, ?abdominal
drain in place in epigastrium/RUQ. negative [**Doctor Last Name **] sign, no
rebound or gaurding.
EXT: 1+ dp/pt pulses, 2+ radial pulses, 1+ B LE edema.
Neuro: A&OX3, CN II-XII intact, strength/sensation intact
grossly, slow/deliberate gait, symmetric, mild asterixis
Pertinent Results:
[**2135-5-15**] 01:27PM ASCITES WBC-87* RBC-353* Polys-20* Lymphs-24*
Monos-8* Mesothe-1* Macroph-47*
[**2135-5-12**] 04:58PM ASCITES WBC-147* RBC-278* Polys-13* Lymphs-29*
Monos-0 Mesothe-8* Macroph-50* Other-0
[**2135-5-15**] 02:35PM ASCITES TotPro-0.4 Albumin-<1.0
[**2135-5-11**] 08:45PM BLOOD WBC-10.2 RBC-2.72* Hgb-8.3* Hct-24.1*
MCV-89 MCH-30.7 MCHC-34.6 RDW-19.0* Plt Ct-178
[**2135-5-11**] 08:45PM BLOOD PT-14.4* PTT-36.3* INR(PT)-1.3*
[**2135-5-11**] 08:45PM BLOOD Glucose-101 UreaN-39* Creat-1.9* Na-127*
K-5.7* Cl-95* HCO3-22 AnGap-16
[**2135-5-11**] 08:45PM BLOOD ALT-29 AST-77* LD(LDH)-446* AlkPhos-133*
Amylase-111* TotBili-1.5
[**2135-5-18**] 04:45AM BLOOD ALT-18 AST-30 LD(LDH)-172 AlkPhos-104
TotBili-1.7*
[**2135-5-13**] 05:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2135-5-18**] 04:45AM BLOOD HIV Ab-NEGATIVE
.
Chest x-ray ([**2135-5-11**]): No radiological evidence of acute
cardiopulmonary process.
.
Abd U/S ([**2135-5-12**]): 1. Cirrhotic liver without focal mass.
Patent hepatic vasculature. 2. Cholelithiasis. 3.
Splenomegaly. 4. Moderate amount of ascites.
.
Duodenal biopsy ([**2135-5-13**]): No abnormality.
.
Echo ([**2135-5-13**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%) and regional wall motion
is probably normal. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. A bioprosthetic aortic valve
prosthesis is present and appears well-seated. The transaortic
gradient is normal for this prosthesis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. No
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
Rest MIBI ([**2135-5-17**]): Normal rest only myocardial perfusion
study.
.
CT abd/pelvis with contrast ([**2135-5-17**]): Conventional arterial
anatomy supplying markedly cirrhotic and shrunken liver. No
focal hepatic lesions seen. Widely patent portal veins and
hepatic veins. Total liver volume is 1395.987 cubic cm.
Brief Hospital Course:
64 year old gentleman with alcohol-related cirrhosis c/b
encephalopathy, ascites, SBP, and portal HTN with varices s/p
EGD w/banding of varices and Strep Viridans in peritoneal fluid,
course complicated by acute renal failure, GI bleed.
.
EtOH Cirrhosis, transplant evaluation. The patient was admitted
for expedited transplant evaluation given multiple recent
admissions to OSH for encephalopathy and reaccumulation of
abdominal ascites. He underwent EGD with banding of grade III
varices with red whale signs on [**5-13**]. The patient underwent
repeat EGD in the setting of acute bleeding (see upper GI
bleeding below) with repeat banding of esophageal varices on
[**2135-5-29**]. His abdominal drain was removed by transplant surgery
[**5-14**]. He underwent diagnostic and therapeutic paracentesis x6
during this hospitalization remarkable for strep viridans growth
in a single sample for which he was successfully treated
(subsequent negative cultures) with antibiotics (see SBP below).
The patient underwent p-mibi revealing a partially reversible
inferolateral defect for which he will follow up with cardiology
as an outpatient (see cardiovascular below). He underwent
colonscopy revealing no significant defect and PFT's revealing a
restrictive lung pattern (FEV1 and FVC in the 70's%). CMV IgG
was negative, CMV IgG positive, CMV IgM negative, RPR
nonreactive, Toxo IgG positive, Toxo IgM negative, Rubella IgG
positive, VZV IgG negative. The patient will follow-up with Dr.
[**Last Name (STitle) 497**] in the near future for further evaluation for possible
transplant. The patient will likely require outpatient cardiac
catheterization in advance of possible transplant. He was
continued on nadolol, lactulose, rifaximin and ciprofloxacin
prophylaxis.
.
Upper GI bleed. The patient was found to have grade III varices
with red whale signs on initial EGD. These were banded. His
course was complicated by hematemesis on [**2135-5-29**] -
hemodynamically stable without significant change in hematocrit.
The patient underwent repeat EGD which revealed bleeding varices
which were again banded. The patient requires repeat EGD in
approximately 2-3 weeks (approximately the last week in [**Month (only) **]).
The patient was noted to have an anemia at baseline and his iron
studies revealed a low-normal ferritin with normal TIBC not
entirely consistent with iron deficiency. He was given iron
supplementation while in the hospital, though this was not
continued on discharge (though his outpatient physicians can
consider restarting this). The patient was guaiac positive on
occult stool testing throughout this admission. The patient did
receive several blood transfusions during this admission with
good Hct response. He was started on nadolol for prophylaxis.
.
SBP. The patient underwent 6 therapeutic and diagnostic
paracentesis. His second paracentesis (on [**2135-5-15**]) was
remarkable for Strep viridans growth in [**1-21**] bottles. The patient
was treated with amoxicillin for approximately a [**10-2**] day
course. Of note, the patient's ascites cell count was not
consistent with SBP at this time point or at any other. He was
entirely asymptomatic (including afebrile) and no subsequent
ascites fluid cultures had any growth. There was high concern in
this patient with past AVR for transient bacteremia with seeding
of his heart valve. He had a TTE on admission that did not show
any vegetations and repeat TTE was deferred in the setting a low
Duke's criteria score. The patient was not a candidate for TEE
in the setting of large esophageal varices. Multiple
surveillance blood cultures were negative. The patient was
continued on ciprofloxacin prophylaxis upon discharge.
.
Hepatorenal syndrome. The patient developed transient acute
renal failure in the setting of large volume paracentesis and
sbp. This likely represented hepatorenal syndrome with low urine
sodium. He was placed on the hepatorenal protocol, including
midodrine, octreotide and daily albumin with complete resolution
of his Cr elevation back to baseline.
.
Cardiovascular. The patient is s/p AVR. He was not placed on
anticoagulation as he has a coagulopathy associated with his
liver disease. The patient underwent p-mibi as part of
pre-transplant evaluation and was found to have a partially
reversible defect in the inferolateral region. In the setting of
hepatorenal syndrome and upper GI bleed, cardiac catheterization
was deferred. The patient will follow-up as an outpatient for
consideration of cardiac catheterization.
.
HIT antibody positive. The patient developed a thrombocytopenia.
He was found to be HIT antibody positive. His platelet count was
trending upward at the time of discharge with all heparin
products held.
Medications on Admission:
MEDICATIONS: (per wife)
lactulose 1tbsp TID
protonix 40mg po QD
rifaximin 200mg po bid
spirinolactone 25mg po bid
lasix 40mg po qdaily
folic acid 1mg po qdaily
metoprolol 12.5mg po qdaily
MVI
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*3*
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Alcoholic cirrhosis
Spontaneous bacterial peritonitis
Bleeding esophageal varices
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for evaluation of your liver failure. Please
follow-up with Dr. [**Last Name (STitle) 497**] for further evaluation and
consideration of a liver transplant.
.
You underwent an endoscopy while in the hospital and had blood
vessels in your throat treated to prevent bleeding. You must
have a repeat endoscopy as an oupatient 2-3 weeks after your
last endoscopy (sometime between [**6-12**].
.
You may have heart disease based upon your stress test while in
the hospital. You must follow-up with a cardiologist for a
possible cardiac catheterization.
.
An aide or nurse will come to your house to continue to provide
physical therapy.
.
Please adhere to a low salt (<2gm/day) diet.
.
Take all medications as prescribed. You must take nadolol daily
to help treat the bleeding vessels in your throat. Also take
ciprofloxacin, an antibiotic, daily to help prevent infection in
the fluid within your abdomen.
.
Call your doctor for any fevers, persistent abdominal pain,
progressive abdominal distention, nausea, vomiting, blood in
your stool or vomit, confusion or any other concerning symptoms.
Followup Instructions:
Please call Dr.[**Name (NI) 948**] office on Monday ([**Telephone/Fax (1) **]) to
schedule a follow-up appointment in approximately 2 weeks. You
must also schedule at the same time a repeat endoscopy.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-7-6**] 2:40
.
Call the cardiology division at [**Telephone/Fax (1) **] to schedule
follow-up regarding your positive stress test while in the
hospital. You should be seen within the next 3-4 weeks if
possible.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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"571.2",
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icd9cm
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[
[
[]
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[
"38.93",
"99.07",
"45.25",
"99.04",
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icd9pcs
|
[
[
[]
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10668, 10729
|
5056, 9789
|
328, 364
|
10855, 10864
|
2731, 5033
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12020, 12665
|
2052, 2134
|
10032, 10645
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10750, 10834
|
9815, 10009
|
10888, 11997
|
2149, 2712
|
250, 290
|
392, 1392
|
1414, 1751
|
1767, 2036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,527
| 189,190
|
24395
|
Discharge summary
|
report
|
Admission Date: [**2127-8-19**] Discharge Date: [**2127-8-23**]
Date of Birth: [**2079-7-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB, fatigue
Major Surgical or Invasive Procedure:
AVR(29 mm CE, tissue), CABG X 1(SVG>PDA) on [**2127-8-19**]
History of Present Illness:
47 y/o male w/LE edema, fatigue, SOB X 1 year. W/U revealed
cardiomyopathy w/ EF 10%, AS, AI.
Past Medical History:
cardiomyopathy
ETOH abuse
bicuspid AV
HTN
GERD
COPD
CHF
Social History:
previous very heavy use, recently down to 3 drinks per day
current smoker, 30 pk years
Family History:
mother w/?CAD at age 42
Physical Exam:
bilat exp. wheezez, otherwise exam pre-op unremarkable
Pertinent Results:
[**2127-8-23**] 05:17AM BLOOD WBC-5.7 RBC-2.77* Hgb-8.6* Hct-24.8*
MCV-89 MCH-31.2 MCHC-34.9 RDW-13.2 Plt Ct-179
[**2127-8-23**] 05:17AM BLOOD UreaN-18 Creat-0.7 K-4.5
[**2127-8-20**] 06:12PM BLOOD Type-ART pO2-69* pCO2-47* pH-7.38
calTCO2-29 Base XS-1
[**2127-8-20**] 06:12PM BLOOD Glucose-100 Na-134* K-4.3 Cl-102
Brief Hospital Course:
Taken to the OR on day of admission, underwent CABG X 1
(SVG>PDA) and AVR (29 CE pericardial) on [**2127-8-19**]. [**Hospital **]
transferred to the CSRU in stable condition, on levophed for
hypotension, which was weaned off by POD # 1. He was
transferred to the telemetry floor on POD # 1, and began to
progress with physical therapy. His po meds were resumed, his
epicardial pacing wires were removed, and he continued with an
uneventful post-operative course. He has remained
hemodynamically stable, and is ready to be discharged home.
Medications on Admission:
MVI
Thiamine
Folic Acid
Lasix 40 QD
Lipitor
Coreg 25mg [**Hospital1 **]
Protonix
Digoxin
Lisinopril 10 QD
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*1 MDI* Refills:*0*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-8**]
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
AS
CAD
cardiomyopathy
HTN
GERD
COPD
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no lifting > 10# for 10 weeks
no driving for 1 month
no creams, lotions or powders to any incisions
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) 34561**] in [**3-7**] weeks
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2127-8-23**]
|
[
"425.4",
"458.29",
"424.1",
"414.01",
"401.9",
"496",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3744, 3815
|
1175, 1719
|
334, 396
|
3895, 3902
|
835, 1152
|
720, 745
|
1875, 3721
|
3836, 3874
|
1745, 1852
|
3926, 4074
|
4125, 4263
|
760, 816
|
282, 296
|
424, 520
|
542, 600
|
616, 704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,052
| 187,487
|
46431
|
Discharge summary
|
report
|
Admission Date: [**2154-1-4**] Discharge Date: [**2154-2-1**]
Date of Birth: [**2086-6-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Cardiac catheterization/RCA angioplasty
CABG x3(LIMA-LAD,SVG-OM,SVG-dRCA)[**1-8**]
PEG placement [**1-28**]
History of Present Illness:
66 yo F with h/o DM2, HTN, CVA ([**2132**]) with residual L sided
weakness, PVD, h/o DVT now on coumadin, PVD s/p ABF bypass
([**2136**]) c/b thrombectomy ([**2147**]) who presents following syncopal
episode. Patient was in USOH until yesterday when patient
developed onset of "indigestion" lasting for several hours,
relieved on its own. Patient then awoke this AM feeling weak
"like her legs were giving out." She thought it was secondary to
low blood sugar. Patient denied any chest pain, shortness of
breath, palpitations at that time. She syncopized and fell and
EMS was called.
.
Upon arrival to the ED, VS: BP 130-60 HR 38 RR28 FS 384. Noted
to have ST elevations in II,III, aVF with reciprocal depression
in I and aVL. CODE STEMI was called, patient was 2mg of atropine
for bradycardia, ASA, SL nitro, plavix 75, integrilin, bblocker
and transferred to the cath lab. Patient underwent balloon
angioplasty to RCA for total occlusion. No other intervention
was performed due to her diffuse disease.
.
On review of symptoms, history is positive for DVT, stroke and
dyspnea on exertion. Denies joint pains, cough, hemoptysis,
black stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, + dyspnea on exertion with minimal activity. Requires a
walker for ambulation. Denies paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope or presyncope.
Past Medical History:
- Type II diabetes since [**2131**]
- Cerebrovascular accident in [**2142**] with left-sided weakness.
- Hypertension.
- DVT on coumadin
- Peripheral vascular disease s/p ABF bypass graft [**2136**];
thrombectomy of that graft in [**2147**].
- Neuropathy.
- History of hyperkalemia.
Social History:
Former smoker (quit [**2140**]). Lives alone in an elder building.
Attends adult day care every day. Has 4 children. Denies EtOH
use.
Family History:
Mother with HTN; Father with stroke. No known early coronary
disease or sudden death
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 96.3, BP 149/59, HR 39, RR 17, 100 O2 on NRB
Gen: WDWN middle aged female wearing face mask. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi anteriorly
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruit on Left. R femoral sheath in
place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
weight on day of discharge: 61 kg
Pertinent Results:
[**2154-1-4**] 11:00AM WBC-9.5 RBC-3.54* HGB-9.7* HCT-30.6* MCV-87
MCH-27.4 MCHC-31.6 RDW-13.5
[**2154-1-4**] 11:00AM PT-24.0* PTT-27.6 INR(PT)-2.3*
[**2154-1-4**] 11:00AM PLT COUNT-332
[**2154-1-4**] 11:00AM UREA N-57* CREAT-4.1*
[**2154-1-4**] 11:14AM GLUCOSE-378* LACTATE-3.3* NA+-128* K+-4.8
CL--96* TCO2-23
[**2154-1-4**] 12:15PM %HbA1c-8.2*
[**2154-1-4**] 12:15PM VIT B12-758
[**2154-1-4**] 12:15PM ALBUMIN-3.0* CALCIUM-7.4* CHOLEST-97
[**2154-1-4**] 12:15PM CK-MB-18* MB INDX-3.3 cTropnT-5.64*
[**2154-1-4**] 12:15PM ALT(SGPT)-28 AST(SGOT)-76* CK(CPK)-548* ALK
PHOS-90 AMYLASE-57 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2154-1-4**] 08:26PM CK-MB-60* MB INDX-4.3 cTropnT-14.96*
[**2154-1-4**] 08:26PM CK(CPK)-1396*
.
Cardiac catheterization [**2154-1-4**]:
Successful POBA of the mid RCA.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal ventricular function.
3. Acute inferior myocardial infarction, managed by acute ptca.
PTCA of RCA vessel.
4. Referral for CABG as definitive treatment
.
ECHO [**2154-1-4**]
.
CT head [**2154-1-5**]:
COMPARISON: [**2153-12-20**].
TECHNIQUE: Non-contrast CT of the head.
FINDINGS: Again demonstrated are bifrontal subdural hygromas,
unchanged. There is no evidence of acute intracranial
hemorrhage, mass effect, or shift of normally midline
structures. There are periventricular white matter hypodensities
bilaterally consistent with chronic microvascular infarctions.
There are punctate hypodensities within the basal ganglia
bilaterally consistent with chronic lacunar infarctions. An old
cerebellar infarct is demonstrated again and is unchanged. There
is no evidence of new infarction. Vascular calcifications are
seen within the vertebral and cavernous carotid arteries. The
visualized paranasal sinuses and mastoid air cells are clear.
Osseous structures are unremarkable.
IMPRESSION: Stable head CT. No evidence of intracranial
hemorrhage.
[**2154-2-1**] 06:35AM BLOOD WBC-13.2* RBC-4.17* Hgb-12.2 Hct-37.2
MCV-89 MCH-29.3 MCHC-32.9 RDW-14.5 Plt Ct-441*
[**2154-2-1**] 06:35AM BLOOD Plt Ct-441*
[**2154-1-28**] 09:35AM BLOOD PT-13.2 PTT-27.8 INR(PT)-1.1
[**2154-2-1**] 06:35AM BLOOD Glucose-200* UreaN-70* Creat-2.7* Na-143
K-3.7 Cl-109* HCO3-22 AnGap-16
[**2154-1-31**] 06:30AM BLOOD Calcium-8.6 Phos-3.3# Mg-2.4
[**2154-1-4**] 12:15PM BLOOD %HbA1c-8.2*
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2154-1-31**] 8:26 AM
CHEST (PORTABLE AP)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman s/p CABGx3
REASON FOR THIS EXAMINATION:
eval for pleural effusions
INDICATION: 67-year-old woman status post CABG. Evaluate for
pleural effusions.
COMPARISON: [**2154-1-25**].
SINGLE VIEW, CHEST: No large pleural effusions were seen. There
may be small radiographically occult pleural effusions. The
right lung base demonstrates better aeration compared to prior
study suggesting resolving atelectasis. Bilateral lung
parenchyma demonstrates good aeration. No focal areas of
opacification are noted. There is no pneumothorax.
Cardiomediastinal silhouette, heart size are within normal
limits.
IMPRESSION: No definitive evidence of pleural effusions. No
significant changes since then [**2154-1-25**].
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 98635**] (Complete)
Done [**2154-1-8**] at 2:20:40 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-6-12**]
Age (years): 67 F Hgt (in):
BP (mm Hg): 138/47 Wgt (lb): 150
HR (bpm): 105 BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 745.5, 428.0, 410.91, 427.89, 786.05, 440.0, 424.0,
424.2
Test Information
Date/Time: [**2154-1-8**] at 14:20 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW4-: Machine: 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 1.9 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Findings
LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Left-to-right shunt
across the interatrial septum at rest. Small secundum ASD.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in aortic arch. Mildly
dilated descending aorta. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. No
TEE related complications. The patient appears to be in sinus
the patient.
Conclusions
PRE-BYPASS:
1. A left-to-right shunt across the interatrial septum is seen
at rest. A small secundum atrial septal defect is present.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %). There is
inferior wall hypokinesis from the base to the apex.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened. Mild (1+)
tricuspid regurgitation is seen.
8. There is a moderately sized right pleural effusion.
POST-Bypass:
Patient was removed from cardiopulmonary bypass on levophed,
epinephrine, dobutamine infusions and was AV paced.
1. Left ventricular function is unchanged, LVEF 40-45%.
2. Right ventricular function is moderately depressed
post-bypass.
3. Aortic contours are intact post-decannulation.
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) **] [**2154-1-8**] 17:41
Brief Hospital Course:
67 yo W with PMH of DM, HTN, hyperlipidemia, hx of DVT on
anticoagulation presents with STEMI and heart block.
Initially in complete heart block. Converted to Mobitz Type II
and intermittently with first degree heart block.
Creatinine rose from 3.1 to 3.9 with acute renal failure.
She was taken to the operating room on [**1-8**] where she underwent
a CABG x 3.
She was transferred to the ICU on levophed, epinephrine,
dobutamine, and propofol. She was seen immediately post op by
electrophysiology as she was in complete heart block with a slow
junctional escape and her epicardial wires failed. A temporary
tranvenous pacing wire was placed. She underwent brochoscopy
later that evening which showed RUL secretions and atelectasis.
She also developed A fib/Aflutter.Renal team consulted . Two
cardioversions were attempted on POD #3 without success.Low dose
vasopressin started whle still pressor dependent. SQ heparin
started for DVT prophylaxis.Zosyn continued for low grade
fevers. and WBC monitored closely. Converted to SR on POD
#7.CVVHD had been started for volume management/ anuria.Pressors
slowly weaned over then next few days.
Extubated on POD #7. Dialysis catheter placed. Dobhoff placed
when she failed a bedside swallow eval. Transferred to the floor
on POD #9. Transferred back to the CVICU on POD #13 for
hyperglycemia control with an insulin drip. [**Last Name (un) **] consult done
for tighter management. Wound care consult also done for left
heel pressure. Zosyn stopped on POD #14. Transferred back to the
floor on POD #15. Thoracic surgery consulted for PEG
placement.Plavix held and PEG done [**1-28**]. Re-evaluated by PT and
rehab screening done.
Free water boluses done for hypernatremia. Multiple adjustments
made for BP control. Target SBP is 120-160. Pt. should get 1-1.5
liters of free water daily with daily monitoring of
sodium/lytes.Creatinine on day of discharge is 2.7. Current
fixed and sliding scale insulin dosing chart is included with
discharge papers as well as instructions for leg care/wound
management.Will probably need transition to ACE-I as an outpt.
under direction of PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Cleared for discharge to rehab on [**2-1**] (POD #24). Pt. is to make
all followup appts. as per discharge instructions.
Medications on Admission:
Calcitriol 0.25 microgram tab PO daily
lisinopril 40 daily
nicardipine 20 mg three times a day
Lopressor 100 b.i.d.
Amitryptiline 50mg qHS
Lasix 40 mg PO bid
Simvastatin 40mg PO daily
Neurontin 400 twice a day
iron 325 daily
Coumadin 4.5mg PO qHS
Humulin 70/30 60U qAM, 40U qpm
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Month/Year (2) **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) neb
Inhalation Q6H (every 6 hours).
4. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day): sub Q.
7. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
9. Hydralazine 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6
hours).
10. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
11. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
TID (3 times a day).
13. Isosorbide Dinitrate 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
(3 times a day).
*******14. insulin - fixed dose and sliding scale charts are
included with discharge papers.
Discharge Disposition:
Extended Care
Facility:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
CAD s/p RCA angioplasty and CABG
Inf. MI
DM, HTN, prior CVA(left side weakness), DVT(coumadin),
Neuropathy, Ao-bifem bypass '[**36**]
acute renal failure
PEG placement
left heel pressure ulcer
postop Afib/flutter
Discharge Condition:
Stable
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week,
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 8 weeks. No driving until
follow up with surgeon.
Please give 1 to 1.5 liters of free water daily while monitoring
daily sodium, as she has been hypernatremic.
Adaptic applied to both shins and wrap in kerlix, and continue
waffle boots on both legs.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] after discharge from rehab
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (renal) Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2154-3-18**] 1:00
Completed by:[**2154-2-1**]
|
[
"428.0",
"410.41",
"599.0",
"285.9",
"997.3",
"276.1",
"250.40",
"518.0",
"263.9",
"785.51",
"428.30",
"427.32",
"427.31",
"414.01",
"585.9",
"997.1",
"707.07",
"403.90",
"426.12",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"96.05",
"39.95",
"37.22",
"36.15",
"43.11",
"38.93",
"99.20",
"96.6",
"39.61",
"00.40",
"38.95",
"88.56",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
15335, 15459
|
11209, 13520
|
327, 437
|
15715, 15724
|
3510, 4332
|
16246, 16552
|
2474, 2560
|
13849, 15312
|
6039, 6068
|
15480, 15694
|
13546, 13826
|
4349, 6002
|
15748, 16223
|
2575, 2575
|
2597, 3491
|
280, 289
|
6097, 11186
|
465, 1997
|
2019, 2305
|
2321, 2457
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,856
| 120,230
|
6548
|
Discharge summary
|
report
|
Admission Date: [**2122-6-16**] Discharge Date: [**2122-6-24**]
Date of Birth: [**2067-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25083**]
Chief Complaint:
Metastatic colon CA to brain
Major Surgical or Invasive Procedure:
IVC Filter Placement
History of Present Illness:
55M with metastatic colorectal CA on routine surveillance chest
CT found to have asymptomatic LLL PE. Of note, one month prior,
he had complained of left sided neck pain, shortness of breath,
and was referred to a local ED and found was negative for PE at
that time by CTA. He now complains of a 3 week duration of L
retroorbital HA initially controlled with percocet. Otherwise
states has been having diarrhea/constipation with chemotherapy.
ROS: Nausea/emesis chemorelated, controlled with zofran, no
f/c. no cp/ chronic sob/ no pnd/orthopnea.
Onc Hx: Dx'd [**2116**] with lower colonic upper rectal CA s/p
neoadjuvant 5-FU and xrt with good response. Then had lower
ant. resection with no colostomy with f/u adjuvant 5-FU
leucovorin. Did well until [**9-/2121**] with rising CEA, and found to
have mass in RUL, s/p resection found to be colon CA. Now s/p 3
course of FOLFOX + avastatin most recently finished on [**2122-6-11**]
Past Medical History:
rectosigmoid CA s/p resection [**2116**] and chemo/XRT
HTN
hyperlipidemia
VATS- RUL/LLL nodule - cervical meiastinoscopy with LN biopsy
revealed no evidence of malignancy, then s/p VATS RUL
Social History:
Seven to ten pack year history, discontinued in
the [**2086**]. He has had exposure to asbestos working in a shipyard
from [**2090**] to [**2095**]. He uses alcohol occasionally and socially.
He denies any exposure to uranium, nickel, cadmium, or radon.
Lives with wife and 2 [**Name2 (NI) 25084**] 17/19.
Family History:
Father died of cirrhosis at the age of 49. One
sibling with paranoid schizophrenia. One grandparent died of TB.
One grandparent had a stroke. One grandparent had an MI.
Physical Exam:
VS 96 160/98 50 18 98RA
Gen: appears older than stated age, NAD,
HEENT: PERRL, EOMI, No LAD, no JVD, anicteric, OP with post
palate erythema, dry MM
CV: RRR no mrg
Chest: Slight rhonchi RLB
Abd: +BS nt/nd no organomegaly
Ext: No c/c/e 2+DP
Neuro: AAOx3 CNII-CNXII intact, no focal deficits, motor [**5-15**]
b/l, sensation intact
Brief Hospital Course:
A/P
55 YO M with metastatic colon CA p/w PE and brain mass
# Brain Mass- He was found to have a new brain lesion on MRI
after presenting to the ED with a left retroorbital headache.
He was started on decadron and was neurooncology, radiation
oncology, and neurosurgery were consulted. There was concern for
leptomeningeal disease, and a lumbar puncture was performed to
evaluate for leptomeningeal disease, which was noted to have a
high opening pressure of 27, but without positive cytology or
suggestive chemistries. Therefore, he was subsequently
evaluated by neurosurgery and brain tumor resection was
performed.
Pt was taken to the OR [**6-19**] electiveley where under general
anesthesia he underwent right occipital craniotomy with excision
of metastatic lesion. He tolerated this well and was transferred
to the PACU overnight for close neurologic monitoring. He
remained stable and was transferred to the floor. Diet and
activity were advanced without difficulty. Wound was clean ,
dry and intact. He was transferred back to Omed [**6-21**]. He was
also started on Dilantin for seizure prophylaxis after his
surgery was performed. He was never noted to have seizures
during his hospital course, continuation of Dilantin and/or
level monitoring was to be performed at a follow up appointment
with neurooncology. The pathology indicated likely colonic
adenocarcinoma. His headached were well controlled on
decadrone, and he was continued on his dilantin, to follow up in
[**Hospital 20891**] clinic for monitoring. His treatment plan was to
include radiation therapy, he was discharged with follow up with
[**Hospital1 18**] radiation treatment.
# PE- He was noted to have a small 1 vessel, segmental thrombus
noted on CT thorax. This was confirmed on a dedicated CTA of
chest, he had negative LENIs and was clinically asymptomatic
without no ekg changes. A IVC filter was placed for prophylaxis.
As his left porta cath had no drawback, and on history was
noted to have neck pain a few weeks prior, his left upper
extremity was dopplered and demonstrated an upper extremity
clot. He was not systemically anticoagulated, and this was to
be discussed at a future oncological appointment, as the risk of
bleed was thought greater than that of a PE.
# Colon CA-s/p resection, adjuvant chemo FOLFOX+avastin . He was
found to have a brain metastasis on this admission. His
headache was well controlled with steroids and narcotics, and
nausea controlled with antiemetics. Further chemotherapy was to
be discussed as an outpatient.
# CV- HTN - Stable continued on lisinopril, HCTZ, and aspirin
was held.
# Depression- He became more depressed during his hospital
course, and his fluoxetine was increased during his hospital
course.
# Seasonal allergies: Held claritin
# Contact: Wife [**Name (NI) 501**] [**Name (NI) 11923**] [**Telephone/Fax (1) 25085**] - called today, no
answer
Medications on Admission:
aspirin 325 mg a day,
Ativan 0.5 mg for sleep,
Compazine 10 mg as needed for nausea,
fluoxetine 40 mg a day
hydrochlorothiazide 12.5 mg qd
lisinopril 40 mg a day
MiraLax 70 g a day
Percocet 1-2 tablets q6hrs prn
trazodone 50 mg at bedtime.
Claritin 10mg qd
zofran prn
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for Insomnia.
Disp:*30 Tablet(s)* Refills:*0*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2-4H (every 2
to 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
11. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
13. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
Disp:*30 Capsule(s)* Refills:*2*
14. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
metastatic colorectal cancer
Discharge Condition:
Stable
Discharge Instructions:
Please take your medications as instructed
If you experience increased headaches, fevers, chills or other
concerning symptoms please call your physician [**Name Initial (PRE) 2227**]
Please pick up copies of your head MRIs and CTs of your head on
CD format at the Radiology Department prior to your departure
Please follow up with the physicians listed below
You will receive an update in regards to your radiation
treatment from Dr. [**Last Name (STitle) **]
Followup Instructions:
You have an appointment with Radiation Oncology on [**6-29**] at
11:00am in the [**Hospital Ward Name 23**] Building [**Location (un) **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 25086**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2122-7-2**] 2:00
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. Date/Time:[**2122-7-17**] 11:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-11-5**] 9:30
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2122-11-5**] 10:00
|
[
"272.0",
"198.3",
"453.42",
"530.81",
"197.0",
"415.19",
"401.9",
"355.8",
"300.4",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"01.59",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7347, 7402
|
2433, 5336
|
346, 368
|
7475, 7484
|
7996, 8635
|
1888, 2060
|
5654, 7324
|
7423, 7454
|
5362, 5631
|
7508, 7973
|
2075, 2410
|
278, 308
|
396, 1335
|
1357, 1548
|
1564, 1872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,632
| 107,794
|
37658
|
Discharge summary
|
report
|
Admission Date: [**2140-10-30**] Discharge Date: [**2140-11-11**]
Date of Birth: [**2118-9-4**] Sex: M
Service: SURGERY
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
S/P ATV accident with traumatic brain injury
Major Surgical or Invasive Procedure:
[**2140-10-31**] right [**Last Name (un) 8745**] bolt placed
[**2140-11-2**] right chest tube for pneumothorax
History of Present Illness:
This is a 22 y/o patient who was transferred from OSH s/p
fall off dirt bike at approximate speed of 35 mph. He was
wearing a helmet and fell over the handlebars. He was found
to be combative by EMS with GCS 6. He was intubated and sedated
at OSH, no imaging was performed. He was transferred to [**Hospital1 18**]
for further management. Mannitol 75 mg given prior to admission.
Past Medical History:
none
Social History:
+ Tobacco
ETOH -
Family History:
non contributory
Physical Exam:
On Admission:
Temp 98 HR47 BP 152/93 Intubated
HEENT Blood in both ears and oropharynx, right pupil 2mm and
reactive, left pupil 4mm and non reactive
Neck Cervicle collar in place
Chest clear and equal breath sounds bilat, no deformities
COR RRR
Abd no masses, right and left flank abrasions
Ext toes upgoing on left, feet warm
Pertinent Results:
[**2140-10-30**] 06:05PM WBC-21.6* RBC-4.85 HGB-15.0 HCT-43.6 MCV-90
MCH-30.9 MCHC-34.4 RDW-13.0
[**2140-10-30**] 06:05PM PLT COUNT-292
[**2140-10-30**] 06:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-10-30**] 06:07PM GLUCOSE-88 LACTATE-1.4 NA+-138 K+-3.3*
CL--101 TCO2-23
[**2140-10-30**] 08:11PM GLUCOSE-100 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2140-10-30**] Head CT :1. Bilateral subarachnoid hemorrhage. Possible
tiny left cerebral subdural hemorrhage measuring less than 2 mm.
2. Hemorrhage within the prepontine cistern and in the pons
(anteriorly).
Linear hyperdensity anterior to the pons is likely extraaxial.
3. Bilateral longitudinal temporal bone fractures extending to
the right
carotid canal. Left lateral and medial orbital wall fractures
and left
zygomatic fracture. CTA is recommended to exclude carotid
injury.
4. Sinus opacification with fractures of the sphenoid sinus.
[**2140-10-30**] Abd/Chest CT : 1. ET and NG tubes positioned adequately.
2. Consolidation in the superior segment of the right lower lobe
and complete consolidation of the left lower lobe which reflect
aspiration.
3. Anterior mediastinal density which is most compatible with
residual thymic tissue. No evidence of aortic injury.
4. Nonspecific hypodense lesions in the liver and right kidney
which are
incompletely characterized
[**2140-10-30**] C Spine CT : 1. No cervical spine fracture.
2. Bilateral skull base fractures, better evaluated on dedicated
head CT.
3. Secretions within trachea surrounding endotracheal balloon
concerning for aspiration.
[**2140-10-31**] Left forearm : No fracture of the left forearm is
detected. Assessment of the left wrist is limited on these
views. Allowing for this, the left wrist is grossly
unremarkable. However, if there is specific clinical concern for
wrist injury, dedicated views of the wrist would be recommended.
[**2140-10-30**] CTA Head :
1. No evidence of carotid artery dissection.
2. Focal abnormality of the right ACA just superior to the
ACA/ACOM junction. This likely represents tortuosity of vessel,
although tiny focal aneurysm cannot be excluded. Repeat CTA or
MRA could be performed in two to three weeks for further
evaluation.
3. Multiple bilateral skull base fractures, unchanged.
4. Bilateral subarachnoid hemorrhage and hemorrhage anterior
to the pons
within the interpeduncular cistern is better appreciated on
non-contrast head CT performed earlier.
[**2140-11-1**] Head CT : 1. Apparent resolution of subarachnoid
hemorrhage.
2. Persistence of possible left cerebral subdural hemorrhage.
3. Bilateral longitudinal temporal bone fractures and left
lateral medial orbital wall fractures and left zygomatic
fracture (see CT fromSeptember 20, [**2140**] for details).
4. Sphenoid sinus opacification and sphenoid fractures.
5. High-density material in the bilateral maxillary sinuses is
likely
hemorrhage.
[**2140-11-1**] CT sinus/mandible :
There is partial opacification of bilateral mastoid air cells as
well as fluid seen within the left external auditory canal.
High-density
material is seen within the bilateral maxillary sinuses and
sphenoid sinuses compatible with blood. The right skull base
fracture extends longitudinally through the temporal bone
(series 2, image 39; series 401B, image 16). There is also a
fracture that extends from the right posterior wall of the
sphenoid sinus (series 401B, image 41; series 2, image 41) into
the right carotid canal. A longitudinal left temporal bone
fracture is noted that extends into the left parietal bone
superiorly series 2, image 4).There is a minimally displaced
fracture of the left zygoma (series 2, image 35) as well as the
left lateral wall of the left orbit. A thin lucency noted at the
superomedial aspect may represent a subtle fracture. No obvious
extension into the TMJ is noted, the lucency noted on the
studies in the posterior aspect of the TMJ relating to the site
of [**Hospital1 **] of the mastoid and squamous portions of the temporal
bone and seen on both sides. Thin non-displaced fracture of the
lateral pterygoid is noted on the left. Scattered foci of air
are noted including the right side of the neck , related to the
trauma. Evaluation for any other subtle
fractures may be limited.
[**2140-11-5**] CTA Chest :
1. Enlarged now moderate-to-large left pneumothorax. Left chest
tube
terminates in the anterolateral subcutaneous soft tissues of the
chest wall. Slight rightward shift of midline structures.
2. Pneumomediastinum. Subcutaneous gas along bilateral
anterior chest wall, tracking up to the thoracic inlet on the
left. Right chest wall laceration.
3. Multifocal consolidation involving all lobes of the lungs,
likely due to aspiration and pneumonia.
4. Assessment is slightly limited due to respiratory motion,
particularly along the lingula, but no evidence of PE seen.
[**2140-11-5**] MRI C Spine ;
Negative cervical spine MRI scan. Incomplete study of the
thoracic spine.
[**2140-11-8**] MRI Head and orbits :
1. Punctate hemorrhagic diffuse axonal injury in the left
parietal
subcortical white matter, and possibly also in the left
posterior frontal
subcortical white matter. Extensive diffuse axonal injury in the
splenium of the corpus callosum and associated infarction, with
a small hemorrhagic
component.
2. Probable evolving acute/early subacute infarct in the right
pons, which is nonspecific but could be related to
nonhemorrhagic axial injury.
3. Bilateral small retrocerebellar subdural hematomas.
4. Subarachnoid hemorrhage again demonstrated.
5. Unremarkable appearance of the orbits.
[**2140-11-10**] CXR : Near resolution of left apical pneumothorax.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] was admitted to the Trauma ICU for management of
his traumatic brain injury. His GCS at the scene was 3 and 7 at
the time of admission. He was seen by the Neurosurgical service
for evaluation and placement of a bolt for ICP monitoring.His
initial ICP was 10. His left pupil was fixed and dilated and he
had a left hemiparesis. His right upper and lower extremities
were moving. He did require sedation while he was intubated as
he was very agitated.
From a neurologic standpoint he has had marked improvement
during his hospitalization. He was treated with dilantin for 12
days and had no seizure activity. Following his extubation from
the respirator he was able to speak and understand, respond to
commands and his left sided weakness improved. He continued to
have a left HP though this had been improving daily. Most
recent MRI of the C and T spine showed no cord contusion. MRI
of his brainshows axonal injury parietal and frontal white
matter on left aswell as in the left corpus collosum and the
right pons infarct,likely the cause of his left hemiparesis. His
left CN III palsey is unchanged. With the help of physical
therapy he is up and walking but needs to refocus and needs
reminders to concentrate.
[**Known firstname **] developed drainage from his right ear about 1 week ago and
the consistency was old blood. He was reevaluated by the
Neurosurgery Service to assure that it was not CSF. His
drainage gradually decreased and resolved 48 hours ago. He will
continue to follow up with Neurosurgery as an outpatient.
He was treated with antibiotics in the ICU for a presumed
pneumonia. His CXR is notable for b/l atelectesis and he has
remained afebrile off antibiotcs for 24 hours. He is using his
incentive spirometer. On [**2140-11-2**] a right chest tube was placed
for a hemothotax and this drained and was removed without
difficulya few days later. There is no effusion or pneumothorax
on his post pull film.
His nutritional status is being monitored and he is tolerating a
regular diet with nectar thick liquids. He has been seen by the
Speech and Swallow Service who recommend strict aspiration
precautions and a repeat study after he gets settled in rehab.
During his hospitalization his family has been with him 24/7 and
are very supportive, attentive and concerned for his future
recovery. They will appreciate
updates as his condition improves or changes.
Medications on Admission:
none
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush: thru [**2140-11-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Traumatic brain injury S/P ATV accident with
1. SAH
2. SDH
3. temporal bone fractures B/L
4. sphenoid sinus fracture
5. Maxillary fracture
6. right pneumothorax
7. pneumonia
8. left eye fixed and dilated secondary to left 3rd nerve
pupillary fibers affected by orbit fracture
Discharge Condition:
Improved, stable hemodynamics, walking with assistance,eating a
soft diet but needs direction and supervision
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending. Follow the Physical Therapists's
recommendations
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call [**Hospital 4695**] clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 4 weeks.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2359**] for a follow up appointment in 6
weeks
Call the Plactic Surgery Clinic at [**Telephone/Fax (1) 5343**] for a follow up
appointment in [**3-15**] wks.
Call [**Hospital 878**] Clinic at [**Telephone/Fax (1) 44**] for a follow up
appointment in 2 weeks
Call [**Hospital **] clinic at [**Telephone/Fax (1) 253**] for a follow up
appointment in 4 weeks
Completed by:[**2140-11-11**]
|
[
"802.8",
"E821.0",
"804.20",
"860.4",
"507.0",
"950.0",
"305.1",
"482.41",
"342.90",
"875.0",
"802.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.04",
"96.6",
"96.71",
"01.10"
] |
icd9pcs
|
[
[
[]
]
] |
10557, 10654
|
7089, 9539
|
314, 426
|
10974, 11086
|
1298, 7066
|
12106, 12661
|
917, 935
|
9594, 10534
|
10675, 10953
|
9565, 9571
|
11110, 12083
|
950, 950
|
230, 276
|
454, 838
|
964, 1279
|
860, 866
|
882, 901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,488
| 166,768
|
40345
|
Discharge summary
|
report
|
Admission Date: [**2135-10-3**] Discharge Date: [**2135-10-16**]
Date of Birth: [**2062-10-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram
coronary artery bypass grafts x4 (SVG-LAD,SVG-DG,SVG-RI,SVG-PDA)
cerebral embolectomy (catheter based)
History of Present Illness:
This 73 year old white female was transferred from [**Location (un) 620**] with
chest pain and ECG changes. She reports that she has been
travelling for the last week and has been having acid reflux
symptoms on and off for the whole week. However, she reports
never having has acid reflux before, and never having had this
GERD feeling before. The day of admission she woke up with
chest pressure and pain down her left arm. She reports that she
was lying in bed when the pain started, that is was pressure and
"squeezing-like" in nature, [**5-2**], and it lasted for 15-20
minutes. She then decided to go the ER in [**Location (un) 620**], where the
pain started again. They took an EKG which showed ST depressions
in V4-V6 and Q-waves in III and aVF. Initially, there was no
comparison from prior, but records have now been obtained that
show that the Q's are old, but the ST-depressions are new. In
the ED, her first set of enzymes were negative. She was given
ASA, SL NTG and started on a Heparin infusion. She reports that
the pain went away 10 mins after the SL NTG.
Enzymes were negative and catheterization revealed triple vessel
disease. Surgical intervention was undertaken. A urinary tract
infection was treated.
Past Medical History:
hyperlipidemia
s/p right benign breast lumpectomy
noninsulin diabetes mellitus
Social History:
lives in [**State 12000**] with her hudband, has 3 kids
-Tobacco history: Denies
-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= 98.5 BP= 145/73 HR= 90 RR= 18 O2 sat= 100% 3L
GENERAL: WDWN 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 flat JVP.
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. Pt
does have some varicosities on both calves and feet bilaterally.
PULSES:
Right: Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2135-10-16**] 01:11AM BLOOD WBC-15.9* RBC-3.08* Hgb-9.6* Hct-30.2*
MCV-98 MCH-31.2 MCHC-31.8 RDW-14.5 Plt Ct-250
[**2135-10-3**] 10:16AM BLOOD WBC-7.0 RBC-4.63 Hgb-14.4 Hct-41.8 MCV-90
MCH-31.1 MCHC-34.5 RDW-13.0 Plt Ct-156
[**2135-10-16**] 06:14AM BLOOD UreaN-6 Creat-0.7 Na-160* K-4.2 Cl-126*
HCO3-25 AnGap-13
[**2135-10-3**] 10:16AM BLOOD Glucose-159* UreaN-12 Creat-0.8 Na-142
K-4.3 Cl-106 HCO3-27 AnGap-13
[**2135-10-15**] 09:11AM BLOOD ALT-23 AST-30 LD(LDH)-414* AlkPhos-78
Amylase-34 TotBili-0.4
[**2135-10-4**] 01:45PM BLOOD ALT-26 AST-21 CK(CPK)-40 AlkPhos-70
Amylase-32 TotBili-0.4 DirBili-0.1 IndBili-0.3
[**2135-10-10**] 07:10AM BLOOD CK-MB-2 cTropnT-<0.01
[**2135-10-4**] 03:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2135-10-3**] 03:45PM BLOOD cTropnT-0.02*
[**2135-10-16**] 06:24AM BLOOD Type-ART pO2-116* pCO2-38 pH-7.45
calTCO2-27 Base XS-3
Brief Hospital Course:
Following admission she remained stable, enzymes remained flat.
Catheterization was performed to reveal triple vessel disease
and surgical intervention was requested. The usual preoperative
workup was indertaken and a urinary tract infection was treated.
She had acouple of brief episodes of angina and was maintained
on a Heparin drip.
On [**10-10**] she went to the Operating Room where quadruple bypass
grafting was done. The left internal thoracic artery was
harvested but too small for suitable conduit use. She weaned
from bypass in stable condition on Propofol alone.She was
stable, weaned and extubated, remained in sinus rhythm and
transferred to the floor on POD1.
On the morning of POD #2, she was awake, talking, and
ambulating. She developed an acute right hemiplegia and aphasia
in the afternoon. The stroke team was notified and she underwent
emergent cerebral angiography to reveal an embolus in the distal
internal carotid artery into the middle cerebral artery. The
MERCI device was utilized for clot retreival. The plegia
persisted, however, the left pupil was initially normal. later
that night the left pupil was noted to be dilated. An emergent
MRI revealed a large left MCA stroke with concern for
herniation.
Neurosurgery was consulted and the option of craniotomy was
presented to the family. Given the poor prognosis of meaningful
recovery, the family refused, and the patient was started on
hypertonic saline solution and mannitol.
She did not improve clinically and by [**10-14**] was noted to have
dilated, unreactive pupils bilaterally. The stroke team
continued to follow her and the family was aware of the grim
prognosis.
The serum sodium became 168 with a serum osmolality of 340. D5W
was infused and the sodium fell to 157. She was episodically
hyperthermic and hypothermic and these episodes treated
appropriately.
While there were no signs of higher function and no cochlear
reflexes, she did have spontaneous respirations on [**10-16**]. After
discussion with Dr. [**Last Name (STitle) **]. neurology and the oragn donation staff,
the family decided to make her comfort measures only and
withdraw support. She was, therefor, extubated at 1140 hours.
The family returned to the bedside immediately after.
The patient had no subsequent spontaneous respirations and had
cardiac standstill at 1155 hours.
Medications on Admission:
metformin (pt unsure of dose, takes "1 pill at night")
welchol (pt unsure of dose)
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Coronary artery disease
left middle cerebral artery stroke (embolic)
urinary tract infection
s/p MERCI retreival of embolism
s/p coronary artery bypass grafts x4
noninsulin dependent diabetes mellitus
hyperlipidemia
s/p right breast lumpectomy (benign)
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2135-10-16**]
|
[
"784.3",
"599.0",
"434.11",
"250.00",
"V49.86",
"414.01",
"997.02",
"411.1",
"414.2",
"E878.2",
"272.4",
"342.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.40",
"39.74",
"99.10",
"39.61",
"88.56",
"88.41",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
6486, 6495
|
3966, 6324
|
334, 486
|
6792, 6802
|
3088, 3943
|
6855, 6892
|
2003, 2118
|
6457, 6463
|
6516, 6771
|
6350, 6434
|
6826, 6832
|
2158, 3069
|
284, 296
|
514, 1748
|
1770, 1851
|
1867, 1987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,599
| 154,308
|
17355
|
Discharge summary
|
report
|
Admission Date: [**2137-11-7**] Discharge Date: [**2137-11-14**]
Date of Birth: [**2081-2-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Headache, fever
Major Surgical or Invasive Procedure:
[**2137-11-7**]: CT Head and Abdomen
[**2137-11-12**]: MRI Spine
[**2137-11-10**]: PICC line placement:Left subclavian PICC line extends
to the lower portion of the SVC
History of Present Illness:
56yo M s/p liver [**Month/Day/Year **] ~2 months ago was in USGH until
awoke ~2am this morning with fever and neck pain. Oral temp
104, + rigors, with malaise. Also reports frontal headache, as
well as non-bilious emesis once without much nausea. Denies
visual scotoma or light sensitivity. On presentation to [**Hospital1 18**],
fever 95, HR 140, BP 98/53 and given 1.5L IVF thus far. Of
note,
underwent ERCP one week ago with finding of persistent CBD
stricture and thus a stent replacement was performed.
ROS: Wife reports mild viral illness over past week. Denies
lightheadedness. Tolerating diet well recently, no diarrhea,
mild constipation. Mild r-sided abdominal pain radiating to
back, which is not new since post-op. Denies CP, SOB, dysuria.
+ thirsty. No rashes.
Past Medical History:
Hepatitis C with cirrhosis
Hepatocellular Carcinoma s/p cyberknife
HTN
DM- diet controlled previous to [**Hospital1 **]. Post OLT, ss insulin
[**2137-8-30**] orthotopic liver [**Month/Day/Year **]
Social History:
Married. Lives with wife
Family History:
Father died of cirrhosis
Physical Exam:
101.4/101.4, 114, 108/64, 19, 100 on 2L (97 on RA)
A&Ox3, NAD, moves around cautiously on stretcher.
Warm to touch, skin flushed
PERRL, no light sensitivity, anicteric, CN II-XII intact
neck supple, no nuchal rigidity, trachea midline
RR, tachy, no murmurs
CTAB
soft, NT, ND. well-healing chevron incision.
WWP, no C/C/E
Pertinent Results:
On Admission: [**2137-11-7**]
WBC-1.8* RBC-3.69* Hgb-11.2* Hct-31.7* MCV-86 MCH-30.4
MCHC-35.3* RDW-14.7 Plt Ct-132*
PT-14.1* PTT-24.8 INR(PT)-1.2*
Glucose-200* UreaN-22* Creat-1.6* Na-133 K-4.0 Cl-97 HCO3-25
AnGap-15
ALT-26 AST-26 AlkPhos-71 TotBili-0.4 DirBili-0.2 IndBili-0.2
Albumin-4.1 Calcium-8.9 Phos-1.8* Mg-0.9*
tacroFK-6.3
On Discharge: [**2137-11-13**]
WBC-3.0* RBC-3.12* Hgb-9.2* Hct-26.6* MCV-85 MCH-29.5 MCHC-34.6
RDW-15.4 Plt Ct-131*
Glucose-95 UreaN-9 Creat-1.0 Na-141 K-3.5 Cl-104 HCO3-32 AnGap-9
ALT-16 AST-24 AlkPhos-61 TotBili-0.2
Calcium-8.4 Phos-4.5 Mg-1.3*
tacroFK-6.4. Dose increased to 4 mg [**Hospital1 **] on discharge
[**2137-11-7**]: CT Head: No evidence of acute intracranial hemorrhage,
mass effect, or increased intracranial pressure.
[**2137-11-7**]: CT Abdomen: 1. No intra-abdominal pathology. 2. Small
bilateral pleural effusions
[**2137-11-12**]: MRI Spine:
1. No evidence for epidural abscess, hematoma, or spinal cord
compression. Study is limited for detection of abscess.
2. Multilevel degenerative joint disease as outlined above with
most
prominent disc protrusion at T6-T7 with associated moderate
spinal canal
stenosis at this level.
3. Mild bilateral tiny pleural effusions. Posterior subcutaneous
fluid
within the back, likely secondary to recent lumbar puncture.
Brief Hospital Course:
Pt is 56yo M p/w fever, neck pain, s/p OLT [**2137-8-30**] for
HCV/cirrhosis who had recent ERCP stent re-placement [**2137-10-31**].
On admission he was tacyhcardic, hypotensive, and febrile to
Tmax 104.0. The patient was admitted to the SICU, where he
received over 10L of fluid and was placed on vasopressors for
septic shock, and placed on vanco, ceftriax, unasyn, cipro,
acyclovir. Blood culture [**3-29**] Gram Negative Rods which were
speciated as E coli. Antibiotics were narrowed initially to
Zosyn and then switched to Ceftriaxone in anticipation of
discharge on 2 weeks of antibiotics, to be completed [**2137-11-25**] if
repeat surveillance blood cultures from [**11-11**] remain negative as
they are now at discharge.
Head and Abdominal CTs were unrevealing for source of
headache/abscess. An LP was performed which was negative. He was
given a trial of Fiorocet which by patient report has helped
greatly in reducing his headache.
Patient received Neupogen x 3 over the course of the
hospitalization, in addition his cellcept was initially held and
then restarted at a lower dose of 250 [**Hospital1 **]. The WBC responded
slightly. Prograf dose was titrated up and repeat outpatient
labs will be obtained on [**11-15**] to evaluate these changes.
He was also having complaints of back pain for which Ortho spine
was consulted. An MRI did not reveal any acute processes. It was
recommended that patient be discharged with plans for outpatient
PT.
By time of discharge he was afebrile, ambulating and tolerating
regular diet. PICC line is in place for antibiotics, home
therapy is arranged.
Medications on Admission:
FK 2.5/2.5, Prednisone 5', MMF 1000'', valcyte 900', fluconazole
400', bactrim ss', protonix 40', cardura 2', celexa 20',
oxycodone prn, colace 100'', lasix 20', NPH 22u'am, HISS
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous once a day: Continue NPH and Humalog
sliding scale with fingerstick blood sugars.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for Migraine
headache.
Disp:*30 Tablet(s)* Refills:*0*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a
day.
12. PICC line care
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin Flush (10 units/ml) 2 mL IV daily and PRN
13. PICC line care
PICC line dressing
Change every 3 days per agency protocol
Dispense # 5 (Five)
Refills 1 (One)
14. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) unit Intravenous Q24H (every 24 hours) for 11 days.
Disp:*11 unit* Refills:*0*
15. Outpatient Physical Therapy
Outpatient Evaluation for back pain
Please assess and devise plan of care for increasing
strength/endurance and pain alleviation
16. CellCept [**Pager number **] mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Bacteremia (E coli)
s/p liver [**Pager number **] [**2137-8-29**]
Headache; treated as migraine with good effect
Discharge Condition:
Stable
Discharge Instructions:
Please call the [**Month/Day/Year **] clinic at [**Telephone/Fax (1) 673**] for fever>
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down food, fluids or medications. Call for increased
abdominal pain or increased problems with your back
[**Name (NI) **] to be drawn Friday [**11-15**]. Trough Prograf to be included
in labs. Fax to [**Telephone/Fax (1) 697**] [**First Name9 (NamePattern2) 5035**] [**Doctor Last Name 1022**].
Continue Ceftriaxone 2 gms daily through [**11-25**]. This course is
recommended if negative blood cultures from [**11-11**] which remain
pending at discharge.
Outpatient PT evaluation for back pain. MRI results given to
patient. Needs outpatient evaluation for physical therapy plan
of care (script given)
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-11-22**] 2:10
ERCP 2 (ST-4) GI ROOMS Date/Time:[**2138-2-6**] 9:00
[**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2138-2-6**]
9:00
Completed by:[**2137-11-14**]
|
[
"V42.7",
"401.9",
"V10.07",
"785.52",
"995.92",
"038.42",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6953, 7005
|
3314, 4922
|
330, 501
|
7162, 7171
|
1978, 1978
|
7975, 8329
|
1595, 1621
|
5152, 6930
|
7026, 7141
|
4948, 5129
|
7195, 7952
|
1636, 1959
|
2325, 2641
|
275, 292
|
529, 1316
|
2650, 3291
|
1992, 2311
|
1338, 1536
|
1552, 1579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,245
| 125,991
|
18892+18893
|
Discharge summary
|
report+report
|
Admission Date: [**2161-8-18**] Discharge Date: [**2161-8-27**]
Date of Birth: [**2115-1-29**] Sex: M
Service: GOLD SURGERY
CHIEF COMPLAINT:
1. Pancreatic mass.
2. Subcapsular hepatic hematoma.
HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old
male who presented to the hospital in the Birkshire
complaining of ten days of painless jaundice, six days of
dark-colored urine and ten days of pruritus. An ERCP was
attempted at the outside hospital which was unsuccessful so
the patient's primary care physician transferred him to [**Hospital6 1760**] where he underwent a second
ERCP which was also unsuccessful due to blood and coffee
grounds in the stomach and oozing at the major papilla and
edema.
On [**2161-8-18**], the patient was admitted to the hospital. He
denied abdominal pain, nausea, vomiting, fever, chills, or
unintentional weight loss. He did admit to loose stools for
six days, although they remained normal in color.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY:
1. Status post laparoscopic cholecystectomy in [**2156**].
2. Tonsillectomy.
3. Nasal polypectomy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS: Tylenol as needed at home.
SOCIAL HISTORY: The patient is a supreme court judge. He is
married with three children. He has an occasional beer or
glass of wine. He does not use tobacco but did smoke two
cigarettes a day for five years. He quit this four years
ago.
FAMILY HISTORY: His maternal grandmother died of pancreatic
cancer in her 60s. His mother died of lung cancer in her
70s. His father died of a ruptured AAA in his 70s.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile. His vital signs were normal. General: He was
an obese, jaundiced, pleasant male in no apparent distress.
HEENT: The patient had scleral icterus. Heart: Regular
rate and rhythm. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, obese, with scars from the laparoscopic
ports. It was nondistended, nontender, no
hepatosplenomegaly. No rebound or guarding. He did have
petechiae secondary to itching.
HOSPITAL COURSE: The patient was admitted on [**2161-8-18**]
to the hospital service upon which time Dr. [**Last Name (STitle) 468**] was
consulted for history of mass in the head of the pancreas
seen on outside hospital CT scan. On admission, the patient
received a CT angiogram to demonstrate the nature of his
pancreatic mass. He also went for percutaneous transhepatic
biliary drain placement on [**2161-8-19**].
On [**2161-8-20**], an MRI was done to determine the nature
of caudate lobe lesion. Upon receiving the images, it was
discovered that the patient had a large subcapsular hematoma
of the liver along with a liver laceration and active
extravasation of contrast during the MRI. The patient was
lightheaded but his vital signs were normal and stable.
He was emergently transferred to the Surgical Intensive Care
Unit at this time and angiography with embolization was
planned. Subsequently, the angiography showed no signs of
hepatic arterial injury. The patient was transfused with 4
units of FFP and 4 units of packed red blood cells at this
time. At this time, he was transferred to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Surgical Service and was monitored in the ICU with
serial hematocrits and arterial and central venous lines.
The patient's hematocrit fell as low as 24.8 at 10:00 p.m. on
[**2161-8-20**]. Serial hematocrits were monitored and the
patient's hematocrit was maintained above 30 from the morning
of [**2161-8-22**].
Hematology/Oncology was consulted on [**2161-8-21**] and recommended
further determination of the need for radiotherapy or
chemotherapy to be done after the time of surgery. Dr.
[**Last Name (STitle) 468**] and Dr.[**Name (NI) 670**] service continued to follow the
patient while he was in the Surgical ICU. He remained stable
and no other events occurred in the SICU.
The patient was transferred to the floor on [**2161-8-24**]
to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Surgical Service. The patient was
continued on bed rest. On [**2161-8-26**], the patient complained
of left knee pain beneath the patella so he was sent for
bilateral lower extremity ultrasounds which served to rule
out a DVT. He also received plain films of the left knee
which showed mild arthritic changes. The patient was
switched to p.o. levofloxacin on [**2161-8-25**]. His hematocrit
remained stable for the rest of the hospital stay. His
biliary tube continued to drain bilious fluid. The patient
was discharged on [**2161-8-27**].
LABORATORY/RADIOLOGIC DATA: The patient had an ERCP done on
[**2161-8-18**] which showed a moderate amount of blood and coffee
grounds in the stomach and active oozing at the major papilla
with unsuccessful attempts at cannulation of the biliary
duct. Common bile duct brushing taken on [**2161-8-19**]
showed rare atypical single cells. A CTA of the abdomen on
[**2161-8-19**] showed a 3.5 by 3.9 cm pancreatic mass
producing obstruction of the common bile duct and
intrahepatic bile ducts. No adjacent vascular involvement,
local grade 1. It also showed a 2.6 by 5 cm lesion in the
caudate lobe of the liver suggestive of either metastases
versus hemangioma.
The patient received an MRI of the abdomen on [**2161-8-20**] which
showed the caudate lobe lesion to be consistent with
hemangioma. This also showed the known pancreatic mass as
well as a large subcapsular hematoma with active bleeding.
Angiography on [**2161-8-20**] showed no subhepatic arterial
injury.
The patient received another CT of the abdomen on [**2161-8-25**] which showed a large subcapsular right lobe hepatic
hematoma with extension into the liver parenchyma. There
also was some compression of the right portal vein due to
mass affect from the intraparenchymal hematoma. The
intrahepatic ductal dilatation resolved. The percutaneous
catheter remained in place. There was a development of a
large right-sided pleural effusion inconsistent with simple
pleural effusion.
Films of the left knee on [**2161-8-26**] showed mild degenerative
changes. No other pathology was seen.
An ultrasound of the bilateral lower extremity veins showed
no evidence of DVT.
Pertinent laboratories during this admission include
hematocrit on admission of 40.5, subsequent drop in
hematocrit, as mentioned in the hospital course, and
hematocrit on [**2161-8-25**] of 30.5.
On admission, the patient's total bilirubin was around 24.
It was checked again on [**2161-8-23**] and was found to be 8.9.
His liver enzymes remained elevated throughout the hospital
stay, although they did decrease significantly. On [**2161-8-23**],
his ALT was 395, AST 105, and alkaline phosphatase 247. On
admission, ALT was 553, AST 292, alkaline phosphatase 465.
AFP measured on [**2161-8-20**] was 2.6. CA19-9 measured at an
outside laboratory was 941.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with services for change of his
biliary drain.
DISCHARGE DIAGNOSIS:
1. Pancreatic mass in the head of the pancreas.
2. Subcapsular liver hematoma.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg one tablet every day.
2. Levofloxacin 500 mg one tablet every 24 hours until the
time of surgery.
3. Percocet 5/325 one to two every four hours as needed for
pain.
FOLLOW-UP: The patient is to have a follow-up appointment on
[**2161-9-14**] at 11:30 with Dr. [**Last Name (STitle) 468**]. He is to go for
CT angiogram on [**2161-9-14**] at 10:15 before he visits
Dr. [**Last Name (STitle) 468**] and will follow the visit with Dr. [**Last Name (STitle) 468**] with
his preoperative visit with Anesthesia and for preoperative
laboratories. The patient's surgery for the Whipple
procedure is scheduled for [**2161-9-22**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (STitle) 47732**]
MEDQUIST36
D: [**2161-8-27**] 10:58
T: [**2161-8-29**] 13:42
JOB#: [**Job Number 51687**]
Admission Date: [**2161-8-18**] Discharge Date: [**2161-8-27**]
Date of Birth: [**2115-1-29**] Sex: M
Service: SURGERY/GOLD
CHIEF COMPLAINT: Subcapsular hematoma of the liver and
pancreatic mass.
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old
male who presented to an outside hospital in the Berkshires
complaining of ten days of pruritus, six days of dark urine
and three days of painless jaundice. His primary care
physician ordered laboratories, CT and endoscopic retrograde
cholangiopancreatography was attempted at the outside
hospital, however, this was unsuccessful. He was transferred
to [**Hospital1 69**] on [**2161-8-18**], for
endoscopic retrograde cholangiopancreatography with stent
which was also unsuccessful due to blood and coffee grounds
in the stomach, oozing and major papillae edema. He was
admitted at this time to the hospitalist service and started
on intravenous Protonix as well as Unasyn. The patient
denied any abdominal pain, nausea, vomiting or unintentional
weight loss, no anorexia. He does complain of loose stools
for six days, however, they were normal in color.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY:
1. Status post laparoscopic cholecystectomy in [**2156**].
2. Tonsillectomy.
3. Nasal polypectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Tylenol p.r.n.
SOCIAL HISTORY: The patient is a supreme court judge and is
married with three children. He did smoke at one time two
cigars a day for five years but quit four years ago. He
drinks beer and wine occasionally.
FAMILY HISTORY: His maternal grandmother died of pancreatic
cancer in her 60s. His mother died of lung cancer in her
70s. His father died of a ruptured abdominal aortic aneurysm
in his 70s. A sister has noninsulin dependent diabetes
mellitus.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient was afebrile at 98.6, blood pressure 150/80,
heart rate 78, respiratory rate 20, oxygen saturation 96% in
room air. The patient is obese, jaundice, pleasant male in
no apparent distress. He had scleral icterus and his skin
was jaundiced. The lungs were clear to auscultation
bilaterally. His heart had a regular rate and rhythm. His
abdomen was soft, obese, with stria and laparoscopy port
scars at the umbilicus. He is nondistended and nontender.
No hepatosplenomegaly. No rebound or guarding, and he has
petechiae secondary to itching.
LABORATORY DATA: His laboratories from the outside hospital
included a CA of 34.3, CA19-9 pending, total bilirubin 15.0
and prothrombin time of 13.0, INR 1.3 and partial
thromboplastin time of 32.0.
HOSPITAL COURSE: The patient was admitted to the hospitalist
service and was sent for endoscopic retrograde
cholangiopancreatography on [**2161-8-18**]. As previously
mentioned, the endoscopic retrograde cholangiopancreatography
was unsuccessful. On [**2161-8-19**], the patient received a CT
angiogram of the abdomen. He also received percutaneous
transhepatic biliary drain by interventional radiology on
[**2161-8-19**]. On [**2161-8-20**], the patient went for a magnetic
resonance scan to determine the nature of caudate lobe
lesion. During this magnetic resonance scan procedure, it
was discovered that the patient had a large subcapsular
hematoma of the liver. The patient reported dizziness at
this time, but he was not tachycardic nor hypotensive. At
this time, his hematocrit was 31.3 and dropped to 29.6 over a
matter of hours. Hematocrit on admission had been 40.5 two
days earlier. The patient was taken to the angiography suite
where mesenteric angiography was performed which showed no
evidence of extravasation or hepatic artery injury. However,
the patient was transferred to the Surgical Intensive Care
Unit for close monitoring of hematocrit and of vital signs.
Two units of packed red blood cells and two units of fresh
frozen plasma were put on reserve for the patient. A central
line and arterial line were placed. At this time, the
patient received a total of four units of packed red blood
cells and four units of fresh frozen plasma. He was stable
overnight and, on [**2161-8-21**], he was transferred back to the
floor under the blue surgery service with attending Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of the hepatobiliary service. The patient was
placed on bedrest at this time. He continued to improve and
his hematocrit remained stable. The patient was seen by the
hematology/oncology service on [**2161-8-21**], who recommended
surgery and determination of the patient's candidacy for
radiotherapy and chemotherapy after surgery. The next day on
[**2161-8-22**], the patient was transferred to the gold surgery
service under attending Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]. He continued to
improve. His hematocrit at this time was 28.7, however, the
patient was asymptomatic. The plan was to transfuse the
patient to a hematocrit of 30.0.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 9547**]
MEDQUIST36
D: [**2161-8-27**] 10:37
T: [**2161-8-29**] 13:53
JOB#: [**Job Number 51688**]
|
[
"715.36",
"998.2",
"228.04",
"998.12",
"576.2",
"157.0",
"V16.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"45.13",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
9726, 9957
|
7221, 8265
|
7116, 7198
|
9480, 9496
|
10795, 13373
|
1204, 1232
|
9312, 9453
|
9980, 10777
|
8283, 8339
|
8368, 9259
|
1683, 2140
|
9282, 9289
|
9513, 9709
|
7012, 7095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,894
| 151,045
|
32639
|
Discharge summary
|
report
|
Admission Date: [**2178-7-30**] Discharge Date: [**2178-8-8**]
Date of Birth: [**2120-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
shortness of breath, stridor
Major Surgical or Invasive Procedure:
Nasotracheal intubation
History of Present Illness:
Mr. [**Known lastname **] is a 57-year-old man with history of type II DM,
hypertension, status post CABG that was complicated by
perioperative arrhythmias, stroke, and subglottic stenosis
(after multiple intubations), CHF with the EF of 35%-40% on
echo, who presented to the ED with shortness of breath &
stridor. Recent history includes tracheal dilation procedure 2
days ago at Mass Eye & Ear. Pt went home following the
procedure. He noted post-procedure hoarseness & throat/neck
pain. Also, may have had some neck discomfort. He developed
SOB & increasing stridor & presented to [**Hospital1 18**] ED for further
eval.
.
In the ED, initial VS were 98.7, 93, 176/114, 32, 98% on nrb.
He was reportedly A&Ox3, though working hard to breathe &
appearing very uncomfortable. He was stridorous and noted to
have signif swelling in anterior neck. He was given Decadron
10mg IV for swelling. He was intubated by anesthesia while
awake via fiberoptic nasotracheal intubation. ENT was
consulted. Per their note, there was "no supraglottic or
glottic edema/ertyhema appreciated, no pus or masses, unable to
appreaciate subglottic stenosis before ETT passed easily into
trachea." Imaging revealed mult ground glass opacities
(possible multi-focal pneumonia) and neck CT showed 3.8 x 1.2 cm
collection anterior to the thyroid cartilage with adjacent
soft-tissue stranding (not drainable collection per radiology).
He got Unasyn, CTX, and levofloxacin for tx of his PNA &
possible neck infection. He is being admitted to the ICU for
further
.
Review of systems limited by pt's sedation & intubated status.
Past Medical History:
CAD status post CABG [**2176**] (five-vessel CABG) complicated by
perioperative arrhythmias
CVA - during perioperative period with residual left hemiparesis
Hypertension.
Mitral valvular disease status post annuloplasty
Diabetes type 2,
CHF, EF of 35%-40% 2/2 ischemic cardiomyopathy
Afib
Subglottic stenosis following multiple intubations
(peri-CABG)-->stridor
hypercholesterolemia
hemorrhoids
Social History:
The patient is Haitian and has lived in the US
since [**2162**]. He is married with two kids, a 16-year-old son and
a
13-year-old daughter and lives [**Location (un) 6409**]. He used to work
driving a delivery truck for Shaw's. He has never smoked. He
never drinks alcohol. He denies any illicit drug use. He is
sexually active and is heterosexual with one lifetime partner,
which is his wife. [**Name (NI) **] denies any STDs. He was last tested for
HIV in [**2158**], which was negative. He has been at [**Hospital1 **] since
[**80**]/[**2176**].
Family History:
Mother with elevated BP, who passed away at the
age of 104. Dad was an alcoholic.
Physical Exam:
T 101.3, 74, 119/77, 100% on 70%
Gen: intubated, sedated, rousable, NAD
HEENT: PERRL, Nasotracheal tube in place
Neck: indurated region over anterior neck (~few cm long)
CV: RRR, No appreciable M/R/G
Lung: Scattered wheezes & upper airway sounds
Abd: sl. distended, no peritoneal signs
LE: trace LE edema
Pulses: 2+DP/PT
Neuro: occasionally responding to questions by nodding/shaking
head, responds to pain
Brief Hospital Course:
57-year-old man with history of DM, hypertension, status post
CABG complicated by CVA and subglottic stenosis (after multiple
intubations), CHF with the EF of 35%-40% on echo, who presented
to the ED with shortness of breath & stridor and was found to
have a fluid collection in anterior neck s/p tracheal dilation
two days prior as well as probable multi-focal PNA.
.
# Airway compromise/Anterior Neck Collection: Patient presented
with stridor and respiratory distress that required nasal
intubation in the Emergency room and he was admitted to the ICU.
He has history of subglottic stenosis s/p multiple intubations
since CABG in [**2176**] with stridor since that time. He had been
started on prednisone 10mg daily for stridor that was to be
continued until the tracheal dilation procedure. Underwent
tracheal dilation at Mass Eye & Ear on [**7-27**] w/ Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
and developed increasing respiratory distress after the
procedure, eventually presenting to the ED 3 days after
procedure. The initial suspicion was that acute compromise in
airway is related to procedure; however, no clear findings on
fiberoptic imaging while intubating. On exam, he has an anterior
neck mass approximately 5 cm x 0.5 cm with induration and
overlying erythema. He was started on empiric antibiotics with
Unasyn and Clindamycin on admission for concerns of infectious
etiology. A neck CT characterized the mass and a chest CT
revealed multifocal consolidations concerning for pneumonia. His
coverage was broadened to Vancomycin and Zosyn. Given the
concerns for pneumonia, a BAL was performed that was negative
and his antibiotic coverage was narrowed to Zosyn alone. He was
extubated successfully and transferred to the floor. An
ultrasound guided drainage of the anterior neck fluid collection
showed frank blood with a negative gram stain and culture,
consistent with hematoma. Clinical exam was much improved after
drainage. Patient will be continued on oral clindamycin for 5
days after discharge to complete a total of 14 days of
appropriate antibiotic coverage for possible superinfection of
anterior neck collection. He will follow up with Dr. [**Last Name (STitle) **] from
ENT after discharge. On admission he was continued on steroids
because the indication for steroids was unclear at that time.
Steroids were tapered and he was discharged without steroids.
.
# Fevers: reportedly up to 102 in ED and was >101 on arrival to
ICU. Suspect fevers are infectious in etiology given probable
PNA on imaging & possible infectious collection in neck. Fevers
improved although patient continued to spike night-time fevers
until 3 days prior to discharge.
.
# Melena: During the course of the hospitalization, he had an
episode of melena confirmed guaiac positive that was not
associated with drop in hematocrit or a change in hemodynamic
stability. Concern was for upper GI bleed given chronic steroid
use. A colonoscopy performed 2 months prior to admission was
without gross abnormality. GI was consulted for possible
endoscopy, however deferred intervention until outpatient given
hemodynamic stability and recent respiratory distress and airway
compromise. On day of discharge he had another episode of melena
with some bright red blood streaking attributed to chronic
hemorrhoids associated with 4 point drop in hematocrit
overnight. He was again hemodynamically stable with no change in
vital signs and asymptomatic. An outpatient GI appointment for
possible EGD had already been scheduled for early [**Month (only) **]
therefore a CBC was ordered for [**Last Name (LF) 766**], [**8-10**] to reassess
and determine if earlier intervention is warranted.
.
# Hematuria: Patient had an episode of hematuria described by
nurses as blood tinged urine. In the setting of recent Foley
catheterization this was attributed to urethral trauma. However,
given concurrent melena and hemoptysis, concern was for more
systemic bleeding diathesis. No further episodes of hematuria
were described.
# Hemoptysis: Patient had several episodes of blood tinged
sputum that had resolved at time of discharge.
.
# Dysphagia: After extubation, a bedside speech and swallow
[**First Name3 (LF) 2742**] was performed followed by a video swallow study that
showed diffuse deficits with no laryngeal elevation. Patient was
continued on NPO status given high risk of aspiration. A repeat
video swallow several days later after ultrasound guided
drainage and clinical improvement in neck exam and handling of
secretions showed improvement and patient was started on soft
diet with thickened liquids. He was discharged on this diet and
a repeat video swallow will be performed in 2 weeks to assess
whether full diet can be resumed. Patient was gicen appropriate
contact information and instructed to call to schedule this
follow up appointment on [**Last Name (LF) 766**], [**8-10**].
.
# CAD: s/p 5 vessel CABG. CE negative x2 since presentation.
No CP. ASA was held given possible procedure for neck collection
and restarted once taking adequate PO's. Coreg and statin were
held while not taking PO's and restarted prior to discharge.
.
# CHF/Cardiomyopathy: last TTE in [**6-23**] w/ EF 35-40%. Lasix,
Lisinopril, coreg and spironolactone were held during ICU and
while not taking PO, then coreg and lasix were restarted prior
to discharge. In the setting of worsening creatinine that was
improving but not at baseline prior to discharge, lisinopril and
spironolactone were held and patient was given directions for
visiting nurses to send Chem 7 on [**Last Name (LF) 766**], [**8-10**] and
discuss with outpatient PCP whether to resume these medications
on his appointment on [**8-12**].
.
#Afib/CVA: Remained in sinus rhythm with a rate in the 70s.
Coumadin had been on hold peri-procedure (trach dilation) and
was held during admission for ultrasound guided drainage of
anterior neck mass, but restarted prior to discharge.
Instructions were sent for visiting nurses to send INR, PT, PTT
on [**Month (only) 766**] [**8-10**] and [**Company 191**] anticoagulation nurses were
contact[**Name (NI) **] to follow up these lab values and adjust coumadin dose
accordingly. Mexiletine was discontinued per outpatient
cardiologist while in the ICU and not restarted prior to
discharge.
.
# H/o postoperative polymorphic VT: Did not received mexilitine
x 6 days while NPO in the ICU. Discussed with pt??????s outpatient
cardiologist Dr [**First Name (STitle) **] and [**Doctor Last Name **] who agree that mexilitine
may be stopped. He continued to have several episodes of
non-sustained V-tach however and this will need to be readressed
at an outpatient cardiology appointment.
#DM II: Not well controlled given last HBA1c of 11%. Was placed
on half dose of home Lantus with insulin sliding scale while
NPO. Increased back to home dose of 32 units when taking
adequate PO's. His blood sugars remained elevated, possible
secondary to steroid use. Will need to check blood sugars at
home and possibly adjust home Lantus dose for tighter blood
sugar control.
Medications on Admission:
Current Medications:
1. Coreg.
2. Aspirin.
3. Omeprazole.
4. Lisinopril.
5. Mexiletine.
6. Flonase nasal spray.
7. Advair.
8. Fexofenadine.
9. Colace.
10. Multivitamin.
11. Prednisone.
12. Senna.
13. Simvastatin.
14. Coumadin.
15. Spironolactone.
16. Albuterol.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Carvedilol 12.5 mg Tablet Sig: Six (6) Tablet PO QAM (once a
day (in the morning)).
3. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO QPM (once a
day (in the evening)).
4. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lantus 100 unit/mL Solution Sig: Thirty Two (32) units
Subcutaneous at bedtime.
7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) PUFF
Inhalation three times a day.
8. Omeprazole 20 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*
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
13. Humulin R 100 unit/mL Solution Sig: Sliding scale Injection
four times a day: Please use sliding scale as administered by
rehab facility.
14. Magnesium Hydroxide 800 mg/5 mL Suspension Sig: 30 (thirty)
mL PO at bedtime as needed for stomach upset.
15. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
16. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
18. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 5 days.
Disp:*40 Capsule(s)* Refills:*0*
19. Outpatient Lab Work
CBC, Chem 7, INR
Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital **] at [**Hospital Ward Name 23**] Atrium.
20. Portable suction
Patient needs portable suction for transient dysphagia and
inability to handle oropharyngeal secretions.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Neck hematoma, possibly superinfected
chronic blodd loss anemia
Hematuria
Acute renal failure
Secondary:
Diabetes Mellitus
Coronary Artery Disease
Atrial fibrillation
Hypertension
Discharge Condition:
Good. Hemodynamically stable and afebrile. Breathing comfortably
and satting well on room air
Discharge Instructions:
You were admitted to the hospital for difficulty breathing and
stridor. In the emergency room you were intubated and
transferred to the ICU. A CT scan revealed a mass in your neck,
likely related to the recent tracheal dilatation procedure you
had prior to admission. After several days, you were extubated
and transferred to the floor. The neck mass was determined to be
either an abscess or a hematoma and was resolving at the time of
discharge.
.
You were also noted to have a black stool that was positive for
blood. The GI service was consulted and determined that no
intervention was necessary at this time, but recommended an
outpatient procedure called an EGD at a later time if you should
continue to have black stools. An appointment was scheduled for
you with an oupatient GI doctor [**First Name (Titles) **] [**Last Name (Titles) 2742**] for possible EGD,
please follow the appointment as scheduled below.
.
You were found to have difficulty swallowing foods and liquids
by a speech and swallow specialist. You were started on a soft
food diet with nectar thickened liquids which should be
continued at home until a repeat study can be done to determine
the safety of eating solid foods and thin liquids again. This
procedure should be scheduled by calling the number as listed
below. You should continue a diet of soft foods and thickened
liquids as described to you until this procedure.
.
The following changes were made to your medications:
1) Added clindamycin 300 mg every 6 hours until [**8-13**]
2) Increased omeprazole from 20 mg daily to 20 mg twice daily
3) Stopped mexilitine
4) Stopped prednisone
5) Held lisinopril until renal function improves (your PCP will
tell you when to restart this medication)
6) Held spironolactone until renal function improves (your PCP
will tell you when to restart this medication)
.
You should follow up with all appointments as scheduled below.
.
A visiting nurse will see you on [**Month (only) 766**] [**8-10**] to collect blood
for your coumadin clinic and your primary care doctor.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**8-11**] for your
previously scheduled appointment.
Please follow up with the Speech and Swallow department in 2
weeks for a repeat swallow [**Month (only) 2742**]. Please call ([**Telephone/Fax (1) 12765**] on [**Last Name (LF) 766**], [**8-10**] to schedule an appointment.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] associate of your
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] on [**8-12**], at 2:50 pm in central suite on
[**Hospital Ward Name 23**] 6.
Please follow up with Dr. [**First Name (STitle) 2643**] (GI) on [**8-24**] at the [**Hospital Unit Name 3269**], [**Last Name (NamePattern1) **]. Your appointment is scheduled for 9:00
AM, but please show up 15 minutes early (at 8:45 AM) to fill out
paperwork. You are encouraged to call his office at
[**Telephone/Fax (1) 76072**] for directions to the [**Hospital Unit Name **].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2178-8-8**]
|
[
"272.0",
"998.59",
"478.74",
"414.8",
"867.0",
"401.9",
"V45.81",
"486",
"682.1",
"998.12",
"E878.8",
"584.9",
"427.1",
"250.00",
"438.20",
"E879.6",
"455.8",
"518.81",
"786.3",
"428.22",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04",
"86.01"
] |
icd9pcs
|
[
[
[]
]
] |
12945, 12951
|
3546, 10633
|
341, 366
|
13185, 13281
|
15375, 16528
|
3016, 3100
|
10947, 12922
|
12972, 13164
|
10659, 10659
|
13305, 15352
|
3115, 3523
|
273, 303
|
10681, 10924
|
394, 2007
|
2029, 2426
|
2442, 3000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,621
| 109,488
|
50991
|
Discharge summary
|
report
|
Admission Date: [**2125-7-13**] Discharge Date: [**2125-7-24**]
Date of Birth: [**2073-8-19**] Sex: F
Service: [**Last Name (un) **]
The patient is a 51-year-old female with past medical history
significant for herpes, hepatitis C, hypertension, diabetes
status post mechanical valve placed in [**2123**], on Coumadin, who
presented with 1-day history of consistent crampy abdominal
pain, periumbilical in nature. It was persistent with loose
watery diarrhea. Pain was consistently getting worse,
radiating to the back. The patient's pain continued to get
worse prior to admission. She then developed nausea and
vomiting, is diaphoretic, and sought attention in the
emergency department.
PAST MEDICAL HISTORY: As above. Hypertension.
Heart disease.
Depression.
Migraines.
Hepatitis C.
Herpes.
PAST SURGICAL HISTORY: Total abdominal hysterectomy.
AVR.
MVR.
St. Jude's valve.
MEDICATIONS:
1. Coumadin.
2. Fioricet.
3. Lexapro.
4. Lisinopril.
5. Toprol.
PHYSICAL EXAMINATION: On examination, she was afebrile.
Vital signs were stable; however, she was in some abdominal
distress. She was admitted with a diagnosis of pancreatitis,
had a significant [**Last Name (un) 5063**] criteria. Amylase was [**2056**] on
admission, LDH was 423. The patient was admitted to the ICU
and was aggressively fluid resuscitated. The patient was
started on a heparin drip in order to maintain the
anticoagulation for her St. Jude's valve. However in the
ICU, after the first night, her INR jumped to 9.1 because of
her acute illness. The patient had increasing difficulties
in the pulmonary status and was intubated prophylactically in
order to be able to continue to ventilate her and was
continued to aggressively be fluid resuscitated. She had a
gas of 7.23, 47, 51, and base deficit of 8. Her abdomen
remained diffusely tender.
Her white count remained slightly elevated around 14 and her
ABG, eventually after fluid resuscitation began to normalize.
HOSPITAL COURSE: The pancreatitis care was continued. The
patient was placed on a heparin drip and Coumadin was
discontinued. NG tube was placed, CVL was placed. Patients
with an INR, though continued after FFP was given. The
patient continued to have some clotting difficulties with the
recent placement of the CVL on the right IJ. On [**2125-7-15**],
the heparin drip was being held because the patient's
anticoagulation continued to be a difficult issue. This was
then rectified after fluid status began to respond. The
patient was continued on n.p.o. and was intubated. In order
to better establish fluid status, a Swan was placed.
However, the patient in a period of agitation self-
discontinued the Swan. She was agitated. On [**2125-7-18**], the
patient had significantly improved. She extubated in the
unit on [**2125-7-17**], significantly improved, and her abdominal
examination continued to improve. It was decided the patient
met criteria for gentle sips. Sips were provided. The
patient tolerated the sips and she continued to do well. On
hospital day 6, it was decided the patient should be
transferred out of the unit. The patient was transferred out
of the unit and was transferred to the floor. She continued
to improve on the floor. Her diet was advanced. Her
activity level was increased. Her access was removed and
peripheral access was used and the patient continued to
improve. She was on TPN; however, this was weaned off, as
she had been on TPN in the unit. This was then weaned off
and the patient was continued to be on a heparin drip with
goal between 60 and 80. However, the Coumadin was started
and when the INR reached therapeutic 2.5, it was decided that
patient had met criteria for discharge. Therefore, the
patient was discharged in stable condition with an INR of 2.5
to protect the St. Jude's valve. She had recovered fully
from her bout of pancreatitis. Was tolerating a regular
diet, and had a normal activity level, and was discharged in
stable condition.
PRIMARY DIAGNOSIS: Pancreatitis.
SECONDARY DIAGNOSIS: Mechanical valve anticoagulation.
TERTIARY DIAGNOSIS: Respiratory insufficiency, needing for
intubation.
OTHER SECONDARY DIAGNOSES: Diabetes mellitus.
Hypertension.
Hepatitis C.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2125-7-23**] 11:53:18
T: [**2125-7-23**] 21:21:44
Job#: [**Job Number 105945**]
|
[
"518.82",
"250.00",
"577.0",
"070.54",
"401.9",
"276.8",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
2004, 4009
|
851, 992
|
4202, 4524
|
1015, 1986
|
4066, 4180
|
4029, 4044
|
737, 827
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,818
| 188,392
|
47854
|
Discharge summary
|
report
|
Admission Date: [**2111-12-2**] Discharge Date: [**2112-1-27**]
Date of Birth: [**2038-7-7**] Sex: F
Service: SURGERY
Allergies:
Meperidine
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
BAL
History of Present Illness:
73yo F with history of metastatic breast cancer, atrial
fibrillation on coumadin, ulcerative colitis and cardiomyopathy
presents transferred from [**Hospital1 13199**] for impending sepsis.
.
Patient was doing well at rehab and was scheduled to go to [**Hospital1 336**]
for a surgical Gtube but had a sudden Hct drop/acute renal
failure/worsening pulmonary function/waxing mental status and
was transferred to [**Hospital1 18**]. In rehab, she was apparently weaned to
trach mask with speaking valve with occasional SIMV. She then
had increased ventilatory support, CT chest [**11-26**] show large
right pleural effusion. Patient had pigtail placed on [**12-1**].
Pleural fluid labs are pending. 1L has been put out. Renal team
felt that her ARF was due to hypotension on [**11-19**] in the setting
of low HCt. She also has persistant hyperkalemia.
.
Of note, patient was just recently admitted from [**Date range (2) 100990**]
with pontine abscess. Infectious source was not identified and
neurosurgery fet that biopsy was too dangerous. She was treated
with multiple antibiotics but eventually responded to penicillin
G for suspicion of Listeria. She is left with a significant
L-facial paresis, is able to move her tongue, but with
difficulties and remains unable to clear her secretions. She was
intubated and trached because of that. She was also treated for
MRSA and stenotrophomonas PNA with vancomycin and bactrim. She
also has significant proximal muscle weakness b/c steroid use.
Hospital course c/b GI bleed from supratherapeutic INR. EGD
showed AVM. She also had multiple hypotensive episode, likely
from primary brainstem lesion in combination with sedation,
blood loss and also after large volume thoracentesis. She also
developed anemia and thrombocytopenia with neg HIT and
eventually stabilized. She also deveoped bilateral large pleural
effusion which was tapped, cytology showed atypical cells,
concerning for adenocarcinoma. However, she was discharged when
this result is available and there has been no follow up.
Past Medical History:
-breast cancer, diagnosed in [**2102**]; bilateral with metastases to
lymph nodes, s/p lumpectomy, local radiation and 5FU/adriamycin
-osteoarthritis
-s/p R-knee and L-hip replacement ([**2109**])
-Atrial fibrillation
-rheumatoid arthritis
-h/o adriamycin-induced cardiomyopathy
-ulcerative colitis, s/p ileostomy
-restrictive lung disease (related to radiation and/or
amiodarone)
-dilated cardiomyopathy
Social History:
The pt denied use of tobacco or illicit drugs. She admitted to
occasional alcohol use. The pt lives alone, not married, no
children, gets assistance from health aids. At baseline walks
with a cane.
Family History:
No history of stroke or other neurologic disease.
Physical Exam:
T96.7 BP120/65 P110
AC400x20 PEEP5 FiO2 0.6
Gen- intubated, sedated\
HEENT- pupils dilated(R>L), sluggish to light(R>L), mmm,obese
neck, hard to assess JVD
CV- irregular, no r/m/g
resp-decreased breath sounds bilateral bases(R>L), mild wheeze,
pleural bag draining yellowish fluid, no accessory muscle use,
no paradoxical breathing pattern
abdomen- soft, obese, no bowel sound, ileostomy bag contains
yeallowish watery stool
neuro- opens eyes spontaneously, does not obey commands,
equivocal plantar reflexes
extremities- 3+ pitting edema, doplerrable distal pulses
Pertinent Results:
[**2111-12-2**] 11:43PM GLUCOSE-128* UREA N-110* CREAT-1.4*
SODIUM-137 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-33* ANION GAP-13
[**2111-12-2**] 11:43PM ALT(SGPT)-16 AST(SGOT)-30 LD(LDH)-222
CK(CPK)-50 ALK PHOS-297* AMYLASE-283* TOT BILI-0.3 DIR BILI-0.2
INDIR BIL-0.1
[**2111-12-2**] 11:43PM LIPASE-138*
[**2111-12-2**] 11:43PM CK-MB-3 cTropnT-0.14*
[**2111-12-2**] 11:43PM ALBUMIN-2.3* CALCIUM-8.2* PHOSPHATE-5.6*#
MAGNESIUM-2.6 IRON-24*
[**2111-12-2**] 11:43PM calTIBC-257* HAPTOGLOB-192 FERRITIN-617*
TRF-198*
[**2111-12-2**] 11:43PM TSH-8.0*
[**2111-12-2**] 11:43PM CORTISOL-18.4
[**2111-12-2**] 11:43PM DIGOXIN-LESS THAN
[**2111-12-2**] 11:43PM WBC-14.1*# RBC-2.91* HGB-9.4* HCT-30.1*
MCV-103* MCH-32.4* MCHC-31.3 RDW-17.5*
[**2111-12-2**] 11:43PM NEUTS-91.8* BANDS-0 LYMPHS-5.3* MONOS-2.5
EOS-0.3 BASOS-0.1
[**2111-12-2**] 11:43PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TARGET-NORMAL BURR-OCCASIONAL TEARDROP-OCCASIONAL
[**2111-12-2**] 11:43PM PLT SMR-NORMAL PLT COUNT-288#
[**2111-12-2**] 11:43PM PT-13.1 PTT-30.6 INR(PT)-1.1
[**2111-12-2**] 11:43PM RET AUT-2.4
.
Echo:
IMPRESSION:Right ventricular cavity enlargement with pulmonary
artery systolic hypertension. Moderate-severe tricuspid
regurgitation. Preserved left ventriculary systolic function.
Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2111-12-28**], the
severity of mitral regurgitation is now reduced.
.
CT Chest:
IMPRESSION:
1. Limited study due to artifact from the arm and left hip.
2. Markedly increased subcutaneous edema in chest, abdomen, and
pelvis.
3. Status post thoracentesis with pigtail catheter terminating
in the azygoesophageal recess.
4. Increased ascites, measuring [**11-7**] Hounsfield units.
5. Gallstones, without gallbladder distention.
6. Status post tracheostomy, with slight overinflation of the
balloon at the level of thyroid gland.
7. Cardiomegaly with enlargement of right atrium.
8. Bilateral pleural effusion.
9. Increased bilateral patchy opacities with consolidation in
right lower lobe, probably representing combination of edema,
atelectasis, and possibly multifocal pneumonia.
10. Status post left hip replacement.
.
CT Abdomen:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Unchanged bilateral pleural effusions, left greater than
right. Improvement in consolidation seen at the right lung base,
but with bibasilar atelectatic changes.
3. Cholelithiasis without cholecystitis.
4. Slight decrease in the amount of ascites seen in the abdomen.
Slight decrease in overall anasarca compared to the prior study.
.
BAL:
Negative for malignant cells.
.
CT Head:
IMPRESSION:
1. Exam limited by motion. No evidence of acute intra- or
extra-axial hemorrhage.
2. Partial opacification of the sphenoid sinus and total
opacification of the mastoid air cells which was also
demonstrated on the CT scan of [**2111-9-20**].
[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 100991**]
FINAL REPORT
HISTORY: 73-year-old woman status post complicated percutaneous
G-tube
placement. Assess for positioning of the tube.
TECHNIQUE: Multidetector axial images of the abdomen and pelvis
were obtained
with contrast. 15 cc of Gastrografin was subsequently infused
through the
gastrostomy tube and immediate scan of the gastrostomy site was
performed
followed by delayed imaging of the abdomen and pelvis.
CT ABDOMEN: There is a moderate-to-large left pleural effusion
and small
right pleural effusion with associated basilar atelectasis. The
liver appears
increased in attenuation on this non-contrast study. Within the
limits of
this non-contrast study, the pancreas, spleen, adrenal glands,
and kidneys are
stable. The gastrostomy tube appears outside of the stomach
lumen and is
positioned posterior to the greater curvature of the stomach.
Injection of
contrast reveals pooling of contrast within the mesentery and
apparently
extraluminal. On the delayed scan, approximately 10 minutes
after injection,
the contrast remains in unchanged position. No contrast is seen
within the
bowel. There is a large amount of intraperitoneal free air. Free
fluid is
also seen tracking along the left pericolic gutter. Large
gallstones are
again identified.
CT PELVIS: Small bowel loops are not dilated. Ileostomy is again
noted. The
bladder and rectum are stable. No pelvic free fluid is
identified. There is
no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. The percutaneous gastrostomy tube appears extraluminal and is
located
posterior to the stomach. There is a large amount of free air
and small
amount of free fluid along the left pericolic gutter.
2. Moderate-to-large left pleural effusion and small right
pleural effusion.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 5004**] THAM
[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 100991**]
FINAL REPORT
HISTORY: 73-year-old woman status post complicated percutaneous
G-tube
placement. Assess for positioning of the tube.
TECHNIQUE: Multidetector axial images of the abdomen and pelvis
were obtained
with contrast. 15 cc of Gastrografin was subsequently infused
through the
gastrostomy tube and immediate scan of the gastrostomy site was
performed
followed by delayed imaging of the abdomen and pelvis.
CT ABDOMEN: There is a moderate-to-large left pleural effusion
and small
right pleural effusion with associated basilar atelectasis. The
liver appears
increased in attenuation on this non-contrast study. Within the
limits of
this non-contrast study, the pancreas, spleen, adrenal glands,
and kidneys are
stable. The gastrostomy tube appears outside of the stomach
lumen and is
positioned posterior to the greater curvature of the stomach.
Injection of
contrast reveals pooling of contrast within the mesentery and
apparently
extraluminal. On the delayed scan, approximately 10 minutes
after injection,
the contrast remains in unchanged position. No contrast is seen
within the
bowel. There is a large amount of intraperitoneal free air. Free
fluid is
also seen tracking along the left pericolic gutter. Large
gallstones are
again identified.
CT PELVIS: Small bowel loops are not dilated. Ileostomy is again
noted. The
bladder and rectum are stable. No pelvic free fluid is
identified. There is
no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. The percutaneous gastrostomy tube appears extraluminal and is
located
posterior to the stomach. There is a large amount of free air
and small
amount of free fluid along the left pericolic gutter.
2. Moderate-to-large left pleural effusion and small right
pleural effusion.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 5004**] THAM
[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 100991**]
PRELIMINARY REPORT
INDICATION: History of breast cancer, pneumonia, with multiple
medical
problems, acute renal failure, DIC, sepsis. Evaluate for
interval change.
Single portable chest radiograph with comparison to examination
from one day
ago shows increase in the size of the left-sided loculated
effusion.
Right-sided effusion is not significantly changed. Again, there
are diffuse
pulmonary opacities, more on the left than the right, largely
due to effusion
with combination of atelectasis. There is persistence of
retrocardiac
opacity. The cardiac silhouette is probably within normal limits
in size.
Lines and tubes are unchanged in position, with tracheostomy
approximately 3
cm above the carina, right IJ in the upper SVC, and left-sided
PICC in the mid
SVC. No pneumothorax.
IMPRESSION: Slight increase in left-sided loculated effusion,
otherwise
unchanged.
[**Known lastname **],[**Known firstname **]: Microbiology Detail - CCC Record #[**Numeric Identifier 100991**]
[**2112-1-26**] 4:24 pm SWAB Source: G tube effluent.
**FINAL REPORT [**2112-1-26**]**
GRAM STAIN (Final [**2112-1-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN SHORT
CHAINS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Hospital Course:
73yo F with history of metastatic breast cancer, atrial
fibrillation on coumadin and amiodarone, GIB from AVM,
ulcerative colitis with ileostomy, adriamycin-induced
cardiomyopathy, transferred from rehab for hypotension:
.
## Septic shock from Acinetobacter/Stenotrophomonas/Pseudomonas
pneumonia:
Last admission patient was admitted and discharged from ICU.
Baseline blood pressure per OMR records were above 100s. During
last admission, she has multiple hypotensive episode in the
setting of sedation, blood loss and large volume thoracentesis.
During this admission, patient's BP ranged from 80-130, with SBP
often running around 80 at night. Pt had had R thoracentesis
and pigtail cath placed on the day before admission. She was
treated with aggressive IVF for the first several days of
admission, with response in her BP. She was guaiac negative x
3. CT Head showed stable sinus findings and stable pontine
abscess. CT abdomen showed small ascites, but no retroperitoneal
bleed. Pleural fluid was clear, yellow, nonbloody. Pt had
pancreatitis with elevated amylase/lipase, and was treated with
IVF, NPO, analgesia, but Hct was stable. MAP was maintained
>65, CVP>10. Pt was on Levophed from admission until [**2111-12-6**],
and then after sepsis cleared, pt was diuresed with stability in
BP.
.
For possible meningitis, pt was started on empiric vancomycin
and ceftriaxone. LP was found to be negative. BAL showed
Acinetobacter, Stenotrophomonas, and Pseudomonas. Throughout
admission, patient was placed on Vanco, Ceftriaxone, Bactrim,
Levofloxacin, Meropenem for the pneumonia. Meropenem was the
last antibiotic, that was stopped on [**2111-12-24**]. Patient remained
stable off antibiotics. She had another episode of uti with
pseudomonas and was treated for a 7 day cousre.
.
Pt was placed on stress dose steroids on [**2111-12-6**], since she
takes prednisone 10 QD for UC. She was ruled out for an MI, and
ruled out for a PE (pt has metastatic breast ca).
.
## Respiratory failure:
Patient was on trach and vent since admission. Pt underwent
effort to wean from vent in [**Hospital Unit Name 153**], but Vd/Vt was found to be
70-80% on 4 measurements. She was placed on AC and SIMV, with
occasional episodes of PS. Decreased FIO2, peep, Vd/Vt of 70%:
portends very difficult (if at all possible) wean. She will
likely need chronic vent facility. On [**1-6**] there were
difficulties with trach seal. ENT was consulted who changed her
from a bovano to portex 7 trach (size of trach the same). She
was also evaluated by IP for a tracheal stent and they
recommended that if she has problems with trach again, she will
likely need a longer (length of trach) rather than a stent. She
did not have any further problems with the trach.
.
## Acute renal faiure:
Patient was admitted in acute renal failure, which was found to
be prerenal in the setting of hypotension. Her ARF resolved
after 2 weeks, and her creatinine returned to her baseline of
1.2. Creatinine was monitored during the stay as she was on
lasix drip, see below.
.
## 4+ Anasarca:
Patient was given aggressive IVF on admission, with resultant 5+
pitting edema. After stabilization of BP and treatment of
infection and weaning off of Levophed, patient was diuresed
gently with Lasix gtt. Patient's creatinine was stable, and
remained around baseline. The edema however did not resolve
with lasix gtt. Starting [**2112-1-16**] her creatinine started to
increase and lasix gtt was held. She will need to be diuresised
further as her BP and renal insufficiency tolerates it.
.
## Hct decrease:
Patient required blood transfusion every week prior to
admission. Guaiac was negative x 3, hemolysis labs were
negative, pt was taking Fe and folic acid. Iron studies showed
anemia of chronic disease. She had one episode of hct <20,
hemolysis labs were negative, anca negative and there was no
clear source. She was later found to have a L chest wall
hematoma, her INR was supratherapeutic at the time and was held
thereafter. Surgery was consulted who suggested monitoring the
hematoma as there would be a chance of wound infeciton. There
were no further episodes like this. Given her anemia of chronic
disease she should be started on epogen after discharge from
hospital.
.
## Atrial Fibrillation:
Metoprolol and Diltiazem did not work well for patient's AFIB,
because her BP would decrease below 80. She was started on
Amiodarone with reasonable rate control in the 100s. Anxiety
(Ativan) and pain (dilaudid, morphine, percocet) medications
also served to decrease patient's HR. Pt ordinarily took
Coumadin as an outpatient, but coumadin was held during
admission, for hematocrit drop as above. She had several
episodes of tachycardia and cardiology was consulted who
recommended digoxin. Her HR was better controlled thereafter.
.
## Diabetes mellitus 2:
Patient was maintained on insulin gtt, and then insulin sliding
scale starting [**12-3**] until discharge.
.
## R chronic endophthalmitis/R retinal detachment:
Ophthalmology agreed that pt would not undergo surgery to
correct her retinal detachment, and would not require further
antibiotics intravitreally. Ultrasound x 2 showed choroidal
detachment as [**Street Address(1) 33553**]. At [**Hospital1 336**], vitreous culture showed P.
acnes, was injected intravitreally with vanc/ceftazidime.
Patient was maintained on 4 eyedrops and erythromycin ointment
as outpatient. Contact at [**Hospital1 18**] is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (retina).
.
## Metastatic breast ca:
Patient follows with Dr. [**First Name8 (NamePattern2) 189**] [**Last Name (NamePattern1) **] at [**Hospital1 **]. She was placed
on Letrozole starting on [**2111-12-11**]. It is believed that her
pleural effusions are associated with her breast ca. Cytology
from R pleural fluid had shown cells suspicious for malignancy,
but pleural fluid sent at [**Hospital1 **] did not show malignant cells.
.
## Adriamycin-induced cardiomyopathy:
Echo during last admission show EF60% with 3+ MR and 4+ TR.
Echo during this admission showed an improved MR to 2+.
.
## Ulcerative colitis with ileostomy:
Patient was admitted on Prednisone 10 QD. Her dose was
decreased to 5 QD, and was continued to be tapered down. GI was
consulted, who confirmed that pt does not require prednisone for
her UC since her colon has been resected.
.
## Gallstone:
Patient had elevated alkaline phosphatase, amylase, lipase, with
gallstones visualized in GB. Patient was treated by NPO, IVF,
and Dilaudid, morphine, percocet for pain control. LFTs
improved slowly over time.
.
## UTI: Episode of pseudomonas UTI, treated with ceftaz for 7
days, last day ~[**2111-1-14**].
.
## FEN:
Patient was admitted with an NGT, and had an OGT placed. She
was kept on Nepro at 35 ml/hr initially. Surgery was consulted
several times for PEG placement, however given her anasarca and
ascities they believed that her risk for peg complications would
be high. This was a limiting factor for her prior to discharge
as she did not have any souce of nutrition other than NGT and
Nursing home wanted a post pyloric NG. GI was consulted who
were successful in placing post pyloric NG tube, however a few
hours later pt pulled the NG tube. IR was consulted and placed
a PEG tube under floro guidance. She will be started on TFs via
PEG>
.
## Code: Full
.
## Communication: HCP (brother) [**Name (NI) 429**] [**Name (NI) 33962**] [**Telephone/Fax (1) 100992**])
On [**1-14**] /[**2111**] percutaneos G tube was attempted and it was felt
not to be optimal procedure for this reason it was further
studied and found to have a leak for this reason several days it
was observed by the IR and medical ICU team, following that the
tube and then manipulated and interrogated and found to have a
leak again on [**1-18**], on [**1-22**] a CT scan was ordered and the results
were called to the team that the G-tube was freely out in the
peritoneum. at this juncture surgery was called. After extensive
discussion that the patient was in grave state and needed to
have emergency surgery for a likely gastric perforation :this
was repaired on the evening on [**1-22**] into the early morning of
[**1-23**]. and was transferred to the ICU thoughout this post
operative course she continued to have a fluid requirement her
creatinine rose steadily and she eventually became anuric in
ATN, throuout this period she developed a pressor requirement
that steadily increased and her pulmonary status worsened. On
[**1-26**] a dialysis line was placed for pending dialysis. After
placement of the dialysis line she continued to have spetic
appearing physiology but had an additional pressor and blood
requirement having a crit drop of several units. This cycle of
sepsis and increased blood requirement continued and again
extensive discussion was taken with the family regarding the
goals of care. She continued to progress and have failure of
all organ systems having a continued blood product requirement
from potential retroperitoneal bleed related to line placement,
DIC related to sepsis, and vent dependent pulmonary failure, as
well as acute renal failure all the while on maximum pressor
suport. Again extensive discussion was undertaken with her kind
and responsive family who felt as if they were being consistent
with her wishes to continue until it was reached that the most
important goal of therapy could no longer bring meaningful
survival. After this discussion was undertaken the patient was
made comfort measures only and the ionotropic support was weened
and the patient expired shortly after with her family present at
the bedside
Medications on Admission:
Prevacid 30g per NG tube [**Hospital1 **]
CaCO3 500mg per NG
erythromycin
Xopenex
atrovent
folic acid
lopressor 75mg Q8h
Digoxin 0.125
RISS
coumadin
prednisone 10mg QD
zofran prn
percocet prn
renagel 1600mg 3x/day
ertapenem 1g Q12 through [**2111-12-5**]
coumadin
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
sepsis, metastatic breast cancer, blood loss anemia,
ventdependent respiratory failure, pontine abscess, acute renal
failure, cardiomyopathy, shock liver, gastric perforation,
failure to thrive , malnutrition, TPN dependence, HTN, ocular
infection,
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2112-1-27**]
|
[
"570",
"V10.3",
"995.92",
"V55.0",
"V58.61",
"482.1",
"577.0",
"401.9",
"349.82",
"250.00",
"599.0",
"427.31",
"996.59",
"286.6",
"263.9",
"V58.65",
"482.83",
"324.0",
"361.89",
"785.52",
"425.4",
"285.1",
"518.83",
"197.2",
"038.3",
"360.03",
"998.2",
"038.43",
"584.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.61",
"33.24",
"97.23",
"00.14",
"97.02",
"38.95",
"43.11",
"96.6",
"03.31",
"96.72",
"33.21",
"88.03",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
22334, 22349
|
12280, 12280
|
282, 287
|
22641, 22647
|
3671, 6381
|
22700, 22735
|
3018, 3069
|
22305, 22311
|
22370, 22620
|
22016, 22282
|
12297, 21990
|
22671, 22677
|
3084, 3652
|
230, 244
|
315, 2354
|
6390, 12257
|
2376, 2783
|
2799, 3002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,621
| 157,211
|
13146
|
Discharge summary
|
report
|
Admission Date: [**2119-4-9**] Discharge Date: [**2119-4-17**]
Service: CCU
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is an 81 year old woman
with chest pain brought to [**Hospital1 188**] via Med-flight from [**Hospital3 417**] Hospital after
presenting with chest pain beginning at 2:00 a.m. on the day
of admission. Her pain improved spontaneously at 7:00 a.m.,
however, recurred when she returned from church approximately
11:00 a.m., six out of ten. The patient presented to outside
hospital at 2:00 p.m. and electrocardiogram showed 2.[**Street Address(2) 27948**] elevations in leads III, aVF and 1.[**Street Address(2) 35043**] elevation in V4 and V5, Q waves in III, aVF. The patient
initially treated with Heparin, Integrilin, Aspirin,
Nitroglycerin, and transferred to [**Hospital1 190**] Catheterization Laboratory. The patient
underwent cardiac catheterization demonstrating total
occlusion of the right coronary artery proximally, left main
coronary artery normal, left anterior descending severe
proximal enlargement, no stenosis, left circumflex with mild
proximal ectasia. The patient underwent treatment of her
right coronary artery clot with Angiojet thrombectomy, PCI,
stenting. The patient had no angina
postprocedure. Cardiac output 4.31, index 2.18, pulmonary
artery 26/14, pulmonary capillary wedge pressure 14.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Fibroid tumor.
3. Lumpectomy of left breast with radiation.
4. Pulmonary embolism seven years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Synthroid.
2. Vitamin D.
SOCIAL HISTORY: Widow, lives alone.
PHYSICAL EXAMINATION: The patient is afebrile, heart rate
junctional rhythm at 70 beats per minute, blood pressure
100/57, oxygen saturation 98% on two liters nasal cannula.
In general, an elderly woman in no acute distress. Head,
eyes, ears, nose and throat - moist mucous membranes.
Extraocular movements are intact. The pupils are equal,
round, and reactive to light and accommodation. Jugular
venous pressure at 10 centimeters. Lungs are clear to
auscultation anteriorly. Cor is regular rate and rhythm.
Abdomen is soft, nontender, nondistended, normoactive bowel
sounds. Extremities - pulses 1+ bilaterally, dorsalis pedis,
posterior tibial. Cardiovascular examination - no murmurs.
Neurologically, the patient is alert, oriented and
appropriate.
LABORATORY DATA: White blood cell count 10.6, hematocrit
39.0, platelet count 279,000. Sodium 140, potassium 4.5,
chloride 101, bicarbonate 27, blood urea nitrogen 17,
creatinine 0.8, platelet count 123,000. CK 922, MB 160,
troponin 10.8 with peak CK at 2204.
HOSPITAL COURSE:
1. Cardiovascular - The patient was transferred to Cardiac
Care Unit status post catheterization for monitoring given
her large right ventricular infarct. The patient was status
post right coronary artery revascularization. Post
catheterization course was complicated by hypotension
requiring Dopamine, atrial fibrillation and junctional
rhythm. On the morning of hospital day one, the patient
developed a junctional bradycardia. The patient was
continued on her Aspirin and Plavix therapy post
catheterization and started on Lipitor 10 mg once daily. Her
ischemic regimen was eventually expanded as her hypotension
resolved to include Metoprolol 50 mg three times a day with
plans to add ace inhibitor in the outpatient setting.
2. Cardiac function - The patient initially with
hypotension, cardiogenic shock requiring Dopamine, however,
this was able to be weaned on [**2119-4-14**]. Echocardiogram
demonstrated an ejection fraction of 50 to 55%, mild right
atrial dilatation, mid inferior and inferior apical
hypokinesis, marked dilatation of the right ventricle with
depressed function, 1+ tricuspid regurgitation.
3. Rhythm - The patient with transient atrial fibrillation
while on Dopamine which did not recur outside of acute
myocardial infarction setting. Recommend continued follow-up
with cardiology.
4. Pulmonary - The patient with left lower lobe
consolidation with collapse on chest x-ray post
catheterization. She had witnessed aspiration of
emesis/coffee grounds during cardiac catheterization. She
was begun on Levofloxacin and Flagyl and will continue to
complete a fourteen day course.
5. Endocrine - The patient was maintained on Levothyroxine.
6. Gastrointestinal - The patient with stable hematocrit and
single episode of coffee ground emesis while in cardiac
catheterization laboratory. Diet is no added salt diet.
7. Prophylaxis - The patient maintained on Protonix,
intravenous Heparin and pneumatic boots until ambulatory.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSIS: Acute myocardial infarction.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg p.o. once daily times nine months.
2. Enteric Coated Aspirin 325 mg p.o. once daily.
3. Toprol XL 50 mg p.o. once daily.
4. Lipitor 10 mg p.o. once daily.
5. Levothyroxine 75 mcg p.o. once daily.
6. Protonix 40 mg p.o. once daily.
7. Metronidazole 500 mg p.o. three times a day times seven
days.
8. Levofloxacin 500 mg p.o. times seven days.
DISCHARGE STATUS: The patient was discharged to home with
services.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2119-5-14**] 16:01
T: [**2119-5-16**] 20:46
JOB#: [**Job Number 40128**]
|
[
"V17.3",
"410.41",
"578.0",
"244.9",
"427.1",
"507.0",
"458.2",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"39.64",
"88.56",
"36.01",
"99.20",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
4727, 4757
|
4783, 5499
|
1589, 1620
|
2700, 4673
|
1681, 2683
|
104, 117
|
146, 1377
|
1399, 1563
|
1637, 1658
|
4698, 4705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,706
| 116,958
|
46527
|
Discharge summary
|
report
|
Admission Date: [**2199-3-8**] Discharge Date: [**2199-3-14**]
Date of Birth: [**2134-1-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 F c COPD, HTN p/w malaise, diaphoresis, SOB for 1 week. Also
c nausea, but no vomiting/diarrhea. No cough, chest pain,
palpitations, LE edema, orthopnea, PND. In ED, vitals were T
98.5, HR 87, BP 172/101, RR 24, sat 94% on 2L NC. Noted to be
in resp. distress, unable to speak in full sentences.
Significant wheezing. ABG showed pCO2 60, p02 71; placed on
BiPAP. CXR clear by radiology report. Treated with nebulizers,
solumedrol, levofloxacin. Also treated for hypertensive urgency
(BP to 200/100 in ED after presentation) with lisinopril and
amlodipine.
.
At baseline, pt has home O2 2.5L NC for daily use & BiPAP at
night. Pt has never been intubated. Pt reports not using her
supplemental 02 during the day, though she says she always uses
her BiPAP for sleep. Has not been using Nebs recently. No
known sick contacts.
.
MICU course: Thought to have COPD flare from non-compliance with
home 02. Hypertension thought [**2-15**] COPD flare and non-compliance
with medications. Treated overnight with BiPAP and nebulizers.
BP well controlled and did not require additional meds.
Past Medical History:
COPD/emphysema
OSA
HTN
hyperlipidemia
GERD
schizophrenia
depression
s/p R ankle ORIF
obesity
s/p T & A
Social History:
Lives alone, close friend [**Doctor First Name **] is very supportive. Former
tobacco 1ppd x 40 years, now "occasional smoking" few
cigs/monthly. Has an estranged brother in FL.
Family History:
mother-deceased brain CA
father-deceased suicide
sister-deceased PE
Physical Exam:
98.6, 193/119, 66, 18, 97% on BiPAP
GEN: BiPAP on, appears well, speaking in largely full sentences
HEENT: MM dry, Left eye w/purulent discharge & matting, PERRL,
no conjunctival irritation. EOMI. No LAD.
CV: RRR, distant sounds. No JVD. Good pulses peripherally.
PULM: diminished bilaterally w/expiratory wheezes throughout. No
focal crackles or consolidations noted.
ABD: soft, NT/ND. +BS. Obese.
EXT: cool feet bilaterally but palpable DP pp x2. No edema.
NEURO: A&Ox3, MAE, CN III-XII intact grossly, strength 5/5 upper
and lower extremities bilaterally, sensation intact to light
touch. Reflexes not tested.
Pertinent Results:
[**2199-3-8**] 02:30PM WBC-16.7*# RBC-5.98* HGB-15.4 HCT-48.8*
MCV-82 MCH-25.7* MCHC-31.5 RDW-15.4
[**2199-3-8**] 02:30PM CK-MB-NotDone cTropnT-<0.01
[**2199-3-8**] 02:30PM CK(CPK)-56
[**2199-3-8**] 02:30PM GLUCOSE-119* UREA N-22* CREAT-0.6 SODIUM-146*
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-33* ANION GAP-14
[**2199-3-8**] 02:47PM LACTATE-1.6 K+-4.2
.
[**2199-3-8**]
CXR: Study is mildly compromised secondary to body habitus. No
superimposed consolidations or effusions are noted. There is
minimal ectasia of the thoracic aorta with atherosclerotic
disease. The cardiac silhouette remains enlarged but stable. No
pleural effusion or pneumothorax is evident.
IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
65 F w/long history of COPD, OSA, and HTN admitted to MICU on
[**2199-3-8**] with COPD exacerbation. The following issues were
investigated during this hospitalization:
.
#. COPD exacerbation: Pt's respiratory distress was likely from
COPD exacerbation triggered by a viral URI. Additionaly,
patient reported non-compliance w/ daytime supplemental 02 which
likely contributed to her presentation. She was treated with an
initial dose of IV solumedrol on admission, then transitioned to
a PO steroids taper. She also received nebs which were
transitioned to an MDI. She continued on BiPAP at night and 02
by NC during the day and was improving, however, it was noted
that her bicarbonate was slowly trending up. An ABG on room air
showed values of 7.37/68/46. This was compared to an ABG in the
MICU with a CO2 of 68. Given the hypoxia, a repeat ABG on 3 L NC
showed values of 7.34/86/86. The pulmonary consult team was
curbsided and advised placing the patient on BiPAP during the
day for a few hours each day in order to allow the patient to
ventilate her CO2. She remained awake and alert with good
mentation despite the readings of the ABG. Additionally, it was
confirmed with the respiratory team that knows the patient, that
the patient's CO2 baseline is close to that reflected in the
initial ABG. She was discharged to pulmonary rehabilitation on 1
L of O2 with a satisfactory O2 saturation of 92%.
.
#. HTN: Patient was found to have several episodes of
hypertensive urgency for which she received one time doses of
Amlodipine and Lisinopril. Both of these medications, which the
patient had been taking as an outpatient, were increased to
maximum values of 10 and 40 mg respectively. A beta blocker was
not an ideal 3rd option given the patient's COPD and while HCTZ
would have been an ideal choice, a sulfa drug allergy prevented
her from safely receiving it. Since increasing Lisinopril, the
patient's BP has been better controlled with a sytolic BP range
between 150s - 160s.
.
#. SCHIZOPHRENIA/DEPRESION: Stable during this hospitalization.
Pt. is followed at Mass Mental as an outpatient. She was
continued on her outpatient regimen of Risperdal, Trazodone and
Prozac.
.
#. GERD: Pt. was maintained on her outpatient PPI.
.
#. HYPERLIPIDEMIA: Pt. was maintained on her outpatient statin.
.
#. OSA: Pt. with known pulmonary artery hypertension and large
body habitus, on BiPAP ([**10-18**] w/ 3L 02) at home, which was
maintained during this hospitalization.
.
# Conjunctivitis L eye: Noted while in MICU, but resolved with
Erythromycin OPH TID.
Medications on Admission:
Prozac 80 mg'
Risperdal 2 mg'
Lisinopril 20 mg'
Norvasc 5 mg'
Trazodone 200 mg po HS
Protonix 40 mp po'
Lipitor 20 mg'
Albuterol
Advair
Combivent
Nebulizers
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): use for DVT
prophylaxis; can discontinue if ambulating.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 doses: Start on [**2199-3-15**].
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Start on [**2199-3-18**].
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: Start on [**2199-3-21**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
COPD exacerbation
.
Secondary:
OSA
HTN
Mild aortic valve stenosis on echo
hyperlipidemia
GERD
schizophrenia
depression
obesity
Discharge Condition:
Afebrile, Mentating well
Discharge Instructions:
You were admitted to the hospital with COPD/emphysema attack.
This was due to possible viral infection. It is critical that
you use your home oxygen and BiPAP as directed.
.
You are being discharged to [**Hospital **] rehab for further management
of your breathing status. They may adjust your BiPAP settings,
please follow these recommendations on discharge to home.
.
It is very important that you stop smoking, please see your
primary care doctor if you need assistance with this.
.
Please take your medications as prescribed.
Followup Instructions:
Please see your primary care doctor [**Last Name (Titles) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **]
[**Telephone/Fax (1) 693**] within 2wks of discharge from the hospital. You
should have pulmonary function tests done; please discuss this
with Dr. [**Last Name (STitle) **].
|
[
"491.21",
"372.30",
"272.4",
"424.1",
"401.9",
"327.23",
"530.81",
"295.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7296, 7368
|
3241, 5805
|
320, 327
|
7548, 7575
|
2509, 3218
|
8154, 8454
|
1790, 1859
|
6012, 7273
|
7389, 7527
|
5831, 5989
|
7599, 8131
|
1874, 2490
|
261, 282
|
355, 1452
|
1474, 1578
|
1594, 1774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,093
| 187,371
|
46092
|
Discharge summary
|
report
|
Admission Date: [**2144-10-13**] Discharge Date: [**2144-10-29**]
Date of Birth: [**2065-3-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
abdominal aoritc aneurysm 5.1 cm
Major Surgical or Invasive Procedure:
open abdominal aoritc aneursym repair with Aorto-bifemoral graft
[**2144-10-14**]
History of Present Illness:
patient with 5.1 cm AAA now admitted for repair
Past Medical History:
1. h/o atrial ectopy and tachycardia- previous stress and holter
monitor testing
2.spinal stenosis
3. AAA- currently stable at 5 x4 cm by CT
4. neuropathy
5. h/o bronchitis
6. HTN
7.hyperlipidemia
8.asthma
9.barrett's esophagus
10.Antral ulcer [**1-1**]
Social History:
Lives at home with son, who is a teacher.Denies Tobacco or ETOH
use.She has a daughter, who is active in her health care and is
a nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 9012**]
Family History:
noncontribitory
Physical Exam:
alert
lungs : Clear to Auscultation
heart: regular rate rythmn
abd: with pulstile mass
pulse exam right and left PT palpable 2+, right and left DP 1+
palpable bilaterally
Pertinent Results:
[**2144-10-13**] 07:22PM WBC-7.0 RBC-4.36 HGB-12.9 HCT-37.2 MCV-86
MCH-29.6 MCHC-34.7 RDW-15.4
[**2144-10-13**] 07:22PM PLT COUNT-118*
[**2144-10-13**] 06:15PM PT-17.0* PTT-45.2* INR(PT)-1.8
[**2144-10-13**] 06:14PM TYPE-ART PO2-242* PCO2-36 PH-7.38 TOTAL
CO2-22 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2144-10-13**] 07:22PM CK(CPK)-92
[**2144-10-13**] 07:22PM CK-MB-NotDone cTropnT-<0.01
[**2144-10-13**] 07:22PM GLUCOSE-183* UREA N-7 CREAT-0.5 SODIUM-144
POTASSIUM-3.5 CHLORIDE-115* TOTAL CO2-20* ANION GAP-13
Brief Hospital Course:
[**2144-10-13**] DOS: open aaa repair with ABF graft.transfused
intraoperatively 4U PRBC"S and 2 Units of cell [**Doctor Last Name 10105**] blood.
Transfered to PACU stable and intubated.
[**2144-10-14**] POD #1 required 16 Liters fluid for volume replacement.
blood pressure labile. HCt. stable. Remained intubated and
transfered to ICU for vent. support and monitering.afebrile
abdominal exam with distention and diminished bowel sounds.
pulses intact.CK's and tropinins remained flat. beta blockade
increased for sinsu tachycardia control. remined NPO and with
NTG inplace. remained in ICU.Cardology consulted for atrial
tachycardia. Recommendations supportive care and adress
underlying caused for tachycardia.
[**2144-10-15**] POD# 2 no overnight events. afebrile. SIMV abg:
7.38/45/114/28 +1 hct stable 29.8 remaines tachycardiac.
hemodynamically staable CI 3.9 exam wwith continued extremity
edema abdominal exame unchanges. wounds clean dry and intact.
Maintain NTG and NPo. wean vent support.heparin held and
feroldapine began .HITT sent. for thrombocytopenia.betablockade
adjusted for rate control.
[**2144-10-16**] POD#3 afebrile. remains tachycardiac but controlled. on
CPAP blood gases 7.41/49/126/32 +5 awake awnsering questions
abdomen remaind mildly distended and tender but bowel souonds
present. Autodiursing. wounds claen dry and intact.HITT
pending. Remains in ICU.Right IJ changed.
[**2144-10-17**] POD#4 extubated. platlet count stable 94 K. NTG
discontiuned. Remain NPO. Remain in ICU.
[**2144-10-18**] POD#5 temperature 99.7-99.3 TPn started. mildly
confused.remin in VICU.
[**2144-10-19**] POD#6 temperature n100.8-100.0 continued with TPN.
diuresisng well.Continue inVICU. Rt. IJ changed over wire.
[**2144-10-20**] POD#7 continued TPN. EPS cardology reconsulted for
continued tachycardia with large doses of beta blockers.
Recommend if develope hemodynamic instablility because of beta
blockers wound consider AV node ablation and permenant
pacermaker.
[**2144-10-22**] POD# 9 toerating full liguids. passed flatus.
transfered to regular nursing floor.
[**2144-10-25**] POD# 12 patient with chest pain and tachycardia and
hypotension. enzymes cycled negative. symptoms relief with
maalox and sublingual NTG.[**Month (only) 116**] go to rehabilitation with
telemetry.
12.01/04 POD#15 await rehab screening. await recommendationd
reguarding need of telemetry from cardology. They felt it wound
not be required at rehabilitation. this would facititate
discharge planning.
[**2144-10-29**] POD# 16 stable d/c to rehabilitation. stable.
Medications on Admission:
albuterol 90mcg puff 2 qid prn
betaxolol 0.5% gtts 1 OD daily
colace 100mgm [**Hospital1 **]
gemfibrozil 600mgm [**Hospital1 **]
hydralazine 25mgm q6h
lisinopril 40mgm daily
lopressor 25mgm [**Hospital1 **]
multivitamin daily
protonix 40mgm daily
pilocarpine 4% gtts 1 OD daily
predforte 1% gtts 1 OS [**Hospital1 **]
ultram 50mgm qid
xalantan0.005
% gtts 1 OD HS
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-29**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
8. Lorazepam 2 mg/mL Syringe Sig: 0.5mgm Injection Q4-6H (every
4 to 6 hours) as needed.
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-29**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
6. Pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
7. Betaxolol HCl 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metronidazole 0.75 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Verapamil HCl 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q 6 PRN
().
15. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q6h prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
abdominal aortic aneurysm
spinal canal stenosis
hypertension
hypercholestremia
chronic low back [**Last Name (un) **]
peptic ulcer disease by EGD
diverticulosis
Discharge Condition:
stable
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) **]. call for appointment. [**Telephone/Fax (1) 3121**]
f/u with cardiology/EP in 1 month dr. [**Last Name (STitle) 98081**]
Completed by:[**2144-10-29**]
|
[
"285.1",
"287.4",
"427.32",
"401.9",
"276.5",
"276.6",
"562.10",
"493.90",
"272.0",
"427.0",
"276.3",
"E934.2",
"458.29",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"93.90",
"39.25",
"39.52",
"89.62",
"99.00",
"99.04",
"88.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7042, 7113
|
1803, 4367
|
349, 433
|
7318, 7326
|
1243, 1780
|
7349, 7540
|
1020, 1037
|
4783, 7019
|
7134, 7297
|
4393, 4760
|
1052, 1224
|
277, 311
|
461, 510
|
532, 787
|
803, 1004
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,263
| 164,035
|
11586+56254
|
Discharge summary
|
report+addendum
|
Admission Date: [**2131-2-25**] Discharge Date: [**2131-3-21**]
Date of Birth: [**2067-6-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Sternal wound infection
Major Surgical or Invasive Procedure:
[**2131-2-26**] Sternal debridement
[**2131-2-28**] Sternal debridement, right rectus muscle flap and
bilateral pec advancement flap
[**2131-3-6**] Placement of PICC Line
History of Present Illness:
63yo F s/p CABGx3 on [**2132-1-4**]. Patient tolerated procedure well
was readmitted on [**2132-1-12**] and [**2132-1-16**] for sternal drainage.
The wound was debrided and plastic surgery was consulted and a
wound vac was placed. CT scan of the chest was equivocal. She
was discharged to home on Cipro for five days. She states that
on [**2131-1-31**] odor began to be emanated from the wound. The wound
vac was removed on [**2131-2-15**]. Green sternal drainage was noted
approximately one week PTA. Patient heard gurgling from wound
on [**2131-2-25**] went to OSH with mild fever, WBC 14.6, She was then
transferred to [**Hospital1 18**] for further management
Past Medical History:
CAD - s/p CABG, HTN, Hypercholesterolemia, GERD, s/p TAH, s/p
appendectomy, s/p tonsillectomy, s/p bladder suspension
Social History:
Married with five children. Retired. Remote tobacco, quit '[**22**].
Occasional ETOH.
Family History:
Father, mother, brother with CAD
Physical Exam:
Vitals: 98.2, 103/56, 78, 24, 98% on room air
General: No acute distress, does not appear septic
Sternal wound open at inferior end, depth around 2", fibrinous
exudate with foul smell present, bed of granulation tissue
noted. No gross purulence. Wound probed without evidence of
sinus.
Sternum stable without click. "Bubbling" noted with inspiration
and expiration.
Abdomen soft, nontender, nondistended.
Extremities warm
Neuro exam nonfocal
Pertinent Results:
[**2131-2-25**] 10:55PM BLOOD WBC-16.0*# RBC-4.37 Hgb-12.9 Hct-37.2
MCV-85# MCH-29.5 MCHC-34.6 RDW-14.1 Plt Ct-362
[**2131-3-7**] 09:00AM BLOOD WBC-17.6* RBC-3.87* Hgb-11.0* Hct-33.4*
MCV-86 MCH-28.4 MCHC-32.9 RDW-14.9 Plt Ct-502*
[**2131-2-25**] 10:55PM BLOOD Glucose-113* UreaN-22* Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-22 AnGap-19
[**2131-3-6**] 05:55AM BLOOD Glucose-87 UreaN-13 Creat-0.6 Na-134
K-3.5 Cl-95* HCO3-31 AnGap-12
[**2131-3-6**] 05:55AM BLOOD Mg-1.6
Brief Hospital Course:
Mrs. [**Known lastname 36821**] was admitted to the cardiac surgical service for
further management of her sternal wound infection. Wound
cultures were obtained and she was empirically placed on
Vancomycin and Levaquin. The plastics service was consulted to
assist in the management of her sternal closure while the
Infectious Disease service was also consulted to assist in the
antimicrobial management of her wound infection. Given her
clinical signs, she was taken to the operating room the
following day for sternal debridement. She tolerated the
procedure and was brought to the CSRU fully sedated and
intubated. She remained intubated and sedated, and returned to
the operating room on [**2-28**] for additional sternal
debridement, with right rectus muscle flap and bilateral pec
advancement flap by the plastic surgery service. Several JP
drains were placed at that time. There were no complications and
she returned to the CSRU in stable condition. Over the next 24
hours, she awoke neurologically intact and was extubated.
Antibiotics were continued. She maintained stable hemodynamics
and was intermittently transfused to maintain hematocrit near
30%. JP drainage was monitored closely and local wound care was
continued. A chest CT scan on [**3-2**] demonstrated
anterior and posterior soft tissue densities and bone
destruction consistent with osteomyelitis. Wound cultures
eventually grew out polymicrobial organisms - Viridans
streptococci, Corynebacterium species, and Coagulase negative
Staphylococcus. Based on the above results, Flagyl was added to
her antibiotic regimen. She eventually transferred to the
cardiac surgical step down unit. She was noted to have
intermittent fevers and had a persistent leukocytosis. White
count peaked to 20K. C.diff was ruled out as a source of
fever/leukocytosis as several cultures were taken, all returning
negative. Blood cultures were also obtained, also negative. She
continued to be followed by the ID and Plastic surgery. Over
several days, several of the JP drains were removed. A PICC line
was placed without complication on [**3-6**]. Her fevers
eventually improved. It was felt she made steady progress and
was cleared for discharge to rehab on [**2131-3-15**]. Just
prior to discharge, it was recommended by the ID service to stop
Levaquin and continue only Vancomycin and Flagyl for four weeks.
At time of discharge, one JP drain remained in place. Her wound
appeared stable without signs of cellulitis. The staples will
need to remain in for approximately three weeks. She will follow
up with Plastics on [**2131-3-20**] and with followup with ID in [**Month (only) 958**].
She will also followup cardiac surgery in [**2-23**] weeks.
Medications on Admission:
Amiodarone, Lopressor, Aspirin, Lasix, Protonix, Ezetimibe,
Pravastatin, Iron
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs qs* Refills:*0*
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Disp:*60 gm* Refills:*2*
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*30 ML(s)* Refills:*0*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*2*
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*qs qs* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
10. 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*
11. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day: inject SC until ready for
d/c.
17. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. Pravachol 80 mg Tablet Sig: One (1) Tablet PO once a day.
19. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 months.
20. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
21. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
22. Tenormin 50 mg Tablet Sig: One (1) Tablet PO once a day.
23. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
24. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
25. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
26. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
27. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
28. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
29. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
30. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Sternal Wound Infection, CAD - s/p CABG, HTN,
Hypercholesterolemia, GERD, s/p TAH, s/p appendectomy, s/p
tonsillectomy, s/p bladder suspension
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions. Call with fever >101,
redness or drainage from incision, or weight gain more than 2
pounds in one day or five pounds in one week. No lifting more
than 10 pounds for 10 weeks. No driving until follow up with
surgeon. Please monitor weekly CBC, lytes, BUN and creatinine.
Results should be faxed to [**Hospital **] clinic at [**Telephone/Fax (1) 1419**].
Followup Instructions:
1)Follow up with Plastic surgeon, Dr. [**First Name (STitle) **] next Tues, [**2131-3-20**]
- call office for appointment and/or any questions,
[**Telephone/Fax (1) 1416**].
2)Follow up with Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**2-23**] weeks -
call office for appointment and/or any questions, [**Telephone/Fax (1) 170**].
3)Follow up with Infectious Disease Clinic on [**2131-4-16**] at 930 AM
- call [**Hospital **] clinic office with any questions, [**Telephone/Fax (1) 457**].
Completed by:[**2131-3-15**] Name: [**Known lastname 6560**], [**Known firstname **]
Unit No: [**Numeric Identifier 6561**]
Admission Date: [**2131-2-25**]
Discharge Date: [**2131-3-21**]
Date of Birth: [**2067-6-26**]
Sex: F
Service:
Addendum is to start on [**2131-4-12**] as follows: PICC line
was placed on [**3-15**] and potassium was repleted. The
plan was to discharge the patient to rehab. Re-evaluation by
plastic surgery, decision was made to hold the patient as she
spiked a temperature. The wound continued to look good, but
antibiotics was to be continued as per infectious diseases
and the patient was to remain in the hospital and be
monitored. Her temperature had spiked to 100.3. She continued
to be pancultured on vancomycin and Flagyl. Blood cultures
were also repeated. Percocet was changed over to Dilaudid,
and a CT scan was ordered to rule out any abscess or fluid
collections in the area of the flap and sternal debridement.
Patient continued to be followed by Dr. [**Last Name (STitle) 2196**] of infectious
diseases and followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 735**] of plastic surgery.
Patient continued to be monitored as she continued to spike
fevers over the next couple days. It took several days for
the patient's temperature to normalize and became afebrile
again on [**3-17**]. She continued to ambulate, increase her
activity level. Her incision continued to look better. She
was instructed to followup with Dr. [**First Name (STitle) 735**] on [**3-22**] as an
outpatient.
ID recommended a probable 6-week course of vancomycin and
Flagyl. She was also instructed to followup with infectious
diseases for a 9:30 a.m. appointment on [**4-16**].
On [**3-18**], her Bactrim was discontinued. There appeared
to be some necrotic skin areas around the area of her sternal
incision, and she continued to be monitored to make sure she
remained afebrile. She spiked again on the evening of the
26th to 101.9.
On the 27th, pain medicines were again rearranged and her
Darvocet was switched over to codeine as needed. Plastics,
again, re-evaluated her abdominal wound and did not express
any concern about it at the time. Patient continued to be
somewhat frustrated as did not appear to be a direct cause of
her fevers. PICC line was discontinued on [**3-19**], and
vancomycin was changed to linezolid. On the 28th, she had
been off antibiotics for 18 hours and the fevers, since her
PICC line, had been removed with a plan that if she remained
afebrile for another 24 hours, she can be discharged home on
oral antibiotics.
Discharge planning included continue linezolid and Flagyl
both oral medications. On the 18th, she was now on day 18 of
a planned 6-week course for polymicrobial gram-positive and
aerobic sternal osteomyelitis. She was again instructed to
keep her [**Hospital **] clinic appointment on [**4-16**] with Dr. [**Last Name (STitle) 2196**].
She remained afebrile for approximately 36 hours. She was
cleared for discharge to home with VNA services, and
instructed to followup with her plastic surgeon, Dr. [**First Name (STitle) 735**]
and infectious diseases as instructed.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 6562**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2131-6-22**] 09:00:24
T: [**2131-6-22**] 09:33:16
Job#: [**Job Number 6563**]
|
[
"250.00",
"V45.81",
"730.28",
"998.12",
"288.8",
"272.0",
"709.8",
"496",
"998.59",
"V15.82",
"401.9",
"414.01",
"530.81",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"86.74",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8580, 8624
|
2478, 5184
|
345, 518
|
8811, 8818
|
1991, 2455
|
9325, 13229
|
1480, 1514
|
5312, 8557
|
8645, 8790
|
5210, 5289
|
8842, 9302
|
1529, 1972
|
282, 307
|
546, 1218
|
1240, 1360
|
1376, 1464
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,802
| 166,375
|
43740
|
Discharge summary
|
report
|
Admission Date: [**2143-5-1**] Discharge Date: [**2143-5-11**]
Date of Birth: [**2074-12-2**] Sex: F
Service: MEDICINE
Allergies:
Theophylline / Ethylene dioxide
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Allergic reaction to dialysis, eosinophilia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
Patient is a 68 year-old female with HTN/DM II and ESRD recently
started on dialsyis in [**2142-11-6**] being transferred from the
[**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] ICU after multiple hypotensive episodes during
dialysis. She initially presented to [**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] on [**4-30**]
after she experienced diapheresis, chest tightness, headache,
shortness of breath, and hypotension (80s) during a dialysis
session. These symptoms at dialysis have been progressive with
each dialysis session. She notes that she had overall felt well
since she was started on HD in [**Month (only) 1096**]. A "few weeks ago," she
began to develop nausea during HD. Last week, she developed
nausea with chest tightness, diaphoresis, dizziness within 30-40
min into HD. On subsequent HD sessions, these symptoms
progressively began earlier in the sessions. Her symptoms tend
to improved following removal of HD.
On presentation to LGH after her last episode on on [**4-30**], her
WBC was noted to be at 54K w/ 80% eos (the day before her WBC
was 12K with 20% eos). Absolute IgE count was 479. Thus, it was
felt that she may be having an allergic reaction to something
during HD. On Monday, they switched her dialyzer to
non-polysulfone, however as soon as the HD started she developed
diaphoresis, dropped her SBP to 90s, became nauseous with chest
tightness. She was then immediately removed from HD and started
on solumedrol. She was then transferred to the ICU for close
monitoring, but by the time she arrived there she was already
feeling better. She has not had a full session of HD in roughly
1 week. She had a hematology consult done prior to transfer for
hypereosinophilia; recommendations included solumedrol to
supress Eos and consideration of BM bx if no improvement. Due to
concern for possible infectious process, sh was started
emperically on daptomycin and meropenem on [**4-30**]. When
questioned, the patient states that she has been on and off
antibiotics since [**Month (only) **] for "bacteria in her blood." She does
mention that she had surgery on her right foot on [**3-13**] for
Charcot foot deformity at [**Hospital1 2177**], for which she was also on
antibiotics.
On the floor, patient feels well, but is incredibly anxious
about what is going on. She denies any pain, palpitations,
shortness of breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Past Medical History:
-Hypertension
- ESRD with dialysis initiated [**12-17**] via tunneled line; vein
mapping done for fistula, but not attempted yet
-DMII
-Breast cancer status post left mastectomy and node dissection
-Hyperlipidemia
-Charcot foot deformities, s/p surgical repair on [**2143-5-13**]
followed by multiple infections
-Hand fracture
-Asthma
-Glaucoma, blind of L eye
- Diabetic neuropathy
- History of allergy: Patient states she used to get IgG shots
which were stopped 5 years ago
Social History:
SOCIAL HISTORY: [**Name (NI) 94010**] husband die 3 years ago with
complications related to HD and DM. She is currently living w/
oldest daughter who is her main care taker due to her use of WC
and this does not fit on the doors at her house. No smoking, occ
ETOH- rarely now, no drugs. She has 3 daughters who live close
by. Overall feeling very stress with her illness.
Family History:
FAMILY HISTORY:
No family hx of kidney disease
Sister DM
Physical Exam:
Admission Physical Exam:
Physical Exam:
Vitals: 98.1 158/70 84 20 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, left - sided
ptosis, although patient states this is chronic
Neck: supple, JVP just above clavicle at 90 degrees, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, nl S1-S2, III/VI SEM cresendo-decresendo loudest on
RUSB, but heard throughout
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: WWP, bil LE trace of pitting edema on shin area, on L shin
pink skin warm to touch, non-tender. On R pt with half cast with
ace wrapping, decrease sensation on bil feet, 2+ peripheral
pulses on L.
Discharge Physical Exam:
Vitals: 98.7 110/50 66 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, left - sided
ptosis, chronic
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, nl S1-S2, III/VI SEM cresendo-decresendo loudest on
RUSB, but heard throughout
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: 1+ pitting edema bilaterally, right foot wrapped in
bandages
Pertinent Results:
Admission labs:
[**2143-5-2**] 02:04AM BLOOD WBC-15.1* RBC-4.21 Hgb-11.8* Hct-39.5
MCV-94 MCH-28.0 MCHC-29.8* RDW-16.7* Plt Ct-208
[**2143-5-2**] 02:04AM BLOOD Neuts-63.3 Lymphs-13.9* Monos-1.1*
Eos-21.5* Baso-0.3
[**2143-5-2**] 02:04AM BLOOD Glucose-270* UreaN-72* Creat-6.7* Na-137
K-5.9* Cl-100 HCO3-21* AnGap-22*
[**2143-5-2**] 02:04AM BLOOD Calcium-9.4 Phos-5.2* Mg-2.4
[**2143-5-2**] 02:04AM BLOOD ALT-16 AST-23 AlkPhos-73 TotBili-0.3
CHEST RADIOGRAPH
INDICATION: Assessment for lymphadenopathy, parenchymal changes.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: A hyperlucency over the left inferior hemithorax is
obviously due
to a lumpectomy or mastectomy. Moderate cardiomegaly without
evidence of
pulmonary edema. No pneumonia, no other relevant parenchymal
changes. No
lung nodules or masses. No pleural effusions. A right dialysis
catheter over
the internal jugular vein is unremarkable.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2143-5-9**] 12:03 PM
Discharge Labs:
[**2143-5-11**] 02:57PM BLOOD WBC-7.7 RBC-3.53* Hgb-9.7* Hct-31.7*
MCV-90 MCH-27.5 MCHC-30.7* RDW-16.1* Plt Ct-215
[**2143-5-11**] 02:57PM BLOOD Neuts-48.0* Lymphs-31.2 Monos-12.5*
Eos-8.1* Baso-0.2
[**2143-5-8**] 10:35AM BLOOD ESR-7
[**2143-5-11**] 07:50AM BLOOD Glucose-167* UreaN-48* Creat-3.4*# Na-140
K-4.0 Cl-101 HCO3-31 AnGap-12
[**2143-5-11**] 07:50AM BLOOD Albumin-3.7 Calcium-7.5* Phos-2.7 Mg-1.9
[**2143-5-8**] 07:30PM BLOOD VitB12-881
[**2143-5-8**] 10:35AM BLOOD ANCA-NEGATIVE B
[**2143-5-8**] 10:35AM BLOOD PEP-NO SPECIFI
[**2143-5-3**] 08:40AM BLOOD IgG-1246 IgM-39*
Brief Hospital Course:
ASSESSMENT AND PLAN: 68 year-old female with HTN/DM II and ESRD
on dialysis via tunneled line, presenting with hypereosinophilia
and multiple episodes of hypotension on initiation of dialysis.
# Hypereosinophilia: It was initially felt that her
hypereosinophilia was a result of hypersenitivity to the
ethylene oxide dialyzer membrane or tubing. The membrane/tubing
was changed. Additionally, the patient was pre-medicated prior
to dialysis with famotidine, singulair, hydroxyzine and IV
solumedrol to prevent further reactions. The patient underwent
dialysis uneventfully five times with this regimen. Her last two
dialysis runs were executed with oral prendisone substitute for
IV solumdrol. The patient's eosinophil count continued to
flucuate throughout the hospitalization, with little correlation
to the patient's dialysis schedule. A large work-up was sent,
much of which was still pending at the time of discharge.
Baseline lab data from her PCP indicated eosinophilia lasting at
least 3 years. Results from hyper eo work-up at the tiem of
discharge: CXR normal, ESR WNL, ANCA negative, SPEP WNL, Strongy
IgG Pending, Stool O+P negative, TCR re-arrangment pending,
T-cell flow pending, cytogenetics pending
# ESRD: After her initial allergic reaction at [**Hospital3 **],
she received two dialysis runs in the MICU here with the
premedication regimen above. These runs were uneventful, and she
was transferred to the floor for dialysis under premedication.
On the floor, she had three additional dialysis runs with
premedication that showed no evidence of allergic reaction to
the dialysis. Her electrolytes were stable throughout
hospitalization.
# DM II: Consultants from the [**Hospital **] clinic helped managed her
blood sugars throughout her hospitalization, which flucutuated
significantly due to the intermitted steroids required for
dialysis. The patient was stabilized with 10 mg of prednisone
qd, and 6 U of NPH were added to her morning insulin regimen
prior to prednisone treatment. The patient has follow-up
scheduled at [**Last Name (un) **] for further work-up.
# HTN: The patient was found to be hypertensive throughout her
hospitalization into the 190s, on one instance requiring a
hydralazine push in the ICU. Accordingly, her daily labetolol
was uptitrated to 400 mg TID and she was started on amlodipine
10 mg QD. With these medication changes, her blood pressure
trended downwards. At discharge, her pressures were typically
140s/60s.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Labetalol 300 mg PO TID
2. Atorvastatin 40 mg PO DAILY
3. Furosemide 80 mg PO BID
4. bimatoprost *NF* 0.01 % OU QHS
5. brinzolamide *NF* Dose is Unknown OU Unknown
6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
3. Furosemide 80 mg PO BID
4. Labetalol 400 mg PO Q 8H
Please start now. Hold for SBP<100 and HR <60
5. Amlodipine 10 mg PO HS
Please hold for SBP<100
RX *amlodipine 10 mg once a day Disp #*30 Tablet Refills:*0
6. Famotidine 20 mg PO 1X Duration: 1 Doses Start: In am
Please give 1 hour prior to each HD session
RX *famotidine 20 mg 3X A week 1 hour prior to dialysis Disp
#*30 Tablet Refills:*0
7. HydrOXYzine 25 mg PO ONCE Duration: 1 Doses Start: In am
Please give 1 hour prior to each HD session
RX *hydroxyzine HCl 25 mg 3X a week 1 hour prior to dialysis
Disp #*30 Tablet Refills:*0
8. Glargine 22 Units Bedtime
NPH 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *Humulin N 100 unit/mL Before BKFT; Disp #*1 Vial Refills:*0
9. bimatoprost *NF* 0.01 % OU QHS
10. brinzolamide *NF* 1 drop OU Frequency is Unknown
11. PredniSONE 10 mg PO DAILY
Prednisone 10mg until [**5-14**], then take Prednisone 5mg for one week
([**Date range (1) 88555**]), then take Prednisone 5mg every other day for one
week ([**Date range (1) 66820**]).
Tapered dose - DOWN
RX *prednisone 5 mg daily Disp #*17 Tablet Refills:*0
12. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid 400 mcg daily Disp #*30
Tablet Refills:*0
13. Montelukast Sodium 10 mg PO 1X Duration: 1 Doses Start: In
am
Please give 1 hour prior to HD on Saturday, [**2143-5-11**]
RX *Singulair 10 mg 3X per week 1 hour before dialysis Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Anaphylactic reaction to dialysis
Hypereosinophilia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized with an allergic-like reaction to
dialysis. We treated this reaction by giving you medications
prior to dialysis. During your hospitalization, we discovered
you had elevated levels of blood cells commonly responsible for
allergic types of reactions, called eosinophils. We are now
giving you a small dose of steroids every day to suppress these
cells in order to make dialysis safe for you.
You will be taking steroids and a specific medication regimen
prior to dialysis. You will need to see the allergist as
outlined below. You should continue taking prednisone 10mg for 1
week with an end date of [**5-14**] ([**Date range (1) 94011**]). You will then taper down
to 5mg daily for another week with an end date of [**5-21**]
([**Date range (1) 88555**]). Finally you will take 5mg every other day for
another week with an end date of [**5-28**] ([**Date range (1) 66820**]).
Medication Changes:
Continue Prednisone 10mg until [**5-14**], then take Prednisone 5mg for
one week ([**Date range (1) 88555**]), then take Prednisone 5mg every other day
for one week ([**Date range (1) 66820**]).
Start Famotidine 20mg to be taken 1 hour before dialysis
Start Hydroxizine 25mg to be taken 1 hour before dialysis
Start Monteleukast 10mg to be taken 1 hour before dialysis
Start Nephrocaps 1 cap daily
Start Glargine 22 Units at bedtime
Start NPH 6 before breakfast
Start Sliding Scale as directed
Start Humalog Sliding Scale
Start Amlodpiine 10mg daily
Followup Instructions:
Transition issues:
1. ESRD/Dialysis--She will need to continue her premedication
regimen of famotidine, singulair, and hydroxyzine 1 hour prior
to each dialysis run to prevent allergic reactions in the
future.
2. Hypereosinophilia work-up--she will need to arrange for
follow-up on her hypereosinophilia to continue to evaluate the
cause of her baseline elevated eosinophil levels. She should
call for appointments on the Monday following discharge to the
offices below.
Wednesday, [**5-22**] at 10 AM
Dr. [**Last Name (STitle) 9978**]
[**Name (STitle) **] [**Hospital 982**] Clinic
[**Telephone/Fax (1) 9670**]
Primary Care Doctor:
Dr. [**Last Name (STitle) **] [**Name (STitle) 94012**]
PLEASE CALL FOR THE FIRST AVAILABLE APPOINTMENT
Phone: [**Telephone/Fax (1) 12551**]
Allergy Doctor:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9313**]
PLEASE CALL FOR THE FIRST AVAILABLE APPOINTMENT ON MONDAY
Phone: [**Telephone/Fax (1) 44274**]
Hematology Doctor:
Dr. [**Last Name (STitle) 3638**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12982**]
Please make an appointment as soon as possible
Phone: ([**Telephone/Fax (1) 14703**]
Completed by:[**2143-5-12**]
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[
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75,581
| 133,735
|
11628+56265
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-12-30**] Discharge Date: [**2179-1-8**]
Date of Birth: [**2110-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Hemetemesis
Major Surgical or Invasive Procedure:
[**2178-12-30**]
1. Minimally-invasive esophagectomy with intrathoracic
anastomosis.
2. Buttressing of intrathoracic anastomosis with
pericardial fat.
3. Laparoscopic jejunostomy.
4. Esophagogastroduodenoscopy
History of Present Illness:
Mr. [**Known lastname 6955**] is a 68 year old male who was diagnosed with
esophageal cancer and underwent He underwent concurrent
chemoradiation therapy with cisplatin and 5-FU and radiation
therapy under Dr. [**Last Name (STitle) 12354**]. He has undergone
post-treatment imaging with a PET scan that shows two foci of
uptake in the distal esophagus with no evidence of distant
disease on this study. He is known to have a lytic lesion in
T11
and the day after our visit, underwent an MRI scan, which showed
no evidence of metastatic disease to the spine. A CT angiogram
was done [**10-3**] in light of his CAD This study showed no
atherosclerotic disease within
the celiac axis or gastroepiploic artery. Finally, has also
undergone a coronary catheterization on [**12-3**]. This study
showed normal LV function with an occluded right coronary and
60%
mid LAD lesion. Based on his symptoms and imaging he was
admitted to the hospital for surgical resection.
Past Medical History:
PMH: HTN, HL, remote tobacco use, PVD, CAD, h/o MI in ([**2160**])
PSH: Coronary angioplasty x2 [**2162**], angioplasty in [**2159**],
tonsillectomy as a child. bilateral CEA
Social History:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:____
quit: _1882_____
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:
Marital Status: [x] Married [ ] Single
Lives: [ ] Alone [x] w/ family [ ] Other:
Family History:
non contributory
Physical Exam:
BP: 149/69. Heart Rate: 60. Weight: 194.3. Height: 66.5. BMI:
30.9. Temperature: 98.1. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 100.
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2178-12-30**] 01:04PM HGB-12.0* calcHCT-36 O2 SAT-98
[**2178-12-30**] 12:45PM GLUCOSE-164* SODIUM-137 POTASSIUM-4.4
CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
[**2178-12-30**] 12:45PM CALCIUM-8.9 MAGNESIUM-1.9
[**2178-12-30**] 06:26PM WBC-12.7*# RBC-3.75* HGB-11.2* HCT-32.6*
MCV-87 MCH-30.0 MCHC-34.5 RDW-18.3*
Pathology
SPECIMEN SUBMITTED: Esophagogastrectomy, Level 7 lymph nodes,
Gastric donut, Esophageal donut, Fundus.
Procedure date Tissue received Report Date Diagnosed
by
[**2178-12-30**] [**2178-12-30**] [**2179-1-4**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/tk??????
Previous biopsies: [**-9/4552**] Slides submitted for
consultation.
[**Numeric Identifier 36895**] CAROTID PLAQUE/bq/ip.
[**-1/4166**] CAROTID PLAQUE/tj/jd.
DIAGNOSIS:
I. Esophagus, esophagogastrectomy (A-AE):
1. Residual intramucosal adenocarcinoma with adjuvant
therapy
effect, arising in a background of Barrett's esophagus with
dysplasia; see synoptic report.
2. Five lymph nodes with no carcinoma seen (0/5;
majority of periesophageal and perigastric soft tissue is
submitted for lymph node evaluation).
II. Level 7 lymph nodes, excisional biopsy (AF-AG):
Twelve lymph nodes with no carcinoma seen (0/12).
III. Gastric donut (AH):
Gastric corpus segment with prominent cautery effect and no
carcinoma seen.
IV. Esophageal donut (AI-AJ):
Squamous esophageal segment with no carcinoma seen.
V. Fundus, segmental resection (AK-[**Doctor Last Name **]):
Gastric corpus segment with mild chronic active gastritis and
focal reactive changes, consistent with adjuvant therapy effect.
No carcinoma seen.
[**2179-1-2**] CTA :
1. No evidence for pulmonary embolus.
2. Gastric pull-through with no evidence for intrathoracic
abscess. There
is, however multiloculated regions of air identified along the
oblique and
horizontal fissures with a small less than 10% dependent
pneumothorax
identified on the right side.
3. Bilateral multifocal infiltrates within both lungs with
compressive
atelectasis noted at the lower lobes bilaterally. Findings may
be as a result of sequelae of infection.
[**2179-1-4**]
CXR :Region of consolidation in the axillary left upper lobe
which developed between [**1-2**] and [**1-3**] is still
present as are larger regions of heterogeneous opacification in
both lower lungs, all strongly suggestive of widespread
pneumonia, particularly the findings in the left lung since
esophagectomy typically entails considerable right basal
atelectasis. Right pleural tube in place. No pneumothorax or
appreciable pleural effusion. Right subclavian infusion port
ends in the low SVC. Midline drain still in place. No
pneumothorax
[**2179-1-5**]
Ba swallow:
No leak,some expected holdup at the pylorus but without
obstruction.
[**2179-1-7**] 2:07 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2179-1-8**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2179-1-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
Mr. [**Known lastname 6955**] was admitted to the hospital and taken to the
Operating Room where he underwent a minimally invasive
esophagectomy (see formal op note for details). He tolerated
the procedure well and returned to the ICU in stable condition.
His pain was initially controlled with an epidural catheter and
he maintained stable hemodynamics.
His tube feedings were started on post op day #0 with replete
and unfortunately he had some cloudy drainage from his JP drain
by post op day 3 along with an elevated triglyceride level
indicating a thoracic duct leak. At that point he was changed
to elemental feedings which he tolerated well and his JP
drainage cleared.
His pain got a bit worse and it was determined that the epidural
was not functioning therefore it was replaced. In the interim he
desaturated and a CTA was done which ruled out a PE. He did
have some infiltrates on xray and therefore underwent vigorous
pulmonary toilet including chest PT and incentive spirometry.
His highest WBC was 11K on [**2179-1-2**]. He was started on
Vancomycin and Zosyn and gradually improved without any other
episodes of desaturation or fevers. His epidural was eventually
removed and his pain was controlled with liquid oxycodone and
Tylenol.
Following transfer to the Surgical floor he had a barium swallow
done which confirmed no anastomotic leak and he subsequently
began a liquid diet. Another trial of tube feedings with
Replete was done but unfortunately his JP drainage again became
cloudy. Currently the plan is for him to continue feedings with
an elemental formula (Vivonex) and only clear liquids orally
until he is reevaluated by Dr. [**First Name (STitle) **]. He will also keep his JP
drain in place to gravity. His dressing should be changed daily
and prn as he has had a large amount of serous fluid draining
from around the drain site.
On [**2179-1-7**] he developed several episodes of diarrhea and a stool
for c difficile was sent which was negative. His IV antibiotics
were stopped and he was treated with Imodium with some effect.
His WBC was 10K and he remains afebrile.
The Physical Therapy service worked with him on many occasions
to help improve his mobility and increase his endurance. He is
gradually improving and starting to ambulate independently.
After a long hospital stay he was discharged to rehab on [**2179-1-8**]
and will follow up with Dr. [**First Name (STitle) **] next week.
Medications on Admission:
metop tartrate 25", nortriptyline 20', omep 40 qam + 20qpm,
lucentis, lorazepam 0.5 q6h prn, citalopram 20', diltiazem ER
240', IMDUR ER 30', NTG 0.4 prn, crestor 40', MVI
Discharge Medications:
1. multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
2. nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. oxycodone 5 mg/5 mL Solution Sig: 5-10 mls PO Q4H (every 4
hours) as needed for pain.
Disp:*500 mls* Refills:*0*
8. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mls PO
Q6H (every 6 hours).
Disp:*500 mls* Refills:*2*
9. isosorbide dinitrate 30 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Tube feedings
Vivonex TEN at 100 mls/hr over 18 hours
Disp 7 boxes
Refills for 3 months
11. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Esophageal cancer
Paroxysmal atrial fibrillation
Thoracic duct leak
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] [**Name (STitle) **] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting
-Increased abdominal pain
-Incision develops drainage
-JP drain will remain in place connected to bulb suction. Empty
daily and record output. Bring the record with you to your next
appointment with Dr. [**First Name (STitle) **].
Pain
-Oxycodone liquid and tylenol as prescribed
-Take stool softners with narcotics but stop if diarrhea
develops
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Tube feeds: Vivonex Full Strength 100 mL cycled from 3pm to 9am
Flush J-tube with water every 8 hours with 10 mls of water,
before and after starting tube feeds and every day at noon.
Clear liquid diet until Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36896**] liberalization.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Danger signs
Fevers > 101 or chills
Increased shortness of breath, cough or chest pain
Incision develops drainage
Nausea, vomiting (take anti-nausea medication)
Increased abdominal pain
Call if J-tube falls out (save the tube and bring with you to
the hospital to be re-placed) or suture breaks
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2179-1-14**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Completed by:[**2179-1-8**] Name: [**Known lastname 1799**],[**Known firstname **] B Unit No: [**Numeric Identifier 6602**]
Admission Date: [**2178-12-30**] Discharge Date: [**2179-1-8**]
Date of Birth: [**2110-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1999**]
Addendum:
Note additional doscharge meds
octreotide acetate 100 mcg/mL Solution Sig: One Hundred (100)
mcg Injection Q 12H (Every 12 Hours).
loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 2075**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**]
Completed by:[**2179-1-8**]
|
[
"457.1",
"V45.82",
"150.8",
"997.39",
"997.99",
"414.01",
"427.31",
"535.50",
"486",
"E878.2",
"530.81",
"401.9",
"272.4",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.29",
"40.3",
"42.42",
"42.87",
"96.6",
"46.32",
"43.5",
"42.52",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14174, 14396
|
7256, 9699
|
322, 540
|
11074, 11074
|
4101, 7233
|
12907, 14151
|
2127, 2145
|
9922, 10862
|
10973, 11053
|
9725, 9899
|
11225, 12884
|
2160, 4082
|
271, 284
|
568, 1534
|
11089, 11201
|
1556, 1734
|
1750, 2111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,415
| 124,026
|
5801
|
Discharge summary
|
report
|
Admission Date: [**2156-11-1**] Discharge Date: [**2156-11-5**]
Date of Birth: [**2090-2-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hayfever
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Exterional chest pain
Major Surgical or Invasive Procedure:
[**2156-11-1**]
Coronary artery bypass graft times 5, left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to diagonal 1, diagonal 2, obtuse marginal 1 and the
posterior descending arteries
History of Present Illness:
66 year old male has new onset exertional chest pain. It occurs
when he walks for 5-10 minutes and stops when he rests. He
denies any symptoms occurring
at rest. He was referred for a stress test, which was done
[**2156-10-22**] and was abnormal. He then referred for cardiac
catheterization. He was found to have multivessel diseaes and is
now being referred to cardiac surgery for revascularization.
Past Medical History:
Hypertension
hyperlipidemia
irritable bowel syndrome
allergic rhinitis
kidney stones s/p lithotripsy
BPH
prostate nodule
snoring
h/o Shingles
? Gout
Past Surgical History:
bilateral hernia repairs
polypectomy
Social History:
Mr. [**Known lastname 1005**] lives with his wife and daughter. [**Name (NI) **] works in
manufacturing. He denies smoking. He reports drinking less than
8 alcoholic beverages per week and denies illicit drug use.
Family History:
non contributory
Physical Exam:
Pulse:53 Resp:18 O2 sat:100/RA
B/P Right:146/77 Left:145/73
Height:5'3" Weight:135 lbs
General: NAD, WGWN
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] 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: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:1+
Radial Right: cath site Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2156-11-3**] 06:05AM BLOOD WBC-8.6 RBC-3.48*# Hgb-9.5* Hct-28.9*
MCV-83 MCH-27.3 MCHC-32.8 RDW-15.0 Plt Ct-149*
[**2156-11-2**] 02:21AM BLOOD WBC-9.2 RBC-2.76*# Hgb-7.7*# Hct-23.6*
MCV-86 MCH-28.0 MCHC-32.8 RDW-13.4 Plt Ct-136*
[**2156-11-3**] 06:05AM BLOOD Glucose-114* UreaN-11 Creat-0.7 Na-134
K-4.4 Cl-98 HCO3-28 AnGap-12
[**2156-11-2**] 02:21AM BLOOD Glucose-120* UreaN-10 Creat-0.7 Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
TTE [**2156-11-1**]
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS
There is preserved biventricular systolic function. The MR is
now trace. The study is otherwise unchanged from prebypass
Brief Hospital Course:
On [**11-1**] Mr. [**Known lastname 1005**] [**Last Name (Titles) 1834**] a coronary artery bypass graft
times 5, left internal mammary artery to left anterior
descending artery and saphenous vein grafts to diagonal 1,
diagonal 2, obtuse marginal 1 and the posterior descending
arteries performed by Dr. [**Last Name (STitle) **]. Please see the
operative note for details. He tolerated the procedure well and
was transferred in critical but stable condition to the surgical
intensive care unit. He was extubated later that same day. On
post-operative day two he ws transferred to the step down unit
and his chest tubes and pacing wires were removed without
incidence. He was working with physical therapy and ambulating
without difficulty. His wounds were healing well and he was
tolerating a full oral diet. He was felt safe for discharge on
POD #4 with VNA services. All follow up appointments were
advised.
Medications on Admission:
ATENOLOL 50 mg Tablet Daily
HYDROCHLOROTHIAZIDE 25mg Daily
LISINOPRIL 2.5 mg Daily
NITROGLYCERIN PRN
ASPIRIN 81 mg Daily
CAMPH-EUCALYPT-MEN-TURP-PET [[**Last Name (un) **] VAPORUB] once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] Dosage uncertain
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 14 days: take with food.
Disp:*42 Tablet(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**12-6**] at 1:15pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 911**] on [**12-2**] at 3:40pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] in [**5-4**] weeks [**Telephone/Fax (1) 608**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2156-11-5**]
|
[
"600.00",
"V12.72",
"V13.01",
"272.4",
"401.9",
"423.9",
"477.9",
"411.1",
"414.01",
"564.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.14",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5469, 5527
|
3258, 4179
|
297, 526
|
5595, 5823
|
2163, 3235
|
6664, 7301
|
1439, 1458
|
4481, 5446
|
5548, 5574
|
4205, 4458
|
5847, 6641
|
1151, 1190
|
1473, 2144
|
235, 259
|
554, 957
|
979, 1128
|
1206, 1423
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,163
| 189,169
|
38293
|
Discharge summary
|
report
|
Admission Date: [**2186-6-15**] Discharge Date: [**2186-6-18**]
Date of Birth: [**2151-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Abdominal pain (transferred to ICU for DKA, renal failure)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 14782**] is a 35 M with a history of type I diabetes since the
age of 19 complicated by gastroparesis, retinopathy, stage III
chronic kidney disease, and multiple prior episodes of DKA who
presents with a one-day history of vomiting and abdominal pain.
He states that he was feeling well until yesterday evening, when
he began vomiting multiple times. Initially emesis was food
particles, but then he began to vomit brownish material. He was
trying to drink fluids (broth, water) but states he had trouble
keeping anything down. He developed abdominal pain consistent
with prior episodes of gastroparesis (right sided, constant) to
[**9-2**] severity (he has no pain at baseline). When he noticed that
emesis was becoming brown, he decided to come to ED for further
evaluation.
.
He states that blood sugars have been high for the past 2-3 days
with many readings > 300 and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of > 400 last night. He
typically takes 5 units of Lantus [**Hospital1 **] (AM and QHS) and uses a
Novolog scale with carb counting for correction with meals (1
unit: [**Unit Number **] g). Prior to 3 days ago he says sugars have been under
control. He has had no associated fever or chills though does
get shaky and diaphoretic with episodes of vomiting. He denies
any diarrhea or other change in bowel habits, no blood in stool
or dark/tarry stool. He has not had cough, sore throat,
congestion, or other recent URI symptoms. He has not had dysuria
or any changes to his urine (not dark, frothy, or otherwise
abnormal) though notes that he last urinated this morning prior
to coming to ED. He reports normal urination every few hours
yesterday. Of note, he typically wears a clonidine patch for BP
control but states he thinks it slipped off because he was
sweaty with the episodes of vomiting.
.
In the ED, initial vs were: T 98.5, HR 106, BP 225/135, RR 22,
100% on RA. Labs on arrival were notable for anion gap of 28 and
creatinine of 6.5 from baseline of upper 2s to low 3s. Patient
was given 2L of IVF bolus with NS, followed by 2 L of IVF with
D5NS at 500 cc/hr after he was started on an insulin gtt (7
units/hr at the time of transfer to floor). He received 20 mg IV
labetalol for his blood pressure and his clonidine patch was
replaced. He also received 4 mg of IV morphine for pain and IV
Zofran and compazine for nausea. Vitals on transfer to the floor
were afebrile, HR 82, BP 136/93, RR 11, 100% on RA. CXR was
grossly clear, U/A could not be obtained as patient did not
void. He was guaiac negative in ED, did not receive NG lavage.
.
Started on insulin gtt. Renal consulted. He had a renal us.
Renal wanted to start sodium bicarb po. He will need dialysis
but not now.
Current VS: 75, 166/106, 99% on RA
On the floor, patient reported pain was [**5-2**] still right-sided
and consistent in quality with prior episodes of DKA and
gastroparesis. He stated that he did not feel the urge to void
(still had not urinated). Nausea was becoming worse again and he
had a small amount of clear emesis/saliva. He was tremulous with
the N/V.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied diarrhea, constipation. No
recent change in bowel habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- Type I diabetes complicated by gastroparesis, retinopathy,
stage III chronic kidney disease, and multiple episodes of DKA
- [**Doctor Last Name 9376**] syndrome
- Hypertension
- Asthma in childhood (no recent exacerbation)
- No surgeries
Social History:
Lives with his girlfriend and two children ages 14 and [**Location (un) 85325**]. Denies tobacco use, alcohol use, or illicit drug use.
Family History:
Father with CAD/MI, HLD, type II DM. Mother with thyroid
cancer.
Physical Exam:
T: 97.1 BP: 144/96 P: 95 R: 24 O2: 100% on RA
General: Appears somewhat pale and uncomfortable with
moving/speaking though no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated (neck veins flat), no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm (though borderline tachycardic with
rate in 90s), normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-distended, TTP worse in lower right quadrant,
bowel sounds present but hypoactive, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no skin tenting
Pertinent Results:
[**2186-6-15**] 07:40AM BLOOD WBC-7.7 RBC-3.27* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.1 MCHC-34.1 RDW-14.5 Plt Ct-184
[**2186-6-18**] 06:45AM BLOOD WBC-6.3 RBC-2.73* Hgb-8.0* Hct-23.9*
MCV-88 MCH-29.5 MCHC-33.6 RDW-14.5 Plt Ct-133*
[**2186-6-15**] 07:40AM BLOOD Glucose-567* UreaN-81* Creat-6.5*# Na-139
K-4.5 Cl-99 HCO3-12* AnGap-33*
[**2186-6-18**] 06:45AM BLOOD Glucose-199* UreaN-57* Creat-5.3* Na-137
K-4.0 Cl-106 HCO3-22 AnGap-13
[**2186-6-15**] 07:40AM BLOOD ALT-14 AST-12 AlkPhos-97 TotBili-1.3
[**2186-6-15**] 07:40AM BLOOD Lipase-38
[**2186-6-18**] 06:45AM BLOOD Calcium-7.9* Phos-5.4* Mg-1.7
[**2186-6-17**] 03:00PM BLOOD calTIBC-244* VitB12-1000* Folate-6.4
Ferritn-134 TRF-188*
[**2186-6-15**] 06:25PM BLOOD Acetone-NEGATIVE Osmolal-323*
[**2186-6-17**] 03:00PM BLOOD PTH-125*
[**2186-6-16**] 05:53AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2186-6-16**] 05:53AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2186-6-16**] 05:53AM URINE Eos-NEGATIVE
.
Urine culture: No growth to date.
.
EKG: Sinus rhythm at upper limits of normal rate. Since the
previous tracing of [**2186-4-17**] T waves are probably improved.
Otherwise, unchanged.
.
CXR: Normal chest radiograph.
.
Renal U/S: Normal renal son[**Name (NI) **]. [**Name2 (NI) **] hydronephrosis.
Brief Hospital Course:
35 y/o man h/o Type I DM presents with vomiting, hyperglycemia
and decreased UOP. On admission found to have DKA complicated by
acute on chronic renal failure (Cr 6.3, baseline [**2-24**]) and
uncontrolled hypertension (SBP >200).
DKA: Patient has had multiple prior admissions for DKA. He did
not have urine sent on arrival so no documented ketonuria, but
did have AG of 28 and glucose>500. Labs following arrival to
floor showed closed gap and negative serum acetone. Precipitant
for this episode is unclear, as patient reports taking his
insulin as prescribed and has not had recent illness. CXR was
clear, EKG without ischemia. DKA was treated with insulin and
fluids till gap closed, acidosis resolved and sugars were
controlled. He was followed by the [**Last Name (un) 387**] consult service who
titrated his fixed dose and sliding scale insulin. In the day
prior to discharge his blood sugars were better controlled,
ranging from 84 to 280. He will follow-up in the [**Hospital 387**] clinic
on Tuesday for further care.
ACUTE-ON-CHRONIC RENAL FAILURE, LOW UOP: Patient's baseline
creatinine is high 2's to low 3's, though was low 4's in early
[**Month (only) 547**]. He is thought to have CKD stage 4. On presentation he had
acute on chronic renal failure with a Cr of 6.5. He received
hydration and had urine electrolytes (FENa >3%) and a renal
ultrasound (normal study). He was followed by the renal consult
service. He likely had a component of pre-renal azotemia but
this also represents progression of diabetic nephropathy. He has
not been able to tolerate ACE in past due to craetinine bump per
notes. His Cr downtrended but nadir'd at >5. He was followed by
the renal consult team. He was started on phosphate binders. He
is felt to be headed towards end stage renal disease. He is a
good candidate for renal-pancreas transplant though he may
require peritoneal or hemodialysis prior to that time. He will
follow-up in the [**Hospital **] clinic for planning regarding his renal
failure.
HYPERTENSION: Patient had uncontrolled hypertension throughout
his stay in the hospital. He was continued on his clonidine
patch, with uptitration of his home amlodipine and labetalol. He
requires further uptitration of these medications as an
outpatient.
ANEMIA: The patient had anemia of chronic disease with slowly
downtrending Hct - to 23 on the day of discharge. The patient
will follow-up in 2 days in the [**Last Name (un) **] clinics for repeat Hct
check, consideration of need for transfusion and consideration
of re-initiation of epocrit (the patient had previously been on
this). Currently he is asymptomatic from this anemia. He did
have iron, b12 and folate studies which were suggestive of
anemia of chronic disease.
Code: Full (confirmed with patient)
Contact: HCP is girlfriend [**Name (NI) **] [**Name (NI) 12330**] [**Telephone/Fax (1) 85322**]
Medications on Admission:
Lantus 5 units Q AM and QHS
Novolog 1 unit : [**Unit Number **] g carbohydrates (correction with meals)
Relgan 10 mg PO TID with meals
Erythromycin 250 mg PO TID with meals
Clonidine 0.3 mg/24 patch once weekly (Sundays)
Omeprazole 40 mg PO daily
Labetalol 300 mg PO BID
Amlodipine 5 mg PO daily
Discharge Medications:
1. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
2. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Tablet(s)
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*4*
7. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day.
8. erythromycin 250 mg Tablet Sig: One (1) Tablet PO three times
a day.
9. Insulin
Glargine: 5 units twice daily
Humalog: According to sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
DM1 uncontrolled with DKA complications
Acute on chronic renal failure
Anemia of chronic disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of abdominal pain, nausea and
vomiting. This may have been due to gastroparesis and improved.
Continue to take your home gastroparesis medication regimen.
You had DKA on arrival. This resolved with insulin and IV
fluids. Continue to take insulin as prescribed. Follow-up on
Tuesday at the [**Hospital **] clinic for further care.
You have chronic kidney disease. Follow-up on Tuesday at the
[**Hospital **] clinic to discuss next steps in treatment including
dialysis and transplant.
You have severe anemia. Have your blood count checked at your
follow-up appointment at the [**Hospital **] clinic and discuss further
management at that time.
Followup Instructions:
Follow-up on Tuesday in Dr.[**Name (NI) 14277**] clinic at [**Last Name (un) **]. Office
number: [**Telephone/Fax (1) **]. You should have your Hct rechecked at this
appointment.
|
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48,340
| 172,547
|
9185
|
Discharge summary
|
report
|
Admission Date: [**2140-7-21**] Discharge Date: [**2140-7-27**]
Date of Birth: [**2071-10-10**] Sex: M
Service: MEDICINE
Allergies:
Tegaderm Frame Style / Prinivil / Reglan / Levofloxacin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Reliability: Patient was AAOx3 however did endorse seeing an
"extra man" in the room when asked how many persons where
present in room. History also obtained from patient's wife and
medical records from rehab and [**Hospital3 **] ED.
.
Patient is 68-year-old male with ESRD status post cadaver kidney
transplant in [**2130**] on tacrolimus/prednisone, type 1 diabetes,
CAD status post CABG x4, PVD status post right popliteal stent
and 2nd right toe amputation in addition to history of MRSA
osteomyelitis,
chronic lower extremity nonhealing ulcers, history of multiple
DVTs on Coumadin with IVC filter, diastolic heart failure,
multiple prior C. difficile episodes in [**2135**], [**2138**], and [**4-/2140**]
among other conditions that presents from rehab with confusion
and low oxygen saturation.
.
Patient was recently admitted to [**Hospital1 18**] in [**2140-4-29**] for
nausea/vomiting with eating with GI work-up revealing
gastroparesis and C. difficile diarrhea treated with PO
vancomycin.
.
At some point, he was admitted to rehab for PT/OT. His rehab
course was complicated by pneumonia and urinary tract infection
(no culture data available), which were treated with a 7-day
course of Ceftin (course was started around [**2140-6-30**]). The
patient required about 2-3 L NC while he had pneumonia.
.
He was in his otherwise normal state of health at rehab until
about 2-3 days ago when he needed nebulizer treatments on Friday
and also developed supplemental oxygen requirement on Saturday
similar to what he needed when he had pneumonia about 3-4 weeks
ago. His wife also stated that at baseline his mental status has
been AAOx3 but he does seem forgetful with hallucinations (e.g.
little kid hiding in the corner) with any illness and
dehydration. Of note, he had a CXR on [**2140-7-14**] that was compared
to his prior chest x-ray showing clearing of bilateral
infiltrates and pneumonia - namely the prominent right perihilar
infiltrate and small left perihilar infiltrate.
.
At the Guardian [**Name (NI) **] rehab, BLS placed him on 100 % NRB for
hypoxemia (unknown number) with O2 sat in 90s.
.
He was taken to [**Hospital3 **] ED where he was thought to be "really
confused" with no focal neurological deficits or post-ictal
state. His O2 sat was low as well (unknown number). He received
500 cc of fluid and a ? dose of Ceftin. He was transferred to
[**Hospital1 18**] given that he received a transplant here.
.
VS prior to transfer from [**Hospital3 **] ED were T 98.8 BP 124/62 HR
71 RR 22 Glc 169
.
In the ED, initial VS were: Triage 17:52 0 97.2 52 90/46 16 98%
4L
.
He arrived to [**Hospital1 18**] ED with relative hypotension with blood
pressures of 90/40, saturating 96% on 2 L nasal cannula with
diffuse crackles and wheezes on his lung fields.
.
Of note, recent BP in clinic per [**Hospital1 581**] are 88/60, 102/82,
92/52, 118/80 from past 2 years. BP at rehab on [**2140-5-6**] was
121/80.
.
BP remained stable in ER, required 2 L NC throughout ER course.
.
Labs were performed
- WBC 3.7 Hgb 8.2 (of note baseline ~ 10) Plt 253 with Diff N
70.9 L 16.5 E 6.6
- INR 2.8 (in setting of coumadin therapy) PTT 44.3
- Na 139 K 5.2 Cl 111 HCO3 23 BUN 17 Cr 1.6 (Cr 1.1-1.2) Glc 83
- cTropnT 0.07
- UA Nit neg pH 6 LE Mod WBC > 182 bacteria many Epi 0 cast Gr
13
.
Diagnostic testing was performed:
- ECG: Sinus bradycardia at 52 bpm, NA, NI except QTc 502 ms, no
ST/T changes or STEMI. Low voltage I, II, III, aVR, aVL, aVF.
Compared to prior dated [**2140-1-25**], rhythm is NSR at 87 bpm, QTc
427 ms
- CXR (prelim): layering effusion, scarring atelectasis in lower
base. Cardiomediastinal unchanged. IVC filter seen.
Impression: Bilateral pleural effusions and cephalization,
post-surgical changes in right lung without definite
consolidation.
.
He was given:
- hydrocortisone 100 mg IV x 1 for stress dose steroids
- cefepime 2 gm IV and vancomycin 1000 mg IV
- 2 L NS with urine output of 95 mL
.
VS on transfer: 18:38 53 100/41 17 97% on 2 L NC
.
On arrival to the MICU, the patient was AAOx3 but thought that
another man was standing behind me - which was not true. He was
also noted that have Tax 94. Urine output was poor, and he
received 2 L NS bolus.
.
He denies any localizing complaints such as cough, abdominal
pain, dysuria although does admit to low oxygen levels.
.
Review of systems:
(+) Per HPI; fatigue, shortness of breath x 2 weeks, worsened
over last week
(-) 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:
-DVT (multiple) s/p IVC filter [**3-/2134**] on coumadin for life
-CAD s/p CABG and MI; s/p stents
-Chronic dCHF
-HTN
-DM1 with retinopathy, neuropathy, ESRD, R charcot foot in [**2125**]
-s/p cadaveric renal transplant in [**9-/2131**] on prednisone and
tacrolimus
-ORIF right arm
-chronic foot ulcer
-amputated right toe
-MRSA right foot with osteomyelitis
-C diff colitis [**5-6**]
-cryptococcal pna in [**4-3**], now on fluconazole suppressive
therapy
-lung nodules
-PVD
-GERD
-b/l cataract surgery,
-s/p [**Doctor Last Name **] artery angioplasty in [**6-4**]
-cellulitis
-chronic osteomyelitis followed in ID clinico
-Anemia
-Arteriogram showing R fem/tib and L tib dz and [**Date Range 1106**] plans
to consider intervention as outpatient.
Social History:
SOCIAL HISTORY
-Lives w/ wifw, has 3 children
-Tobacco history: Former smoker, 2ppd for many years
-ETOH: Infrequent now that in [**Hospital1 1501**]
-Illicit drugs: None
-uses wheelchair for ambulation
.
Family History:
FAMILY HISTORY:
DM type II in father and paternal grandfather. Mother had "heart
disease".
Physical Exam:
Admission PE:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, shoddy lymphadenopathy of
anterior cervical chain, more prominent on left than right
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased inspiratory effort, mild rhonchi at right base,
however difficult to appreciate given limited exam.
Abdomen: distended, non-tender, difficult to appreciate
organomegaly given firmness of abdomen.
GU: no foley
Ext: multiple ulcers over LE bilaterally in various stages of
healing, 2+ edema of LE b/l, multiple scars present, amputation
of digits present.
Neuro: grossly normal sensation, non focal exam
Discharge PE:
VS: T 98, Tm 98.3, 60-70s, 120-140s/50-70s, 18-20, 98-100% RA
Glucose: 117-207
General: Alert, oriented, in NAD
HEENT: some bloody appearance to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2281**]
CV: RRR, no murmurs
Lungs: Inspiratory rales at L base, otherwise CTAB
Abdomen: soft, non-tender, nondistended, +BS
Ext: multiple ulcers over LE bilaterally in various stages of
healing with dressing in place
Pertinent Results:
ADMISSION LABS
[**2140-7-21**] 07:33PM URINE HOURS-RANDOM UREA N-517 CREAT-240
SODIUM-69 POTASSIUM-98 CHLORIDE-43
[**2140-7-21**] 07:33PM URINE OSMOLAL-576
[**2140-7-21**] 06:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD
[**2140-7-21**] 06:40PM URINE RBC-2 WBC->182* BACTERIA-MANY YEAST-NONE
EPI-0
[**2140-7-21**] 06:30PM LACTATE-1.2
[**2140-7-21**] 06:26PM GLUCOSE-86 UREA N-17 CREAT-1.6* SODIUM-139
POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-23 ANION GAP-10
[**2140-7-21**] 06:26PM cTropnT-0.07*
[**2140-7-21**] 06:26PM TSH-8.9*
[**2140-7-21**] 06:26PM CORTISOL-6.9
[**2140-7-21**] 06:26PM WBC-3.7* RBC-3.36* HGB-8.2* HCT-26.7* MCV-80*
MCH-24.5* MCHC-30.7* RDW-15.6*
[**2140-7-21**] 06:26PM NEUTS-70.9* LYMPHS-16.5* MONOS-5.8 EOS-6.6*
BASOS-0.3
[**2140-7-21**] 06:26PM PLT COUNT-253
[**2140-7-21**] 06:26PM PT-29.4* PTT-44.3* INR(PT)-2.8*
Micro:
ucx [**2140-7-21**]:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
urine legionella Ag: neg
CMV viral load undetectable
CXR [**2140-7-21**]:
Bilateral pleural effusions and pulmonary [**Month/Day/Year 1106**] congestion.
Post-surgical changes seen in the right lung
TTE [**2140-7-22**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 65%). However, the inferior wall may be mildly
hypokinetic. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). 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. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Transplant renal U/S [**2140-7-22**]:
1. Interval increase in elevated intrarenal resistive indices
with no
discernable antegrade diastolic flow noted throughout. In
addition, there is a notable increase in peak systolic velocity
of main renal artery with normal waveforms and velocity
identified in the left iliac artery. No stenosis identified.
2. Extensive transplanted interlobar renal artery and main renal
artery
calcifications.
3. No hydronephrosis, masses, or perinephric fluid collection
evident.
Discharge Labs:
[**2140-7-27**] 05:55AM BLOOD WBC-4.6 RBC-3.92* Hgb-9.4* Hct-31.0*
MCV-79* MCH-24.1* MCHC-30.3* RDW-15.4 Plt Ct-276
[**2140-7-27**] 05:55AM BLOOD PT-24.7* PTT-44.3* INR(PT)-2.4*
[**2140-7-27**] 05:55AM BLOOD Glucose-152* UreaN-14 Creat-1.1 Na-139
K-4.8 Cl-110* HCO3-24 AnGap-10
[**2140-7-26**] 06:05AM BLOOD ALT-19 AST-29 LD(LDH)-180 AlkPhos-207*
TotBili-0.1
[**2140-7-27**] 05:55AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6
Brief Hospital Course:
68-year-old male with ESRD status post cadaver kidney transplant
in [**2130**] on tacrolimus/prednisone, DM1, CAD s/p MI and CABG, PVD
with chronic lower extremity nonhealing ulcers, history of
multiple DVTs on coumadin, diastolic heart failuire among other
conditions that presents with confusion, low oxygenation
saturations, acute renal failure, and relative hypotension
concerning for sepsis from a urinary source.
.
Acute diagnoses:
#Sepsis from UTI source: Patient is immunocompromised in setting
of kidney transplant and presents with leukopenia, hypothermia
in setting of positive UA/UCx suggestive of sepsis from a
urinary source. Prior urine culture data suggestive of E. coli
and Proteus that are resistant to certain drug classes. CXR
without consolidation. Host factors include immunosuppresion
with tacrolimus/prednisone, HCAP exposure. On presentation, pt
met SIRS criteria, with lactate elevation and [**Last Name (un) **]. He was
treated with fluid resuscitation and empiric abx (Vanc/Zosyn).
MICU COURSE: patient was admitted to the MICU for respiratory
distress and relative hypotension in setting of Sepsis of
urinary source and [**Last Name (un) **] possibly [**12-31**] renal transplant failure. Pt
on vanc/cefepime during MICU adm. Pt had improvement in his
respiratory status and was hemodynamically stable at the time of
transfer from the MICU. Transitioned to IV ceftriaxone. Ucx grew
e coli. Blood cultures were negative. Pt transitioned to PO
cefpodoxime [**7-25**] with plan for 14d course total of ABX to end
[**2140-8-4**].
.
# Dyspnea/hypoxia: Patient is reporting a subacute course of
dyspnea with acute flare starting on admission with new O2
requirements. Although immobile, he is low-risk (1.3%) based on
[**Doctor Last Name 3012**] score. Troponin - and ECG with no acute changes. BNP
elevated, JVD, volume up on exam. Appears patient was right
sided volume overloaded and improved with some diuresis.
Secondary consideration would include diaphragmatic contribution
given prior RUL resection with volume loss. TTE with no changes
from prior. In MICU, pt did not require ventilatory (invasive
or non-invasive) assistance. Respiratory status improved and pt
satting 98-100% RA.
.
# Status post kidney transplant with acute renal failure: Pt's
allograft function was compromised on admission given recent
baseline Cr 1.1-1.2, rehab lab on [**2140-7-20**] Cr 1.4, and admission
Cr 1.6. His urine output had been marginal. Admission urinalysis
showing protein 100 with last UA in [**5-10**] showing trace protein.
FeUrea 20.27, prerenal. UA shows granular casts. He may have
hypotension that has lead to ATN. Urine eosinophils are negative
speaking against AIN in setting of mild peripheral eosinophilia.
Secondary consideration is tacrolimus vasoconstriction also
contributing to ? ATN picture. Creatinine has downtrended after
fluid resuscitation. UCx positive as above. Lasix 40mg QD
restarted [**7-24**]. Renal ultrasound generally unremarkable
.
# Pressure Ulcers: Multiple pressures ulcers: R lateral tibia
(full thickness), R heal (originally Stage III), L Lateral foot
(healing stage III-IV). Wound care consulted and patient treated
per their recs: Remove pressure from area, constant
repositioning, waffle boots at all times. He has stage I sacral
ulcer and multiple areas of skin breakdown in lower extremities.
Sacral coccygeal area blanchable
.
# Immunosuppression: Continued tacrolimus and prednisone.
Continued bactrim ppx. Followed daily tac levels with goal
trough between [**3-4**].
.
# Acute toxic-metabolic encephalopathy: home mirtazapine held;
vitamin B12, RPR, TSH was elevated however T4 was within normal
limits. BK virus undetected
.
# Microcytic, Hypochromic anemia: Admission Hgb is 8.2 (of note
baseline ~ 10). Fe studies c/w anemia of chronic disease (low
Fe, low transferrin and TIBC, normal ferritin). Last EGD and
colonoscopy were in [**2136**] with polyps in the sigmoid colon
(polypectomy) and mild-moderate gastritis (biopsy). H/H stable.
Pt initially on Fe supplementation, but discontinued for iron
studies that seemed more c/w anemia of chronic disease.
.
# Prolonged QTc and Sinus bradycardia: QTc noted to be 502 ms [**First Name (Titles) **] [**Last Name (Titles) **]n ECG. Resolving bradycardia. On telemetry. Resolved
(QTc down to 430 and no longer bradycardic).
.
# History of multiple DVT. INR max was 6.3 on [**7-26**]. Most likely
nutritional deficiency from poor PO intake in the setting of ABX
use. Patient has a history of difficult to control INR levels.
No documented dose of coumadin since [**7-22**]. LFTs WNL. Pt given 5
mg PO vit K. INR down to 2.4 on day of discharge. Pt to resume
coumadin at dose of 0.5mg daily with close INR monitoring.
.
# CAD s/p CABG and MI s/p stents
- continue plavix/aspirin, atorvastatin
- hold other anti-ischemic regimen
.
# T1DM: pt with hypoglycemia with bld glucose down to 50s.
Lantus decreased to 8, then 4 units with stable blood glucose in
the 100s. Discharged pt on 6u QHS and would continue to monitor
and adjust as needed. He was also continued on a humalog sliding
scale.
.
# History of cryptococcal pneumonia: continued fluconazole
suppressive therapy
.
# BPH: tamsulosin held, will restart on discharge
.
# HTN: pt restarted on reduced dose of metoprolol. Pt discharged
with plan to restart amlodipine at rehab as BPs improved during
hospitalization. Pt discharged off imdur.
.
Transitional Issues:
# Full Code
# Pt will return to rehab.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/[**Name (NI) 31571**] rehab list.
1. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<60
2. Clopidogrel 75 mg PO DAILY
3. Fluconazole 200 mg PO Q24H
4. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hodl for sbp<100 or hr<60
6. Metoprolol Tartrate 50 mg PO BID
hold for sbp<100 or hr<60
7. Mirtazapine 7.5 mg PO HS
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Travatan Z *NF* (travoprost) 0.004 % OS qday
12. Tamsulosin 0.4 mg PO HS
13. Actonel *NF* (risedronate) 35 mg Oral q Sunday
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral qhs
16. Ascorbic Acid 500 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Acetaminophen 650 mg PO Q4H:PRN pain
do not exceed 4 g in 24 hour period
19. Aspirin 81 mg PO DAILY
20. Atorvastatin 80 mg PO DAILY
21. Pantoprazole 20 mg PO Q12H
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/hwheezing
23. Warfarin 1 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
do not exceed 4 g in 24 hour period
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/hwheezing
3. Ascorbic Acid 500 mg PO BID
4. Atorvastatin 80 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Fluconazole 200 mg PO Q24H
7. Multivitamins 1 TAB PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Travatan Z *NF* (travoprost) 0.004 % OS qday
12. Cefpodoxime Proxetil 100 mg PO Q12H
Total of 14 days (to end [**8-4**])
13. Furosemide 40 mg PO DAILY
14. Pantoprazole 20 mg PO Q12H
15. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral qhs
16. Tamsulosin 0.4 mg PO HS
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
18. Mirtazapine 7.5 mg PO HS
19. Aspirin 81 mg PO DAILY
20. Actonel *NF* (risedronate) 35 mg ORAL Q SUNDAY
21. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 100 or HR < 60
22. Miconazole 2% Cream 1 Appl TP [**Hospital1 **] perineum
23. Warfarin 0.5 mg PO DAILY16
24. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
25. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<60
Discharge Disposition:
Extended Care
Facility:
Guardian [**Name (NI) **] - [**Name (NI) 1474**]
Discharge Diagnosis:
Primary Diagnosis
Sepsis
Urinary Tract Infection
Acute Renal failure
Secondary Diagnosis
History of renal transplant
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr [**Known lastname **],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were confused with worsening of
your renal function. You were found to have an infection in your
urinary tract that was likely causing your symptoms. You were
given antibiotics through the IV and then converted to pills.
You symptoms improved but you will need to continue taking
antibiotics for 8 more days (last dose [**2140-8-4**]). Your INR was
also elevated so we held your blood thinner. This will need to
restarted once this number improves.
We made the following changes to your medications
1. START Cefpodoxime for 8 more days
2. STOP fludrocortisone
3. STOP isosorbide mononitrate
4. DECREASE metoprolol to 25 mg twice a day
5. DECREASE lantus to 6 units at night
6. DECREASE warfarin to 0.5mg daily
You should continue to take all other medications as instructed.
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
Name: [**Doctor Last Name **] [**Last Name (NamePattern4) 31572**],MD
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Department: NEUROLOGY
When: TUESDAY [**2140-8-9**] at 1 PM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2140-8-16**] at 10:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2140-7-27**]
|
[
"V45.82",
"443.9",
"038.9",
"599.0",
"996.81",
"707.19",
"707.24",
"V49.72",
"285.21",
"V15.82",
"428.0",
"995.91",
"530.81",
"V58.67",
"600.00",
"584.5",
"V12.51",
"E878.0",
"349.82",
"707.23",
"250.51",
"428.32",
"V45.81",
"707.07",
"250.61",
"414.00",
"357.2",
"707.09",
"362.01",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18722, 18797
|
10852, 16269
|
330, 336
|
18982, 18982
|
7503, 10393
|
20133, 21289
|
6228, 6306
|
17576, 18699
|
18818, 18961
|
16356, 17553
|
19167, 20110
|
10409, 10829
|
6321, 7047
|
16290, 16330
|
4691, 5203
|
7061, 7484
|
278, 292
|
364, 4672
|
18997, 19143
|
5225, 5973
|
5989, 6196
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,385
| 175,971
|
30606
|
Discharge summary
|
report
|
Admission Date: [**2146-5-27**] Discharge Date: [**2146-6-17**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2146-5-31**] Cardiac Catheterization
History of Present Illness:
This is an 83 year old female with long standing history of
aortic stenosis. She was recently admitted to [**Hospital 1562**] Hospital
with congestive heart failure. She ruled in for an NSTEMI with
positive troponins. She required aggressive diuresis and was
transfused with multiple packed red blood cells for anemia. She
was also treated with antibiotics for an urinary tract
infection. A most recent echocardiogram on [**2146-5-24**] showed an
aortic valve area of 0.5cm2 with a peak gradient of 69 and mean
of 47mmHg. LVEF was estimated at 55%. There was mild aortic
insufficiency. Due to persistent symptoms of congestive heart
failure, she was transferred to the [**Hospital1 18**] for further evaluation
and treatment.
Past Medical History:
- Aortic Stenosis
- Recent NSTEMI
- Diabetes Mellitus
- Peripheral Vascular Disease - s/p Left Popliteal Atherectomy
- Hypertension
- Dyslipidemia
- Crohns Disease
- Polymyalgia Rheumatica
- History of Giant Cell Arteritis
- Glaucoma
- Colon Cancer - s/p Colonic Resection and Colostomy Reversal
Social History:
Quit tobacco many years ago. Denies ETOH.
Family History:
Denies premature coronary artery disease
Physical Exam:
Vitals: T 99.3, BP 156/62, HR 67, RR 22, SAT 97% on room air
General: elderly female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 4/6 systolic ejection murmur
radiating to carotid
Lungs: clear bilaterally
Abdomen: soft, nondistended, mild tenderness, normoactive bowel
sounds
Ext: warm, trace edema, no varicosities
Pulses: 1+ distally
Rectal: normal tone, guaiac positive
Neuro: alert and oriented, no focal deficits
Pertinent Results:
[**2146-5-27**] Chest X-ray: There is a focal increased density within
the left lower lobe which is nonspecific and may be related to
focal pneumonia in the proper clinical setting. There are
increased interstitial markings at the bases bilaterally.
Cardiomediastinal silhouette is within normal limits.
[**2146-5-30**] Carotid Ultrasound: Less than 40% ICA stenosis
bilaterally.
[**2146-5-27**] 10:05PM BLOOD WBC-10.1 RBC-4.13* Hgb-12.7 Hct-37.5
MCV-91 MCH-30.7 MCHC-33.9 RDW-16.7* Plt Ct-354
[**2146-5-27**] 10:05PM BLOOD PT-13.0 PTT-22.0 INR(PT)-1.1
[**2146-5-27**] 10:05PM BLOOD Glucose-262* UreaN-29* Creat-1.1 Na-140
K-4.8 Cl-100 HCO3-29 AnGap-16
[**2146-5-27**] 10:05PM BLOOD ALT-22 AST-15 AlkPhos-34* TotBili-0.9
[**2146-5-27**] 10:05PM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1
[**2146-5-30**] 05:21PM BLOOD CRP-39.6*
[**2146-5-30**] 05:21PM BLOOD ESR-24*
Brief Hospital Course:
Mrs. [**Known lastname 72597**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation for an aortic valve
replacement. Cartoid non invasive studies showed less than 40%
stenoses of the internal carotid arteries. She was seen by the
dental service who cleared her for surgery after clinical and
radiographic examination found no evidence of infection. She was
also seen by the GI service who recommended to lower the
Prednisone dose to 10mg daily, and found no contraindication for
surgery. She eventually underwent cardiac catheterization which
revealed a right dominant system with single vessel coronary
artery disease. The left main, left anterior descending and
circumflex had no angiographically apparent flow limiting
stenosis. The right coronary artery was a dominant vessel with a
90% ostial lesion. From a cardiac standpoint, she remained
relatively asymptomatic with minimal shortness of breath. During
hospitalization, she had a rise in creatinine(peak 1.8) which
prompted discontinuation of Lasix and Lisinopril. From a GI
standpoint, she continued to experience nausea and vomiting with
poor PO intake.
She was admitted to the vascular surgery service for chronic
mesenteric ischemia. On [**6-2**], she underwent diagnostic
abdominal aortogram and pelvic arteriogram, selective
catheterization of the celiac and superior mesenteric artery. A
brachial artery puncture with first order catheterization was
used x2 and a stent of the celiac and superior mesenteric artery
was placed. She experienced post-procedure abd pain and
hypotension and was admitted to the ICU.
On [**6-7**] she was intubated for impending respiratory failure
secondary to fluid overload. She was extubated for 3 hours and
desaturated and was reintubated. She was extubated on [**6-8**].
She was started on vancomycin on [**6-8**] for MRSA+ sputum and blood
cultures with a recommendation to remain on vanc for 6 weeks.
Bronchoscopy was done on [**6-9**] which she was electively intubated
for, which showed secretions and no infective process. She was
again reintubated on [**6-9**] for respiratory distress. CT on [**6-9**]
showed celiac/SMA stents are widely patent.
[**6-13**] TEE no vegetations, EF >55%, severe AS
[**6-14**]: extubated
[**6-16**]: transferred to VICU, placed on regular diet, doing well
[**6-17**]: transferred to floor, PICC line placed, transferred to
rehab. ID recommends culture of pts valve during AVR and blood
cultures prior to AVR. She will be continued on vancomycin IV
for 5 more weeks.
Medications on Admission:
Alphagan eye gtts, Xalantan eye gtts, Cosopt eye gtts, Aspirin
81 qd, Celexa 40 qd, Folate 1 qd, Glucophage 500 [**Hospital1 **], Regular
Insulin sliding scale, Lasix 40 qd
Levaquin 500 qd, Lisinopril 5 [**Hospital1 **], Lomotil prn, Maalox prn, KCL
20 meq [**Hospital1 **], Prednisone 20 qd, Protonix 20 qd, Mercaptopurine 50
qd, Synthroid 75mcg qd, Atenolol 12.5 qd, Zocor 20 qd
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*1 * Refills:*2*
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
14. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO daily ()
for 3 doses.
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 5
doses.
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q
24H (Every 24 Hours) for 5 weeks: hold [**6-17**],
restart [**6-18**].
17. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
21. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 59839**]
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease - Recent NSTEMI
Diabetes Mellitus
Peripheral Vascular Disease - History of Left Popliteal
Atherectomy
Hypertension
Dyslipidemia
Polymyalgia Rheumatica
History of Giant Cell Arteritis
Glaucoma
History of Colon Cancer - s/p Colonic Resection and Colostomy
Reversal
Chronic mesenteric ischemia - s/p
Aortic Stenosis
Coronary Artery Disease - Recent NSTEMI
Diabetes Mellitus
Peripheral Vascular Disease - History of Left Popliteal
Atherectomy
Hypertension
Dyslipidemia
Polymyalgia Rheumatica
History of Giant Cell Arteritis
Glaucoma
History of Colon Cancer - s/p Colonic Resection and Colostomy
Reversal
chronic mesenteric ischemia s/p celiac and SMA stent
Discharge Condition:
Stable
Discharge Instructions:
Take medications as directed. Call EMS if start to experience
chest pain or shortness of breath.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72598**] surgeon, call office for
appointment ([**Telephone/Fax (1) 1504**]
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]- call office for a 2 week follow up
appointment
[**Telephone/Fax (1) 67148**]
|
[
"458.29",
"725",
"790.7",
"365.9",
"V10.05",
"410.71",
"V09.0",
"518.5",
"578.9",
"250.00",
"424.1",
"428.0",
"401.9",
"V15.82",
"443.9",
"557.1",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.05",
"99.15",
"88.72",
"88.47",
"37.22",
"88.56",
"96.72",
"00.48",
"00.41",
"99.04",
"96.04",
"96.6",
"38.93",
"39.90",
"39.50",
"33.22",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8048, 8100
|
2909, 5461
|
281, 323
|
8836, 8845
|
2027, 2886
|
8990, 9272
|
1473, 1515
|
5892, 8025
|
8121, 8815
|
5487, 5869
|
8869, 8967
|
1530, 2008
|
222, 243
|
351, 1078
|
1100, 1398
|
1414, 1457
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,278
| 114,478
|
2245
|
Discharge summary
|
report
|
Admission Date: [**2115-6-24**] Discharge Date: [**2115-6-29**]
Date of Birth: [**2040-11-16**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Transfer from ICU, patient originally presented with acute
shortness of breath.
Major Surgical or Invasive Procedure:
P-MIBI, gastric emptying study.
History of Present Illness:
Mr. [**Known lastname 11875**] is a 74 year old male with a history of HTN, DM2,
ESRD on HD with atrophic L kidney, who presented to the ED on
[**2115-6-24**] with a chief complaint of dyspnea on his way to
hemodialysis. The patient is a poor historian, and it is
difficult to get a history from him even with an interpreter,
however the following was obtained: He had last received his
regularly scheduled HD on [**2115-6-21**]. Patient denies any history of
chest pain, palpitations, or change in diet (no high salt
intake). He does describe some nausea, emesis, and lack of
apetite for the last few months. About 1 week ago he noted
increased peripheral edema, and on the night prior to admission
he began having increased SOB. He denies any fevers. He
describes a recent weight loss secondary to his nausea and
decreased apetite, however he is uncertain of how much. He may
have had some mild abdominal pain, but this is only over the
last few days.
On presentation to the ED, he was afebrile, with bp 220/148, HR
103, RR 30s, saturating 94-97% on 100%NRB. He was placed on
BIPAP and NTG drip with good response: RR decreased to 20s, BP
decreased to 173/115, and the patient was transfered to the MICU
for further management of what was felt to be most likely a CHF
exacerbation based on physical exam findings of volume overload.
No recent echo reports, however patient had a stress test in
[**2106**] with 9.5 minutes of [**Doctor First Name **] protocol, no ischemia or EKG
changes.
The patient was transferred to the MICU for further management
of his CHF exacerbation. A CXR showed moderate CHF with small
bilateral pleural effusions. EKG was without ST,T wave changes.
He received HD with good response - normalization of BP, IV
nitro drip was weaned. Received second HD [**6-25**] (day after
admission to ICU), and was subsequently transferred to the
floors.
Past Medical History:
HTN
DM2
Nephrolithiasis, s/p bilateral ureteral stents in [**2110**]
ESRD on HD (M,W,F)
Atrophic L kidney
Liver biopsy c/w granulomatous hepatitis
h/o infected R IJ permacath s/p removal 3/04
L forearm AVG [**1-17**]
Social History:
Patient denies ever drinking alcohol, smoking, or doing drugs.
Married, but no children. Lives at home where he says he has
plenty of support, but won't elaborate regarding who the support
is. Has difficulty with transportation to dialysis, and is very
interested in acquiring this transportation.
Family History:
Difficult to elicit, even with translator.
Physical Exam:
VS: 96.2, P 76, BP 126/81, R 16.
Gen: African American male, resting comfortably in bed, NAD.
HEENT: Anicteric sclera, [**Name (NI) 3899**], PEARL, pterygium in R eye.
Neck: No JVD, supple, no lymphadenopathy.
CVS: RR, normal rate, no M/R/G.
Lungs: Rales b/l at the bases.
Abd: Normoactive BS. Mild RUQ tenderness, worse with
inspiration. No organomegaly.
Extr: 1+ bipedal edema extending up to knees. Palpable radial,
DP pulses b/l.
Pertinent Results:
[**2115-6-24**] WBC-13.4*# RBC-4.15*# Hgb-14.2# Hct-44.5# MCV-107*#
MCH-34.3*# MCHC-31.9 RDW-13.3 Plt Ct-226
[**2115-6-24**] Neuts-66 Bands-0 Lymphs-29 Monos-5 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
[**2115-6-28**] 03:30PM BLOOD WBC-8.1 RBC-4.27* Hgb-14.5 Hct-42.0
MCV-98 MCH-33.9* MCHC-34.5 RDW-13.8 Plt Ct-240
[**2115-6-27**] 07:10AM BLOOD Neuts-55.7 Lymphs-27.5 Monos-11.6*
Eos-4.6* Baso-0.7
[**2115-6-24**] PT-12.2 PTT-24.0 INR(PT)-1.0
[**2115-6-24**] Glucose-190* UreaN-42* Creat-7.5* Na-135 K-4.5 Cl-95*
HCO3-24 AnGap-21* Calcium-9.7 Phos-5.8* Mg-2.2
[**2115-6-29**] 07:35AM BLOOD Glucose-143* UreaN-40* Creat-6.7*# Na-138
K-3.9 Cl-95* HCO3-29 AnGap-18
[**2115-6-26**] 07:05AM BLOOD ALT-74* AST-28 AlkPhos-204* TotBili-0.5
[**2115-6-27**] 07:10AM BLOOD ALT-54* AST-22 AlkPhos-196* TotBili-0.5
[**2115-6-29**] 07:35AM BLOOD ALT-32 AST-19 AlkPhos-192* Amylase-228*
TotBili-0.5
[**2115-6-24**] CK(CPK)-213*, cTropnT-0.33*
[**2115-6-25**] CK(CPK)-160, CK-MB-5, cTropnT-0.42*
[**2115-6-25**] CK-MB-4 cTropnT-0.41*
[**2115-6-27**] 07:10AM BLOOD Lipase-84*
[**2115-6-27**] 07:10AM BLOOD calTIBC-231* VitB12-1102* Folate-16.9
Ferritn-1297* TRF-178*
[**2115-6-27**] 07:10AM BLOOD Triglyc-139 HDL-82 CHOL/HD-2.7
LDLcalc-115
[**2115-6-27**] 07:10AM BLOOD TSH-1.3
[**2115-6-27**] 07:10AM BLOOD Free T4-1.7
Echocardiogram [**2115-6-26**]: Left to right shunt across the
interatrial septum consistent with a stretched patient foramen
ovale or small atrial septal defect. Left ventircular wall
thickness was normal. The left ventricular cavity size is
normal. Resting regional wall motion abnormalities include
distal anterior and septal apical hypokinesis, inferior
hypokinesis/akinesis and basal inferoseptal hypokinesis with
mild hypokinesis elsewhere. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Trivial/physiologic pericardial effusion.
Brief Hospital Course:
The patient was transferred to the MICU for further management
of his CHF exacerbation. A CXR showed moderate CHF with small
bilateral pleural effusions. EKG was without ST,T wave changes.
He received HD with good response - normalization of BP, IV
nitro drip was weaned. Received second HD [**6-25**] (day after
admission to ICU), and was subsequently transferred to the
floors.
1) CHF - The patient was still mildly volume overloaded on PE
upon arrival to the floors, with mild bipedal edema and rales at
the right base, [**Last Name (un) 11876**] he received hemodialysis M,T,W with more
than 11 kg fluid removed, and is without signs of failure on
physical exam currently. As to the cause of the CHF
exacerbation, renal feels that patient may not have been having
enough fluid removed at HD since patient has recently lost
weight, and therefore dry weight may have been overestimated,
and therefore they weren't removing as much fluid as they should
have been. They do not feel that the patient needs to be on
Lasix, as they will remove fluid via HD, which he will continue
as an outpatient M,W,F.
Cardiac enzymes were ordered to rule out a myocardial infarction
as a cause of his CHF, with Troponin T elevated, however in this
patient with renal failure, a TnI would be more useful. CK-MB
has been wnl. We also ordered an echocardiogram in order to
evaluate his pump function, which showed diffuse hypokinesis of
the left ventricle, as described in the pertinent results
section. As the patient has never had a stress test before, we
ordered a p-MIBI in order to further evaluate his cardiac risk,
which was a poor study secondary to failure of the patient to
achieve greater than 60% of his maximum heart rate, and was
stopped after 4 minutes. In light of this, the interpretation
of perfusion defects is somewhat unreliable. No perfusion
defects were seen on this limited study. What was able to be
determined, however, was that his EF was only 26%, indicating a
cardiomyopathy. Cardiology recommends a dobutamine echo as an
outpatient to further evaluate his coronary vasculature. We
started him on Aspirin 325 mg PO qday.
2) ESRD - Patient currently receiving HD and being followed by
renal. Most likely secondary to his DM, and HTN. We felt that
addition of an ACE-I would be beneficial in this patient with
Diabetes, CHF, and HTN, and started Lisinopril 2.5 mg qday,
discontinuing his calcium channel blocker in order to allow for
this addition. We also started him on nephrocaps 1 tab PO qday,
Phoslo 2 tabs TID for phosphate binding, and Renagel. We
continued his epogen, and held a couple of doses secondary to
normal hematocrit. He continued to put out some of his own
urine.
3) HTN - Patient's b.p. was elevated in the MICU, however has
been well controlled on the floors, and was responsive to fluid
removal. As discussed above, we discontinued his calcium
channel blocker (Nifedipine CR 30 mg PO qday), and started
Lisinopril 2.5 mg PO qday. We also decreased his atenolol to
once a day in order to add the Lisinopril.
4) Lipids - This patient was continued on Lipitor 10 mg PO qd.
We obtained a lipid profile to help evaluate his cardiovascular
risk, which showed: Chol 225, LDL 115, TG 139, HDL 82, ratio
2.7. This is a surprisingly good lipid profile, with quite high
HDL, and therefore his lipitor dose was maintained and not
increased, especially in light of his mild transaminitis.
4) Nausea/abdominal pain - The patient seems to have been having
some nausea, with decreased apetite and weight loss prior to
this hospitalization. He says these have resolved since
admission, however, and may have been related to uremia. A
gastric emptying study was performed which was normal, making
gastroparesis less likely in this diabetic patient. Of note,
the patient was noted to have changes consistent with chronic
pancreatitis on a MRI of the abdomen in [**2114-1-29**], and this may be
the cause of his recurrent nausea and vomitting. The patient is
being scheduled for an appointment with Dr. [**Last Name (STitle) 7307**] in
gastroenterology to further evaluate his nausea and vomiting.
He may want to consider a trial of pancrelipase.
5) Granulomatous Disease: The patient has a history of
granulomatous hepatitis on liver biopsy, and in light of his
nausea, we did a hepatic/biliary ultrasound which showed some
heterogeneity of the liver, with no distinct masses, no
choledocholithiasis or cholecystitis. His AST and ALT were
found to be 28, and 74, respectively, on [**6-26**], and 22, 54 on
[**6-27**], with an ALP > 200. He has had a transaminitis in the
past, which was what brought him to the attention of
gastroenterology.
His prior course: A hepatic ultrasound on [**2114-1-23**] showed a
heterogeneous liver with multiple small nodules and cirrhosis
versus metastatic disease as the primary cause, as well as
bilateral renal calculi. A follow up MRI on [**2114-1-29**] showed a
heterogeneous liver, and a liver biopsy revealed a granulomatous
hepatitis. Additionally, this patient has been found to have a
polyclonal hypergammaglobulinemia, and a CT of the
abdomen/pelvis on [**2111-5-15**] showed multiple buttock granulomas.
The patient has also been found to have bilateral hilar and
mediastinal lymphadenopathy on CT [**2115-4-30**] consistent with a
diagnosis of sarcoidosis.
In summary, it seems most likely that this is a patient with
sarcoidosis, when taking all evidence into account: Bilateral
hilar and mediastinal lymphadenopathy, restrictive PFTs,
granulomatous hepatitis, buttock granulomas, perhaps the chronic
nephrolithiasis, and now with a cardiomyopathy on echo and
stress test. We discussed the risks versus benefits of steroid
therapy in this patient in light of the possible myocardial
involvement (though we do not know that this is due to
sarcoidosis), however even if the myocardial involvement were
due to sarcoidosis we do not believe steroids would be
indicated. Not only have steroids not been conclusively shown
to be effective in sarcoidosis, but they also would not improve
any fibrosis that has already developed causing the organ
dysfunction that he has. Most importantly, this is a 74 year
old male with diabetes, hypertension, and renal failure -
steroids could exacerbate his diabetes, his hypertension, and
worsen his volume overload. It is therefore recommended to
simply continue observation. A dobutamine echo has been
recommended by cardiology to further evaluate whether or not
this cardiomyopathy is due to ischemia or another process (such
as sarcoidosis). If it is due to ischemia, he may be a
candidate for a cath. Dr. [**Last Name (STitle) 8499**] should make these
arrangements should he deem them appropriate.
5) DM - His diabetes was managed with an insulin sliding scale
while in the hospital, and finger stick readings were generally
less than 200. He seemed to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] in the 200s every
night at 10 pm, and the patient says that he does take
medication for his diabetes at home, however he was unable to
tell us what it was. We continued his insulin sliding scale,
and he will be restarted on his outpatient diabetes medications
by Dr. [**Last Name (STitle) 8499**] when he sees him next week.
5) GU - We continued this patient's Detrol while in the
hospital. He had a couple of episodes of incontinence after we
removed the foley catheter that he had while in the MICU. A UA
revealed both yeast, and bacteria, and we know he has had
persistent yeast in the urine in the past. We started a course
of Levaquin, renally dosed, to treat the UTI. He received a
loading dose of 500 mg while in the hospital, and will continue
250 mg PO q 48 hours after leaving the hospital, his second dose
being tomorrow ([**2115-6-30**]). He has been asymptomatic.
6) Prophylaxis: He was given subcutaneous heparin TID.
7) PT: The patient was able to walk up and down 2 flights of
stairs, and down the hallway without assistance. He took them
slowly and carefully, somewhat weakened from the last few days
of bedrest, though not unsteady. He feels ready to go, and has
a wife at home for support.
IN SUMMARY: More than 11 kg of fluid removed via HD this
admission. CHF exacerbation resolved. This patient should most
likely have a dobutamine echocardiogram set up as an outpatient.
He should also have an appointment with Dr. [**Last Name (STitle) 7307**] set up (I
am unable to do this now as it is the weekend) - I am not sure
if he will be able to do this on his own - maybe Dr. [**Last Name (STitle) 8499**]
can help to facilitate this. He will continue dialysis M,W,F.
He is on a 14 day course of Levaquin (7 doses) for a UTI. He
was started on Lisinopril. His CCB was stopped, atenolol was
decreased to qday. He was started on Aspirin. An echo and
stress test showed diffuse left ventricular hypokinesis, most
likely a cardiomyopathy. A diagnosis of Sarcoidosis is strongly
suspected after reviewing all of the information, however would
not start steroids.
Medications on Admission:
Atenolol 50 mg [**Hospital1 **]
Detrol 4 mg qhs
Humalin
Lasix 80 mg QOD on non-HD days
Nifedipine 30 mg PO qd
Protonix 40 mg PO qd
Lipitor 10 mg PO qd
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Tolterodine Tartrate 4 mg Capsule, Sust. Release 24HR Sig:
One (1) Capsule, Sust. Release 24HR PO at bedtime.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
Disp:*15 Tablet(s)* Refills:*2*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO every other
day for 14 days: 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
CHF exacerbation.
ESRD.
DM2.
Likely sarcoidosis.
Discharge Condition:
Stable
Discharge Instructions:
Take all of your medicines as directed. Do not take your
nifedipine (Procardia) anymore. Take atenolol only once a day.
New medications: Lisinopril, Aspirin.
Take levofloxacin (Levaquin) every other day for a total of 7
doses.
Return to the hospital if you become short of breath again.
See Dr. [**Last Name (STitle) 8499**] next Wednesday ([**2115-7-3**]) at 3:15.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7976**] Next Wednesday
([**2115-7-3**]) at 3:15. Call to change.
Gastroenterology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7307**] [**Telephone/Fax (1) 1954**]. Call to make
an appointment.
|
[
"428.0",
"414.8",
"135",
"577.1",
"599.0",
"250.40",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15893, 15979
|
5529, 14598
|
391, 425
|
16072, 16080
|
3431, 5506
|
16497, 16826
|
2914, 2958
|
14799, 15870
|
16000, 16051
|
14624, 14776
|
16104, 16474
|
2973, 3412
|
272, 353
|
453, 2341
|
2363, 2581
|
2597, 2898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,862
| 143,843
|
7963
|
Discharge summary
|
report
|
Admission Date: [**2123-2-2**] Discharge Date: [**2123-2-10**]
Date of Birth: [**2065-2-1**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol / Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
fever, somnolence
Major Surgical or Invasive Procedure:
Double lumen Power PICC placed [**2-9**]
History of Present Illness:
57 yo F c PBC c/b cirrhosis, HCC s/p segmentectomies x 2 ([**2-14**],
[**6-17**]) and recurrence s/p TACE of R, L hepatic arteries ([**7-19**],
[**8-19**]) c/b biliary ischemia and hepatic abscesses growing
separate pansensitive and ciprofloxacin-resistant <i>Pseudomonas
aeruginosa</i> s/p surgical drain placement in [**2122-11-10**] and
indefinite inititation of home IV meropenem. Interval imaging
showed decrease in abscess size in [**Month (only) 404**]; her last imaging was
a CT scan on [**2123-1-18**] and showed no change in abscess size since
[**Month (only) 404**] and showed intrahepatic biliary dilatation, as well as
ill-defined opacity in caudate lobe worrisome for tumor
recurrence. Her AFP was documented as 4.2 at that time and she
was scheduled for ERCP for stent placement. ERCP was performed
[**2123-1-26**] and revealed no evidence of extrahepatic biliary
stricturing, diffuse stenosis of intrahepatic ducts with no
lesion appropriate for stent placement.
.
Since the ERCP, patient has noted increased somnolence and
fatigue; she has been falling asleep during conversations and
has trouble going up and down stairs. On day prior to
admission, she was noted to have temperature on VNA assessment
of 100.0 and was noted to have WBC count of 2.5 on lab draw.
Patient said that her skin felt warm but she denied feeling
feverish, chills, or night sweats. Patient endorses increased
abdominal distention and LE edema over last two weeks; she is
unclear as to whether she has gained weight recently. Stable,
chronic, non-radiating RUQ pain well controlled with oxycodone
prn. Patient was admitted from clinic today after detailing
these complaints for management of suspected infection and
possible hepatic encephalopathy.
.
Currently, patient is resting comfortably in the hospital bed
and is lucid, oriented x 3, and without acute complaints.
.
ROS: See HPI. Patient complains of mild HA, nasal congestion x
2 days with no associated sinus congestion or SOB. Mild cough x
2 days slightly productive of sputum. Altered taste and poor
appetite. Denies CP, N/V/D/C, dysuria.
Past Medical History:
ONCOLOGIC HISTORY
1. [**2-14**]: Resection of segment VII HCC
2. [**6-17**]: Resection of segment VI HCC
3. [**6-18**]: Multifocal HCC in both the left lobe and remainder of
right lobe. Underwent TACE of the right hepatic lobe on [**2122-7-30**]
4. [**2122-9-8**]: TACE of the left hepatic lobe
.
PAST MEDICAL HISTORY:
1. Primary biliary cirrhosis diagnosed in [**2096**]. EGD on [**2122-4-10**] demonstrated normal esophagus without esophageal or gastric
varices.
2. Ulcerative colitis x10 years.
3. Frequent urinary tract infections.
4. HCC s/p segmentectomy
Social History:
She is a dentist who works with her husband in a mutually owned
dental practice in [**Location (un) 686**]. She smoked tobacco between the
ages 12 and 19 and does not drink alcohol.
Family History:
Significant for primary biliary cirrhosis in one of her sisters.
Physical Exam:
Vitals - T: 97.1 BP: 90/60 HR: 101 RR: 16 02 sat: 99% RA
Wt: 61.7 kg
GENERAL: NAD, AAOx3
HEENT: NCAT, OP clear, MM dry
CARDIAC: RRR s mrg
LUNG: CTA with diminished BS at bases bilaterally
ABDOMEN: mildly distended, S, mild TTP R side > L side without
rebound, guarding, or rigidity, no appreciable fluid wave or
shifting dullness
EXT: WWP, [**12-12**]+ pitting edema to knees bilaterally, 2+ pulses
NEURO:
DERM: Spider angiomata on trunk.
PSYCH: Appropriate affect, intact thought processes and content.
Pertinent Results:
Labs on admission [**2122-2-2**]:
[**2123-2-2**] 07:34PM URINE HOURS-RANDOM UREA N-339 CREAT-48
SODIUM-LESS THAN POTASSIUM-27 CHLORIDE-11
[**2123-2-2**] 07:34PM URINE OSMOLAL-223
[**2123-2-2**] 04:46PM GLUCOSE-104* UREA N-25* CREAT-0.8 SODIUM-121*
POTASSIUM-4.1 CHLORIDE-88* TOTAL CO2-27 ANION GAP-10
[**2123-2-2**] 04:46PM ALT(SGPT)-78* AST(SGOT)-117* ALK PHOS-174*
TOT BILI-18.6* DIR BILI-14.2* INDIR BIL-4.4
[**2123-2-2**] 04:46PM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-3.2
MAGNESIUM-2.0
[**2123-2-2**] 04:46PM OSMOLAL-265*
[**2123-2-2**] 04:46PM WBC-3.1* RBC-3.85* HGB-11.9* HCT-35.3* MCV-92
MCH-30.8 MCHC-33.7 RDW-15.8*
[**2123-2-2**] 04:46PM NEUTS-63 BANDS-1 LYMPHS-14* MONOS-20* EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2123-2-2**] 04:46PM PLT SMR-VERY LOW PLT COUNT-59*
[**2123-2-2**] 04:46PM PT-17.8* PTT-32.8 INR(PT)-1.6*
.
CT [**2123-1-18**]:
1. Clamped right-sided transhepatic pigtail catheter in place
with no
appreciable change in size of two hepatic abscesses within
segments VII and VIII since [**2122-12-18**].
2. Ill-defined low-attenuating area in caudate lobe concerning
for tumor recurrence as suspected on prior CT, is better
depicted on multiphasic study of [**2122-11-16**].
3. Interval increase in size of a moderate right pleural
effusion.
4. Cirrhosis with intrahepatic biliary dilatation. Unchanged
perigastric and perisplenic varices as well as splenomegaly with
mass effect on left kidney.
.
ERCP [**2123-1-26**]:
Cannulation of the biliary duct was obtained and contrast medium
was injected, revealing a normal-appearing CBD, cystic duct and
gallbladder. Diffuse narrowing of the intrahepatic ducts is
present, consistent with cirrhosis. An area of contrast
extravasation at the right posterior intrahepatic duct
apparently corresponds to a prior drain site seen on a previous
CT examination.
.
Blood cultures [**Date range (1) 28561**] positive for
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
Cefepime & CEFTAZIDIME sensitivity testing confirmed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
RUQ U/S [**2123-2-3**]:
Nodular cirrhotic liver with a dominant 2.6-cm mass in the
caudate lobe and several smaller suspicious nodules scattered
elsewhere.
Doppler assessment is normal. There is no residual fluid
collection seen
following prior drainage. Gallstones and splenomegaly also
noted.
.
ECHO [**2-4**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve. The
estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: no obvious vegetations
.
CT abd/pelvis [**2-7**]:
IMPRESSION:
1. Removal of the right transhepatic drainage catheter with
reaccumulation of
fluid posterior to the right hepatic lobe.
2. New areas of low attenuation in both hepatic lobes, the
largest in the
left hepatic lobe measures 2.7 cm, concerning for new hepatic
abscesses.
3. Caudate lobe mass consistent with growing hepatocellular
carcinoma.
Multiple treated HCC as before.
.
Brief Hospital Course:
This is a 58 year female with history of PBC complicated by
cirrhosis, HCC s/p surgical resection, HCC recurrence s/p TACE
complicated by biliary ischemia and hepatic abscesses s/p
surgical drain placement and IV abx who presented with
somnolence as well as fevers and was found to be hyponatremic
with recurrent hepatic abscesses and blood cultures positive for
MDR Pseudomonas.
.
#. MDR Pseudomonas bacteremia, hepatic abscesses: The patient's
blood cultures were positive for MDR Pseudomonas from [**Date range (1) 28561**]
likely secondary to recurrent hepatic abscesses which were
discovered on a CT scan. The Pseudomonas was cefepime/meropenem
resistant, ceftazidime intermediate resistance, and cipro/zosyn
sensitive. A TTE was negative for any vegetations. The
infectious disease consult service followed the patient closely
throughout her admission. Her old PICC line was discontinued
and she was started on cipro monotherapy given her documented
allergy to penicillin. A new double lumen power PICC was placed
on [**2-9**] after the patient had been blood culture negative and
afebrile for several days. She was also desensitized to
penicillin per MICU protocol and started on Zosyn prior to
discharge. Zosyn/Cipro will be continued indefinitely with the
[**Hospital **] clinic following surveillance labs. Interventional radiology
was consulted for hepatic abscess drainage, but felt that the
abscesses were small enough where antibiotic penetration would
be possible without drainage.
.
#. HCC: A CT abdomen/pelvis performed on [**2-7**] demonstrated
progression of her known HCC as well as recurrent hepatic
abscesses with no significant ascites. Her MELD score was 22 on
discharge, but the patient is not a transplant candidate. She
was treated with lactulose, lasix, aldactone, cholestyramine,
ursodiol, and oxycodone with only minor modifcations in dosing
when compared to her previous home regimen.
.
#. AMS/somnolence: Likely secondary to hyponatremia (Na=121 on
admission) along with a component of hepatic encephalopathy.
Mental status improved to baseline and patient was alert and
oriented times 3 on discharge after sodium correction with fluid
restrcition and administration of lactulose.
.
#. Ulcerative colitis: Remained stable. The patient's home
mesalamine regimen was continued.
.
#. CODE: The patient's code status was established as DNR/DNI
this admission following a conversation with the patient and her
family concerning her poor prognosis given her worsening liver
failure secondary to treatment refractory, progressive HCC.
.
#. DISPO: Home with hospice services and IV Cipro/Zosyn
Medications on Admission:
calcitonin 200u spray 1 hs
questran 4g qday
folic acid 1 mg qd
lasix 40 mg qd
meropenem 1g IV q8h
mesalamine 1.2g tid
mesalamine enema qd
oxycodone 5-10 mg q8-12h prn pain
compazine 5mg q12-24h prn nausea
spironolactone 100 mg qd
ursodiol 500 mg [**Hospital1 **]
Vit C 500 qd-tid
Ca/Vit D 500/200 [**Hospital1 **]
MVI
cranberry extract 500 qd
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal HS (at bedtime).
2. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. Mesalamine 4 gram/60 mL Enema Sig: One (1) enema Rectal HS
(at bedtime).
6. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Ascorbic Acid 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO BID (2 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: [**12-12**] to 1 Tablet PO every four (4)
hours as needed for pain.
15. Ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400)
mg Intravenous twice a day.
Disp:*QS * Refills:*2*
16. Zosyn 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every
eight (8) hours.
Disp:*QS * Refills:*2*
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*QS ML(s)* Refills:*0*
18. Compazine 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for nausea.
19. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mL PO every six (6)
hours as needed for pain.
Disp:*2 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Hepatic abscesses
Multi drug resistant Pseudomonas bacteremia
Primary Biliary Cirrhosis
Hepatocellular Carcinoma
Secondary diagnoses:
- Ulcerative Colitis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of fevers and fatigue. You were found to have
recurrent liver abscesses and your blood was infected with an
antibiotic resistant bacteria called Pseudomonas. Your old PICC
was removed as a result of the infection and a new one was
placed several days later for continued long term IV antibiotic
treatment. You were desensitized to pencillin and will be
started on an extended course of Zosyn (a stronger penicillin
related antibiotic) and Cipro. It appears that the abscesses
are too small to be drained at this time and should respond to
your antibiotic regimen. Unfortunately, it also appears as
though your known liver cancer continues to progress despite all
the treatments you have received.
.
The following changes have been made to your home medication
regimen:
- You will be on Zosyn 4.5 grams IV every 8 hours indefinitely
- You will be on ciprofloxaxin 400mg IV twice daily indefinitely
- Your home furosemide dose has been decreased to 20mg daily
- Your home spironolactone dose has been decreased to 50mg daily
- You will be started on lactulose which should be titrated to
help ensure daily bowel movements
.
Please follow-up with your scheduled appointments listed below.
Followup Instructions:
Please follow-up with your scheduled appointments listed below:
.
1. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2123-3-1**] 9:30
.
2. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2123-3-1**] 11:40
.
3. Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2123-5-28**] 2:30
|
[
"275.41",
"155.0",
"790.7",
"733.00",
"782.4",
"556.9",
"572.0",
"276.1",
"780.97",
"041.7",
"571.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12783, 12834
|
7902, 10532
|
328, 371
|
13034, 13034
|
3912, 7879
|
14459, 14956
|
3306, 3373
|
10925, 12760
|
12855, 12969
|
10558, 10902
|
13182, 14436
|
3388, 3893
|
12990, 13013
|
271, 290
|
399, 2505
|
13049, 13158
|
2847, 3090
|
3106, 3290
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,362
| 121,153
|
33064
|
Discharge summary
|
report
|
Admission Date: [**2179-6-19**] Discharge Date: [**2179-6-21**]
Date of Birth: [**2158-5-11**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 3129**]
Chief Complaint:
Hypertension, Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
21 year old female with MPGN s/p renal transplant ([**7-13**]) and
recurrent MPGN who was recently admitted several times over the
last few months for hypertensive emergency and for generalized
tonic clonic seizures at the end of [**Month (only) 596**]. She recently started
peritoneal dialysis. She began to complain of headache, nausea
and vomiting and was unable to take her blood pressure
medications.
In the ED, she was hypertensive to 260/120. Head CT was negative
for bleed. She was given labetalol 10 iv x 1 then started on
labetalol gtt. She was noted to have a K of 6.5 so she was given
bicarb, insulin, glucose, and calcium. BUN/cr notably increased
from baseline despite peritoneal dialysis. She was admitted to
the ICU for further evaluation and blood pressure control.
In the ICU, she is very tired, pressure was down to 180's and
she feels that her headache is a bit better than when she first
arrived. She c/o nausea.
Past Medical History:
1) MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two year. In
[**6-/2178**] pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of [**Year (4 digits) **]. She is now transferred her care to Dr. [**Last Name (STitle) **]
at [**Hospital1 18**] to an adult clinic.
2) Peripheral edema and abdominal striae [**1-9**] steroids
3) HTN [**1-9**] steroids and renal disease, multiple admissions for
Hypertensive emergency.
4) Hemolytic Anemia - was seen by heme/onc who felt it was [**1-9**]
to malignant hypertension.
5) Migraines
Social History:
Lives at home with [**Month/Day (2) **], brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit
drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VS: T 98.5 BP 187/135 P 106 R 18 95% RA
GEN: eyes closed, does not open when asks, but will answer
questions
[**Name (NI) 4459**]: EOMI, PERRL, anicteric. OP clear, MMM
RESP: CTAB no w/r/r
CV: RRR 2/6 SM LUSB no rubs
CHEST: HD catheter in right chest wall
ABD: Soft ND + BS no rebound or guarding but mild ttp on
epigastrium. PD catheter in place
EXT: Warm well perfused, no peripheral edema
SKIN: no rashes but excoriations over back
NEURO: nonfocal neuro exam, diffusely weak on strength exam but
?cooperative
Pertinent Results:
[**2179-6-19**] 05:07AM
GLUCOSE-107* LACTATE-2.9* NA+-140 K+-6.0* CL--94* TCO2-25
[**2179-6-19**] 05:07AM freeCa-1.20
[**2179-6-19**] 07:55PM GLUCOSE-161* UREA N-66* CREAT-11.6*#
SODIUM-137 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20
ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-383* ALK PHOS-49 AMYLASE-71
TOT BILI-0.1
ALBUMIN-3.4 CALCIUM-9.5 PHOSPHATE-5.9*# MAGNESIUM-1.4*
WBC-8.3 RBC-3.49*# HGB-10.2*# HCT-31.4*# MCV-90 MCH-29.2
MCHC-32.4 RDW-18.0*
ECG Study Date of [**2179-6-19**] 6:50:56 AM
Sinus tachycardia. Poor R wave progression. Non-specific ST-T
wave changes. Compared to the previous tracing of [**2179-5-22**] sinus
tachycardia is new and the T waves are now upright.
CHEST (PORTABLE AP) Study Date of [**2179-6-19**] 5:29 AM
IMPRESSION: No signs of acute cardiopulmonary process.
CT HEAD W/O CONTRAST Study Date of [**2179-6-19**] 5:30 AM
IMPRESSION: Normal head CT.
Brief Hospital Course:
21 year old female with MPGN s/p renal transplant ([**7-13**]) and
recurrent MPGN now on PD with multiple recent admissions over
the last few months for hypertensive emergency and for
generalized tonic clonic seizures at the end of [**Month (only) **] again
presents with hypertensive emergency.
# Hypertension. On initial presentation, the patient was
hypertensive to 260/120. Head CT was negative for bleed. She was
given labetalol 10 IV x 1 and was then started on labetalol gtt.
Additionally upon presentation, she was noted to have a K of 6.5
so she was given bicarb, insulin, glucose, and calcium. BUN/cr
notably increased from baseline despite peritoneal dialysis.
From the ED, she was admitted to the ICU where she was continued
on a labetalol drip until 9am; it was d/c'd after she was able
to tolerate her PO antihypertensive medications. After
reinitiation of her oral meds and discontinuation of labetalol
gtt, her BP remained consistantly 140s/70s. She was discharged
to the medical floor and remained normotensive. She was
discharged on ger home anti-hypertensive regimen.
# Nausea/vomiting. Patient reported this has been an ongoing
issue. Symptoms improved with antiemetics and at the time of
discharge the patient was able to tolerate PO meds.
# Hyperkalemia: Likely in the setting of worsened renal function
and has since remained normal after initial treatment as
outlined in HPI. Potassium was 4.7 on discharge.
# Renal Failure d/t recurrent MPGN in transplant. Pt on
ambulatory peritoneal dialysis as outpatient. During her
hospital course, the concentration of dextrose in her bath
solution was lowered to 1.5% due to hyponatremia and concern
that intravasular dehydration in the setting of her nausea and
vomiting. Hyponatremia resolved and the patient was discharged
on her home regimen of 4.25% dextrose dialysate.
# Metabolic acidosis. Anion gap was 23 on admission. Althouth
lactate was elevated, there were no clear localizing symptoms of
infection and she was been afebrile without leukocytosis.
Peritoneal fluid negative for infection by cell counts. A CXR
was without e/o infiltrate. Over the course of admission, the
anion gap was trending down and was 15 at the time of discharge.
Medications on Admission:
Aliskiren 150mg daily
Renagel tid
Clonidine 0.1mg tid
Clonidine 0.2 patch weekly
Furosemide 80mg [**Hospital1 **]
Hydralazine 100mg tid
Isradipine 15mg tid
Lisinopril 40mg daily
Losartan 100mg [**Hospital1 **]
Metoprolol 150mg [**Hospital1 **]
Cellcept 250mg [**Hospital1 **]
Ondansetron 4mg [**Hospital1 **] prn
Prednisone 5mg qod
Nephrocaps daily
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO daily ().
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Isradipine Oral
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
12. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
13. Losartan 100 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Nausea Vomiting
ESRD
Discharge Condition:
Pt was hemodynamically stable, afebrile and without pain.
Discharge Instructions:
You were admitted for treatment of your high blood pressure.
During your hospitaization, you were given IV medication to
lower your blood pressure and your fluid status was carefully
monitored. You responded well to this therapy and the day of
discharge your blood pressures were relatively well controlled
on your home medications. We have discontinued your lasix, but
you should otherwise take your blood pressure medications as
previously described.
You were also found to have elevated potassium on admission and
this was thought to be related to your worsening renal function.
This imbalance was corrected and your potassium was normal upon
discharge. You should continue your home peritoneal dialysis as
directed.
You have been scheduled for an appointment with Dr. [**First Name (STitle) **].
Please follow-up as directed below. You should also follow-up
with your primary nephrologist, Dr. [**Last Name (STitle) 118**].
Please call your doctor or return to the emergency room if you
develop fevers, chills, nausea, vomiting, diarrhea, chest pain,
shortness of breath, changes in vision, worsening headache,
abdominal pain or any other symptoms of concern.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD
Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-6-28**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD
Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2179-7-13**] 6:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD
Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-7-22**] 1:00
Completed by:[**2179-10-25**]
|
[
"585.6",
"285.21",
"276.1",
"403.01",
"276.7",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
7947, 7953
|
4119, 6345
|
316, 322
|
8039, 8099
|
3206, 4096
|
9319, 9781
|
2586, 2658
|
6745, 7924
|
7974, 8018
|
6371, 6722
|
8123, 9296
|
2673, 3187
|
246, 278
|
350, 1288
|
1310, 2372
|
2388, 2570
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,881
| 162,040
|
3746
|
Discharge summary
|
report
|
Admission Date: [**2165-6-25**] Discharge Date: [**2165-6-27**]
Date of Birth: [**2091-1-9**] Sex: M
Service: Thoracic Surgery
CHIEF COMPLAINT: Left lower lobe lung mass.
HISTORY OF PRESENT ILLNESS: The patient was a 74-year-old
male status post bilateral nephrectomy for renal cell
carcinoma who had a suspicious mass in the left lower lobe on
a follow-up chest x-ray for metastatic renal cell carcinoma.
He was admitted for wedge resection.
PAST MEDICAL HISTORY: Non-insulin dependent diabetes
mellitus, hypertension, end stage renal disease secondary to
bilateral nephrectomy for renal cell carcinoma, coronary
artery disease status post CABG times three,
hypercholesterolemia, pacemaker.
MEDICATIONS: On admission, Captopril 50 mg tid, enteric
coated Aspirin one q d, Glyburide 2.5 mg q d, Lipitor,
Prilosec, Nephrocaps, Coreg, Ativan 2 mg daily, Benadryl 800
mg [**Hospital1 **], TUMS tid.
ALLERGIES: IV contrast and Morphine.
HOSPITAL COURSE: The patient underwent an elective left
thoracoscopy, limited left thoracotomy and wedge resection
left lower lobe. He tolerated the procedure well and was
taken to the ICU for postoperative management. Renal consult
was obtained for his renal issues. Electrophysiology consult
was also obtained because he was pacing at 40 beats per
minute postoperatively. They interrogated the pacer and
reset it. He was stable in the ICU though he needed to
remain on Neo-Synephrine drip to maintain his blood pressure.
On postoperative day #2 he was off the Neo-Synephrine and
stable enough for transfer to a regular floor. He did
remarkably well on regular floor, his analgesics and po pain
medication and he was deemed ready for discharge.
DISCHARGE MEDICATIONS: All the same as preoperative
medications with the addition of Percocet 1-2 tablets po q
4-6 hours prn.
FOLLOW-UP: With Dr. [**Last Name (STitle) 175**] in one week.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2165-6-27**] 13:26
T: [**2165-6-27**] 18:19
JOB#: [**Job Number 16854**]
|
[
"585",
"272.0",
"197.0",
"V45.81",
"V10.52",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"39.95",
"32.29"
] |
icd9pcs
|
[
[
[]
]
] |
1737, 2184
|
977, 1713
|
162, 190
|
219, 464
|
487, 959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,595
| 167,816
|
5865
|
Discharge summary
|
report
|
Admission Date: [**2117-10-11**] Discharge Date: [**2117-10-13**]
Date of Birth: [**2042-5-8**] Sex: M
Service: NMED
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left sided weakness, slurred speech.
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation.
History of Present Illness:
Patient is a 75 year old right handed male with past medical
history of coronary artery disease s/p NQWMI [**1-25**], s/p LAD
angioplasty and stent [**4-25**], dementia, hyperlipidemia, aortic
stenosis, atrial fibrillation on coumadin who presented from his
eye doctor's office wtih acute onset left sided weakness and
dysarthria. Patient was in his usual state of health until
around 12:15 on day of admission. Was at this doctor's office
and complained of severe headache. Thereafter, wife noted
development of left sided weakness, facial droop, slurring of
speech. Sent to [**Hospital1 18**] for evaluation emergently.
ED course: Arrived at [**Hospital1 18**] at 12:30. Finger stick blood glucose
120. Rest of vitals BP 112/70, HR 60. Blood pressure up to 230s
systolic. Seen emergently by stroke team. Initial NIH stroke
scale of 33. Head CT showed large right intracerebral
hemorrhage. Intubated for airway protection at 13:35 after
Fentanyl, Etomidate, Vecuronium and Succhinylcholine given.
Started on Labetalol and then Nipride drip for BP control;
discontinued as goal BP in 130-160s. Received 10 mg SC Vitamin K
and 2 units FFP while in ED. Pupils noted to be fixed and
dilated at 14:10. Loaded with Dilantin and 50 grams Mannitol.
Transferred to intensive care unit.
Past Medical History:
1. Atrial fibrillation, on coumadin
2. Coronary artery disease status post NQWMI [**1-25**], s/p LAD
angioplasty and stent [**4-25**]. Known non-dominant 90% RCA lesion
not intervened upon.
3. Dementia
4. Mild-moderate aortic stenosis
5. Hyperlipidemia
6. Colon cancer
7. Obstructive sleep apnea
8. Anxiety
9. Diabetes mellitus, on oral medications
Social History:
Married. Lives with wife. One son, in area. Social alcohol. No
tobacco, drug use.
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAM (Examined off of Propofol):
Tc: 96.7 BP: 120/48 HR: 61 RR: 14 O2Sat.:
100%, ventilated.
Gen: WD/WN male, comfortable appearing, intubated, not sedated.
HEENT: NC/AT. Anicteric. MMM. +Endotracheal tube.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Coarse breath sounds anterolaterally.
Cardiac: Irregularly irregular. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: No response to voice, sternal rub. Grimaces to
nasal tickle.
Cranial Nerves: Pupils fixed at 7mm bilaterally. Very weak
flicker of inner canthus on left with corneal stimulation. No
oculocephalic reflex. Left facial droop. No gag provoked, but
biting ETT at times. Tongue midline.
Motor: Normal bulk. Increased tone x4 with LEs>UEs. No
withdrawal to noxious stimuli. Bilateral feet externally
rotated.
Sensation: No withdrawal to noxious stimuli.
Reflexes: Absent in LUE, left ankle. Striking left patellar
tendon results in sustained clonus of left leg. Toes upgoing
bilaterally. [**1-27**] RUE, absent right ankle.
Coordination: Unable to assess.
Gait: Unable to assess.
Pertinent Results:
[**2117-10-11**] 12:39PM WBC-9.1 RBC-4.29* HGB-14.1 HCT-38.7* MCV-90
MCH-32.8* MCHC-36.4* RDW-14.7
[**2117-10-11**] 12:39PM PLT COUNT-147*
[**2117-10-11**] 12:39PM PT-20.0* PTT-32.4 INR(PT)-2.5
[**2117-10-11**] 12:39PM GLUCOSE-101 UREA N-25* CREAT-1.0 SODIUM-142
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13
[**2117-10-11**] 12:39PM CK(CPK)-200*
[**2117-10-11**] 12:39PM cTropnT-<0.01
[**2117-10-11**] 12:39PM CK-MB-7
[**2117-10-11**] 09:45PM CK(CPK)-196*
[**2117-10-11**] 09:45PM CK-MB-3 cTropnT-<0.01
[**2117-10-12**] 03:30AM BLOOD CK(CPK)-312*
[**2117-10-12**] 03:30AM BLOOD CK-MB-5 cTropnT-<0.01
[**2117-10-11**] 01:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2117-10-12**] 11:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2117-10-12**] 10:17AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CT head without contrast [**2117-10-11**]: FINDINGS: There is a large
region of high attenuation within the right frontal lobe and the
region of the right basal ganglia. This is consistent with
intraparenchymal hemorrhage, more likely hypertensive in
etiology. No significant subarachnoid or intraventricular
hemorrhage is appreciated. There is mass effect present with
shift of the normally midline structures towards the left. There
is also left sided subfalcine herniation. There is no
hydrocephalus. The visualized osseous structures and paranasal
sinuses are unremarkable. IMPRESSION: Large intraparenchymal
hemorrhage within the right frontal lobe. This most likely
relates to hypertensive hemorrhage, as opposed to a ruptured
right middle cerebral artery aneurysm.
Brief Hospital Course:
Patient was a 75 year old right handed male with past medical
history of atrial
fibrillation on coumadin, coronary artery disease,
hyperlipidemia, dementia with sudden onset left sided weakness,
dysarthria. Head CT demonstrated a large right intracerebral
hemorrhage, centered around basal ganglia and putamen. We felt
this was likely secondary to hypertension. While still in the
emergency department, he had rapid decompensation necessitating
intubation for airway protection. Examination post intubation
but off intubations showed clinical evidence of elevated
intracranial pressure and brainstem compression. The overall
prognosis was guarded. He was admitted to the
Neurology/Neurosurgery ICU.
He was loaded with Mannitol and Dilantin in the emergency room.
He was evaluated by the Neurosurgery service and they did not
feel a surgical intervention or ventriculary drain was
warranted. After arrival in the ICU, patient was followed with
neuro checks every 1 hour. Sedation was held to allow for
frequent exams. Head of bed was kept at 30 degrees. Labetalol
continuous infusion was titrated for systolic blood pressure of
130-160. Mannitol and Dilantin were continued. After lengthy
discussion, the patient's wife opted to make him DNR on
afternoon of [**2117-10-11**].
Overnight, fresh frozen plasma was given for goal INR of <1.4.
On serial exams by neurology and ICU attendings in the morning
on [**2117-10-12**], patient had no clinical signs of brainstem
activity. Namely, he was unresponsive. Pupils were fixed and
dilated. No corneal, gag, oculocephalic, and oculovestibular
reflexes were elicited. He was not overbreathing his ventilator.
At this point, patient was felt to have clinical signs
consistent with brain death. Plans were made to proceed with
apnea testing. However, after discussion with patient's wife,
this was postponed with test planned on [**2117-10-13**]. Full medical
care and managment continued overnight [**Date range (1) 23212**].
At approximately 06:00 on [**2117-10-13**], the patient became
bradycardic. He lapsed first into a junctional rhythm and then
had very infrequent ventricular escape beats on telemetry.
Finally, he went asystolic. He was not resuscitated as per
previous conversations with his wife. [**Name (NI) **] was pronounced dead at
06:59 am. The patient's wife was notified. The attending was
notified as well.
Medications on Admission:
1. Coumadin
2. Lipitor
3. Toprol XL
4. ASA
5. Zoloft
6. Glucophage
7. Aricept
8. Namenda
9. Artificial Tears
Discharge Medications:
Not applicable.
Discharge Disposition:
Extended Care
Facility:
Patient deceased.
Discharge Diagnosis:
Not applicable; patient deceased.
Discharge Condition:
Not applicable.
Discharge Instructions:
Not applicable.
Followup Instructions:
Not applicable.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"431",
"414.01",
"272.4",
"427.31",
"401.9",
"V45.82",
"424.1",
"294.8",
"V10.05",
"412",
"250.00",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.91",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7764, 7808
|
5190, 7564
|
329, 369
|
7885, 7902
|
3432, 5167
|
7966, 8076
|
2167, 2186
|
7724, 7741
|
7829, 7864
|
7590, 7701
|
7926, 7943
|
2201, 2717
|
253, 291
|
397, 1678
|
2810, 3413
|
2732, 2794
|
1700, 2051
|
2067, 2151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,251
| 121,790
|
45440
|
Discharge summary
|
report
|
Admission Date: [**2153-2-14**] Discharge Date: [**2153-2-19**]
Service: MEDICINE
Allergies:
Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
tachypnea, fever, mental status change.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F h/o af, s/p multiple [**Hospital 96978**] nursing home resident, who was
noted to acutely become unable to speak, hypoxic, and tachypnic
at 7:15PM (VS RR40s 98/50 hr 125 98% on 2L). Pt usually awake,
able to chat, walks with cane, legally blind. Per report, pt was
evaluated by MD, put on NRB without improvement, and referred to
ED with concern for stroke on the basis of garbled speech, and
inability to walk.
.
Upon arrival to [**Hospital1 18**] ED @8PM, VS=98.8 133/114 124 32 96% . Tmax
101.6 rectal. CXR unremarkable, EKG with poor baseline [**1-6**]
rigors, unable to perform ABG or LP. CT head with maxillary
sinusitis, CT abd/pelvis unchanged from prior (pancreatic and
liver mass). Venous lactate 6, +diarrhea per ER report. pt given
1.5L IVF. She was not intubated [**1-6**] confirmation that pt is
DNR/DNI. UA unremarkable. She was empirically started on
vanco/aztreonam/flagyl.
Pt admitted to ICU for further monitoring and w/u.
Past Medical History:
-- CAD: s/p MI x2; s/p Cypher stent to RCA in [**2148**]; [**12-11**] P-MIBI:
Normal pharmacologic stress myocardial perfusion with normal
left ventricular cavity size and wall motion.
-- Chronic diastolic CHF: Echo [**2151-3-4**] EF >55%, 1+MR, 1+ TR,
mild PA systolic
pressure
-- Hypertension
-- Diabetes mellitus
-- Atrial fibrillation - per history but currently in sinus. Not
on coumadin
-- Sjogren's syndrome / scleroderma.
-- squamous cell carcinoma
-- Interstitial lung disease
-- osteoporosis, with vertebral compression fractures.
-- GERD / esophageal dysmotility / peptic ulcer disease.
-- Macular degeneration
-- h/o DVT
-- s/p colectomy
-- s/p CVA x4
-- s/p TAH/RSO
-- s/p post appendectomy
-- h/o femoral hernia repair
-- Pancreatic lesion that needs follow up
-- influenza [**2-/2153**]
Social History:
Patient was a [**Hospital1 18**] employee x 36 years, widowed. She has 2
children, one in [**State **] and [**State 4565**]. PAtient walks with a
cane/ Patient lives in [**Location **] Place [**Hospital3 **]. Patient
reports she walks with cane assist only although she is legally
blind.
Tobacco: 15 pk-yr, quit 65 yrs ago
ETOH: None
Illicts: None
Family History:
One child died at age 60 of CAD/cancer
Father died at 52 of MI
Physical Exam:
VS: 114 150/136 36 99%5L
GEN: uncomfortable.
HEENT: PERRLA, [**Hospital3 3899**], sclera anicteric, OP clear, MMM, no LAD, no
carotid bruits. No JVD.
CV: tachy, nl s1, s2, no m/r/g.
PULM: coarse breath sounds anteriorly, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL.
NEURO: moving all four extremities spontaneously, does not
follow commands, repeats "right" or "no" only
Pertinent Results:
[**2153-2-19**] 06:40AM BLOOD WBC-9.8
[**2153-2-18**] 07:05AM BLOOD WBC-11.4* RBC-3.38* Hgb-10.4* Hct-31.5*
MCV-93 MCH-30.9 MCHC-33.2 RDW-16.0* Plt Ct-313
[**2153-2-15**] 02:06AM BLOOD WBC-14.8*# RBC-3.57* Hgb-11.3* Hct-33.4*
MCV-94 MCH-31.6 MCHC-33.7 RDW-15.8* Plt Ct-335
[**2153-2-15**] 02:06AM BLOOD Neuts-89.7* Bands-0 Lymphs-7.1* Monos-2.3
Eos-0.8 Baso-0.1
[**2153-2-15**] 02:06AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2*
[**2153-2-19**] 06:40AM BLOOD UreaN-10 Creat-0.9 Na-140 K-3.9 Cl-106
HCO3-25 AnGap-13
[**2153-2-14**] 08:00PM BLOOD Glucose-79 UreaN-18 Creat-1.3* Na-140
K-5.5* Cl-103 HCO3-22 AnGap-21*
[**2153-2-15**] 09:15PM BLOOD CK(CPK)-103
[**2153-2-15**] 02:06AM BLOOD ALT-20 AST-41* CK(CPK)-81 AlkPhos-112
Amylase-72 TotBili-0.9
[**2153-2-15**] 09:15PM BLOOD CK-MB-4 cTropnT-0.10*
[**2153-2-15**] 10:53AM BLOOD CK-MB-3 cTropnT-0.09*
[**2153-2-15**] 02:06AM BLOOD CK-MB-3 cTropnT-0.08*
[**2153-2-14**] 08:00PM BLOOD CK-MB-3 proBNP-8372*
[**2153-2-18**] 07:05AM BLOOD Mg-1.7
[**2153-2-16**] 06:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.4
[**2153-2-14**] 08:00PM BLOOD Calcium-9.8 Phos-1.5* Mg-1.6
[**2153-2-15**] 02:06AM BLOOD VitB12-794 Folate-GREATER TH
[**2153-2-15**] 02:06AM BLOOD TSH-0.80
[**2153-2-14**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2153-2-15**] 01:38AM BLOOD Type-ART O2 Flow-3 pO2-82* pCO2-23*
pH-7.57* calTCO2-22 Base XS-0
[**2153-2-14**] 08:19PM BLOOD Glucose-77 Lactate-6.0* Na-142 K-4.8
Cl-104 calHCO3-23
[**2153-2-15**] 02:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2153-2-15**] 02:05AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2153-2-15**] 02:05AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2153-2-14**] 09:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2153-2-14**] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.0 Leuks-NEG
Blood and urine cultures negative at time of discharge.
DFA for influenza negative.
Urine legionella antigen negative.
[**2153-2-15**] 2:13 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2153-2-19**]**
FECAL CULTURE (Final [**2153-2-19**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2153-2-17**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2153-2-17**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2153-2-17**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2153-2-17**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2153-2-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Cardiology Report ECG Study Date of [**2153-2-15**] 10:12:38 AM
Sinus rhythm with frequent premature atrial contractions. Left
axis deviation.
Possible prior inferior myocardial infarction. Anterior T wave
inversions.
Non-specific lateral T wave changes. Rule out anterior
myocardial ischemia.
Compared to tracing #1 anterior T wave inversions are prominent.
TRACING #2
Portable AP chest radiograph compared to [**2153-2-5**].
The cardiomegaly is moderate-to-severe, unchanged. Mediastinal
contours are stable.
Bilateral hilar enlargement and increase in interstitial
markings are consistent with mild volume overload although no
overt pulmonary edema is demonstrated. These findings might also
represent infection such as viral or atypical bacterial such as
mycoplasma. No appreciable pleural effusion is demonstrated.
IMPRESSION:
Described finding consistent with either mild volume overload or
pulmonary infection such as viral or atypical bacterial.
Findings discussed with Dr. [**Last Name (STitle) **] over the phone at the
time of dictation by Dr. [**Last Name (STitle) **].
CHEST RADIOGRAPH OBTAINED ON [**2153-2-14**].
CLINICAL HISTORY: [**Age over 90 **]-year-old woman with altered mental status,
tachypnea, rigors, evaluate for pneumonia.
FINDINGS: AP upright portable chest radiograph is obtained.
Comparison is made with limited views through the lower chest on
subsequently performed CT scan of the abdomen and pelvis.
Cardiomegaly is noted. There is no overt CHF. Blunting at the
right CP angle, likely related to small pleural effusions seen
better on the CT abdomen and pelvis performed subsequently.
There is coarsening of interstitial markings along the periphery
of both lungs, which is compatible with patient's known
interstitial lung disease, also better assessed on corresponding
CT abdomen and pelvis images. Pulmonary vasculature is within
normal limits. Mediastinal contour is grossly unremarkable.
Atherosclerotic calcification along the aortic knob is noted.
There is no pneumothorax. No displaced rib fractures are seen.
Bones are osteopenic. Visualized upper abdomen demonstrates an
unremarkable bowel gas pattern. Degenerative changes are noted
in the thoracic and visualized portions of the lumbar spine.
IMPRESSION:
Cardiomegaly, small right pleural effusion, without evidence of
CHF or pneumonia. Coarsened interstitial markings correspond
with patient's known interstitial lung disease.
CT HEAD WITHOUT CONTRAST: No comparison studies. No intracranial
hemorrhage, mass effect, shift of normally midline structures,
or major vascular territorial infarct is apparent. There is
moderate prominence of sulci and ventricular system consistent
with age-appropriate central atrophy. There is an air-fluid
level in the right maxillary sinus with associated mucosal
thickening. There is hypertrophy of the left maxillary sinus
with evidence of prior sinus surgery. There is mild mucosal
thickening of the ethmoid cells and right frontal sinus. Mastoid
air cells are clear. No acute fractures are identified. There
are marked degenerative changes at the atlantodental interval.
IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Air-fluid level in the right maxillary sinus, which could
indicate acute sinusitis in the right clinical setting.
CT ABDOMEN W/O CONTRAST [**2153-2-14**] 8:42 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: eval for source of presumed sepsis, please do IV
contrast on
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
Sudden onset aphasia, inability to walk at 715. From [**Hospital1 599**].
usually awake, chatting. Hx AF, DM, multiple strokes.
REASON FOR THIS EXAMINATION:
eval for source of presumed sepsis, please do IV contrast only
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Sudden onset of aphasia, inability to walk. History
of AF, DM, multiple strokes. Evaluate for source of presumed
sepsis.
TECHNIQUE: MDCT acquired axial images from the lung bases to the
pubic symphysis were acquired without intravenous or oral
contrast material and displayed with 5-mm slice thickness.
Multiplanar reformations performed.
CT ABDOMEN WITHOUT CONTRAST: There is a small right-sided
pleural effusion. There are abnormally increased interstitial
markings in the visualized portions of the lung bases,
indicating interstitial lung disease. There is mild-to-moderate
cardiomegaly. There is a 2.9 x 1.9 cm hypoattenuating lesion in
the left lobe of the liver, incompletely characterized on this
non-contrast study. The spleen is normal in size. The stomach is
unremarkable. There is an umbilical [**Doctor Last Name **] hernia without
evidence of obstruction. There are innumerable mostly exophytic
cysts arising from both kidneys. There is a 2.6 x 2.1 cm lesion
in the body of the pancreas measuring fluid density. There is no
ascites. There are marked atherosclerotic calcifications of the
abdominal aorta and its major tributaries.
CT PELVIS WITHOUT CONTRAST: There is a moderate amount of stool
in descending colon, sigmoid colon, and rectum. The bladder is
distended. There are multiple phleboliths. The uterus is not
seen. There is no free fluid.
BONE WINDOWS: There are degenerative changes throughout the
visualized portions of thoracic spine and the lumbar spine with
bridging anterior osteophytes at multiple levels. There are
central depressions of the superior endplates of L1 and L3,
chronic in appearance. There is marked disc degeneration between
L3 and S1 with intervertebral disc space narrowing, subchondral
sclerosis and cyst formation. There also is marked facet
arthropathy of the lumbar spine. No acute fractures are
identified. No suspicious lytic or sclerotic lesions.
IMPRESSION:
1. Small right-sided pleural effusion.
2. Interstitial lung disease.
3. A 3 cm hypoattenuating lesion in the left lobe of the liver,
incompletely characterized on this non-contrast study.
4. A 2.6 x 2.1 cm cystic lesion in the body of the pancreas,
incompletely characterized.
5. Innumerable bilateral renal cysts.
6. Abdominal hernia containing non-obstructed small bowel.
7. Distended bladder.
8. Severe degenerative changes in the lumbar spine as described.
Brief Hospital Course:
Despite code stroke being called, no signs of acute CVA noted on
CT head. patient symptoms resolved with fluids and antibiotics.
It was likley delirium cause by acute renal failure (poor po
intake) and pneumonia (atypical). After initial broad spectrum
antibiotics, she was tapered to doxycycline to complete course
for 10 days. Hypoxia resolved. Patient was afebrile prior to
discharge. Delirium completely resolved and patient was back to
baseline mental state. IVF were initially given for renal
failure that resolved. Patient should be closely monitored by
nutrition to ensure she is eating adequately at rehab.
Acute renal failure - resolved with hydration.
Sinusitis, likely viral (maxillary) - no symptoms neted.
Delirium - resolved
History of hypertension, atrial fibrillation, hyperlipidemia,
coronary artery disease
as per discussion with PCP and son [**Name9 (PRE) **] - it is possible that
patient may need long term car eplacement after rehab if she is
unable to return to her [**Hospital3 **].
Dr [**Last Name (STitle) 665**] informed of discussion with son on day of discharge.
Medications on Admission:
1.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2.Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
3.Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day.
4.Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
5.Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Risedronate 35 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
7.Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
8.Escitalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
9.Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10.Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11.Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
12.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14.Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
15.Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
16.Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
17.Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5 minutes as needed for chest pain: Please take
every five minutes for a total of 3 doses for chest pain. If
your pain doesn't resolve, please call Emergency Medical
Service.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): till completely ambulating.
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 6 days.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): hold if somnolent.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
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. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain: as directed.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-13**]
hours as needed for pain.
16. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week:
Every Monday.
Give with 2 cups of water and have patient sit upright for
atleast 45 mins after the tablet. .
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO QDAILY ().
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Atypical pneumonia
Acute renal failure
Sinusitis, likely viral (maxillary)
Delirium - resolved
History of hypertension, atrial fibrillation, hyperlipidemia,
coronary artery disease.
Discharge Condition:
Stable. Mentation at baseline.
Discharge Instructions:
You were diagnosed with pneumonia and dehydration likely related
to pneumonia and inadequate oral intake.
The rehab is recommended for further physical therapy. Dr
[**Last Name (STitle) **] is aware of your hospitalization as you know. Please
follo wp with him in [**12-6**] weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Date/Time:[**2153-2-27**] 11:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2153-3-5**] 1:20
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2153-3-6**] 3:30
Provider: [**Name10 (NameIs) 6800**] CLINIC Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2153-3-6**]
3:30
|
[
"250.00",
"461.9",
"401.9",
"486",
"733.00",
"414.01",
"293.0",
"427.31",
"584.9",
"272.4",
"369.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16657, 16729
|
12109, 13206
|
388, 395
|
16955, 16988
|
3101, 9383
|
17319, 17826
|
2597, 2661
|
14943, 16634
|
9420, 9548
|
16750, 16934
|
13232, 14920
|
17012, 17296
|
2676, 3082
|
309, 350
|
9577, 12086
|
423, 1388
|
1410, 2215
|
2231, 2581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,395
| 185,242
|
54223
|
Discharge summary
|
report
|
Admission Date: [**2192-6-28**] Discharge Date: [**2192-7-7**]
Service: MEDICINE
Allergies:
Aleve
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]-year-old man with recently diagnosed lymphoplasmacytic
lymphoma on rituximab presented from [**Hospital1 **] long-term facility
with 2 days of loose stools, abdominal pain, chills, low-grade
fevers, and generalized malaise. Patient was hospitalized at
[**Hospital1 18**] in [**2192-5-17**] for E. coli bacteremia and was found to be
neutropenic secondary to lymphoplasmacytic lymphoma. He was then
discharged to [**Hospital1 **]. He received his first dose of rituximab on
[**2192-6-21**]. Patient has been neutropenic. On [**2192-6-26**], he started
having diarrhea and was started on metronidazole 500 mg PO bid.
C. diff toxin came back positive today, [**2192-6-27**]. Patient
continued to do poorly, with low-grade fever and chills, and
therefore was transferred to [**Hospital1 18**] on [**2191-6-28**].
.
In the ED, T 100.4, HR 99, BP 82/45 (but on repeat SBP 132
before any intervention), RR 18, 98%RA. His abdomen was
distended as baseline and was moderately tender. Abdominal CT
revealed colitis. His WBC was 0.8 with 29% neutrophils, 27%
bands, and 39% lymphs. He was given cefepime, PO vancomycin, IV
vancomycin and admitted to BMT.
Past Medical History:
ONCOLOGIC HISTORY:
# Lymphoplasmacytic lymphoma:
- [**5-/2192**]: presented with E. coli bacteremia secondary to
neutropenia. Bone marrow biopsy revealed a hypercellular bone
marrow with involvement by a chronic lymphoproliferative
disorder. By immunohistochemical stains, B-cells comprise 10-20%
of overall marrow cellularity, with dim co-expression for CD5.
Reactive T-cells are present and express CD3. Plasma cells are
reactive for CD138, and comprise <10% of marrow cellularity. The
absence of significant lymphadenopathy, presence of cytoplasmic
immunoglobulin inclusions in plasma cells in the marrow and
rather strong expression of CD20 by flow cytometry suggest
lymphoplasmacytic lymphoma or, alternatively, small lymphocytic
lymphoma (total lymphocyte count <4,000), with plasma cell
differentiation.
- [**2192-6-21**]: first dose of rituximab
.
OTHER MEDICAL HISTORY:
- recurrence malignant melanomas (including local recurrences),
last [**2191**] that was pT1b
- [**Doctor Last Name **] 3+3 prostate adenocarcinoma (diagnosed [**2183**]) followed
by surveillance with Dr. [**Last Name (STitle) **]
- benign prostatic hypertrophy
- cholecystectomy
- known chronic intestinal pneumatosis
- DM2 on insulin
- HTN
- asthma
- hyperlipidemia
- GERD
Social History:
(from OMR) Smoked 6-7 years as a young adult, none since.
Lifelong nondrinker. Retired 11 years ago after working as a
travel [**Doctor Last Name 360**] for 50+ years; also worked conducting a band.
Family History:
Father had DM, Mother had Asthma and Brother died of MI.
Physical Exam:
On admission:
Gen: elderly Caucasian man lying in bed, awake, alert, NAD
HEENT: EOMI, conjunctivae clear, sclerae anicteric, OP moist
without lesion
Neck: supple
Lungs: CTAB
CV: normal S1/S2, regular rhythm, no murmur
Abd: soft, distended (baseline per patient), nontender, BS
present, no fluid wave
On discharge: same.
Pertinent Results:
[**2192-6-27**] 10:10PM WBC-0.8*# RBC-2.78* HGB-8.5* HCT-24.8* MCV-89
MCH-30.6 MCHC-34.4 RDW-16.5*
[**2192-6-27**] 10:10PM NEUTS-29* BANDS-27* LYMPHS-39 MONOS-3 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2192-6-27**] 10:10PM PLT COUNT-207
[**2192-6-27**] 10:10PM PT-13.6* PTT-24.7 INR(PT)-1.2*
[**2192-6-27**] 10:14PM LACTATE-1.4
[**2192-6-27**] 10:10PM GLUCOSE-182* UREA N-64* CREAT-2.8*#
SODIUM-134 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-16
[**2192-6-27**] 10:10PM ALT(SGPT)-22 AST(SGOT)-15 ALK PHOS-296* TOT
BILI-0.7
[**2192-6-27**] 10:10PM LIPASE-15
[**2192-6-27**] 10:10PM cTropnT-0.03*
[**2192-6-27**] 10:10PM ALBUMIN-3.2*
[**2192-6-30**] 06:08AM BLOOD WBC-0.3* RBC-2.91* Hgb-8.6* Hct-25.9*
MCV-89 MCH-29.5 MCHC-33.0 RDW-16.6* Plt Ct-175
[**2192-7-1**] 06:16AM BLOOD WBC-0.6*# RBC-2.92* Hgb-8.8* Hct-26.5*
MCV-91 MCH-30.3 MCHC-33.4 RDW-16.7* Plt Ct-168
[**2192-7-2**] 06:12AM BLOOD WBC-0.8* RBC-3.04* Hgb-9.4* Hct-27.5*
MCV-90 MCH-30.9 MCHC-34.2 RDW-16.7* Plt Ct-180
[**2192-7-3**] 06:30AM BLOOD WBC-1.1* RBC-3.12* Hgb-9.6* Hct-28.8*
MCV-92 MCH-30.8 MCHC-33.4 RDW-16.2* Plt Ct-177
[**2192-7-4**] 06:00AM BLOOD WBC-1.0* RBC-3.07* Hgb-9.4* Hct-28.2*
MCV-92 MCH-30.7 MCHC-33.4 RDW-15.8* Plt Ct-155
[**2192-6-28**] 06:33AM BLOOD Neuts-46* Bands-0 Lymphs-47* Monos-6
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2192-6-30**] 06:08AM BLOOD Neuts-52 Bands-0 Lymphs-36 Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2192-7-2**] 06:12AM BLOOD Neuts-37* Bands-5 Lymphs-45* Monos-5
Eos-2 Baso-0 Atyps-5* Metas-1* Myelos-0
[**2192-7-3**] 06:30AM BLOOD Neuts-28* Bands-11* Lymphs-51* Monos-8
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2192-7-4**] 06:00AM BLOOD Plt Ct-155
[**2192-7-3**] 06:30AM BLOOD Plt Ct-177
[**2192-7-2**] 06:12AM BLOOD Plt Smr-NORMAL Plt Ct-180
[**2192-7-1**] 06:16AM BLOOD Plt Ct-168
[**2192-6-28**] 06:33AM BLOOD Gran Ct-230*
[**2192-6-30**] 06:08AM BLOOD Glucose-98 UreaN-52* Creat-1.8* Na-139
K-4.1 Cl-112* HCO3-18* AnGap-13
[**2192-7-1**] 06:16AM BLOOD Glucose-43* UreaN-51* Creat-1.6* Na-137
K-3.7 Cl-111* HCO3-18* AnGap-12
[**2192-7-2**] 06:12AM BLOOD Glucose-77 UreaN-49* Creat-1.5* Na-137
K-4.4 Cl-112* HCO3-18* AnGap-11
[**2192-7-3**] 06:30AM BLOOD Glucose-42* UreaN-49* Creat-1.4* Na-137
K-4.0 Cl-111* HCO3-19* AnGap-11
[**2192-7-4**] 06:00AM BLOOD Glucose-80 UreaN-46* Creat-1.5* Na-138
K-4.2 Cl-113* HCO3-20* AnGap-9
[**2192-6-28**] 06:33AM BLOOD Calcium-7.7* Phos-4.1 Mg-1.1*
[**2192-6-29**] 05:40AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.5*
[**2192-6-30**] 06:08AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.7
[**2192-7-1**] 06:16AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.0
[**2192-7-2**] 06:12AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.8
[**2192-7-3**] 06:30AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.7
[**2192-7-4**] 06:00AM BLOOD WBC-1.0* RBC-3.07* Hgb-9.4* Hct-28.2*
MCV-92 MCH-30.7 MCHC-33.4 RDW-15.8* Plt Ct-155
[**2192-7-5**] 06:00AM BLOOD WBC-1.0* RBC-3.00* Hgb-8.6* Hct-27.8*
MCV-93 MCH-28.8 MCHC-31.1 RDW-16.6* Plt Ct-148*
[**2192-7-6**] 09:34AM BLOOD WBC-1.1* RBC-2.95* Hgb-9.0* Hct-26.7*
MCV-91 MCH-30.6 MCHC-33.8 RDW-16.6* Plt Ct-135*
[**2192-7-3**] 06:30AM BLOOD Neuts-28* Bands-11* Lymphs-51* Monos-8
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2192-7-5**] 06:00AM BLOOD Neuts-50 Bands-1 Lymphs-34 Monos-11 Eos-3
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2192-7-6**] 09:34AM BLOOD Neuts-49.7* Lymphs-44.4* Monos-4.7
Eos-0.7 Baso-0.5
[**2192-7-5**] 06:00AM BLOOD Plt Smr-LOW Plt Ct-148*
[**2192-7-6**] 09:34AM BLOOD Plt Ct-135*
[**2192-6-28**] 06:33AM BLOOD Gran Ct-230*
[**2192-7-4**] 06:00AM BLOOD Gran Ct-390*
[**2192-7-6**] 09:34AM BLOOD Gran Ct-540*
[**2192-7-3**] 06:30AM BLOOD Glucose-42* UreaN-49* Creat-1.4* Na-137
K-4.0 Cl-111* HCO3-19* AnGap-11
[**2192-7-4**] 06:00AM BLOOD Glucose-80 UreaN-46* Creat-1.5* Na-138
K-4.2 Cl-113* HCO3-20* AnGap-9
[**2192-7-5**] 06:00AM BLOOD Glucose-64* UreaN-43* Creat-1.4* Na-139
K-4.5 Cl-112* HCO3-21* AnGap-11
[**2192-7-6**] 09:34AM BLOOD Glucose-165* UreaN-40* Creat-1.4* Na-137
K-5.2* Cl-110* HCO3-21* AnGap-11
STUDIES:
# Abd/pel CT [**2192-6-27**]: (prelim) Marked wall thickening and
inflammatory changes involving the sigmoid colon, with mild
distension of the descending colon, c/w colitis, likely
infectious. Mild inflammatory changes surrounding the cecum.
# CXR [**2192-6-27**]: (my read) elevated right hemidiaphragm, no
infiltrate, unchanged from [**2192-6-8**]
Brief Hospital Course:
[**Age over 90 **]-year-old man with recently diagnosed lymphoplasmacytic
lymphoma, neutropenic on rituximab, recently with E. coli
bacteremia, presented with C. diff colitis and neutropenia.
.
# C. diff colitis: with evidence on CT. Patient was
hemodynamically stable, and was started on Vanco PO and
metronidazole IV, which improved his diarrhea. Patient shall
continue to take Vanco PO for 2 weeks after discontinuation of
all other antibiotics.
.
# Neutropenic fever: fevers most likely due to C. diff colitis.
But in the setting of neutropenia and recent E. coli bacteremia,
we initially covered broadly.
The patient was on Cefepime until ANC is above 500. He should
now receive Oral Vancomycin for 2 weeks after stopping other
antibiotics, with the goal of stopping vancomycin on [**7-19**], [**2191**].
.
# Lymphoplasmacytic lymphoma: received first dose of weekly
rituximab on [**2192-6-21**]. Currently neutropenic, with rising ANC.
Patient received Rituximab as inpatient on Friday [**2192-7-6**]. Will
follow up with outpatient oncology regarding this and whether to
restart GCSF therapy.
.
# [**Last Name (un) **]: Cr 2.8 from baseline of 1.6, most likely due to prerenal
azotemia in the setting of colitis. This resolved after patient
was give intravenous hydration with creatinine going back to
baseline.
.
# BPH:
- continue finasteride 5 mg daily
- hold tamsulosin 0.4 mg daily in setting of serious infection
.
# DM2: Had an episode of hypoglycemia of glucose 37, but did
better with IV dextrose. [**Month (only) 116**] be necessary to decrease evening
NPH if continues.
- insulin lispro s.s.
- NPH 5 units SC qam, 25 units qhs
.
# Hyperkalemia - patient developed mild, asymptomatic
hyperkalemia over the final 2 days of hospitalization. This was
presumed secondary to mild tumor lysis. He received kayexalate
for a K of 5.9, was kept on allopurinol and explicit
instructions to check his K+ were given the the rehab facillity.
Medications on Admission:
allopurinol 100 mg daily
bimatoprost 0.03% one drop both eyes
finasteride 5 mg daily
insulin aspart s.s.
montelukast 10 mg daily
tamsulosin 0.4 mg daily
timolol 0.5% drop both eyes daily
acetaminophen prn
docusate NPH 5 units SC qam, 25 units qhs
omeprazole 20 mg [**Hospital1 **], senna
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): stop [**7-19**].
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Timolol 0.5 % Drops Sig: One (1) Ophthalmic once a day.
8. Insulin Aspart 100 unit/mL Cartridge Sig: One (1) sliding
scale Subcutaneous as prescribed.
9. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic once a day.
10. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
11. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: 5 units
qAM 25units qhs Subcutaneous as prescribed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day as needed for constipation.
13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
14. Sodium Polystyrene Sulfonate 15 g/60 mL Suspension Sig:
15-30 g PO ONCE (Once) as needed for Potassium > 5.5: ONLY GIVE
IF POTASSIUM IS > 5.5. This is a SPECIAL prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
neutropenia
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 **],
You have been admitted to our facility for the treatment of your
diarrhea as well as low counts of white blood cells. We have
been giving you antibiotics and your diarrhea has since
resolved. You should be getting Vancomycin by mouth 125 mg
liquid every 6 hours for 2 weeks starting today (finish on
[**2192-7-19**]). Please continue taking your other home
medications as prescribed.
Followup Instructions:
You have the following follow up appointments:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-7-12**] at 10:00 AM
With: [**Name6 (MD) 18072**] [**Name8 (MD) 18073**], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2192-7-24**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-7-26**] at 2:00 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2192-7-7**]
|
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icd9cm
|
[
[
[]
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|
[
[
[]
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|
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|
237, 243
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3035, 3322
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,421
| 178,445
|
43898
|
Discharge summary
|
report
|
Admission Date: [**2106-5-15**] Discharge Date: [**2106-5-26**]
Date of Birth: [**2053-9-14**] Sex: M
Service:
CHIEF COMPLAINT:
Confusion and hypoxia.
HISTORY OF PRESENT ILLNESS: This is a 52-year-old,
African-American male with a history of mild mental
retardation, depression, psychosis, asthma, and restrictive
lung disease on a home oxygen requirement of three liters.
He presented from home after feeling confused this morning.
At baseline, Mr. [**Known lastname **]' pulmonary disease leaves him with a
chronic, nonproductive cough and limits him from walking any
length of time or climbing stairs. He was in his usual state
of health until the morning of admission when he awoke and
felt confused and lethargic. He was unable to eat his
breakfast which he states demonstrates a major deviation from
baseline. According to his mentor, he has had episodes of
confusion where he is unable to recall the day of the week.
This has been happening intermittently over the course of the
week prior to admission.
Upon arrival to the Emergency Department, his oxygen
saturation was 97 percent on three liters oxygen. At the
time of this interview, he denied worsening shortness of
breath, and in fact, says that this is a good day for his
breathing. He also denies increase in the severity of his
cough from baseline, chest pain, pleuritic chest pain,
headache, nausea, vomiting, diarrhea, melena, bright red
blood per rectum, abdominal pain, dysuria, fever, chills,
night sweats or unexplained loss of weight.
The patient has had a medication change in the past couple of
weeks. His outpatient psychiatrist, Dr. [**Last Name (STitle) 23168**],
discontinued his Paxil and risperidone and started him on
Zyprexa 15 mg q.6:00 p.m. instead. Mr. [**Known lastname **] has a known
mixed restrictive obstructive lung disease of unknown
etiology and is followed by the pulmonary team at [**Hospital1 346**], in particular by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], M.D.
His baseline chest x-ray shows an interstitial pattern with a
patchy infiltrate on the left lower lobe. He has a history
of multiple presentations to this hospital with symptoms of
shortness of breath, confusion, and chest x-rays that show an
interstitial pattern. He has been treated empirically
multiple times for pneumonia and asthma flares. He was
intubated once in [**2101**] at which time he had a pneumonia with
empyema.
PAST MEDICAL HISTORY: His past medical history is
significant for restrictive lung disease with his last
pulmonary function test on [**2106-2-5**] with an FEV1 of 0.92
liters, 36 percent of predicted and an FVC of 1.5 liters
which is 36 percent of predicted. His TLC is 40 percent of
predicted, and DLCO 15 percent of predicted as reported on
[**2105-10-21**]. His oxygen saturations tend to run approximately
91 percent in room air. It decreases to 86 percent in room
air with exercise. He is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of
the Pulmonary Service. It is unclear of the exact nature of
his disease. It may be a complicated picture including an
interstitial lung process of unknown etiology as well as
obstructive sleep apnea, asthma, and possibly a neuromuscular
disorder as well.
The patient has a history of Methicillin resistant
Staphylococcus aureus and pneumonia. He had a last empyema
which required thoracotomy and decortication in 02/[**2101**]. He
was intubated and required hospitalization in the Medical
Intensive Care Unit at that time.
He also has a history of hypertension. The patient had an
electrocardiogram in [**1-/2106**] which showed a right ventricular
dilation. He has a history of depression with psychosis.
The patient is noted to have a self-inflicted abdominal wound
where he stabbed himself in the stomach in [**2100**]. It was
apparently after his father had passed away. He was admitted
for psychiatric hospitalization in [**2102**] with auditory
hallucinations and again in [**5-/2105**] with a hypomanic episode.
He has a history of mild mental retardation, history of
gastrointestinal bleed from internal hemorrhoids, total left
hip replacement status post septic arthritis of that hip,
hernia repair, cervical stenosis of C3-4 with bilateral hand
weakness.
He has a history of obstructive sleep apnea which was
confirmed by a sleep study prior to admission. He has a
history of corneal ulcer status post right corneal
transplant. He has stasis dermatitis on bilateral lower
extremities followed by Dermatology with negative
.................... in the past.
MEDICATIONS: His medications on admission included albuterol
two puffs q.i.d., Flovent two puffs b.i.d., Singular ten
puffs p.o. q.h.s., Serevent two puffs t.i.d., [**Doctor First Name **] 60 mg
p.o. b.i.d., Cardura 2 mg p.o. q.h.s., Monopril 10 mg p.o.
q.day, Lasix 40 mg p.o. q.day, Neurontin 300 mg p.o. q.a.m.,
600 mg p.o. q.h.s., Zyprexa 15 mg p.o. q.6:00 p.m., Tylenol
100 mg p.o. q.i.d. p.r.n., Detrol 2 mg p.o. q.day,
prednisolone acetate eye drops one drop to both eyes t.i.d.
ALLERGIES: The patient is allergic diltiazem and lactose.
FAMILY HISTORY: His father died of a myocardial infarction
at age 87. Mother died of cancer. The patient also reports
asthma in his sister.
SOCIAL HISTORY: The patient has attended special needs
classes through the ninth grade and worked in hospitals as a
housekeeper. He is currently in a mentor program and lives
with a family and attends the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13089**] Center five days
per week. He has a caseworker whose name is [**Name (NI) **] [**Name (NI) 4427**]. He
states he has a number of friends at the senior center
program and denies drug and alcohol use now and in the past.
PHYSICAL EXAMINATION: Temperature on admission was 99.3,
blood pressure 104/77, pulse 104, respiratory rate 18, oxygen
saturation 97 percent on three liters oxygen nasal cannula.
Generally, he was awake and alert, breathing comfortably,
pleasant, oriented to place and cooperative with exam. HEENT
exam revealed pupils are equal, round, and reactive to light,
extraocular movements intact, oropharynx clear, moist mucous
membranes. His neck had no jugular venous distention and was
supple with full range of motion.
His lungs revealed some inspiratory crackles, left greater
than right and decreased lung sounds at the right base.
Cardiovascular exam revealed a regular rate and rhythm,
slightly tachycardiac, normal S1 and S2; no murmurs, rubs or
gallops appreciated. His abdomen had a large midline scar,
positive bowel sounds, soft and obese, nontender and
nondistended. His extremities had evidence of chronic stasis
dermatitis, no edema or cyanosis, and his neurological exam
was nonfocal.
LABORATORY DATA: On admission, his white count was 6.4,
hematocrit 34.9, platelets 240. Sodium 144, potassium 5.4,
chloride 103, bicarbonate 33, BUN 38, creatinine 1.4, glucose
91, CK 242, MB 7, troponin of less than 0.3, ALT 102, AST 53,
alkaline phosphatase 376, total bilirubin 0.3, theophylline
4.6. His urinalysis was unremarkable. Chest x-ray shows
slight left ventricular enlargement, right pleural effusion,
and a lower lobe infiltrate possibly consistent with
consolidation.
His electrocardiogram showed normal sinus rhythm at 109 beats
per minute with a normal axis and some new T wave inversions
changed from prior electrocardiogram in leads V2-V4.
HOSPITAL COURSE: Briefly, this is a 52-year-old male with
severe asthma, obstructive sleep apnea, restrictive lung
disease, and a psychiatric history with a recent psychiatric
medication change who presented with episodes of confusion,
lethargy, and hypercarbia.
PROBLEM #1: Pulmonary: The patient was admitted with
confusion and elevated bicarbonate. His pulmonary picture
was likely multifactorial. He has a history of obstructive
sleep apnea confirmed by a sleep study as well as both severe
restrictive lung disease of unknown etiology and asthma. The
patient also has a history of multiple elevated CK enzymes in
the past thought to be from a muscle source as well as a
markedly abnormal EMG which raised the concern of a
neuromuscular component to his hypercapnia. The patient is
followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from Neurology.
Of note, his vital capacity decreases 25 percent when he lies
flat compared to sitting upright. At the time of admission,
the patient was on three liters of oxygen via nasal cannula
chronically at home which he started several months ago.
However, the patient had refused BI-PAP because he did not
tolerate it.
At the time of his initial presentation, the patient had an
oxygen saturation in the high 90s and described his breathing
as comfortable. Because of the concern about a possible left
lower lobe infiltrate on his chest x-ray, a fever, and a
cough, the patient was treated with a seven-day course of
levofloxacin. Initially during his hospitalization, he was
not on BI-PAP and had multiple episodes at night where he
would desaturate into the 60s when lying flat on his three
liters of oxygen. He is a carbon dioxide retainer, and one
night after his oxygen was increased to ten liters per minute
because of his desaturation, the patient became somnolent and
confused. He was briefly transferred to the Medical
Intensive Care Unit for observation and placed on BI-PAP with
resolution of his confusion and somnolence. The patient was
then continued on BI-PAP at night which he tolerated very
well initially.
During the remainder of his hospitalization, the patient also
had a high resolution chest CT to rule out pulmonary embolism
which showed no evidence of pulmonary embolism. He was
continued on his metered dose inhalers and theophylline and
had no evidence of worsening of his asthma throughout his
hospital course. He also had no evidence of congestive heart
failure on exam and was not felt to have congestive heart
failure as a contributing factor to his hypoxia.
He was scheduled for a muscle biopsy to further evaluate his
possible neuromuscular disease, but the patient had become
increasingly psychotic by that time and was unable to consent
for the procedure. During the last five days of his
admission, he remained stable from a pulmonary point of view
on his home three liters of oxygen. He did, however, start
to refuse his BI-PAP at night as he became more agitated and
paranoid, although he did not have evidence of desaturation
at night after he had completed a course of levofloxacin.
PROBLEM #2: Cardiovascular: Mr. [**Known lastname **] has no known history
of coronary artery disease and has had no signs or symptoms
of congestive heart failure while at [**Hospital1 190**]. His electrocardiogram in the Emergency
Department, however, did show some evidence of right heart
strain as well as some T wave inversions in leads V2-V4 that
were not present on a prior electrocardiogram. He was ruled
out for myocardial infarction with multiple enzymes which
were notable, however, for the fact that his CKs were
elevated, although his MB fractions were quite low, again
indicating possible chronic myositis. The patient had no
episodes of chest pain throughout his hospitalization. His
electrocardiogram was rechecked several times and was stable
without any changes from the electrocardiogram done in the
Emergency Department.
He had a transthoracic echocardiogram done during admission
which showed an ejection fraction of 65 percent. It also
showed some evidence of right ventricular hypokinesis
consistent with pressure overload and revealed some
underlying pulmonary hypertension.
PROBLEM #3: Gastrointestinal: The patient was noted to have
mildly elevated liver function tests during his admission,
but he did not complain of any gastrointestinal symptoms of
abdominal pain. A right upper quadrant ultrasound was
obtained which showed no evidence of gallstones or biliary
obstruction but did show mildly dilated common bile duct. If
his liver function tests remain elevated in the future, he
can get an MRCP as an outpatient.
PROBLEM #4: Psychiatric: This patient has mild mental
retardation as a baseline as well as an extensive psychiatric
history including manic depression with psychotic episodes.
Two weeks prior to admission, his Paxil and risperidone were
discontinued by his outpatient psychiatrist, and he was
started on Zyprexa 15 mg p.o. q.6:00 p.m. It was given at
6:00 p.m. to minimize morning sleepiness. On the day of
admission, the patient seemed alert and calm and was very
pleasant and answered questions appropriately.
His mental status declined over several days into his
hospital course when he was febrile and had become acutely
hypercarbic secondary to being on ten liters of oxygen which
caused him to retain carbon dioxide. He was felt, at that
time, to be delirious secondary to his metabolic issues. His
thyroid function was normal. His B12 had recently been
checked and was also normal as were his electrolytes. A head
CT was done which showed no evidence of intracranial
pathology. He was treated with BI-PAP briefly in the Medical
Intensive Care Unit and had resolution of his hypercapnia and
resolution of his mental status as well.
He was transferred back to the floor; however, he was felt to
be still more confused and less alert in the mornings
compared to the afternoons. His evening dose of Neurontin
was decreased to 300 mg q.p.m. He was then evaluated by
Psychiatry who thought, at that time, that his mental status
issues were still largely metabolic in nature. His Zyprexa
was decreased to 7.5 mg q.6:00 p.m., down from 15 mg p.o.
q.6:00 p.m. to try to improve his confusion in the morning.
After his Zyprexa was decreased, he began to be more
agitated, paced around his room, muttered to himself, and
hallucinated. He would speak to people who were not present
and began to act very hypervigilant, fearful, and somewhat
paranoid. Psychiatry again came to evaluate him, and his
Zyprexa dose was then increased to 10 mg p.o. q.6:00 p.m.
The last several days of his hospital course were significant
in that the patient remained medically stable; however, he
continued to have evidence of increasing psychosis. He began
to refuse his BI-PAP again at night and became very
distrustful at times alternating with times when he would not
want to be left alone. It was felt that his medical issues
were stable and that his [**Last Name 16423**] problem was becoming
psychiatric and that he would benefit from transfer to an
inpatient psychiatric facility.
PROBLEM #5: Fluids, electrolytes and nutrition: The patient
had a slightly elevated potassium on admission and was
treated with Kayexalate in the Emergency Room. His potassium
remained stable throughout the rest of his hospital course.
He was continued on a lactose-free diet.
PROBLEM #6: Renal: His creatinine was 1.4 on admission
which was increased over baseline of 1.0, but it returned to
baseline of 1.0 with good oral intake of fluids during his
hospital course.
DISCHARGE STATUS: Discharge to [**Hospital3 672**] Hospital for
inpatient psychiatric treatment.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Albuterol two puffs q.i.d., Flovent
two puffs b.i.d., Singular 10 mg p.o. q.h.s., Serevent two
puffs b.i.d., [**Doctor First Name **] 60 mg p.o. b.i.d., Cardura 2 mg p.o.
q.h.s., Monopril 10 mg p.o. q.day, Lasix 40 mg p.o. q.day,
Neurontin 300 mg p.o. q.a.m., 300 mg p.o. q.h.s., Zyprexa 10
mg p.o. q.h.s. at 6:00 p.m., Tylenol p.r.n., Detrol 2 mg p.o.
q.day, Haldol 1-2 mg p.o./intramuscularly q.6 hours p.r.n.
agitation, prednisolone acetate eye drops one drop to both
eyes t.i.d., oxygen three liters nasal cannula all the time.
Do not exceed three liters. BI-PAP at night for obstructive
sleep apnea.
DISCHARGE DIAGNOSIS:
1. Restrictive lung disease.
2. Asthma.
3. Obstructive sleep apnea.
4. Carbon dioxide retention.
5. Methicillin resistant Staphylococcus aureus precautions.
6. Hypertension.
7. Depression with psychosis.
8. Mild mental retardation.
9. Neuromuscular disease of unclear etiology.
10. Corneal ulcers.
11. Cervical stenosis.
DR.[**First Name (STitle) **],[**First Name3 (LF) 2515**] 12-927
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2106-5-26**] 14:51
T: [**2106-5-26**] 15:01
JOB#: [**Job Number 94248**]
|
[
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"358.9",
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
]
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|
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|
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|
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|
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|
5329, 5812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,854
| 100,428
|
3939
|
Discharge summary
|
report
|
Admission Date: [**2142-12-27**] Discharge Date: [**2142-12-31**]
Date of Birth: [**2066-5-31**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
s/p R THR
History of Present Illness:
76 yo F w/long standing cardiac history (followed by [**Hospital1 18**] cards
Dr. [**Last Name (STitle) 9764**] including severe AS and MR, with longstanding
h/o R hip pain, difficulty with ADLs, and limited ROM. She was
thought to meet clinical and radiographic criteria for R hip
total arthroplasty. She was not cleared from a cardiac
perspective, however, despite extensive work up and discussion
about resolving cardiac issues surgically before undergoing
orthopaedic intervention, she refused cardiac treatment and
elected to undergo R THR, understanding the substantial risks
posed by this. The patient was otherwise feeling well prior to
the procedure, and now presents for R THR.
Past Medical History:
Past Medical History: Rheumatic heart disease as a child with
above-mentioned severe aortic stenosis and 4+ mitral
regurgitation, no evidence of any coronary disease to my
knowledge. She also has hypertension. She apparently has had
syncope twice in the past, and of course, has severe heart
murmurs. She has GERD, but no ulcer history and chronic anemia.
History of colon cancer resection [**2132**] and osteoarthritis.
Surgical History: [**2132**] partial colectomy for cancer, no
subsequent problems, [**2139**] left distal radius ORIF.
Social History:
Russian physician, [**Name10 (NameIs) 4183**] to USA in [**2130**].
Lives locally with son and husband. G1, P1 nonsmoker, denies
alcohol use, rarely able to exercise.
Family History:
Non-contributory
Physical Exam:
Russian interpreter present, but we are
able to communicate somewhat even in the absence of the
interpreter. Her English is reasonable. She is 5 feet, 3
inches, 155 pounds with a BMI of 27.5. Focal examination
revealed prior workup showing right hip flexion only to 100
degrees. Leg lengths equal, 10 degrees internal, 20 degrees
external rotation right hip with pain at the extremes. Retained
[**4-27**] hip flexion and abductor strength. Good vascular inflows
without peripheral edema.
Brief Hospital Course:
On [**2142-12-27**] patient was brought to the operating room and
underwent right total hip replacement. The case was
uncomplicated with 500cc EBL. Please see Dr. [**Last Name (STitle) **] operative
note for details. Post-operatively, the patient was transferred
overnight to the ICU for overnight monitoring given her
significant cardiac issues. The patient was treated with 24
hours of antibiotic for prophylaxis of infection. Lovenox was
given for DVT prophylaxis and TEDS and pneumoboots were used.
The patient was made WBAT on the operative extremity with
posterior hip precautions and physical therapy assisted with
mobilization. Home medications were restarted.
On POD 1, she was found to have hct 25 and low UO of 25-20cc.
she was otherwise stable for a HD standpoint. The patient was
transfused 1U for this, with appropriate bump in her hct and UO.
The patient was transferred to the floor in stable condition on
POD 2. Per medical recommendations to keep hct>30, received 2U
additional units on POD 2 but was otherwise HD stale. 20IV
lasix x1 was given afterwards for prevention of fluid overload.
Otherwise, pt did very well w/o any cardiac issues.
Prior to discharge the patient was afebrile with stable vital
signs. Pain was adequately controlled on a PO regimen. The
operative extremity was neurovascularly intact and the wound was
benign. Patient was discharged in stable condition on POD 4.
Medications on Admission:
HCTZ 12.5 mg every other day, isosorbide 5 mg
sublingual p.r.n. rarely, metoprolol 25 mg q.p.m., Diovan 80 mg
q.h.s., Prilosec 200 mg daily, albuterol 90 mcg 1-2 puffs
p.r.n.,
calcium, multivitamins. She takes naproxen 375 mg 3 times a
day,
which does not seem to bother her GERD but does not help with
the
hip. Acetaminophen 500 mg t.i.d.
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30ml injection
Subcutaneous Q12H (every 12 hours) for 3 weeks.
Disp:*42 30ml injection* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing, SOB.
5. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO EVERY
OTHER DAY (Every Other Day).
6. Isosorbide Dinitrate 5 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual TID PRN () as needed for PRN chest
pain.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 3
weeks: After finishing lovenox course.
Disp:*21 Tablet(s)* Refills:*0*
10. Multi-Vitamin Hi-Po Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
R hip OA
Discharge Condition:
Good
Discharge Instructions:
Seek immediate medical attention for fever >101.5, chills,
increased redness, swelling or discharge from incision, chest
pain, shortness of breath, or anything else that is troubling
you.
Wound Care: OK to shower but do not soak incision until follow
up appointment, at least. Pat incision dry after showering.
Staples will be removed in clinic at follow-up appointment
Activity: WBAT RLE. No strenuous exercise or heavy lifting until
follow up appointment, at least. Posterior hip precautions.
Anticoagulation: Take lovenox 30 mg sc bid x 3 weeks and then
take aspirin 325 mg [**Hospital1 **] x 3 weeks. [**Month (only) 116**] discontinue all blood
thinners 6 weeks post-operatively.
Other: Do not drive or drink alcohol while taking narcotic pain
medications. Resume all home medications. Call your surgeon to
make follow up appointment
Physical Therapy:
Weight bearing as tolerated R leg; posterior hip precautions
Treatments Frequency:
Staples to be removed at follow up appointment; change dressing
as need daily, otherwise, may leave open to air; Ok to shower
once incision is dry
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2143-1-11**]
1:30
Completed by:[**2142-12-31**]
|
[
"V10.05",
"396.2",
"715.35",
"530.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"00.74"
] |
icd9pcs
|
[
[
[]
]
] |
5355, 5440
|
2387, 3807
|
330, 342
|
5493, 5500
|
6636, 6790
|
1835, 1853
|
4200, 5332
|
5461, 5472
|
3833, 4177
|
5524, 5712
|
1868, 2364
|
6382, 6443
|
6465, 6613
|
280, 292
|
5724, 6364
|
370, 1062
|
1107, 1633
|
1649, 1819
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,030
| 150,113
|
48079
|
Discharge summary
|
report
|
Admission Date: [**2159-4-5**] Discharge Date: [**2159-4-13**]
Date of Birth: [**2082-8-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
Open Cholecystectomy
History of Present Illness:
The patient is a 76 year old male with a history of HTN, HL who
presented to the ER on [**2159-4-4**] after developing nausea,
vomiting, abdominal pain after eating dinner around 5:30 pm. The
patient was watching The Sopranos on TV after dinner and
developed sharp, epigastric pain radiating to his right flank.
He had two episodes of nonbilious vomiting. He denies any recent
fevers/chills/sick contacts/diarrhea/constipation. He admits to
occasional alcohol and had 3 beers that night with his meals. He
also admits to drinking one glass of scotch. He denies a history
of heavy alcohol use.
.
The patient says that he has had 1 similar episode to this in
the past about 15 years ago that he believes was gastric reflux.
.
In the ED, the patient received dilaudid for pain control and
IVF at 200 cc/hr for 3 liters. His amylase was noted to be 151,
lipase 125, Hct 40, and Cr 1.3. An abdominal ultrasound showed:
Redemonstration of cholelithiasis. No evidence of cholecystitis.
Normal CBD. No other imaging was performed. He was admitted for
pain control which is now well controlled with dilaudid.
.
ROS:
.
No chest pain, shortness of breath, cough, fevers, chills,
diarrhea or constipation. No weight loss or jaundice. No bloody
stools, no blood in urine.
Past Medical History:
HTN
Hyperlipidemia
Elevated PSA/ ? prostate cancer - Followed by Dr. [**Last Name (STitle) **]
Cataracts s/p surgical removal in both eyes
CRI Cr 1.1-1.2, CT in [**8-16**] showed severe chronic right
uteropelvic junction obstruction (believed to be congenital)
Diverticulosis
Colonic polyps
h/o cholelithiasis
Social History:
The patient lives with his wife [**Name (NI) 6409**]. He drinks on
occasion but denies heavy alcohol use. He drinks 1 glass of
scotch on occasion (not daily) + 1-3 beers. Denies tobacco.
Family History:
Mother died at 60 of pancreatic cancer; father
died at 74, unsure of the cause of death possibly black lung as
he was a coal miner
Physical Exam:
Tc=97 P=80 BP=122/70 RR=16 85-90% on RA
.
Gen - NAD, AOX3
HEENT - anicteric, MMM, external JVD to jaw, internal JVD [**7-20**]
cm pulsations
Heart - RRR, no M/R/G, physiologic split S2
Lungs - Crackles at both bases extending 1/2 up on the right
Abdomen - Soft, NT, ND, + BS, no hepatosplenomegaly, no palpable
masses
Ext - No C/C/E, +1 d pedis bilaterally
Back - No back pain, CVAT
Skin - No rashes noted
Neuro - CN II-XII grossly intact
Pertinent Results:
[**2159-4-5**] 12:17AM PT-11.9 PTT-26.4 INR(PT)-1.0
[**2159-4-5**] 12:17AM PLT COUNT-318
[**2159-4-5**] 12:17AM MICROCYT-1+
[**2159-4-5**] 12:17AM NEUTS-72.8* LYMPHS-18.9 MONOS-4.8 EOS-2.4
BASOS-1.1
[**2159-4-5**] 12:17AM WBC-7.0 RBC-4.80 HGB-13.9* HCT-40.4 MCV-84
MCH-29.0 MCHC-34.5 RDW-15.5
[**2159-4-5**] 12:17AM ALBUMIN-4.2 CALCIUM-9.1 PHOSPHATE-3.2
MAGNESIUM-2.4
[**2159-4-5**] 12:17AM LIPASE-125*
[**2159-4-5**] 12:17AM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-70
AMYLASE-151* TOT BILI-0.6
[**2159-4-5**] 12:17AM estGFR-Using this
[**2159-4-5**] 12:17AM GLUCOSE-148* UREA N-23* CREAT-1.3* SODIUM-140
POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-31 ANION GAP-15
[**2159-4-5**] 06:50AM PLT COUNT-308
[**2159-4-5**] 06:50AM MICROCYT-1+
[**2159-4-5**] 06:50AM NEUTS-93.2* LYMPHS-3.7* MONOS-2.6 EOS-0
BASOS-0.5
[**2159-4-5**] 06:50AM WBC-14.5*# RBC-5.00 HGB-13.6* HCT-42.4 MCV-85
MCH-27.2 MCHC-32.1 RDW-15.6*
[**2159-4-5**] 06:50AM MAGNESIUM-2.1
[**2159-4-5**] 06:50AM LIPASE-52
[**2159-4-5**] 06:50AM ALT(SGPT)-16 AST(SGOT)-23 ALK PHOS-69
AMYLASE-171*
[**2159-4-5**] 06:50AM GLUCOSE-132* UREA N-20 CREAT-1.1 SODIUM-142
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-15
[**2159-4-5**] 06:50AM GLUCOSE-132* UREA N-20 CREAT-1.1 SODIUM-142
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-15
[**2159-4-5**] 02:34PM URINE HYALINE-0-2
[**2159-4-5**] 02:34PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2159-4-5**] 02:34PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-4-5**] 02:34PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
.
[**2159-4-5**] EKG
Sinus bradycardia at 50 bpm. NL axis. No ST changes. Nonspecific
TWI in AVL. Q waves in III, AVF. Compared to [**2152**], no change.
CHEST (PORTABLE AP) [**2159-4-5**] 6:53 PM
Right lower lobe atelectasis without evidence for pneumonia.
.
CHEST (PORTABLE AP) [**2159-4-5**] 4:28 AM
Portable AP chest radiograph compared to [**2153-10-17**]. The
heart size is normal. Mediastinal and hilar contours are
unremarkable. There is mild perihilar haziness and bronchial
wall thickening which may represent fluid overload as well as
small left pleural effusion cannot be excluded. There is no
pneumothorax or focal lung consolidation.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2159-4-5**] 2:45 AM
FINDINGS: A 1.3 cm stone is again noted in the gallbladder neck.
Additional nondependent foci along the gallbladder wall are
consistent with small polyps or adherent stones. There is no
wall thickening or pericholecystic fluid. The common duct is not
dilated. Again seen is massive right hydronephrosis.
IMPRESSION: Cholelithiasis without evidence of cholecystitis.
.
[**2159-4-6**]- CT abdomen/pelvis- in discussion with radiologist,
evidence of acute cholecystitis, with stone in cystic duct, fat
stranding.
.
Brief Hospital Course:
The patient is a 76 year old male with a history of HTN, HL,
?prostate cancer who presents with nausea/vomiting,epigastric
pain->back believed to be consistent with pancreatitis.
.
#Acute pancreatitis-
The patient reports an equivocal history of alcohol use. His
mother had pancreatic cancer. The patient has only one
functional kidney with a Cr of 1.3. CT scan not performed on
admission as felt patient had greater risk than benefit at this
point to further assess the pancreas. Abdominal ultrasound shows
cholelithiasis without obstruction, cholecystitis. Continue to
monitor progression of pain, trended enzymes. cholelithiasis and
alcohol considered as likely etiology. Zofran for nausea,
morphine, then to oxycodone for pain. Patient had minimal
discomfort on admission. Fever to 102.4 and leukocytosis
worsening overnight day two of admission. CT abdomen/pelvis
ordered. Performed [**4-6**] night. [**4-7**] 7AM, CT with evidence of
acute cholecystitis. Abx initiated, unasyn. Pt with +[**Doctor Last Name **]
sign, very tender RUQ. Surgery contact[**Name (NI) **]. To OR for lap
cholecystectomy. Hydration as tolerated, given CHF.
.
Hypoxia- Desaturation post 3 liters fluid given in ED. JVP
elevated. Only sparse crackled. To 85% RA transiently. Stable on
2L NC. CXR with atelectasis at right base. Held on further
hydration. Considered PE. Compression given splinting. Pt was
moved out of the ICU after 3 days and his respiratory efforts
improved. On HD 7 the patient was able to maintain adequate
saturations of 97% on RA
.
# CHF, EF unknown. Evidence of hypoxia with crackles bilaterally
on exam after aggressive fluid hydration with NS at 200 cc/hr x
3 liters in ED. DC'd IVF for now 10 mg IV lasix given hypoxia
by nightfloat admitting resident. The patient had been sat'ing
100% on RA prior to receiving 3 liters of IVF in ED. Sats stable
at 95% 2L, CT abdomen with lung cuts to assess bases.
.
# Glutealregion hematoma- as per previous CT scan in 06. Patient
will likely need repeat MRI as outpatient as per Dr. [**Last Name (STitle) 4026**] to
reassess as still present.
.
# HTN - HCTZ re initiated.
.
# Hyperlipidemia- Continue Lipitor 10 mg PO QD.
.
#FEN - NPO, IVF - held given fluid overload and desaturation.
Repleted potassium.
.
PPX - Hep SQ TID, PPI
.
Code - FULL
Pt was able to tolerate a full regular diet on HD 7. His foley,
JP drain were removed and his IVs were heplocked on HD7. Staple
were romved on POD #6. Pt was tolerating a regular diet and was
discharched home.
Medications on Admission:
Lipitor 10 mg PO QD
HCTZ 25 mg PO QD
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Gangrenous cholecystitis
Discharge Condition:
Good, Tolerating POs, ambulating, voiding
Discharge Instructions:
You had your gallbladder removed. Your drains were removed
during your hospital course. You will be discharged on pain
medication. Do drive or operate heavy machinery while on this
medication. You will not be discharged on antibiotics. You may
go about your usual daily activities.
Please call the clinic or go to your local Emergency department
for the following
1) Temperate >101.5
2) Increased pain
3) Increased redness around the incision sites
4) Increased drainage out of incision sites
5) Inability to pass flatus
6) Inability to pass stool for several days
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2159-7-18**] 9:30
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2159-7-19**] 11:40
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2159-7-24**] 10:00
You should follow up with Dr. [**Last Name (STitle) 6633**] in her clinic in 2 weeks.
You should call [**Telephone/Fax (1) 2998**] to schedule an appointment. When
making the appointment be sure to tell the nurse that you are
scheduling your 1st post-operative appointment
Completed by:[**2159-4-13**]
|
[
"486",
"518.5",
"401.9",
"591",
"577.0",
"V12.72",
"272.4",
"428.0",
"574.00",
"V64.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.53",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
8797, 8803
|
5711, 8217
|
330, 353
|
8872, 8916
|
2805, 5688
|
9529, 10310
|
2197, 2330
|
8305, 8774
|
8824, 8851
|
8243, 8282
|
8940, 9506
|
2345, 2786
|
274, 292
|
381, 1643
|
1665, 1977
|
1993, 2181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,480
| 159,804
|
36551
|
Discharge summary
|
report
|
Admission Date: [**2140-5-15**] Discharge Date: [**2140-5-21**]
Date of Birth: [**2057-12-13**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Found collapsed at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 82 yo LHW with hx of HTN and hypercholesterolemia
who was found down per family today and initially taken to
[**Hospital3 3583**] where she was found to have a large left ICH
with mass effect. She was hypertensive at [**Hospital1 46**]
to 264/100 per records. Given the large ICH, she was
transferred here for further evaluation.
Per family, she was last seen well at 3pm yesterday and ROS
completely negative including fever, cough, HA, N/V/D. She is
an independently ambulating, still driving, highly functioning
82yo per family who did not want to have heroic measures to
sustain life.
Patient was seen per NSURG who advised about the pros and cons
regarding neurosurgical intervention.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
Social History:
Lives alone and performs all ADLs and IADLs independently
including driving. Was an administrative assistance before
retiring. Remote tobacco hx and no EtOH per family. DNR/DNI
per daughter, [**Name (NI) **] who is also her HCP.
Family History:
Non-contributory
Physical Exam:
T 96.7 BP 182/63 HR 92 RR 16 O2Sat 100% 2L NC
Gen: Lying in bed, NAD - desheveled appearing with poor skin
care
HEENT: [**Location (un) 2848**] J collar
CV: RRR, no murmurs/gallops/rubs
Lung: Coarse, transmitted upper airway sounds
Abd: +BS, soft, nontender
Ext: 1+ bilateral edema with venous stasis skin changes
Neurologic examination:
Mental status: Awake and alert to self. Thinks that she is
home. Answers yes or no but unclear if she comprehends since she
was answering yes to everything initially. Does seem to say no
to headache but yes to nausea. Dysarthric. Follows commands
with L side.
Cranial Nerves:
R pupil appears larger than left and may be surgical. (3&2
respectively) - both minimally reactive. EOMI intact although
mildly decreased vertical gaze. No skew. Blinks to visual
threat on both sides but less on L side and face appears
symmetric. Not brisk but positive gag.
Motor:
Moves L side purposefully and spontaneously against gravity but
nothing except for extension on RUE to nox stim and withdrawal
on RLE to nox stim. Increased tone on RUE only.
Sensation: Intact to noxious stim.
Reflexes:
2's on biceps bilaterally but trace brachioradialis and patellar
but none on Achilles. Toes upgoing bilaterally.
Pertinent Results:
LABS:
[**2140-5-15**] 06:55PM BLOOD WBC-16.7* RBC-3.30* Hgb-9.4* Hct-28.5*
MCV-86 MCH-28.5 MCHC-33.0 RDW-14.4 Plt Ct-250
[**2140-5-17**] 03:57AM BLOOD WBC-13.1* RBC-2.81* Hgb-8.4* Hct-24.9*
MCV-88 MCH-29.7 MCHC-33.6 RDW-14.7 Plt Ct-239
[**2140-5-15**] 06:55PM BLOOD Neuts-91.8* Lymphs-5.1* Monos-3.0 Eos-0.1
Baso-0
[**2140-5-15**] 06:55PM BLOOD PT-14.9* PTT-22.7 INR(PT)-1.3*
[**2140-5-17**] 03:57AM BLOOD PT-14.6* PTT-22.6 INR(PT)-1.3*
[**2140-5-15**] 06:55PM BLOOD Glucose-137* UreaN-65* Creat-1.5* Na-145
K-3.9 Cl-110* HCO3-19* AnGap-20
[**2140-5-17**] 03:57AM BLOOD Glucose-136* UreaN-61* Creat-1.7* Na-155*
K-2.9* Cl-120* HCO3-21* AnGap-17
[**2140-5-15**] 06:55PM BLOOD CK(CPK)-482*
[**2140-5-16**] 01:39AM BLOOD CK(CPK)-789*
[**2140-5-15**] 06:55PM BLOOD CK-MB-19* MB Indx-3.9
[**2140-5-15**] 06:55PM BLOOD cTropnT-0.03*
[**2140-5-16**] 01:39AM BLOOD CK-MB-20* MB Indx-2.5 cTropnT-0.02*
[**2140-5-16**] 01:39AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
[**2140-5-16**] 07:27PM BLOOD Osmolal-339*
[**2140-5-17**] 03:57AM BLOOD Osmolal-340*
[**2140-5-15**] 07:05PM BLOOD Lactate-2.0
MICRO:
Blood Cx ([**5-15**]): No growth x2
IMAGING:
ECG ([**5-15**]): Sinus tachycardia at a rate of 100 with borderline
A-V conduction delay. Right bundle-branch block. No previous
tracing available for comparison.
CXR ([**5-15**]): IMPRESSION:
1. No acute intrathoracic process.
2. Probable unfolded thoracic aorta. If there is strong clinical
concern for aortic abnormality, a PA and lateral view may be
obtained to further assess.
CT Head ([**5-15**]): IMPRESSION: Massive left cerebral parenchymal
hemorrhage with extension into the ventricle system. Rightward
subfalcine herniation and left-sided uncal herniation noted.
Recommend close followup. Findings are worrisome for impending
downward transtentorial herniation.
CT C-spine ([**5-16**]): IMPRESSION:
1. No acute fracture or evidence of traumatic malalignment.
2. Severe spinal stenosis at C5-6, secondary to broad-based
disc-osteophyte complex with severe bilateral neural foraminal
narrowing at this level.
Though these findings are chronic, they may produce acute cord
compression with appropriate mechanisms of injury; if patient
has new myelopathic symptoms, further evaluation with MRI
(including STIR sequence) is recommended.
3. Large parenchymal hemorrhage within the left occipital lobe
only partially imaged and better appreciated on prior CT of
head.
4. Severe calcification, carotid artery bifurcations
bilaterally.
Brief Hospital Course:
The patient is an 82 year old left handed woman with a history
of hypertension and hyperlipidemia who initially presented to an
OSH after being found down by her family. At the OSH her bp was
264/100, and head CT showed a large left ICH with mass effect.
She was transferred to [**Hospital1 18**], where physical exam on admission
showed the patient was alert to self, answered yes/no questions,
dysarthric, no movement of the right arm/leg, and upgoing toes
bilaterally. Head CT showed massive left cerebral parenchymal
hemorrhage with extension into the ventricle system, rightward
subfalcine herniation and left-sided uncal herniation noted, and
findings worrisome for impending downward transtentorial
herniation. She was initially admitted to the NeuroICU, where
she was started on Mannitol 50 gms IV then 25 gms IV q6 hr which
subsequently was stopped given increased serum Na and osm. On
[**5-16**], her exam showed attempt to say her name, follows one step
commands, anisocoria R 2.5-->2mm,
L 1.5-->1 mm. On [**5-17**], her respiratory status deteriorated, and
she no longer followed commands. She was made CMO, and
transferred to the Neurology floor.
Palliative care was consulted. She was placed on Morphine IV->SL
prn and Scopolamine patch. Many of her family members came to
her bedside. She passed away on [**2140-5-21**].
Medications on Admission:
1. Lipitor
2. BP meds - names unknown; uses CVS on [**Location (un) 8072**] St per family
3. ASA 81mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Left parieto-occipital intracerebral hemorrhage, with
interventricular extension and midline shift
Discharge Condition:
Inapplicable
Discharge Instructions:
None
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"348.5",
"348.4",
"277.30",
"427.31",
"723.0",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6737, 6746
|
5211, 6549
|
341, 347
|
6889, 6904
|
2712, 5188
|
6957, 7076
|
1414, 1432
|
6708, 6714
|
6767, 6868
|
6575, 6685
|
6928, 6934
|
1447, 1762
|
278, 303
|
375, 1084
|
2067, 2693
|
1801, 2051
|
1786, 1786
|
1106, 1148
|
1164, 1398
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,315
| 104,516
|
6329
|
Discharge summary
|
report
|
Admission Date: [**2163-10-8**] Discharge Date: [**2163-10-25**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 89-year-old male with
history of hypertension, diabetes mellitus, end stage renal
disease on hemodialysis who presented to an outside hospital
with hypoglycemia. Apparently, on the morning of
presentation he had a reported glucose of 10, though did not
have the typical symptoms of hypoglycemia such as
diaphoresis. Family members reported decreased p.o. at that
time. He went to the dialysis as scheduled, however post
dialysis he had six episodes of emesis, non-bloody containing
food material. His fingersticks at this point had improved,
however his blood pressure was found to be low with a
systolic between 90 and 100 with his baseline being about 150
to 160. His fingerstick at that point was in the 700s. He
therefore received 10 units of regular insulin three times
and then started on insulin drip. At that point, he also had
an anion gap of 24 and was believed in DKA.
His EKG showed new ST depressions in leads V3 through V6. He
was therefore heparinized and started on aspirin. The
patient, himself, denied any chest pain, shortness of breath,
diaphoresis, fevers, abdominal pain, polydipsia. He makes
minimal urine at baseline. He was transferred to the [**Hospital1 1444**] Medical Intensive Care Unit
because lack of ICU beds at the outside hospital.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. End stage renal disease on dialysis.
3. Hypertension.
4. Polycythemia [**Doctor First Name **].
5. Nephrolithiasis.
6. Status post transurethral resection of prostate.
MEDICATIONS UPON TRANSFER:
1. Adalat 60 b.i.d.
2. Phos-Lo two tabs b.i.d.
3. Nephrocaps one q. day.
4. Aspirin 81 p.o. q.d.
5. Colace 100 b.i.d.
6. Tylenol #3 as needed.
7. Insulin 75/25 30 units in the morning and 10 units in the
evening.
SOCIAL HISTORY: He is widowed. Functioning relatively
independently. He is a pastor at a local church and very
active socially.
PHYSICAL EXAMINATION: Temperature 96.4 F, blood pressure
101/42, heart rate 100, respiratory rate 16, saturating 100%
on nonrebreather. In general awake, alert and appropriate in
no acute distress. Head, eyes, ears, nose and throat:
Pupils equal and reactive to light. Oropharynx clear. Neck:
No jugular venous distention. Chest: Clear to auscultation
bilaterally. Cardiovascular: Tachycardia, but regular, S1,
S2 with no murmurs, rubs, or gallops. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities reveal no cyanosis, clubbing or edema.
Neurological exam: He is grossly nonfocal.
LABORATORY DATA ON ADMISSION: Include white count of 20.2,
hematocrit 39, platelets 356. Sodium 131, potassium 3.8,
chloride 89, bicarbonate 18, BUN 31, creatinine 3.3, glucose
764. His LFTs were unremarkable. He has an albumin of 2.9,
positive acetones and INR of 1.2.
HOSPITAL COURSE:
1. ENDOCRINE: Upon initial presentation, the patient was
believed to be in DKA. This is evident by his anion gap
acidosis, ketones in blood and urine as well as extremely
elevated glucose. He was started on insulin drip and
aggressive hydration which lead to quick resolution of his
symptoms.
A consultation with the [**Last Name (un) **] Service was obtained and the
impression was that this most likely is not true DKA. There
thoughts were that he probably had hyperglycemia as well as
concomitantly occurring metabolic acidosis which could have
been out of starvation or other metabolic processes. He had
no further episodes of hypoglycemia and only occasional
episodes of glucose between 300 and 400. He responded very
well to 14 units of Humalog q. two hours until blood pressure
was normalized.
In the hospital he was left on NPH insulin 20 units in the
morning and 8 units at night with very good glucose control,
however he did occasionally require encouraging intakes of
p.o. as his sugars were several times in the 60s to 80s.
2. CARDIOVASCULAR: During his MICU stay, the patient had an
episode of several hypotension with blood pressure about
70/palp. A set of cardiac enzymes at this point revealed a
troponin of 50 and the patient was taken for catheterization
to the Cardiac Lab. The catheterization there revealed a
stenotic lesion in the LDA about 90% which was stented. It
also revealed an RCA lesion of 70 to 80% which was nothing to
intervene upon on. A following bedside echo following the MI
revealed an ejection fraction of about 20%.
A consultation with the Heart Failure Service was obtained
and their recommendations included continuing beta blocker
and ACE inhibitor as started by the patient as well as
aspirin and Plavix. The discussion was initiated about the
possible options given the RCA lesion. It was felt that at
this point, given the patient's overall condition, it would
be best not to intervene upon those lesions. There are
several options in the future such as doing a stress test to
see whether the patient has symptomatic pain from the defects
versus purely medical management versus cardiac
catheterization in the future if the patient improves
symptomatically.
We decided to obtain on the day of discharge, another cardiac
echocardiogram now that his cardiac function has somewhat
stabilized to assess his ejection fraction and to determine
the for systemic coagulation if he has a low ejection
fraction.
3. GASTROINTESTINAL: Patient remained relatively stable
from a gastrointestinal standpoint. He continued to complain
of abdominal pain, however those are believed to be due to
urinary obstruction which was relieved after straight
catheterizing him and finding 1000 cc in his bladder. He had
diarrhea during hospital course, but numerous samples were
sent for Clostridium difficile and all of those were
negative. We obtained several imaging studies of his belly
all of which revealed no evidence of obstruction or lesions
to explain abdominal pain.
It must be noted that abdominal pain waxed and wane together
with his mental status. Additionally, consultation was
obtained with Speech and Swallowing Service. They performed
a video swallow which revealed possible aspiration with some
liquids, therefore their recommendation included thick and
nectar consistency type diet while awaiting for improvement
in his mental status and overall function before advancing to
thin liquids.
4. INFECTIOUS DISEASE: On initial presentation, the patient
had occasional fevers as well as a white count, however
search for infectious source was unrevealing. He received a
full seven day course of Ceftriaxone for possible pneumonia
during his stay on the regular medical floor. The only
evidence of infection was an equivocal urinalysis which
revealed some white blood cells and bacteria. The urine
culture is negative. He received a short course of
Ciprofloxacin for potential urinary tract infection. There
was no other source of an infectious process and his fevers
resolved.
5. MUSCULOSKELETAL: During his stay on the Medical Floor,
the patient was found to have a significant amount of right
shoulder pain. An x-ray revealed no signs of fracture or
dislocation. The consultation with the Orthopedic Service
was obtained and their opinion was that this is most likely a
chronic rotator cuff injury. Would of liked to obtain a MRI
of his shoulder to further characterize this, but given
patient's mental status, this is an unrealistic test at this
point.
6. NEURO: Patient's mental status remained somewhat altered
following his MICU stay. Apparently he receives very high
doses of benzodiazepine, Haldol and other medications
effecting his mental status. Also such medications were
discontinued on the Medical Floor and he had mild improvement
in mental status. A consultation with the
.................... Service was obtained and there feeling
is that this is most likely medication induced contusion and
delirium which will hopefully resolve as time goes by. An
EEG was obtained which showed changes consistent with toxic
metabolic picture and no evidence of seizures.
7. RENAL: Patient continued to receive hemodialysis while
in the hospital. His electrolytes remained well-controlled
and there are no acute issues from a renal standpoint. Note,
patient makes small amounts of urine, but has somewhat
reluctant to void and had required Foley catheter for this
purpose.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Diabetes mellitus.
2. Metabolic acidosis, now recovered.
3. Status post acute myocardial infarction.
4. Right shoulder rotator cuff chronic injury.
5. Hypertension.
6. End stage renal disease on hemodialysis.
DISCHARGE MEDICATIONS:
1. Insulin 20 units NPH AM, 8 units q.h.s.
2. Insulin sliding scale.
3. Lipitor 10 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d. for the next 20 days.
5. Lansoprazole 30 mg p.o. q.d.
6. Nephrocaps one cap p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Lopressor 25 mg p.o. b.i.d.
9. Lisinopril 2.5 mg p.o. q.d.
10. Colace 100 mg p.o. b.i.d.
11. Senna two tabs p.o. q.h.s.
12. Dulcolax 10 mg p.o. p.r. p.r.n.
13. Lactulose 30 mg p.o. q.h.s. p.r.n.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2163-10-25**] 13:33
T: [**2163-10-25**] 14:03
JOB#: [**Job Number 24499**]
|
[
"250.11",
"403.91",
"410.91",
"238.4",
"414.01",
"599.0",
"276.4",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"38.93",
"39.95",
"88.56",
"36.06",
"88.53",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
8755, 9451
|
8513, 8732
|
2944, 8412
|
2048, 2607
|
2627, 2668
|
132, 1423
|
2683, 2927
|
1445, 1893
|
1910, 2025
|
8437, 8492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,344
| 182,494
|
3374
|
Discharge summary
|
report
|
Admission Date: [**2137-12-1**] Discharge Date: [**2137-12-17**]
Date of Birth: [**2070-1-23**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
Lower Extremity Weakness
Major Surgical or Invasive Procedure:
C7-L10 Fusion
History of Present Illness:
67F presented to OSH ([**2137-11-30**]) for progressive lower extremity
weakness, now POD#4 from C7-L10 Fusion. In early [**Month (only) **] the pt
had severe in the thoracic spine pain while lifting a 20lb
[**Country 1073**]. Pain described as sharp pain, radiating bilaterally
anteriorly in a band like fashion below her breasts. The pt took
ibuprofen for the pain and later took hydrocodone( which made
her nauseous)
.
On [**11-30**], pt noted to have "rubbery legs", unable to walk.
Bladder and bowel intact. Went to OSH were CT scan revealed T5
and L1 compression fractures, thoracic spinal cord compression,
and subsequently transferred to [**Hospital1 18**].
.
At [**Hospital1 18**], pt noted to have mild lower extremity weakness,
sensory loss below T5 and and bilateral upgoing Babinski. MRI
showed pathologic compression fracture at T5, with diffusely
abnormal signal intensity involving vertebral body, pedicles,
and laminae. Also noted was severe spinal cord compression from
epidural soft tissue component. Also a prevertebral soft tissue
component and several scattered lesions of increased signal
intensity in the spine, including the sacrum, representing
metastatic lesions.
.
On [**2137-12-1**], pt underwent fusion of the C5-L2 vertebrae with
bx and lymph node sent for immunophenotyping and pathology. Pt
subsequent sent to TSICU for care following laminectomy during
which received 5000ml LR, 631ml PRBCs for 2500 EBL. Pt was seen
by the pain service post-operatively.
.
Per report the pathology preliminary has revealed sheets of
plasma cells consistent with plasmacytoma/multiple myeloma.
Past Medical History:
1. Osteopenia.
2. History of engorged turbinates status post sinus procedure.
3. Removal of a ruptured epidermal cyst on right buttock and a
dermatofibroma from the left buttock in [**2127**].
4. History of cystic breast lesions, evaluated by ultrasound.
5. Mammogram [**2133**] WNL
Social History:
Single and lives alone. Previously Married, now divorce. She has
no children. Lived briefly in the Phillipines. Formerly worked
as a clinical educator. Lives in [**Location 6981**], [**State 350**]. She
enjoys gardening. She smoked briefly in college. She does not
drink alcohol regularly.
Family History:
Mother: died from acute leukemia in her 60s.
Father: alcoholism, died in his 50s
Brother: [**Name (NI) **] 66 hx of Hodgkin's.
Brother: [**Name (NI) **] 63
Brother: [**Name (NI) **] 60 hx of pulmonary emboli, s/p VATS
Maternal Aunt: diagnosed with colon cancer in 70s
Maternal Uncle: diagnosed with colon cancer in 70s
Physical Exam:
(On Transfer to BMT Service POD#4)
Vitals: T: 99.2 BP: 125/70 HR: 70 RR: 16 96 O2Sat:
GEN: AOx3, NAD, Well-nourished
HEENT: PERRL, EOMI, sclera anicteric, MMM, OP Clear
NECK: No JVD, no bruit
CARD: S1 S2, no M/G/R, radial pulses +2, minor decrease in sharp
sensation along T5 distribution
PULM: Lungs CTAB, no W/R/R, Tenderness to palpation left
suprascapular area. No focal masses appreciated
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: CN II ?????? XII grossly intact. Moving all 4 extremities.
Strength 5/5 in upper and lower extremities. Patellar DTR +1.
Equivocal Babinski tests bilaterally.
BACK: Vertical Wound Dressings C/D/I
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
RECTAL: Normal Tone
Pertinent Results:
ADMISSION LABS:
[**2137-11-30**] 08:45PM WBC-6.3 RBC-3.72* HGB-12.4 HCT-34.9* MCV-94
MCH-33.4* MCHC-35.6* RDW-13.4
[**2137-11-30**] 08:45PM NEUTS-74.1* LYMPHS-20.3 MONOS-4.3 EOS-1.0
BASOS-0.2
[**2137-11-30**] 08:45PM PLT COUNT-231
[**2137-11-30**] 08:45PM PT-14.7* PTT-25.7 INR(PT)-1.3*
[**2137-11-30**] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2137-11-30**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
.
PERTINENT LABS/STUDIES:
.
Hct: Ranged from 24.7 and 31.1 on this admission.
LDH: 115 -> 251 - > 263 -> 299 -> 332 -> 270
SPEP: IgG 280, IgA 748 IgM 8
.
ECG: [**2137-12-1**]:
Sinus rhythm. Borderline low QRS voltage in the limb leads.
Diffuse non-diagnostic repolarization abnormalities. Cannot
exclude prior septal myocardial infarction.
.
MR C,T,L SPINE W& W/O CONTRAST - [**2137-12-1**]
1. Severe pathologic compression fracture of T5 vertebra, with
diffusely altered areas of signal intensity involving the
vertebral body as well as the pedicles on both sides and the
laminae on both sides, with significant amount of epidural soft
tissue component, overall resulting in severe compression of the
cord. There is also prevertebral soft tissue component, with
some enhancement.
2. Several scattered focal lesions of increased signal intensity
on the STIR sequence and enhancement on the post-contrast images
in the spine, including the sacrum, representing metastatic
lesions.
3. As the primary malignancy is not known, further workup, to
evaluate for primary malignancy is recommended. CT torso can be
performed for this reason; evaluation for bony details for the
spine can be better performed with sagittal and coronal
reformations on the same. Otherwise, CT of the spine- thoracic,
and if necessary, cervical and lumbar regions can be considered
for better evaluation of bony details.
4. Small bilateral pleural effusions, with
collapse/consolidation of the adjacent portions of the lung,
which can be better evaluated with CT chest.
5. Small 0.8 cm T2 hyperintense lesion, in the left kidney, may
represent a cyst but can be better evaluated at time of CT
torso.
.
L- Spine: [**2137-12-1**]:
In comparison with the previous study of this date, an extensive
surgical procedure has been performed with multiple rods and
hooks extending from C6 through L2.
.
Skeletal Survey [**2137-12-4**]:
There is marked loss of height of the L1 vertebral body. Several
areas of lucency are seen in the posterior aspect of the
calvarium. Although these could merely represent venous lakes,
the possibility of metastases cannot be excluded. CT or MR would
be necessary to exclude this possibility. The views of the
appendicular skeleton show no definite lytic lesion.
.
Pathology T5 and Lipoma of Left Hip:
1) Soft tissue, left hip, excision: Mature adipose tissue
consistent with lipoma. 2) Soft tissue and bone, T5, excision:
Plasmacytoma, see note.
Note: The sections are of multiple fragments of bone and soft
tissue infiltrated by sheets of plasma cells with focal areas of
necrosis. By immunohistochemistry, CD138 highlights sheets of
plasma cells. By kappa/lambda light chain immunostaining,
plasma cells are kappa restricted. In the context of appropriate
clinical, laboratory and radiologic findings, this is consistent
with features of plasma cell myeloma (see also subsequent bone
marrow specimen). Please correlate with clinical, laboratory
and radiologic findings.
.
Tissue: Immunotyping, Lymph node: Non-specific T cell dominant
lymphoid profile; diagnostic immunophenotypic features of
involvement by a non-Hodgkin B cell lymphoma are not seen in
specimen. Tissue sections reveal sheets of plasma cells.
Correlation with clinical findings and morphology (see
S08-49708H) is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas as due to topography, sampling or
artifacts of sample preparation.
.
Bone Marrow Biopsy ([**12-6**]): Cellular marrow with increased
plasma cells.
Note: Plasma cells are enumerated at 42% (aspirate). The
morphological findings along with the recently diagnosed
plasmacytoma (T5) are consistent with a plasma cell
dyscrasia/plasma cell myeloma. Correlation with clinical,
radiologic, and other laboratory studies are needed for
definitive confirmation/categorization. Immunostains are pending
and will be reported as an addendum.
.
.
DISCHARGE LABS:
.
Brief Hospital Course:
67 yo female with h/o osteopenia who presented with back pain
and lower extremity weakness and was found to have a
plasmacytoma and multiple myeloma.
.
# Plasmacytoma: The patient on admission was found to have a
large mass at T5, with spinal cord compression. This mass was
resected and biopsied and pathology was found to be consistent
with a plasmacytoma. Radiation Oncology was consulted, but it
was decided that the patient would undergo medical treatment
with with Valcade and Decadron instead of radiation therapy.
The patient received Decadron 40 mg IV daily for four days,
twice, and she will be followed by Dr. [**Last Name (STitle) **] for further
treatment of her plasmacytoma and multiple myeloma.
.
# Multiple Myeloma: The patient has a history of osteopenia and
was found to have a plasmacytoma on admission. A SPEP was then
performed which demonstrated an elevated IgA level. The patient
underwent a bone marrow biopsy on [**12-5**], which demonstrated
multiple myeloma. The patient was started on high dose Decadron
for four days, from [**12-4**] through [**12-7**]. The patient then
underwent another course of high dose Decadron from [**12-13**] through
[**12-16**]. The patient tolerated this medication well, and she will
follow up with Dr. [**Last Name (STitle) **] as an outpatient for Valcade and
Decadron therapy. The patient was also noted to have persistent
anemia during this hospitalization, yet her creatinine reamined
within normal limits. Finally, the patient was started on
Bactrim DS for PCP prophylaxis in the setting of high-dose
steroid use.
.
# C5-L2 Fusion: The patient presented to an OSH with back pain
and lower extremity weakness. She was found to have a large
mass compressing the spinal cord. The patient was orginally
admitted to the Ortho-Spine service, under the care of which she
had the mass resected and a C7-T10 fusion on [**12-1**]. The patient
was followed closely by the Ortho-Spine service during this
admission, and she was fitted for a back brace on POD #6. The
patient worked with physical therapy and occupational therapy
during this admission, and she has a follow-up appointment with
Dr. [**Last Name (STitle) 363**] on [**2137-12-19**].
.
# Pain Control: The patient was evaluated by the pain service on
this admission. She was initially placed on Percocet, but this
was later changed to Oxycodone. The patient's pain was well
controlled on this medication, and she did not have any acute
events during this hospitalization.
.
# Hypophosphatemia: The patient had a phosphate level of 1.2 on
admission. She received 30 mEq of K Phos which increased her
level to 2.7. Of note the patient received KPhos in the setting
of a national shortage of PO Neutraphos.
Medications on Admission:
Calcium - On Occasion
Discharge Medications:
1. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO every
M/W/F.
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for insomnia.
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Multiple Myeloma
Plasmacytoma
Secondary:
Discharge Condition:
Good. Patient's VS are stable, and she is able to ambulate with
assistance.
Discharge Instructions:
You were admitted to the hospital because you were experiencing
back pain and lower extremity weakness. While you were here, we
found that you had a large mass in your spine, a plasmacytoma,
and you bone marrow showed evidence of a condition called
Multiple Myeloma. While you were here, you underwent surgery on
your spine with Dr. [**Last Name (STitle) 363**]. After this procedure, you were
transferred to the BMT service, where you were given 4 days of
Decadron. You tolerated this treatment well, and you will
return to see Dr. [**Last Name (STitle) **] in clinic upon discharge.
While you were here, we made the following changes to your
medications:
1. We started you on Protonix for GI prophylaxis while on the
Decadron
2. We started you on Senna and Colace to regulate your bowel
movements while on Oxycodone
3. We started you on Lorazepam, as you were noticing significant
anxiety and difficulty sleeping
4. We started you on Bactrim for infection prophylaxis during
the time you are taking Dexamethasone.
Please take all medications as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider if you
experience increasing pain in your back, increasing lower
extremity weakness, chest pain, shortness of breath, fevers,
chills, or any other concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 363**]. Date/Time: [**2137-12-19**] at 9:30 am. Phone:
[**Telephone/Fax (1) 3573**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2137-12-19**] 2:00
Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2137-12-19**] 2:00
Completed by:[**2137-12-17**]
|
[
"733.90",
"338.3",
"275.3",
"737.10",
"203.80",
"285.1",
"214.1",
"733.13",
"336.3",
"344.1",
"788.41",
"203.00",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"41.31",
"81.66",
"77.79",
"83.39",
"77.49",
"81.64",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
11606, 11685
|
8153, 10891
|
294, 309
|
11780, 11859
|
3694, 3694
|
13245, 13756
|
2580, 2901
|
10963, 11583
|
11706, 11759
|
10917, 10940
|
11883, 13222
|
8126, 8130
|
2916, 3675
|
230, 256
|
337, 1950
|
3710, 8110
|
1972, 2257
|
2273, 2564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,752
| 169,900
|
48068
|
Discharge summary
|
report
|
Admission Date: [**2149-7-30**] Discharge Date: [**2149-8-7**]
Date of Birth: [**2085-4-15**] Sex: M
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
gentleman without was transferred from the Coronary Care Unit
secondary to a hypotensive episode which was treated with
dopamine and had dyspnea which had resolved in the Coronary
Care Unit. Now the patient is off dopamine with improved
blood pressures.
He has a history of metastatic esophageal cancer treated with
radiation therapy. His hypotensive episode happened a couple
of days ago; at which point he was taken to the Emergency
Department and cardioverted secondary to an atrial flutter
with a hypotensive episode. His blood pressure transiently
improved, but it required monitoring, and the patient was
transferred to the Coronary Care Unit secondary to a
decreased blood pressure again.
After stabilization in the Coronary Care Unit, the patient
was then transferred to the C-MED floor for follow-up care
and treatment.
PAST MEDICAL HISTORY:
1. Metastatic esophageal cancer with radiation therapy.
2. Atrial flutter.
3. Hypertension.
4. Gastrojejunostomy tube placement.
5. Hypothyroidism
6. Depression.
7. Cerebrovascular accident at the age of 48.
8. History of aspiration.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Vancomycin 1 g q.12h.
2. Levoxyl.
3. Tamsulosin 0.4 mg by mouth q.h.s.
4. Colace.
5. Methisazone.
6. Fentanyl patch 100 mcg transdermally q.72h.
7. Oxycodone 30 mg by mouth q.6h.
8. Senna.
9. Ambien by mouth as needed.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed his temperature was 98.3 degrees
Fahrenheit, his blood pressure was 137/83, his heart rate was
75, his respiratory rate was 18, and his oxygen saturation
was 95% on room air. Physical examination on transfer
revealed the patient was in no acute distress. A pleasant
gentleman. Head, eyes, ears, nose, and throat examination
revealed the mucous membranes were moist. No jugular venous
distention. Pupils were equal, round, and reactive to light
and accommodation. Extraocular muscles were intact. The
lungs were clear to auscultation bilaterally. Cardiovascular
examination revealed irregularly irregular heart sounds. No
murmurs, rubs, or gallops. Extremity examination revealed no
clubbing, cyanosis, or edema. The abdominal examination
revealed bowel sounds were present. The abdomen was
nontender and nondistended.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed his white blood cell count was 7.1, his
hematocrit was 39, and his platelets were 18. His INR was
2.6. Sodium was 136, potassium was 4.6, chloride was 101,
bicarbonate was 28, blood urea nitrogen was 24, creatinine
was 2, and blood glucose was 80. Urinalysis showed moderate
bacteria; otherwise all were negative.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is a 64-year-old gentleman with a history of
metastatic esophageal cancer with atrial flutter awaiting
transesophageal echocardiogram with cardioversion who was
admitted to the C-MED Service.
1. CARDIOVASCULAR ISSUES: On the day of admission,
cardiovascularly, his hypotension was resolved. He was still
in atrial fibrillation/atrial flutter. Kept him in
telemetry.
2. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS PNEUMONIA
ISSUES: He had a methicillin-resistant Staphylococcus aureus
pneumonia, but his lungs were clear to auscultation. We
continued his vancomycin q.12h. He was on day 7 of 14 and
was to finish a 14-day course as prescribed previously.
3. INCREASED INR ISSUES: He had an increased INR. The
patient received Coumadin prior to admission. Followed INR
closely.
4. ESOPHAGEAL CANCER ISSUES: Time to get his radiation
therapy while on service, and for pain control received
oxycodone q.6h. for pain with a Fentanyl patch 100 mcg
transdermally q.72h.
5. NUTRITION ISSUES: His diet was a low-sodium diet. He
had a gastrojejunostomy tube which was flushed regularly.
Made him nothing by mouth the night before electrophysiology
procedure; which was presumably on the [**Year (4 digits) 766**] after this
admission. For his feeds, he was on thickened fluids only by
mouth but regular food by mouth okay.
6. CODE STATUS ISSUES: He was full code.
Since admission, he was awaiting electrophysiology procedure
for ablation procedure. He was made nothing by mouth after
midnight on the Sunday prior to the procedure for the
ablation. His rate was controlled with medications properly.
He had a slight increase in his creatinine which was closely
monitored. Urine studies were sent and were pending on [**2149-8-2**]. This was concerning since his normal creatinine was
about 1 on [**2149-7-26**] but then increased to 1.2 to then
1.4 and then to 2 and then to 2.4 and then 2.5. He also had
some muddy casts; all consistent with an acute tubular
necrosis.
At this time he was then reassessed for his volume status.
On [**2149-8-3**], the patient was cardioverted chemically
because of atrial fibrillation that persisted and was coming
back and was making the patient's heart rate go up anywhere
from the 120s to 140s. The patient's rate was refractory to
verapamil 2.5-mg intravenous pushes. Electrophysiology was
consulted and decided to chemically cardiovert him with
ibutilide. After 2 mg of ibutilide, the patient cardioverted
into a normal sinus rhythm with a heart rate in the 70s to
80s. The patient was hemodynamically stable and without any
complaints.
Status post cardioversion, electrocardiogram QTc was 384
microseconds; same as his prior atrial flutter QTc on
admission. He was then monitored closely for Q-T elevation
throughout the day and without any difficulties and was
awaiting electrophysiology procedure the next morning. Each
of the 1-mg ibutilide infusions were given over a 10-minute
course with prolonged saline infusion/flush. Status post
cardioversion peripherally inserted central catheter line was
flushed with 2 cc of heparin.
On [**2149-8-4**], the patient continued to have his acute
renal failure; most likely secondary to acute tubular
necrosis. Continued with hydration and monitored creatinine
closely. On [**2149-8-4**], the patient had an atrial
fibrillation ablation done but then the patient was back into
atrial fibrillation since.
The plan at this point was to continue amiodarone 400 mg by
mouth twice per day times two weeks then to 400 mg by mouth
once per day times one month and then to 200 mg by mouth once
per day after that with followup with the Electrophysiology
Service. If his heart rate remained largely over 100, the
patient was planned for getting started verapamil as well.
On [**8-5**], because of his atrial fibrillation, he was started
on amiodarone. He was sent out for liver function tests and
pulmonary function tests; which were pending, with a goal
heart rate of less than 100 consistently and with the hope of
cardioverting him with amiodarone over time. His increased
creatinine was starting to improve, so his acute renal
failure was improving; which was most likely secondary to
acute tubular necrosis given that his fractional excretion of
sodium was 3%; consistent with an acute tubular necrosis
picture. He had good urine output. We continued to monitor
his creatinine still. For his methicillin-resistant
Staphylococcus aureus, he still continued to receive his
vancomycin without difficulty.
On the day of discharge, the patient was back on Coumadin
with a goal INR of 2 to 3 with follow-up INR check regularly.
He was continued on his amiodarone. He was set up with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] of Hearts monitor times two weeks, to then be set up
with primary care physician or in the Electrophysiology
Service for followup on the results. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]
has an appointment with the patient on [**2149-8-18**]. The
patient was to follow up with Dr. [**Last Name (STitle) 284**] then and to
discuss the results at that time. The patient also had an
appointment with Dr. [**Last Name (STitle) **] at [**Hospital6 733**] for INR
checks and creatinine checks. His creatinine started to go
down even further. On the day of discharge, his creatinine
was down to 2.4. He continued to have good urine output.
His hypertension was relatively well controlled.
Hypertension needs to be better controlled and dose adjusted
by his primary care physician to then be discussed with Dr.
[**Last Name (STitle) **] when the patient saw Dr. [**Last Name (STitle) **] the next week.
The patient's pain was well controlled while in the hospital
with a Fentanyl patch and with oxycodone. The patient was to
continue that and to adjust doses by primary care physician.
[**Name10 (NameIs) **] patient's condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to have followup with Oncology as
previously planned.
2. The patient was to take it easy for the next several
weeks and followup with physician appointments as outlined
below.
3. In case of an emergency or not feeling well, the patient
was advised to seek medical attention as soon as possible.
4. The patient was instructed to follow up with Dr. [**Last Name (STitle) **]
(his primary care physician) and to have his INR checked on
[**2149-8-11**] at 3:30 p.m. (telephone number [**Telephone/Fax (1) 250**]).
5. The patient also had a follow-up appointment with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] on [**2149-8-18**] to discuss [**Doctor Last Name **] of Hearts
monitor results.
6. The patient was instructed to follow up with
electrophysiology (telephone number [**Telephone/Fax (1) 2207**]) on [**2149-8-18**] at 2:30 p.m.
7. The patient was instructed to follow up with Dr. [**Last Name (STitle) **].
The patient was to call Dr.[**Name (NI) 101372**] office to verify time of
appointment for tomorrow. Dr. [**Last Name (STitle) **] is the patient's
oncologist and follows very closely.
DISCHARGE STATUS: The patient was discharged to home with
[**Hospital6 407**] services.
FINAL DISCHARGE DIAGNOSES:
1. Atrial fibrillation.
2. Status post right atrial fibrillation ablation.
MAJOR INVASIVE/SURGICAL PROCEDURES: Ablation; right atrial
isthmus for atrial flutter.
CONDITION AT DISCHARGE: Condition on discharge was
stable/improved.
MEDICATIONS ON DISCHARGE:
1. Levothyroxine 112 mcg by mouth once per day
2. Fentanyl patch 100-mcg per hour patch transdermally
q.72h.
3. Methisazone 150-mg tablet by mouth twice per day.
4. Bisacodyl 5-mg tablets two tablets by mouth as needed.
5. Tamsulosin 0.4 mg by mouth q.h.s.
6. Zolpidem 5 mg by mouth as needed (for insomnia).
7. Senna by mouth as needed.
8. Docusate 100 mg by mouth twice per day.
9. Oxycodone 5-mg tablets four tablets (20 mg equivalent)
q.4-6h. as needed (for low back pain); the patient was
instructed not to exceed 16 pills daily and hold if there
were any signs of respiratory problems.
10. Amiodarone 200-mg tablets two tablets by mouth twice per
day; the patient was to take two tablets 400 mg twice per day
for 11 more days and then decrease daily dose to two tablets
(or 400 mg in total) once per day for one month and then
decrease to 200 mg by mouth until needed. The patient was to
get liver, thyroid, and pulmonary tests regularly.
11. Warfarin 5 mg by mouth once per day (with regular
followup with a goal INR of 2 to 3).
12. Verapamil 80 mg by mouth q.8h.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Dictator Info 47734**]
MEDQUIST36
D: [**2149-10-20**] 15:20
T: [**2149-10-24**] 08:14
JOB#: [**Job Number 101373**]
|
[
"197.0",
"244.9",
"150.9",
"426.10",
"198.5",
"790.92",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"99.61",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
10475, 11840
|
1355, 2911
|
8939, 10184
|
2945, 8906
|
10403, 10448
|
10211, 10388
|
162, 1026
|
1048, 1329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,917
| 143,161
|
5971
|
Discharge summary
|
report
|
Admission Date: [**2102-9-9**] Discharge Date: [**2102-9-14**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Chest pain / shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Reason for MICU transfer: Hypotension, alcohol withdrawal
.
Reason for admission: Chest pain
.
HPI: Briefly, this is a 47M PMH of alcohol abuse with history of
DTs, cocaine abuse, alcohol related dilated cardiomyopathy (EF
40-45%), Hepatitis B and C who presents with chest pain and
intoxication. Was discharged from [**Hospital1 18**] 2 days PTA, but he
developed chest pain and thought he should return. He notes SOB
with the CP. He says it's "all over" and "is very bad." No
n/v/diaphoresis. Drinks liter of vodka per day, denies any other
drug use. He also reports reinjury to L foot, and significant
foot pain (reports chronic fracture) after his friend stepped on
his foot yesterday. He is able to walk, but only on heel of
foot.
Past Medical History:
- EtOH abuse with multiple admissions for w/d
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy (last [**Hospital1 18**] records indicated
an EF of 40-45% with mild global HK) [**5-8**]
- cocaine abuse
- hypothyroidism: TSH 10 on [**2102-8-22**] -does not take prescribed
levothyroxine
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated Aspergillous
fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]. Multiple
r/o for TB negative. Pt did not comply with course of
anti-fungals, had 3 AFB smears here which were nagative
- h/o C. diff colitis
- h/o IVDA per OSH records (pt notes only cocaine iv)
- HBV (core Ab, surface Ab positive [**2102-6-23**])
- HCV ([**2102-6-23**])
- HIV negative [**2102-6-23**]
Social History:
Social History: Tobacco, unable to say how long, [**1-3**] PPD
currently. Prior to that he smoked 1 ppd. Heavy EtOH use,
currently 1L vodka daily. Sober x10 years, started drinking
again 2 years ago. Also reports cocaine and marijuana. Sexually
active with his girlfriend
Family History:
Mother - CAD. Sister - h/o CVA.
Reports his father was the "[**Location (un) 86**] [**Location (un) 23530**]," and that he and
his mother changed their names after his arrest, etc.
Physical Exam:
micu
.
PE:
VITALS: T 98 P 89 BP 95/64 RR 19 O2sat 98%RA
GENERAL: Sitting up in bed, NAD
[**Location (un) 4459**]: Sclera anicteric, PERRL, EOMI, MMM
NECK: Flat JVP
CV: RRR, no MRG
LUNGS: CTAB
ABDOMEN: NABS, soft, NTND, no HSM
EXTREMITIES: No CCE
SKIN: No jaundice, no spider angioma
NEURO: CN II-XII intact, A&Ox3, biceps reflex [**2-5**], no
tremulousness or asterixis
.
Floor
.
Vitals - T 98.8 P 79 BP 145/100 RR 18 O2sat 98%RA
Gen - Well-appearing, but anxious man sitting up in bed talking
with his girlfriend on the telphone
[**Name (NI) 4459**]: NC/AT, Sclera anicteric, conjunctivae pink, pupils equal,
EOMI, poor dentition, MMM, OP clear.
Neck: No LAD or JVD. Extensive loss of neck fullness in L neck
s/p surgical dissection. Well-healed surgical scars present.
Cor - Regular rhythm. Nl s1, s2. No murmurs, rubs, or gallops
appreciated.
Pulm - CTAB, no wheezes, rales, or rhonci appreciated.
Abd - Soft, non-tender, non-distneded, no organomegaly. +BS.
Ext - No clubbing, cyanosis, or edema. No spider angiomata, no
palamr erythema, no suputryens contractions. Strength 5/5
bilaterally in extremities.
NEURO: CN II-XII intact except sensation along distribution of
V3 on left. Sensation otherwise intact to light touch. A&Ox3. No
tremulousness or asterixis.
Pertinent Results:
CBC
[**2102-9-9**] 08:40PM WBC-6.9 RBC-3.55* HGB-11.9* HCT-34.2* MCV-96
MCH-33.4* MCHC-34.7 RDW-16.9* PLT Count-522
[**2102-9-9**] 08:40PM NEUTS-47.7* LYMPHS-43.7* MONOS-6.3 EOS-1.2
BASOS-1.1
[**2102-9-13**] 04:45AM BLOOD WBC-3.9* RBC-3.20* Hgb-10.8* Hct-32.0*
MCV-100* MCH-33.7* MCHC-33.6 RDW-16.5* Plt Ct-311
Coags
[**2102-9-9**] 08:40PM PT-13.4* PTT-28.9 INR(PT)-1.2*
Lytes
[**2102-9-9**] 08:40PM GLUCOSE-100 UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-18
[**2102-9-9**] 08:40PM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2102-9-11**] 10:38PM BLOOD Glucose-93 UreaN-24* Creat-1.5* Na-144
K-3.6 Cl-103 HCO3-29 AnGap-16
[**2102-9-14**] 04:50AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-142
K-3.7 Cl-105 HCO3-28 AnGap-13
Cardiac enzymes
[**2102-9-9**] 08:40PM BLOOD CK-MB-4 cTropnT-<0.01
[**2102-9-10**] 05:24AM BLOOD CK-MB-5 cTropnT-<0.01
[**2102-9-11**] 06:07AM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-9-11**] 10:38PM BLOOD CK-MB-2 cTropnT-<0.01
Serum Tox
[**2102-9-9**] 08:40PM BLOOD ASA-NEG Ethanol-435* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
Urine Tox
[**2102-9-9**] 10:15PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
UA
[**2102-9-9**] 10:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Urine Lytes
[**2102-9-12**] 03:01AM URINE Hours-RANDOM UreaN-958 Creat-357 Na-64
Micro - Blood and Urine cultures negative
ECG
[**9-9**] Sinus tachycardia. Poor R wave progression which is
non-diagnostic.
Lateral and inferolateral ST wave abnormalities which are
non-specific.
Compared to tracing of [**2102-9-1**] there is no significant
diagnostic change.
[**9-11**] Sinus rhythm. Peaked P waves with rightward P wave axis.
Non-specific lateral ST segment changes. Compared to the prior
tracing of [**2102-9-11**] the rate has increased. Otherwise, no
diagnostic interim change.
Chest X-ray
- [**9-9**] Pleuroparenchymal scarring in the upper lobes bilaterally,
unchanged compared to the prior study. No definite cavitary
lesion is seen.
- [**9-11**] No new cardiopulmonary abnormality. Hyperinflation due to
emphysema or small airways obstruction is longstanding. The
contents of the left apical cavity have decreased which may
represent expectoration of previous mycetoma. Smaller right
apical lesion and adjacent pleural thickening are longstanding.
No pulmonary edema, pneumonia or indication of pulmonary
hemorrhage. Heart size normal. No pleural effusion
Foot films [**9-10**]
A healing fracture is present at the base of the second
metatarsal. Additionally, sclerosis is present at the base of
the fourth metatarsal, consistent with a healing fracture at
this site. In retrospect, a transverse lucency is seen through
this area on the original study of [**2102-8-21**].
Additionally, there is a more subtle area of sclerosis at the
base of the third metatarsal, also likely related to a healing
fracture.
Brief Hospital Course:
In the ED his vitals were T 98.1, HR 106, BP 169/104, O2 sat 96%
RA. He was given ASA and placed on a CIWA scale. His tox screen
was positive for alcohol with a level of 435. Also positive for
cocaine and benzos. He denied using these since the previous
week. His cardiac enzymes were negative x 1.
.
He was admitted to SIRS1 in the morning of [**9-11**]. He reported
hardly any CP or SOB, endorsed left foot pain and anxiety, and
requested valium. ROS was otherwise negative.
.
On the medicine floor his cardiac enzymes were negative x 2,
completing his rule-out. He was evaluated by psychiatry and
placed on a CIWA scale. His anxiety was managed with seroquel.
He was given thiamine, folate, and MVI for his alcoholism. He
recieved a total of 560mg IV/PO valium over the course of the
day and was found to be hypotensive to 70/30 at 2200. He also
had SBPs in the 170s and 180s earlier in the day. He had no
signs of distress, lethargy, or obtundation - he was mentating
well and protecting his airway. He was given a 500cc bolus x1 w/
correction of BP to 90/60. He was then given a second bolus
before transfer to the MICU for observation.
.
In the MICU, he was observed and given gentle IV fluid
hydration. His blood pressure medications were held and he was
continued on a less agressive CIWA scale (10mg q2hrs) held for
hypotension or sedation. He was found to have negative cardiac
enzymes, which were not repeated. His LFTs and CXR were
unremarkable, and blood and urine cultures were unrevealing. He
was found to have an increased creatinine to 1.5; urine lytes
revealed a FeNA<1%, and the creatinine improved with hydration.
Psychiatry saw the patient and recommended discontinuation of
benzos and seroquel with the addition of zyprexa for anxiety.
.
Upon transfer, the patient reported that he was very anxious and
required 50mg of valium every 4 hours to avoid withdrawal. He
was experiencing diffuse myalgias that are alteranting in
intensity. He complained of sharp, electric inferior sternal
chest pain lasting a few seconds, followed by several minutes of
shortness of breath. He also complained of severe L foot pain,
and requested 50mg demerol for treatment. He denied current CP,
SOB, nausea, vomiting, fevers, chills, lightheadedness, or other
changes in sensation.
.
He noted that he strongly wished to enter an alcohol
rehabilitation program, and has arranged to leave his apartment
and put his belongings into storage to further this goal. Per
the patient, he had difficulty in entering programs because of
his MassHealth insurance.
.
# Hypotension: Responded quickly to 500c bolus. Most likely
secondary to large amount of valium patient received over course
of day per CIWA protocol, as well as hypovolemia.
.
# Substance abuse: EtOH, cocaine use. History of DTs; has
required ativan gtt in ICU setting in the past. Patient received
valium 560 mg in early hospital course - per psychiatry, this
was likely contributed to by his anxiety and med-seeking
behavior. These medications were stopped on transfer to the
medicine floor outof consideration for likely self-taper.
Patient had no objective signs of alcohol withdrawal on the
medicine floor, and only occasional complaints of anxiety. Per
psychiatry recs, his anxiety was managed with oral zyprexa. He
called a large number of residential alcohol rehabilitation
programs, and is looking forward to beginning detox.
.
# Hypertension: Pt suffered from mixed systolic & diastolic
hypertension after transfer from MICU. Differential included
essential hypertension vs. volume overload vs. withdrawal. Pt
was euvolemic by exam and demonstrated no other signs of
withdrawal. He was restarted on his ACEI and begun on a
beta-blocker fro blood pressure control with excellent results.
.
# Acute renal failure. Brief creatinine elevation resolved with
IV fluids - almost certainly prerenal azotemia.
.
# Chest pain: Brief "tazer-like" chest pain followed by SOB.
Intermittent throughout hospital course. Patient asymptomatic
last 24-26 hours of hospital course. Cardiac enzymes negative x
4. No acute ECG changes during symptomatic episodes. Thought
likely related to anxiety given pain description. Stress testing
was therefore not felt to be indicated during this
hospitalization.
.
# Dilated cardiomyopathy with EF 40-45%: Most likely related to
alcohol use.
- Continued ASA, increased lisnopril, added small-dose
betablocker.
.
# Anxiety: Contributed to high CIWA scales, likely cause of
chest pain. Per patient, greatly relieved with Zyprexa 2.5mg PO
TID.
.
# Left foot pain: Has chronic fracture, no new injury.
- Ultram and tylenol given for pain with good relief
.
# Hypothyroidism: No active issues.
- TSH nl (3.6)
- Levothyroxine continued
Medications on Admission:
Pt denied taking any medications on admission out of concern
that they would interact with ethanol or his illicit drugs.
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*50 Tablet(s)* Refills:*1*
10. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety. Tablet(s)
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for PRN: insomnia / anxiety.
Disp:*15 Tablet(s)* Refills:*0*
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Ethanol Intoxication
Ethanol withdrawal
Secondary Diagnoses:
Cocaine ingestion
Anxiety
Hypertension
Discharge Condition:
Pt shows no signs of intoxication or withdrawal. The patient is
not agitated, and his vital signs are stable. He is anxious to
begin treatment for his ethanol abuse.
Discharge Instructions:
You were seen, evaluated, and treated at [**Hospital1 18**] for chest pain
and intoxication. While here, you were also treated for
variations in your blood pressure. Your lab tests are reassuring
that you did not incur any damage to your heart. You appear to
have elevated blood pressure, and should be on medications to
treat this condition. As you know, you also have multiple
substance abuse problems, most prominently ethanol abuse. To
help with these conditions we recommend:
- Take your medications as prescribed
- Go to Father [**Name (NI) 23534**] [**Name (NI) **] today and continue to contact the
longer-term facilities that were discussed.
- Call your pcp or return to the ED for severe chest pain,
shortness of breath, fainting, seizure, or other conerning
symptoms.
Followup Instructions:
[**Hospital **] Community Health Center: Please call [**Telephone/Fax (1) 23520**] to
schedule an appointment to be seen within the next 2 weeks.
|
[
"425.5",
"291.81",
"300.00",
"304.21",
"428.22",
"304.31",
"V15.81",
"303.01",
"244.9",
"070.54",
"428.0",
"401.9",
"V10.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12920, 12926
|
6737, 11458
|
347, 354
|
13090, 13258
|
3742, 6714
|
14087, 14236
|
2257, 2439
|
11629, 12897
|
12947, 12947
|
11484, 11606
|
13282, 14064
|
2454, 3723
|
13028, 13069
|
275, 309
|
382, 1124
|
12966, 13007
|
1146, 1951
|
1983, 2241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,915
| 194,424
|
22932
|
Discharge summary
|
report
|
Admission Date: [**2182-11-11**] Discharge Date: [**2183-1-15**]
Date of Birth: [**2129-4-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Leukopheresis
Central line placement and removal
Arterial line placement and removal
Intubation
Bronchoscopy
History of Present Illness:
53yoF with h/o DM2, Etoh abuse who presented to an OSH with
confusion and urinary/fecal incontinence after approximately two
to three months of non-specific symptoms, most noticeably
fatigue. Her symptoms had progressed, and on the day of
admission, she was found by her husband sitting on the floor,
quite confused, and was taken to OSH ED. There had also been a
complaint of dry cough and rhinorrhea x 2d. At OSH labs notable
for WBC 60 with 80% blasts, Hct 12. CXR with R sided infiltrate,
noncontrast Head CT normal. Pt was agitated/obtunded and was
intubated, then transferred to [**Hospital1 18**]. In the [**Hospital Unit Name 153**], she was
leukopheresed and started on hydroxyurea.
Of note, pt had recent a recent work-up in [**Month (only) **]/[**Month (only) **] for
weightloss (~30lbs over past year) which included labs notable
only for anemia and CT Abd which per husband "showed
pancreatitis."
Past Medical History:
Type two diabetes
Alcohol abuse
Social History:
Pt lives with her husband outside of [**Name (NI) 86**] and has two
children. She works for a medical billing company. She has a
heavy alcohol use history and has been drinking up to a few days
prior to admission. Smoking history includes a thirty pack year
history.
Family History:
No known family history of hematologic malignancy.
Physical Exam:
t 100.1, bp 106/44, hr 102, rr 22, spo2 98%
gen- ill appearing female, sedated/intubated, slight diffuse
icterus
heent- mildly icteric sclera, op clear with mmm
neck- no jvd, no lad
cv- rrr, s1s2, no m/r/g
pul- mechanically ventilated, moves air well, occ slight rales,
no wheezing
abd- soft, non-distended, normoactive bowel sounds
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/indentations/color changes
neuro- sedated. perrl, normoactive reflexes.
Brief Hospital Course:
1. Respiratory failure -- Initially intubated at an OSH, Mrs.
[**Known lastname 59246**] proved difficult to extubate because of poor oxygenation
related to large bilateral diffuse pulmonary infiltrates. Given
her low EF, this was first felt to be related to pulmonary
edema, however, when these continue to worsen despite adequate
diuresis, an infectious source became the prime suspect.
Because of her history of cough/myalgias, she underwent nasal
washings for the flu and was put on droplet precautions; the DFA
came back positive, and per ID's reccomendations, oseltamivir
was begun. Given her functionally neutropenic state, cefepime
and vancomycin also were initiated for a possible bacterial
process, with azithromycin added later for atypicals. She
spiked a temperature to 104 the first night, but all cultures
failed to grow. Although afebrile following this, her
temperature curve could not be interpreted due to steroids given
in stress-dosing.
On this antimicrobial regimen along with diuresis, her sats
intially improved, and she was able to be extubated. However,
the following day her steroids were stopped and she became
increasingly tachypneic and re-spiked a temperature. Her chest
x-ray showed progression of the infiltrate and she wae
re-intubated, primarily for bronchoscopy. She was unable to be
weaned off the ventilator, and eventually developed pulmonary
changes consistent with end-stage ARDS/fibrosis. She was
started on steroids, and remained intubated. After 2 weeks on
steroids repeat CXR should slight improvement of diffuse
infiltrates. Her ventilatory settings were gradually weaned and
she was able to tolerate PS with minimal pressures and PEEP.
She was tolerating PS for 24 hour periods at a time.
Unfortunatley she had an event of hemoptysis in which she
desaturated into the 70's and required increase vent support.
Two felx bronchs were done which could not identify a focal
source for the bleeding. She only lost a small amount of blood
and ultimately it was felt to be caused by aggressive
suctioning. After this event she had no further hemoptysis
however she required AC on the vent. Attempts were made to try
PS but the patient only lasted 15 minutes or so before tired.
Also around this time she developed fevers and bacteremia. It
was then decided to hold off any attempts at weaning and keep
the patient on full vent support until she cleared the
infections and was afebrile. CXR during this period showed
persistent signs of ARDS with no improvement in lungs on CXR.
The patient had increasing respiratory distress from [**2183-2-8**]
onward and became increasingly difficult to ventilate with
worseining CXR on full coverage of antimicrobial agents. In
addition, she required three pressors support over the period
from [**Date range (1) 8361**]. The decision was made by the family to withdraw
pressors on [**1-15**]. She died within hours.
2. Blast crisis -- Most likely AML. She was intially
leukopheresed, bringing her WBC down from 60,000 to 30,000 and
was started on hydroxyurea and allopurinol. DIC and tumor lysis
labs were followed every six hours but remained negative. More
definitive chemotherapy was initially put on hold given her poor
respiratory function/infection (as described below) and her
initial echo with and EF of 30%. Her counts continued to drop
while on hydrea, until eventually it was discontinued. She was
transfused multiple times to keep her Plt > 10 and Hct > 20,
eventually having a minimal response to transfusions. DAT was
positive for anti-SDH, which according to the blood bank, was
not enough to account for what would have been the degree of
hemolysis needed for the lack of response. Oncology determined
that the patient was too ill to begin chemotherapy; her WBC
eventually decreased to consistently below 1000 total. She
remained neutropenic for 2-3 weeks then as she improved her WBC
began to slowly rise again. She had a period where she was
non-neutropenic for about 7 days during whichc she was afebrile
and off of antibiotics. Also noted during this period was that
she had no blasts in her peripheral blood samples. Thus it was
decided to re check a bone marrow biopsy to determine if the
patient had AML or more of a MDS picture. Bone marrow biopsy
demonstrated 20% blasts indicative of AML. After being
non-neutropenic for 7 days or so her counts began to drop at
which point it was discovered she had VRE and MRSA bactermia.
Also she now had blasts back in her peripheral blood. At this
point from heme/onc position the patient would require induction
chemotherapy to induce remission and then the only curative
measure would be BMT. However given the patients condition this
was not an option as she would not survive chemotherapy given
her state of health. Discussion was held with the family and
goal was for patient to go to rehab with possibilities of
regaining her strength their and maybe at some point down the
line she may be strong enough to go through chemo.
3. Anisochoria -- Noted on the first morning of admission, the
patient's anisochoria manifested as a dilated right pupil that
was sluggishly reactive as compared to a smaller, reactive left
pupil. This finding was [**Location (un) **] out in both bright and dim light
and was clearly different from her admission physical exam. A
stat head CT was obtained without obvious abnormalities and
neurology was consulted. An MRI additionally failed to provide
and explanation, and ultimately, it was felt that this was due
to the disease process, possibly a leukemic infiltrate. She was
given intrathecal methotrexate empirically, followed by
intrathecal cytarabine. On CT she was also noted to have
splenic infarcts; however, her other respiratory and infectious
problems prevented any further workup for possible infiltrative
disease.
4. Elevated LFTs -- Present upon admission, the top two theories
were alcholic hepatitis versus leukemic infiltration. She had
an ultrasound that showed findings consistent with fatty liver
disease and a solitary nodule. Hepatitis panels were negative.
Her LFT's remained stable but elevated, and CT showed liver
disease, which would have required MRI or biopsy; however, other
clinical problems prevented further workup. Her LFT's remained
slightly eleavted with high ALT, TBili, Alk phos. These were
monitored and remained unchanged. RUQ uUS showed no evidence of
cholecystitis but she did have a thickened GB fundus indicative
of possible adenomyomatosis. This will need to be followed up
after d/c from the hospital. Otherwise she had no specific abd
complaints and her labs were followed.
5. ID: The patient had a positive DFA, and was started on
tamiflu empirically. She was also then started on amantadine
empirically. She underwent several BALs during the admission,
which were all negative for everything except influenza A--the
final one was negative for the flu. She was started on broad
spectrum antibiotics for frequent fevers. She was also started
on ambisome, which was discontinued due to renal failure; then
caspofungin, which was changed to voriconazole due to concerns
for cholestasis. Blood cultures from her RSC line grew VRE, for
which she was treated with 14 days of daptomycin. She was
continued on imipenem and voriconazole empirically for febrile
neutropenia. Galactomannan and histoplasma antigen were both
negative. Pt was then on imipenem and voriconazole for several
weeks while she was neutropenic. Her counts gradually came up
and she remained afebrile. After she was non-neutropenic for
several days and afebrile the imipenem and voriconazole were
removed. She was off antibiotics for at least seven days. Then
her counts dropped again and she developed fevers. Bld cultures
initially grew out VRE. So she was restarted on daptomycin, and
cefepime was added as well for fever of neutropenia. Her
central line was removed and changed to PICC line however she
then developed MRSA in her bld cultures. This was a high grade
bacteremia with multiple cultures coming back positive. She was
continued on the daptomycin which will cover both VRE and MRSA.
All central lines were removed and she was converted to PIV's,
giving her a central access holiday. She continued to spike and
was found to have sparce growth of aspergillus in her sputum.
Galactomannan was sent and was pending. However given this
finding and persistent fevers of neutropenia voriconazole was
added back to abx regimen.
6. Hypotension: The patient was on and off pressors throughout
the hospitalization. Echo initially showed decreased EF, which
gradually became hyperdynamic as she continued to be septic.
She was on levo, then vasopressin, and is currently off
pressors. She did not require any further pressors. Even with
her bacteremia her BP remained in the 100's. She was given
fluid boluses as needed and PRBCs. Her volume status corrected
on its own as the patient autodiuresed which helped to
substantially decrease her peripheral edema.
7. Right dilated pupil- First noted around the time of
admission. There was concern for CVA so MRI was done which was
negative for stroke. At that point it was felt the dilated may
have been secondary to infiltration due to AML. However given
her other medical conditions this was not further worked up
until later in her course. As she improved form a resp
standpoint, her right eye was re-addressed. Along with mental
status changes there was concern for stroke. Once again MRI of
head was done. This time there was evidence of ischemia in 2
areas of the brain. One was a watershed area which may have
occurred when the patient was hypotensive. The other was a
small stroke that was concerning for embolic event. However
neither stroke could account for her MS changes or the dilated
right pupil. Ophtho was consulted and it was discovered that
the patient had acute angle glaucoma in the right eye which
could account for the dilation. She was started on drops and
her IOP slowly decreased. It was felt she likely had acute
glaucoma around time of admission leading to the dilatation of
the right eye.
8. Neuro- As we were weaning the patint off the sedatives she
was very slow to respond and given the dilated right pupil there
was concerns about stroke and malignanat involvement of the CNS.
As described above she had MRI which showed evidence of two
areas of ischemia in the brain. However they were small and
could not account for her MS changes. Lumbar puncture was done
to rule out malignant involvement. This came back negative for
malignant cells in the CSF. Her stroke risk was also worked up
with negative vascular disease, carotid stenosis, and negaitve
echo. Her MS slowly improved with time and was felt to have
been caused by slow metabolism of the on board sedatives. She
gradually woke up and retured to relatively baseline MS.
Unfortunately she had developed severe muscle weakness during
her stay likely secondary to steroids and critical illness. EMG
and nerve conduction studies showed severe ICU myopathy and
polyneuropathy. Her strength very slowly improved and PT saw
the patient and gave the family exercises to work on with the
patient.
Discharge Disposition:
Expired
Discharge Diagnosis:
death from respiratory failure
Discharge Condition:
died
|
[
"359.81",
"117.3",
"305.00",
"284.8",
"434.91",
"286.7",
"577.0",
"038.11",
"995.92",
"487.0",
"518.84",
"584.9",
"289.59",
"573.9",
"V09.0",
"205.00",
"365.22",
"484.6",
"305.1",
"996.62",
"250.00",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"99.04",
"03.92",
"43.11",
"99.07",
"38.93",
"99.15",
"99.05",
"96.6",
"41.31",
"38.91",
"00.17",
"99.25",
"03.31",
"99.72",
"96.56"
] |
icd9pcs
|
[
[
[]
]
] |
13536, 13545
|
2299, 13513
|
325, 435
|
13619, 13626
|
1735, 1787
|
13566, 13598
|
1802, 2275
|
276, 287
|
463, 1377
|
1399, 1432
|
1448, 1719
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,886
| 159,280
|
32348
|
Discharge summary
|
report
|
Admission Date: [**2177-9-10**] Discharge Date: [**2177-9-14**]
Date of Birth: [**2102-6-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest pain
Abnormal ECG
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 75 year old man with a history of PVD, Barrett's
esophagus admitted on [**9-8**] to [**Hospital3 **] for elective LE
angiogram and underwent bilateral iliac stenting. Shortly after
the procedure, the patient became hypoxic and febrile and was
diagnosed with aspiration pneumonia (started on
ampicillin-sulbactam on [**9-9**]). Also, at 2:00 AM on [**9-9**], the
patient had an episode of chest pain lasting 20 minutes
associated with 1mm horizontal ST depressions in V3-V6 that
resolved in approximately 30 minutes. He had other episodes at
7:00AM on [**9-9**], and 9:30PM on [**6-9**], and 12:41AM on [**6-10**]. The
pain was initially relieved with sublingual nitroclyerin but due
to recurrent episodes of rest pain, he was eventually started on
nitroglycerin gtt and heparin gtt, aspirin and beta-blocker. He
reportedly had 6 sets of negative troponins. Of note, patient's
hematocrit was 41.8 on admission and 31.8 at 4:30 AM on [**6-9**].
On the day of transfer, his hematocrit was 28.8 and he was
transfused 1 unit PRBC with 20mg furosemide IV. The patient's
last episode of chest pain was at 2pm, responsive to nitrates.
Today patient was requiring 100% NRB to keep sats in the mid to
high 90's. Yesterday, sats were 88% on 6 liters. He was
evaluated by cardiology consultation at [**Hospital3 4107**] and
referred to [**Hospital1 18**] for cardiac catheterization.
.
On review of symptoms, 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 chest pain and dyspnea
as above. No history of paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
# Right Carotid endarterectomy in [**2177-4-18**]
# Peripheral PVD, S/P bilateral iliac stenting [**8-/2177**]
# diet controlled DM
# prior tobacco abuse
# hypertension
# GERD wit Barrett's esophagus
# hyperlipidemia
# arthritis
Social History:
Social history is significant for the past tobacco use 50
pack-year history, quit eight years ago, and rare alcohol use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T:99.3, BP:125/51 , HR:96 , RR:18 , O2 % 94 on 100% NRB
Gen: Chronically ill-appearing elderly male in NAD, resp or
otherwise. Oriented x3. Mood, affect appropriate. Pleasant.
Dining.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Intermittent S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases
bilaterally, but no wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+, +bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2177-9-10**] 06:51PM GLUCOSE-138* UREA N-15 CREAT-0.9 SODIUM-134
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-12
[**2177-9-10**] 06:51PM estGFR-Using this
[**2177-9-10**] 06:51PM CK(CPK)-160
[**2177-9-10**] 06:51PM CK-MB-4 cTropnT-<0.01 proBNP-994*
[**2177-9-10**] 06:51PM CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-1.7
[**2177-9-10**] 06:51PM WBC-13.4* RBC-3.44* HGB-10.7* HCT-30.5*
MCV-89 MCH-31.1 MCHC-35.0 RDW-14.6
[**2177-9-10**] 06:51PM PLT COUNT-281
[**2177-9-10**] 06:51PM PT-12.3 PTT-49.5* INR(PT)-1.1
.
AP chest ([**9-10**]):
Extensive heterogeneous consolidation of the right lung more
likely pneumonia or pulmonary hemorrhage than asymmetric
pulmonary edema since the left lung shows only borderline
vascular congestion and there may be a second region of
consolidation at the medial aspect of the left lung base, and
the heart is normal size. Pleural effusion, if any, is minimal.
There is suggestion of a hiatus hernia.
.
Echo ([**9-12**]):
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests
impaired relaxation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with normal
systolic function and moderate diastolic dysfunction. Mild right
ventricular dilation with mild estimated pulmonary artery
systolic hypertension.
Brief Hospital Course:
Pt was admitted to the CCU for further work-up and treatment of
his shortness or breath, chest pain and fever. The following
issues were adressed:
.
1. Aspiration Pneumonitis
Pt was thought have aspirated causing a severe chemical
pneumonitis as CXR suggested a large R sided infiltrates in both
upper, middle and lower lung. Pt had a mild fever on
presentation and was on Ampicillin sulbactam on presentation
from OSH but clinically never had a cough and no bump in the
white count so pt likely did not have aspiration pneumonia. Due
to the large AA gradient and oxygen demand (pt had to be on
no-rebreather for 48 hrs before transitioning placed on nasal
canula) the abx course was finished with complete 7-day course
on [**2177-9-16**] (in case there was a partial penumonia as part of
the infiltrate)
.
2. Chest pain
Given absence of biomarker elevation and ST depressions only in
the setting of aspiration, hypoxia and anemia as well as
improvement and resolution, the primary team had low suspicion
for acute coronary syndrome. Pt was monitored on tele without
any significant events. Cardiac enzymes were checked again and
were negative. When pt first prsented, heparin gtt,
nitroglycerin gtt, was continued but then eventually stopped.
Aspirin, atenolol, valsartan, lisinopril, and atorvastatin were
continued (amlodipine was also continued for blood pressure
control). TTE was done on the morning after admission to assess
for new wall-motion abnormality and demonstrated mild left
ventricular hypertrophy with normal systolic function and
moderate diastolic dysfunction (EF>55%). It also showed mild
right ventricular dilation with mild estimated pulmonary artery
systolic hypertension. He was discharged with instructions to
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] for a stress test within 1 week.
.
3. Acute diastolic heart failure - Patient clinically was found
to have CHF based on crackles at bilateral bases, bilateral
infiltrates on chest x-ray. He was diuresed approximately 4
litres. He was discharged on prescription for furosemide 20mg
daily to maintain his fluid balance. Continued lisinopril,
valsartan.
.
4. GERD - Continued pantoprazole
.
5. Diet-controlled DM - Insulin sliding scale while in house.
.
6. PPx - Continued pantoprazole
Medications on Admission:
Aspirin 81mg daily
Atenolol 50mg daily
Diovan 80mg daily
Amlodipine 5mg daily
Prinovil 20mg daily
Pantoprazole 40mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# Chemical pneumonitis
. Acute diastolic heart failure
Secondary diagnosis:
# Peripheral PVD, S/P bilateral iliac stenting [**8-/2177**]
# diet controlled DM
# prior tobacco abuse
# hypertension
# GERD with Barrett's esophagus
# hyperlipidemia
# arthritis
Discharge Condition:
Stable, oxygenating well, respiratory distress resolved.
Discharge Instructions:
You were admitted for shortness of breath and chest pain and was
diagnosed with pneumonia. The breathing problem improved with
oxygen.
You were prescribed antibiotics and have 2 more days left.
Please complete this course, even if you no longer have any
symptoms. Your atenolol dose was increased to 75mg daily and
you have a new prescription for this. You were started on a new
medication called furosemide 20mg once a day, and you also have
a new prescription for this. It is important that you call your
cardiologist to schedule a stress test within the next week.
If you develop chest pain, worsening shortness of breath, fever
greater than 101F or if you at any time become concerned about
your medical condition please present to the nearest ED or call
us at [**Telephone/Fax (1) **]
Followup Instructions:
Please follow-up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**], ([**Telephone/Fax (1) 75565**]. You need to call his office to schedule a stress
test. Please call within the next 1 week.
|
[
"V15.82",
"518.5",
"443.9",
"715.90",
"272.4",
"285.9",
"428.33",
"786.59",
"428.0",
"997.3",
"530.81",
"507.0",
"530.85",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9056, 9062
|
5695, 8016
|
339, 347
|
9381, 9440
|
3703, 5672
|
10284, 10528
|
2705, 2787
|
8188, 9033
|
9083, 9083
|
8042, 8165
|
9464, 10261
|
2802, 3684
|
276, 301
|
375, 2299
|
9178, 9360
|
9102, 9157
|
2321, 2551
|
2567, 2689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,341
| 191,131
|
46298
|
Discharge summary
|
report
|
Admission Date: [**2132-7-28**] Discharge Date: [**2132-8-17**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
infected PEG tube
Major Surgical or Invasive Procedure:
[**2132-7-30**] - laparotomy and open debridement of L abdominal abscess
and necrotizing fasciitis with new gastrostomy tube placement
History of Present Illness:
89 yo female with pmhx sig for a-fib, aortic stenosis, recently
admitted to [**Hospital1 18**] in [**Month (only) **] for SDH, s/p evacuation. Her hospital
course was complicated by seizures, hypoxic respiratory failure,
and VAP requiring intubation and subsequent trach and PEG
placement on [**2132-7-11**]. She was discharged to [**Hospital 100**] Rehab on
[**2132-7-19**] but remained vent-dependent with recurrent high fevers.
She was temporarily changed from Vancomycin to Linezolid when
her PICC was removed, but then restarted on Vancomycin recently
although culture data remained negative. Per records from
[**Hospital 100**] Rehab, her TFs had been held secondary to an ileus which
resolved with an aggressive bowel regimen. When the TFs were
restarted yesterday, feeds were noted to immediately return out
of the abdomen around the g-tube. When the g-tube was placed to
gravity, 200 cc of thick green pus came out of the tube this
morning, and pus was easily expressed around the site. She was
transferred to the [**Hospital Unit Name 153**] for further management.
.
Currently she is responsive to voice, able to follow commands
and answer questions; denies pain but heavily grimaces with
palpation of her abdomen.
Past Medical History:
PMHx:
Atrial Fibrillation, not on coumadin since [**2130**]
Congestive Heart Failure, LVEF 50-55%
Aortic stenosis
duodenal ulcer
Depression
Hyperlipidemia
Appendectomy
C-Section
Bilateral Cataract Surgery
Arthritis
Social History:
She is a widow with one adult child. She lives
alone. She is retired. Prior to retiring she was a piano
teacher.
Her daughter, [**Name (NI) 17**] [**Known lastname 2455**], lives in [**Name (NI) 3844**]. [**Telephone/Fax (1) 98456**].
currently resides at [**Hospital **] rehab. Prior to that she was living
alone, daughter lives in [**Name (NI) 3844**]
Family History:
Mother died at the age of 70 from lung cancer .
Physical Exam:
GEN: elderly female, lying semi-upright, alert, repsonsive, NAD
HEENT: + alopecia, + temporal wasting, anicteric sclera, PERRLA,
EOMI, dry mucosa, thick whitish yellow coating on tongue, OP
clear
NECK: no LAD, trach site appears clean, in proper place
CV: regular rhythm, normal rate, 3/6 systolic murmur best at
right sternal border, radiates to carotids
LUNGS: decreased at bases, prolonged exp phase, no accessory
muscle use
ABD: mildly distended, soft, diffusely tender to palpation,
hypoactive BS. PEG site with erythema, pus easily expressed,
balloon visible against skin
EXT: warm, dry. Stage I ulcer on buttock, DP pulses faint B/L.
No [**Location (un) **].
NEURO: awake, alert. Moves all extremities, follows commands
including finger grip. No nystagmus.
Pertinent Results:
[**7-15**]- blood cultures positive for MSSA
[**7-19**]- blood cultures negative
[**7-16**]- cath tip negative
[**7-17**]- pleural fluid negative
[**7-28**]- PEG swab: 2+ PMNs, 2+ GNRs, mod growth GNRs (sparse
pseudomonas - pan-sensitive; sparse strep viridans)
[**7-31**] - abscess swab with 1+ PMN, 1+ GPR, 1 GNR
[**7-31**] - abscess drainage with 2+ PMN, 4+ GNR, 3+ GPR, 3+ yeast, 1+
GPC in pairs and clusters
[**2132-8-6**] sputum: 4+ GNRs, 1+ budding yeasts
.
Fe studies: vit B12 1430, folate 9.8, Fe 32, TIBC 95, ferritin
1727, TRF 73
.
[**7-29**] G tube check: multiple small amounts of extravasation into
skin, but not intraabdominally. multiple dilated loops of bowel
c/w ileus v SBO. evidence of free air in peritoneum c/w
manipulation of PEG.
.
[**7-29**] I+O- CT abd/pelvis: prelim report shows evidence of 9cmx3cm
abscess extending from g-tube into pelvis
.
[**2132-7-30**] - to OR with laparotomy and open debridement. new
gastrostomy tube placement
.
[**2132-7-31**] L subclavian central line placed without complication
.
[**2132-8-5**] RUE doppler US: neg for DVT
.
[**2132-8-6**] CT head: slight decrease in size of L frontal SDH. no
acute IC bleed
Brief Hospital Course:
89 yo female with recent SDH s/p evacuation with complicated
course including intubation, VAP; and eventual trach and PEG
placement. Pt readmitted from rehab for recurrent fevers, found
to have infected PEG tube with necrotizing fasciitis, now with
afib and RVR. Hospital course by problem:
.
# A-fib - H/o of A fib during prior admission, on [**8-3**] in afib
with RVR up to 130's-140s. Increased sympathetic drive in
setting of hypotension may have contributed to elevated HR.
ROMI'd. HR reduced to 90s with 3x 5mg IV dilt on [**8-3**]. Patient
was started on a heparin drip. She continued to be in afib with
better rate control until [**8-5**] - increasing HR into 130s
unresponsive to IV amiodarone and diltiazem with decreasing
MAPs. Pt tried on esmolol drip for rate control on [**8-6**] which
failed secondary to poor rate control and decrease in SBPs to
80s. There was poor rate control on diltiazem drip (110s-150s)
and we were unable to increase diltiazim drip rate per
decreasing SBPs. Improved rate control with po diltiazem
(90s-100s) briefly despite levophed; however she continued to
demonstrate rapid ventricular rate on [**8-9**]. Dilt drip was
restarted on [**8-9**] and was attempted to be weaned several times,
but was unable to be weaned given pt's tenuous HR control.
Phenylephrine drip was used to maintain blood pressure and
increased to maintain MAPs 50-60s. Rate fluctuated from 60s to
110s. The patient's daughter did not want elective cardioversion
and given the patient's overall poor prognosis she was made
comfort measures only and the drips were turned off.
.
#) hypotension - pt had decreased UOP since admission. She was
given multiple crystalloid boluses per day and many colloid
boluses, including 2u PRBC on [**7-29**], 25mg albumin on [**7-31**], and
1uPRBC and 25g albumin on [**8-1**] with UOP consistently ~20cc/hr.
There was evidence of pulmonary edema on CXR and much peripheral
edema on exam without evidence of oxygen desaturation. She was
losing a significant amount of fluid from her wound and so I/O
recordings were not accurate assessment of her fluid status. She
was believed to be intravascularly very volume depleted. Pt was
aggressivley hydrated with good response to UOP and CVP at
target (19-20); however, aggressive hydration was held per
increased pulmonary edema on CXR with increasing FiO2
requirement. Pt intermittently became hypotensive and pressor
dependent due to volume depletion and/ or RVR. As above, it was
eventually decided by her daughter that she would be weaned off
of pressors and fluid would be stopped as she was made CMO.
.
# Respiratory [**Name (NI) 37370**] pt initially with hypoxemic respiratory
failure thought to be secondary to pulmonary edema from severe
aortic stenosis, but also with VAP. She was unable to be weaned
from the vent. [**2132-8-6**] CXR showed diffuse pulmonary edema with
large bilateral effusions, likely a result of aggressive fluids.
Pt failed PS trial and required AC on increased FiO2. She was
kept on the ventilator until she expired, per her daughter's
request.
.
# [**Name (NI) **] pt with increasing leukocytosis over several days with no
clear source, with 4+ GNRs, klebsiella pna and pseudomonas on
[**8-6**] sputum despite vancomycin and aztreonam treatment, and low
grade fever. Started meropenem and tobramycin on [**8-11**] for double
coverage of pseudomonas, d/c'd aztreonam as sensitivities were
not performed for aztreonam.
.
# Infected PEG tube/ abscess/ necrotizing fasciitis - pt with
recurrent fevers and bandemia while at rehab despite
antibiotics. PEG tube was draining frank pus on day of
admission. PEG tube removed by GI on [**7-28**] with foley in place to
maintain tissue tract. CT abdomen/ pelvis [**7-29**] showed presence
of 9cmx3cm abscess from g-tube to pelvis. PEG tube swab showed
2+GNR with sparse growth of pseudomonas. General surgery was
consulted on [**7-30**] to evaluate for management of abscess. Pt was
taken to OR by general surgery on [**7-30**] for laparotomy s/p abscess
drainage and debridement for necrotizing fasciitis. Pt lost
large volumes of fluid through the wound --> eventually a
woundvac was placed, and surgery did not feel the wound was
infected several days post-op, but that her poor nutritional
status compromed wound healing.
Levo/ flagyl for gut flora coverage was started on admission -->
changed to aztreonam on [**7-30**] when wound culture grew pseudomonas
--> flagyl restarted and fluconazole added on [**7-31**] for anaerobic
and yeast coverage s/p surgical debridement; patient was on
vancomycin, flagyl, and fluconazole when she expired.
.
# R hand discoloration: The patient developed RUE swelling and
purplish discoloration. RUE doppler US was negative for DVT.
Vascular surgery thought there was evidence of vascular emboli
in her hands though this was also thought possibly secondary to
frequent FS checks. She was kept on a heparin drip titrated to
PTT 60-80 and her hand was kept elevated. Swelling decreased
somewhat, but remained.
.
# hyponatremia - etiology thought to be hypervolemic
hyponatremia from vasopressin administration or from multiple
fluid boluses. improved after vasopressin had been d/c'd.
present again, patient was on vasopressin again until pressors
were weaned when she became CMO
.
# hyperglycemia - pt had increased glucose on FSS on [**8-1**] -->
insulin added to TPN, increased FS again, so insulin gtt was
started
.
# Anemia- macrocytic, baseline hct 25-30. Fe studies here are
consistent with anemia of chronic disease. History of LVH in
setting of critical aortic stenosis is concerning for possible
subendocardial ischemia in the setting of decreased hct. Pt was
transfused 2u PRBC for goal hct > 30 on [**7-29**], and 1u PRBC on [**8-1**]
for goal hct > 25. Hct remained stable thereafter.
.
#) MSSA bacteremia - pt with recurrent fevers and bandemia while
at rehab despite antibiotics in setting of history of pneumonia
and MSSA bacteremia, for which she was on vancomycin. Vancomycin
was started on [**7-15**] with plan to continue for 3-4wks per ID
fellow ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**]); it was subsequently continued as part of
broad-spectrum coverage.
.
# Acid/base - primary nonanion gap metabolic acidosis with
primary respiratory alkalosis; an increase in bicarb was seen on
[**8-8**] - probable contraction alkalosis given volume depletion,
subseqyently resolved. urine lytes c/w type 1 RTA.
.
# FEN- electrolytes were repleted as needed (K, Mg, Phos); she
was fed via tubefeeds, nutrition was consulted and made
recommendations throughout..
.
#Pain- the patient had been on a fentanyl patch. this was
discontinued when she was made CMO and she was started on a
morphine drip.
.
# Access- R PICC, L subclavian
.
# Communication- daughter [**Name (NI) 17**] [**Telephone/Fax (1) 98456**]([**Name2 (NI) **]),
[**Telephone/Fax (1) 98457**] (c)-->prefers cell as back and forth between NH
.
Dispo: The patient was made CMO on [**8-16**] and expired on [**2132-8-17**]
@5:15am.
Medications on Admission:
meds on transfer:
Vancomycin- since at least [**7-15**], unclear stop and resume dates
while at rehab
lactulose
colace
MOM
dulcolax
nystatin swish and swallow
combivent
pantoprazole
tylenol PRN
heparin sc
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
Completed by:[**2132-9-3**]
|
[
"458.9",
"V44.0",
"536.42",
"682.2",
"518.81",
"276.1",
"428.0",
"728.86",
"272.4",
"511.9",
"424.1",
"536.41",
"482.0",
"112.2",
"285.29",
"789.5",
"427.31",
"790.7",
"041.11",
"482.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.19",
"99.15",
"43.19",
"86.22",
"96.72",
"83.44",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
11651, 11660
|
4323, 4587
|
237, 373
|
11711, 11720
|
3132, 4230
|
11783, 11827
|
2274, 2329
|
11623, 11628
|
11681, 11690
|
11394, 11394
|
11744, 11760
|
2344, 3113
|
180, 199
|
4615, 11368
|
401, 1634
|
4239, 4300
|
1656, 1878
|
1894, 2257
|
11412, 11600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,500
| 183,822
|
8130+8131
|
Discharge summary
|
report+report
|
Admission Date: [**2127-10-15**] Discharge Date: [**2127-10-31**]
Date of Birth: [**2059-2-24**] Sex: F
Service:
CHIEF COMPLAINT: Ischemic left leg.
HISTORY OF PRESENT ILLNESS: The patient was transferred here
from an outside hospital on [**2127-10-15**]. She is a 68 year old
female with past medical history significant for end stage
renal disease, history of AVR, one vessel CABG in [**2123**],
status post multiple lower extremity bypass grafts with right
fem to AK popliteal with Dacron and left fem AK [**Doctor Last Name **]. She
presented to an outside hospital at [**Hospital3 **] on [**2127-10-1**]
with abdominal pain. Found to have a thickened cecum which
was resected with primary anastomosis. Postoperatively
developed increased left lower extremity pain, pallor,
mottling suspicious for arterial occlusion. She was not able
to tolerate an angiogram and was put on heparin GGT. She was
transferred to [**Hospital1 18**] for further management of this acute
event as this is where she had her previous surgeries.
PAST MEDICAL HISTORY: Significant for a-fib, status post
AVR, CABG, CHF, positive C.diff, VRE positive, COPD,
diabetes, end stage renal disease hemodialysis dependent on
Monday, Wednesday, Friday, ischemic colitis status post
colectomy, cecectomy, desmoid cyst resection, left first toe
amputation, CABG in [**2124**] with bovine, right fem AK [**Doctor Last Name **] Dacron
in 5/00 by Dr. [**Last Name (STitle) **], left fem AK [**Doctor Last Name **] with Dacron in
7/00, right fem redo fem [**Doctor Last Name **] with Dacron in 11/00, right TMA
in [**2125-11-21**] with right STSG, PermCath placement.
MEDICATIONS: Heparin GGT 800 units an hour, Percocet,
PhosLo, atenolol 12.5 mg once a day, vitamin C 500 p.o.
b.i.d., Neurontin 300 mg t.i.d., Levoxyl 25 mcg once a day,
Colace 100 mg p.o. b.i.d., Nephrocaps one tab q.d.,
amiodarone 200 mg once a day, Ambien 5 mg q.h.s.
ALLERGIES: Include Levaquin, Synercid.
PHYSICAL EXAMINATION: On arrival temperature was 98.3, 68,
100/66, 16, 94% on 2 liters. Physical exam was remarkable
for pulses as follows: on the right extremity femoral
palpable, dopplerable popliteal, weak monophasic DP, biphasic
PT. On the left she had nothing.
HOSPITAL COURSE: She had likely ischemic left lower
extremity. No signals by exam. Leg was mottled and cool
with good neuromotor function. Patient underwent angio
emergently. Cardiology and renal medicine were consulted on
her arrival as well. Cardiology said no active disease and
should proceed. She underwent thrombectomy, patch
angioplasty of left fem to popliteal graft on [**2127-10-16**]. She
was on antibiotics, vancomycin, and was transferred to VICU
on [**10-18**] because of postoperative need for pressor support.
Patient was lined and monitored. We continued
anticoagulation at this point as well as vancomycin. On
[**2127-10-19**] patient continued on pressor support and heparin GGT
to therapeutic range. We continued antibiotic prophylaxis
and insulin sliding scale and insulin continued on patient
per her regimen. We were unable to wean the neo off and
continued dialysis. On [**2127-10-20**] patient still had neo
requirement and we continued her anticoagulation status post
left thrombectomy fem/[**Doctor Last Name **] bypass graft.
Patient remained in the intensive care unit. Had increasing
white count which had reached 30 on [**10-21**]. General surgery
was consulted under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] and suspicion of
cholecystitis was raised. CT scan done showed patient did,
indeed, have cholecystitis, increased white count. Patient
was taken to the operating room on [**2127-10-21**] by general surgery
where she had cholecystectomy and lysis of adhesions with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**]. Postoperatively from open chole
patient remained in the intensive care unit and was at this
point receiving triple antibiotic therapy with ceftriaxone,
Flagyl and vancomycin. Patient remained intubated. She had
a persistent neo requirement at that time. Nephrology
remained involved and was dialyzing patient.
The patient was transferred to the vascular intensive care
unit on [**10-26**] after she no longer required Neo-Synephrine and
she had been successfully extubated. In the meantime we
continued anticoagulation and started her on Coumadin to
which she responded and eventually attained INR as high as
3.3 at one point. Her white count remained elevated at 22.9
which was much reduced from her prior white count in the ICU.
Patient received full pancultures which were negative and
there was no source of infection that we could find. Patient
was MRSA screened and found to be MRSA negative and was taken
off MRSA precautions. Her hemodialysis continued. On [**10-27**]
rehab screening began as well as disposition planning.
Heparin GGT was discontinued on [**10-28**] after INR shot up to
3.3. Also on [**10-28**] antibiotics were stopped. Patient
remained afebrile off antibiotics. She was started on
Coumadin as the only dosing.
Briefly by systems during the patient's stay:
1. Cardiac. Patient initially postoperatively required
pressor support which was eventually weaned off. We
continued beta blockade on her after that as well as
amiodarone for atrial fibrillation history.
2. Respiratory. Immediately post-op patient had a
Neo-Synephrine requirement for which she went to the ICU.
She remained intubated until after her open cholecystectomy
at which point she was weaned off the respirator and at the
appropriate point extubated and transferred to the VICU.
Aggressive pulmonary toilet and nebulizer treatments were
administered to patient.
3. GI. Patient is taking a diet as of now and has been
receiving prophylaxis in the form of Protonix.
4. Renal. Patient is hemodialysis dependent, has a PermCath
and has been receiving dialysis throughout the course of her
hospital stay.
5. ID. Patient was initially on vancomycin, then after the
diagnosis of cholecystitis was made, patient was put on
ceftriaxone, Flagyl in addition. Patient's antibiotics were
discontinued and she remained afebrile. Cultures have all
been negative to date for this admission.
6. Tubes, lines and drains. Patient has a PermCath and does
not void.
7. Heme. Patient is being continued on anticoagulation with
Coumadin.
Her physical exam at this point reveals the following. Heart
as of this morning had regular rhythm, although she has a
history of a-fib. Lungs are mostly clear with diminished
breath sounds at the bases without any significant crackles.
Abdominal wounds are stable. Abdomen is fairly soft.
Patient's leg on the left side shows that she has a
dopplerable PT and DP pulse which has been inconsistently
dopplerable. However, the site does not show any new
evidence of ischemia, although the distal aspect of the foot
is dark and unchanged, revealing some ischemic tissue.
DISCHARGE MEDICATIONS:
1. Synthroid 25 mcg p.o. q.d.
2. Nephrocaps one cap p.o. q.d.
3. Amiodarone 200 mg p.o. q.d.
4. Epogen 12,000 units subcu IV to be given at each
dialysis.
5. Tylenol p.r.n.
6. Gabapentin 300 mg p.o. t.i.d.
7. Percocet one to two tabs p.o. q.4-6h. p.r.n. pain.
8. Vitamin C 500 mg p.o. b.i.d.
9. Docusate sodium 100 mg p.o. b.i.d.
10. Zolpidem tartrate 5 mg p.o. q.h.s.
11. Dilaudid 0.25 to 0.5 mg IV q.3-4h. p.r.n.
12. Coumadin dose to INR of 2.5.
13. Lopressor 25 mg p.o. b.i.d.
14. Protonix 40 mg p.o. once a day.
15. Reglan 10 mg p.o. t.i.d.
16. Miconazole powder applied to both groins.
17. Silver sulfadiazine applied to left lower extremity where
a blister was opened.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2127-10-31**] 10:16
T: [**2127-10-31**] 10:31
JOB#: [**Job Number 28972**]
Admission Date: [**2127-10-15**] Discharge Date: [**2127-10-31**]
Date of Birth: [**2059-2-24**] Sex: F
Service: Vascular
The patient will be receiving 1 mg Coumadin tonight, each
day. This is based on INR, which came back today at 2.6. The
final hematocrit, prior to discharge, is 29.4. The last
potassium is 3.8. BUN and creatinine at 22 and 4.8. Total
CO2 24 bicarbonate. The patient is negative for C.
Dictated By:[**Name8 (MD) 28973**]
D: [**2127-10-31**] 12:50
T: [**2127-10-31**] 13:40
JOB#: [**Job Number 28974**]
|
[
"496",
"996.74",
"444.22",
"427.31",
"458.2",
"568.0",
"574.00",
"250.70",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"96.72",
"39.95",
"89.64",
"54.59",
"38.91",
"39.49",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
7023, 8531
|
2266, 7000
|
2001, 2248
|
151, 171
|
200, 1056
|
1079, 1978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,728
| 197,836
|
18650
|
Discharge summary
|
report
|
Admission Date: [**2140-1-19**] Discharge Date: [**2140-1-22**]
Date of Birth: [**2080-8-19**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Prednisone
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
L knee pain
Major Surgical or Invasive Procedure:
[**2140-1-19**] L TKA
History of Present Illness:
59F with long history of L knee OA.
Past Medical History:
niddm,dyslipid,htn,asthema,OSA-w/cpap,renal insuffic,
Social History:
Single, former smoker, has not smoked for 30
years. She drinks minimally. She is a travel consultant.
Family History:
n/c
Physical Exam:
PHYSICAL EXAM AT THE TIME OF DISCHARGE:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
Pertinent Results:
[**2140-1-19**] 11:35PM PLT COUNT-307
[**2140-1-19**] 11:35PM WBC-13.2* RBC-2.92* HGB-8.7* HCT-24.8* MCV-85
MCH-29.8 MCHC-35.0 RDW-15.7*
[**2140-1-19**] 11:35PM CALCIUM-8.2* PHOSPHATE-5.5* MAGNESIUM-1.7
[**2140-1-19**] 11:35PM estGFR-Using this
[**2140-1-19**] 11:35PM GLUCOSE-184* UREA N-29* CREAT-1.6* SODIUM-135
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
Brief Hospital Course:
The patient was admitted on [**2140-1-19**] and, later that day, was
taken to the operating room by Dr. [**Last Name (STitle) **] for L TKA without
complication. Please see operative report for details.
Postoperatively the patient did well. The patient was initially
treated with a PCA followed by PO pain medications on POD#1.
The patient received IV antibiotics for 24 hours
postoperatively, as well as lovenox for DVT prophylaxis starting
on the morning of POD#1. The patient was placed in a CPM
machine with range of motion that started at 0-45 degrees of
flexion before being increased to 90 degrees as tolerated. The
drain was removed without incident on POD#1. She had respiratory
distress and her oxygen saturations dropped into the 80s. She
was transferred to the MICU and was stabilized on CPAP. The
Foley catheter was removed without incident on POD 2. The
surgical dressing was removed on POD#2 and the surgical incision
was found to be clean, dry, and intact without erythema or
purulent drainage. She received 2 units PRBC on POD 2 for a HCT
of 20. She was asymptomatic.
While in the hospital, the patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
stable, and the patient's pain was adequately controlled on a PO
regimen. The operative extremity was neurovascularly intact and
the wound was benign. The patient was discharged to home with
services or rehabilitation in a stable condition. The patient's
weight-bearing status was WBAT. The patient is to continue
using the CPM machine advancing as tolerated to 0-100 degrees.
MICU COURSE [**Date range (3) 51185**]
# Hypoxia: Pt was noted to hypoxic off of CPAP in the PACU
following Lt total knee replacement. Portable chest x-ray in the
PACU notable for vessel cephalization. In the OR and PACU she
received a total fluid load of 1.3L, pt was give a total of 30mg
Furosemide for which she put out a vast amount of urine although
interestingly enough her oxygenation failed to improve.
Differential negative pressure pulmonary edema as pt has not
history of cardiac dysfunction and did not receive a vast amount
of fluid in the OR. Treated with albuterol nebs. BNP 65.
Cardiac biomarkers flat. Continued CPAP. Improved to 2L nc.
# Anemia: Pot-op hct noted to be 6 points lower than her pre-op
Hct, pt's EBL noted to be minimal per surgery, pt also only
received 1.3L in the OR. No signs/symptoms of bleeding.
#. Leukocytosis: WBC noted to be elevated, however pt was
post-op which likely explains WBC elevation. Pt currently on
Cefazolin post-operatively. Cultures negative thus far.
#. Diabetes: Oral medications held as patient was not eating and
patient in acute renal failure. Covered with SSI. Lisinopril
held.
#. S/p Total Knee replacement: Pt is s/p Lt TKR for
osteoarthritis, currently on a Dilaudid PCA, placed in brace
with hemovac drain in place. Pt also on Cefazolin post op.
Continued PCA. D/c'ed ketorolac given acute renal failure.
Lovenox d/c'ed given acute renal failure and patient started on
heparin sq tid for DVT ppx.
#. Acute Renal Failure on Chronic Renal Insufficeny: Pt's
Creatinine elevated to 1.6, over past few months pt's Creatinine
has been elevated 1.3. Diabetes medications and lisinopril as
above.
#. HTN: Pt has a history of HTN, currently SBP have ranged in
the low 100s. Will hold Lisinopril and HCTZ as pt's Creatinine
is elevated at 1.6. Held Lisinopril and HCTZ as Creatinine is
elevated at 1.6.
#. OSA: Pt has diagnosis of OSA, she usually uses CPAP during
naps, at bedtime at 8cm. Currently on CPAP settings now. Likely
would benefit from reassessment of respiratory support as last
sleep study was 6 years ago - should follow up as an out patient
upon discharge.
#. Depression: Continued home regimen of Venlafaxine
#. PPx: Heparin gtt given renal failure, Pantoprazole.
#. FEN: Currently on sips, ADAT to diabetic/cardiac diet.
#. FULL CODE
Medications on Admission:
e
f
f
e
x
o
r
,
g
l
i
p
i
z
ide,ibuprof,lisinopril,metformin,prilosec,valium,vicodin,mvi,Ca,
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H () as
needed.
Disp:*65 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
once a day for 3 weeks.
Disp:*21 * Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Diazepam 5 mg Tablet Sig: One (1) Tablet PO PRN (as needed).
12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for anxiety.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
17. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
19. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
L knee OA
Discharge Condition:
stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by a visiting nurse at 2 weeks
after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 4 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to
prevent deep vein thrombosis (blood clots). After completing
the lovenox, please take Aspirin 325mg twice daily for an
additional three weeks.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by VNA in 2 weeks. If you are going to
rehab, the rehab facility can remove the staples at 2 weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at 2 weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment. ***Continue to use your CPM machine as
directed.***
Physical Therapy:
Physical therapy -- WBAT. CPM advancing as tolerated to 0-100.
Lovenox injections. Wound checks. VNA to remove staples at 2
weeks.
Treatments Frequency:
Physical therapy -- WBAT. ***CPM advancing as tolerated to
0-100.*** Lovenox injections. Wound checks. VNA to remove
staples at 2 weeks.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2140-2-19**] 11:40
|
[
"311",
"272.4",
"584.9",
"493.90",
"715.36",
"250.00",
"403.90",
"585.9",
"518.4",
"327.23",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7084, 7154
|
1192, 5310
|
285, 309
|
7208, 7217
|
790, 1169
|
10008, 10211
|
589, 594
|
5453, 7061
|
7175, 7187
|
5336, 5430
|
7241, 8867
|
609, 771
|
9691, 9823
|
9845, 9985
|
234, 247
|
8879, 9673
|
337, 374
|
396, 451
|
467, 573
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,600
| 196,550
|
5594
|
Discharge summary
|
report
|
Admission Date: [**2109-10-11**] Discharge Date: [**2109-10-12**]
Service: MEDICINE
Allergies:
Epinephrine
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82M with h/o CAD s/p CABG [**2103**], cardiomyopathy with EF 40-45%,
PAF, and sick sinus syndrome s/p pacer placement presents with
chest pain.
States pain started night prior to admission while watching tv.
Described as left-sided, "tearing", located in his pectoral
region/axilla. Accompanied with mild nausea, diaphoresis,
slight feeling of lightheaded, clammy. Rates pain [**6-6**],
constant. Patient taken to [**Hospital3 4107**], given nitropaste
and baby aspirin there, troponin reported as positive at .03,
BNP 201. Pt then transferred to [**Hospital1 18**] ED.
.
In the ED, vitals were HR 70, BP 138/66, RR 18, 99% on 2L NC.
Pt given SL nitro, nitropaste removed. Full dose aspirin was
administered and morphine which finally brought the pain down to
a 1/10. EKG unchanged, first set of cardiac enzymes were
negative. Pt was admitted to CCU for further management.
.
On review of symptoms, he notes prior TIA, no deep venous
thrombosis, no pulmonary embolism, history of ischemic colitis,
no myalgias, significant back pain. No recent cough,
hemoptysis, black stools or red stools. Does have occasional
BRBPR, last episode about 10 days ago. 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 chest pain as described
above, currently [**2-6**]. No recent dyspnea on exertion or change
in exercise tolerance. No paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
OUTPATIENT CARDIOLOGIST: [**Doctor Last Name 1016**]
PCP: [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 22477**]
.
ALLERGIES: Epinephrine (induction of AF)
.
PMH:
1. CAD
--s/p PCTA with BMS placement in OM [**2101**]
--s/p CABG [**2103**] (LIMA to LAD, SVG to OM2, SVG to D2)
2. Cardiomyopathy, LVEF 40-45% by echo in [**2108**]
3. AV block, s/p pacemaker in [**2100**]
4. PAF
5. Hypertension per records in CCC
6. Dyslipidemia
7. GERD, hiatal hernia
8. Prostate cancer, s/p radiation
9. Spinal stenosis/Chronic lower back pain
10. s/p excision of squamous cell cancer from face
11. Shingles
12. History of malaria
13. s/p Hemorrhoidectomy
14. Hernia repair x 2
15. Obstructive sleep apnea (CPAP)
16. TIA [**2103**] (no specifics on workup)
17. Compression fractures T8/L2
.
Further Cardiac History:
Percutaneous coronary intervention, in [**2103**] anatomy as follows:
1. Selective coronary angiography of this right dominant system
revealed significant obstructive two vessel disease. The left
main was normal. The LAD revealed discrete mid 70-80% and distal
70% stenoses, with its proximal D1 branch exhibiting 70%
stenosis and D2 branch with diffuse disease up to 70%. The LCx
revealed a mid-vessel 40% lesion, with its OM3 branch exhibiting
a 30-40% stenosis proximal to the widely patent stent. The RCA
revealed discrete proximal 70-80% and distal 60% stenoses.
.
Pacemaker, in [**2100**], generator replaced in [**8-/2109**]- DDD
Social History:
Social history is significant for the absence of current tobacco
use, quit 50 years ago. There is no history of alcohol abuse.
The patient lives with his wife at [**Location (un) 5481**].
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
GEN: sleeping, arousable. Lying semi-upright comfortably, NAD
HEENT: anicteric sclera, mucosa somewhat dry, EOMI, OP clear
NECK: JVP about 10 cm
CV: [**3-5**] holosystolic murmur, ? S4, RRR. Chest pain
non-reproducible
LUNGS: CTA B/L, good inspiratory effort, no wheezes, crackles,
or rales
ABD: soft, nt, nd, NABS
EXT: warm, dry. No [**Location (un) **]. Multiple varicosities.
SKIN: no rashes, ulcers, venous stasis
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:
[**2109-10-11**] 01:36PM URINE HOURS-RANDOM UREA N-527 CREAT-44
SODIUM-137
[**2109-10-11**] 01:36PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2109-10-11**] 01:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2109-10-11**] 01:36PM URINE EOS-NEGATIVE
[**2109-10-11**] 12:28PM GLUCOSE-106* UREA N-28* CREAT-1.4* SODIUM-140
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2109-10-11**] 12:28PM CK(CPK)-135
[**2109-10-11**] 12:28PM CK-MB-5 cTropnT-<0.01
[**2109-10-11**] 03:53AM GLUCOSE-106* UREA N-31* CREAT-1.7* SODIUM-138
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
[**2109-10-11**] 03:53AM CK(CPK)-152
[**2109-10-11**] 03:53AM cTropnT-<0.01
[**2109-10-11**] 03:53AM CK-MB-4
[**2109-10-11**] 03:53AM WBC-4.5 RBC-2.78* HGB-9.6* HCT-29.1* MCV-105*
MCH-34.7* MCHC-33.1 RDW-13.5
[**2109-10-11**] 03:53AM PT-13.4* PTT-23.9 INR(PT)-1.2*
.
EKG demonstrated V-paced, no significant change compared with
prior dated 8/[**2109**].
.
2D-ECHOCARDIOGRAM performed on [**2108-10-31**] demonstrated:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed EF 40-45%. Right ventricular chamber size and free
wall motion are normal. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-29**]+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
.
ETT performed on [**5-/2103**] demonstrated:
This 76 yo man (s/p stent amd pacemaker '[**00**]; CVA
'[**02**]) was referred to the lab for CAD evaluation (viability;
ischemia). The patient was administered 5 ug (5 min stage), 10,
20, 30 and 40 ug/kg/min (3 min stages) of Dubutamine for a total
infusion duration of 17 minutes. No neck, arm, back, or chest
discomforts were reported throughout the procedure. The ECG is
unintepretable secondary to AV paced rhythm. No ectopy was noted
during the procedure. A progressive and subtle drop in blood
pressure was noted during the infusion (nonspecific finding w/
Dobutamine infusion). The rate did not change during the
infusion.
The patient did not report any symptoms.
The EKG was uninterpretable due to the presence of a paced
rhythm.
Resting images were acquired at a heart rate of 69 bpm and a
blood pressure of 172/96 mmHg. These demonstrated significant
left ventricular systolic dysfunction with global hypokinesis
to akinesis. Focused Doppler demonstrated trace aortic
regurgitation and mild to moderate mitral regurgitation.
Compared with a prior study from [**2100-9-10**] (baseline for exercise
echo), there has been a significant deterioration in left
ventricular function.
At low dose dobutamine [5 mcg/kg/min; heart rate = 69 bpm, blood
pressure = 178/96 mmHg), there was failure to augment systolic
function of all segments. At mid-dose dobutamine [20
mcg/kg/min; heart rate = 69 bpm, blood pressure = 178/86 mmHg),
there was augmentation of the basal inferoposterolateral wall
and anterior wall. At peak dobutamine stress [40 mcg/kg/min;
heart rate = 69 bpm, blood pressure = 158/76 mmHg), there was
persistent augmentation of the basal inferoposterolateral wall
and anterior wall. Cavity size was smaller.
.
CARDIAC CATH performed on [**2103**]:
Right dominant system revealed significant obstructive two
vessel disease. The left main was normal. The LAD revealed
discrete mid 70-80% and distal 70% stenoses, with its proximal
D1 branch exhibiting 70% stenosis and D2 branch with diffuse
disease up to 70%. The LCx revealed a mid-vessel 40% lesion,
with its OM3 branch exhibiting a 30-40% stenosis proximal to the
widely patent stent. The RCA revealed discrete proximal 70-80%
and distal 60% stenoses.
2. Resting hemodynamics revealed a mean RA pressure of 6 mmHg,
PA
pressure of 30/12 mmHg, mean PCW pressure of 11 mmHg, LVEDP of 8
mmHg
and a cardiac index of 3.1 l/min/m2.
3. Left ventriculography revealed a moderately severe
anterolateral and apical hypokinesis, with posterobasal and
inferior akinesis. The
ejection fraction was 27%.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe systolic ventricular dysfunction.
.
CXR [**10-11**]
AP UPRIGHT CHEST: The patient is status post median sternotomy.
There is a left-sided pacemaker with leads in standard
position. The heart size is stable when compared to the prior
study. The thoracic aorta is somewhat tortuous, but unchanged
given differences in technique. There is blunting of the left
costophrenic angle suggestive of a small effusion. The right
costophrenic angle is excluded from the film. No pulmonary
vascular congestion is appreciated. There are linear opacities
also in the right mid lung and left base consistent with
atelectasis.
IMPRESSION:
Small left-sided pleural effusion with associated atelectasis.
No definite change in the cardiac or mediastinal contour from
prior studies given differences in technique. Please note for
the detection of aortic pathology, CT is more sensitive.
.
CXR PA and lat [**10-11**]:
Small left pleural effusion is confirmed, and there is also a
probable very small right posterior effusion. Heart is upper
limits of normal in size. Aorta is tortuous. Minor bibasilar
atelectasis is present. Permanent pacemaker remains in standard
position.
.
Persantine MIBI [**10-11**]:
1) Mild inferior wall defect likely representing attenuation.
2) Moderate global hypokinesis and biventricular dilation with
ejection fraction of 35%.
Brief Hospital Course:
# Cardiac
Patient presented with chest pain that was not typical of
ischemic pain, but given his significant history of coronary
disease, he was treated as a possible acute coronary syndrome.
He was continued on aspirin, statin, and a beta-blocker. His
cardiac enzymes were followed, and were found to be negative.
The day after presentation, the patient received a persantine
MIBI which was found to have EF of 35% and a mild inferior wall
defect thought to be secondary to attenuation.
.
The patient has known chronic diastolic and systolic heart
failure with an EF of 40%; he was euvolemic throughout his
admission.
.
Mr. [**Known lastname **] also has a h/o AV block and AFib s/p PPM; he was
monitored on telemetry and had no significant events during his
admission.
.
# Acute renal failure
Patient has baseline creatinine 1.0-1.4, found to be 1.7 on
admission. He received gentle IV fluids and urine was sent for
electrolytes and eosinophils. His lasix was held. Creatinine
improved to 1.2 on the day of discharge.
.
# Anemia
Patient has a chronic macrocytic anemia, and his hematocrit was
at his baseline (25-31). B12 and Folate were checked and were
found to be normal. He reported that his PCP is aware of his
anemia and has been working him up.
.
# Hypertension
Patient's carvedilol was continued. His son, who is his health
care proxy, was [**Name (NI) 653**] about why his father is not on an ACE
inhibitor. The was not sure why an ACE inhibitor was not
included among the patient's medications. He was advised to
discuss the matter with the patient's primary doctor, as an ACE
inhibitor would be recommended for this patient.
.
# Back pain- Patient complained of chronic back pain, for which
he receives percocet at home. He did receive some percocet for
this pain during his admission.
Medications on Admission:
Colace 100mg twice a day
Lasix 20mg every other day
L-Thyroxine 50mcg daily
Amiodarone 200mg daily every morning
Coreg 25mg one tablet twice a day
Protonix 40mg daily every morning
Zocor 10mg daily every evening
Aricept 10mg daily every evening
Zoloft 25mg one tablet every morning
Ditropan XL 5mg one tablet every morning
Gas-X one pill twice a day
Aspirin 81mg daily every evening
MVI one daily every morning
Citracal two tablets every morning
Tylenol arthritis two tablets twice a day
Magnesium supplement one tablet twice a day
Hydrocodone 5-325mg one tablet every evening
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for back pain.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every other
day.
13. Ditropan 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: chest pain
Secondary Diagnoses: CAD, cardiomyopathy with EF 40% by echo in
[**2108**], sick sinus syndrome s/p pacemaker in [**2100**], paroxysmal
atrial fibrillation, spinal stenosis, chornic low back pain
Discharge Condition:
Good, afebrile with stable vital signs, chest pain free.
Discharge Instructions:
You were admitted to the hospital with chest pain. You were
evaluated with blood tests and a stress test and found not to
have had a heart attack. You had a chest xray that showed some
fluid outside your lung (a pleural effusion) on the left side.
You should have a CT scan of your chest to further evaluate this
as an outpatient.
Please take all of your medicines as directed and follow up with
your primary care doctor and your cardiologist.
Call your primary care doctor and seek medical attention at once
if you develop:
** recurrent chest discomfort, shortness of breath,
lightheadedness or dizziness, or other symptoms that worry you
Followup Instructions:
Provider: [**Name10 (NameIs) 8673**] [**Last Name (NamePattern4) 8674**], MD Phone:[**Telephone/Fax (1) 1091**]
Date/Time:[**2109-12-13**] 9:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2386**] Follow-up appointment
should be in 6 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5483**] Appointment
should be in [**8-6**] days
Completed by:[**2109-10-17**]
|
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icd9cm
|
[
[
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icd9pcs
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[
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13529, 13535
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9971, 11781
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232, 239
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4187, 8532
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3315, 3506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,251
| 192,721
|
34275
|
Discharge summary
|
report
|
Admission Date: [**2135-12-9**] Discharge Date: [**2135-12-16**]
Date of Birth: [**2104-8-11**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Headache, blurry vision and HD line displacement
Major Surgical or Invasive Procedure:
HD Tunneled Line Placement
History of Present Illness:
This is a 31 yo male with h/o biliary atresia s/p liver
[**First Name3 (LF) **] age 4, now again with cirrhosis, ESRD on HD, awaiting
liver/kidney [**First Name3 (LF) **], recently discharged with klebsiella
bacteremia and MSSA cellulitis, completed abx therapy on
Tuesday, who presented to the ED after his HD catheter fell out.
He reported nausea, vomiting, and dark stools. He also reported
"white vision" as well while in the ED.
.
In the ED, initial VS: 98.2 F, BP 131/83, HR 108, R 21, O2-sat
98% RA. Given the visual changes, patient had an initial head CT
which was negative. Neurology evaluated the patient and
recommended an MRI/MRA. That was also obtained in the ED with
multiple cortical/subcortical infarcts which could be consistent
with septic emboli. The patient was being evaluated by
ophthalmology for the visual loss, and while he was being
examined, the patient had a seizure. Ativan 1 mg x 1 was given,
and the patient was then noted to be post-ictal and not
following commands. He was placed on a NRB for his O2 sats. At 4
pm, when he was re-evaluated by neurology, he was following come
commands, and also was moving all extremities. LP was not
performed in the ED because consent could not be obtained while
patient was post-ictal. He was given vancomycin and 2 gm CTX in
the ED for meningitis coverage. He is also being given
ampicillin as well. The patient also had a new HD catheter
placed and a new post pyloric tube placed by IR while he was in
the ED as well. Blood cultures were drawn and pending. Neurology
recommended a repeat head CT while he was in the ED, which was
performed prior to transfer. He was also loaded with Keppra, 500
mg x 1, followed by repeat 500 mg in 4 hours, followed by 500 mg
daily with add'l 500 mg after HD. LENI's were also ordered in
the ED given his h/o of R to L shunt on prior ECHO with bubble
study and were negative for DVT. An ECHO was also ordered, but
not done prior to transfer. ID was notified of the patient's
admission and agreed with the above antibiotic regimen.
.
Currently, patient appears comfortable. HA still present but
unchanged from earlier in the day. Otherwise denies pain, denies
blurred vision. States he is hungry, eager for dinner. Generally
speaks in simple sentences but is cooperative with exam.
Past Medical History:
-biliary Atresia s/p liver [**First Name3 (LF) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection
Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work.
Family History:
NC
Physical Exam:
Vitals - T: 98.4 BP: 132/92 HR: 102 RR: 22 02 sat: 95% on RA
GENERAL: Awake, oriented to [**Hospital1 18**], date, in NAD laying in bed in
MICU at time of exam
HEENT: No cervical LAD, no thyroidmegaly, neck supple, no JVD,
HD catheter in place R neck
CARDIAC: Tachycardic to ~100, regular, no clear murmur
LUNG: CTA bilaterally
ABDOMEN: Soft, NT/ND, +NABS, no organomegaly
EXT: Pitting edema of LE bilaterally, 2+ radial and DP pulses
b/l
NEURO: Strength 5/5 in UE and LE; sensation grossly intact b/L,
CN II-XII intact, although eye movements (vertical and
horizontal) are not smooth (unclear whether patient has
difficulty following commands; looks away frequently during
exam). No Babinski. Patellar reflexes difficult to assess (given
absence of reflex hammer) but are present and equal ([**11-26**]+).
DERM: Multiple (dozens) discrete skin lesions on arms, abdomen,
lower legs that appear to be the result of
scratching/excoriations, scabbed over, some with surrounding
erythema suggestive of possible superinfection. No lesions on
back where patient is unable to reach. Marks on lower spine
where LP was attempted. Well-healed scars on abdomen from
[**Month/Day (2) **] at age 4.
Pertinent Results:
[**2135-12-9**] 04:10PM GLUCOSE-95 UREA N-20 CREAT-2.3* SODIUM-137
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2135-12-9**] 04:10PM CALCIUM-8.0* PHOSPHATE-5.7*# MAGNESIUM-2.0
[**2135-12-9**] 11:00AM CK(CPK)-49
[**2135-12-9**] 11:00AM cTropnT-0.01
[**2135-12-9**] 04:00AM ASCITES WBC-45* RBC-1605* POLYS-0 LYMPHS-70*
MONOS-0 MESOTHELI-0 MACROPHAG-30*
[**2135-12-9**] 12:19AM GLUCOSE-115* LACTATE-1.9 NA+-139 K+-3.3*
CL--101 TCO2-30
[**2135-12-9**] 12:05AM GLUCOSE-119* UREA N-15 CREAT-2.1* SODIUM-138
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-10
[**2135-12-9**] 12:05AM ALT(SGPT)-13 AST(SGOT)-40 CK(CPK)-57 ALK
PHOS-418* TOT BILI-0.7
[**2135-12-9**] 12:05AM LIPASE-28
[**2135-12-9**] 12:05AM ALBUMIN-1.2* CALCIUM-7.6* PHOSPHATE-3.5
MAGNESIUM-1.8
[**2135-12-9**] 12:05AM ASA-NEG ETHANOL-NEGIMPRESSION:
MR [**Name13 (STitle) 430**]: [**2135-12-9**]
1. Multiple foci of acute infarction in both cerebral
hemispheres. The wide, inter-territorial distribution and
uniform temporal appearance of the lesions, in this clinical
context, are strongly suggestive of "watershed" infarction; an
embolic etiology is less likely.
2. Normal MRA and MRV of the brain and MRA neck. ACETMNPHN-8.0*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Repeat MR [**Name13 (STitle) 430**]: IMPRESSION: Evolution of previously seen foci of
decreased diffusion. The distribution may represent a
combination of a "watershed" type infarct related to
hypoperfusion and embolic (either bland or septic) phenomenon.
However, there is no new infarct identified.
EEG: This is an abnormal noncontinuous extended routine EEG due
to slowing and disorganization of the background rhythm and
bursts of
semirhythmic, moderate voltage, bifrontally predominant
generalized
theta/delta activity. The first finding suggests a mild to
moderate
encephalopathy. Medications, toxic/metabolic disturbances, and
infections are common causes. The generalized slowing suggests
possible
deep or midline dysfunction. No epileptiform discharges or
electrographic seizures were seen during this recording and this
telemetry captured no pushbutton activations.
TEE: No thrombus is seen in the left atrial appendage. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 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. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
.
MRI L spine:
IMPRESSION: No valvular vegetations seen. Moderate mitral
regurgitation. Normal biventricular function.IMPRESSION:
1. Diffuse central clumping of the cauda equina in this patient
with a
congenitally narrow canal. The findings suggest arachnoiditis
and are similar to the prior study.
2. Severe canal narrowing just inferior to the L4-5 disc space
secondary to
osseous proliferative changes and epidural lipomatosis.
3. Moderate bilateral subarticular zone narrowing at L4-5 with
what appeared to be mildly swollen bilateral L5 roots.
4. Bilateral L5 spondylolysis with fluid clefts and surrounding
edema is most likely all degenerative. No drainable fluid
collection is identified and the lack of interval change from
the study one month prior makes infection unlikely though should
be correlated with clinical findings.
.
Brief Hospital Course:
Mr [**Known lastname 40167**] was admitted for (1) replaced of his tunneled line
and (2) a constellation of neurological findings including
headache, changes in vision, and while in ED, a seizure. He was
admitted to the ICU for airway protection and loaded with
Keppra. EEG was negative for epileptiform activity. Two MICU
teams attempted an LP however they were unsuccessful in
obtaining fluid. He was empirically started on antibiotics for
meningitis, however all of his symptoms acutely resolved. He
was transferred to the floor where repeat EEG again was
non-epileptiform although showing nonspecific activity in the
occipital area. An MRI showed evidence for embolization; septic
emboli was a possibility, however other embolic phenomena were
also a possibility, given that embolization could have occured
at the moment of displacement of his HD line. The presence of
AV shunts secondary to hepatopulmonary syndrome would have
allowed for migration of venous emboli. Infectious work up
repeatedly revealed negative blood and urine cultures. Chest
x-ray was unremarkable. MRI of L spine given prior fluid
collection was not suspicious for infection. Peritoneal fluid
was negative for SBP. TEE was negative for vegetations. Repeat
MRI showed continued presence of previously seen MRI but again
was not necessarily consistent with septic phenomena. Given
resolution of symptoms, antibiotics were discontinued and he
continued to remain at his baseline. Keppra was continued given
his prior seizure with instruction to discontinue Keppra after 2
weeks if no seizure event occured. Follow up with renal,
neurology, and opthamology was obtained and time of discharge.
Medications on Admission:
albuterol sulfate inhaler [**11-26**] every 6 hours PRN
furosemide 20 mg by mouth once daily
ipratropium bromide 1 daily PRN
Lactulose 30 ml up to 1 times daily (written for up to 4times
daily but doesnt need it)
metoprolol 25mg twice daily
oxycodone 5 mg Q8 hours PRN pain
Reglan 1 tablet 4 times a day
sucralfate 10 ml 4 times a day
tacrolimus 0.5 mg twice daily.
Caltrate 600 Plus Vit D
Omeprazole 40mg twice daily
Lidoderm patch 5% on low back
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for titrate to 3 BMs daily.
2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD
PROTOCOL (HD Protochol): please take 1 tablet during
hemodialysis .
Disp:*30 Tablet(s)* Refills:*2*
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchiness.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Discharge Disposition:
Home With Service
Facility:
VNA Southeastern MA
Discharge Diagnosis:
1. Emboli to brain causing seizure, nausea/vomiting, blurry
vision - now clinically resolved, unlikely septic, more likely
ischemic
2. Cirrhosis secondary to congenital biliary atresia
3. End stage renal disease secondary to post-strep GN on
hemodialysis
Discharge Condition:
Stable for home, saturating normally at room air.
Discharge Instructions:
Dear Mr [**Known lastname 40167**],
It was a pleasure caring for you while you were at [**Hospital1 **]. You were admitted because your [**Hospital1 2286**] line fell
out; you also experienced multiple symptoms including nausea,
vomiting, and blurry vision. You also had a seizure while you
were here. We performed an imaging study of your brain which
showed several areas that were concerning for a stroke or
infection. Because we were worried about infection, we
performed several studies to search for an infectious source,
however we could not find any sign of infection in your body. We
did briefly start you on antibiotics but your symptoms cleared
spontaneously, which suggests that this is less likely to be an
infection. For this reason, you do not need to take antibiotics
when you go home.
.
Because you had a seizure, we started you on a medicine called
Keppra, which helps prevent seizures. You should continue to
take this medicine for another two week period. This helps to
prevent further seizures. If by the end of two weeks, you have
had no further seizures, neurology can help you to stop this
medicine. You will need to see neurology as an outpatient.
Your follow up appointments are scheduled below.
.
The medication changes we made during this hospitalization are:
(1) We started you on keppra 500 mg daily. You should continue
to take this daily and you will also receive it just prior to
hemodialysis.
(2) Instead of taking tacrolimus 0.5 mg twice a day, you should
take tacrolimus 0.5 mg daily in the morning.
(3) You should take nephrocaps 1 capsule daily every morning.
This medicine is good for your kidneys.
(4) We have decreased your metoprolol dose to 12.5 mg twice a
day.
(5) We have decreased your omeprazole to 40 mg daily.
(6) We started you on Vitamin D 800 units daily.
Followup Instructions:
1. Please follow up with Dr [**Last Name (STitle) **] from Neurology on [**1-16**] [**2135**] at 230 PM at the [**Hospital 878**] clinic at [**Hospital1 **].
2. Please follow up with your liver doctor [**First Name (Titles) **] [**2135-12-28**]
at 1 PM. If you have any questions regarding this appointment,
please call [**Telephone/Fax (1) 673**].
3. Please follow up with opthomology at [**Hospital 13128**] given
your vision difficulties. Please call [**Telephone/Fax (1) 78900**] to set up
this appointment at your earliest convenience.
|
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71,665
| 113,811
|
37396
|
Discharge summary
|
report
|
Admission Date: [**2125-11-14**] Discharge Date: [**2125-11-19**]
Date of Birth: [**2043-8-9**] Sex: M
Service: MEDICINE
Allergies:
Diltiazem
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypotension, rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yo M with history of multiple episodes of past syncope, CAD,
hypopituitarism. He is not the most clear historian; however, he
reports periods of uncontrollable shaking in his rehab facility
prior to presenting to the [**Hospital6 12112**] ED the
night of [**2125-11-13**]. He was assessed in triage there as having a
BP of 59/36 with temp of 96 pulse of 53. At [**Last Name (un) 4199**] ED, he had a
WBC count of 8.9, HCT of 32.9, and a lactate of 1.7. A head CT
was performed and noted opacified left maxillary sinus, though
no acute intracranial pathology. He reports a clear nasal
drainage, though denies any facial pain or yellowish nasal
drainage. He has had a scant cough, though denies a productive
cough. He reports diarrhea in the last week. He was given 1.5 L
of fluid, was started on dopamine and avelox and was then
transferred to the [**Hospital1 18**] ED.
He notes that he was treated at [**Hospital1 2025**] (records state that he was
hospitalized from [**10-30**] to [**11-6**] for syncopal event and UTI) one
week ago and was discharged to rehab, where he has remained in
the last week. He was reported as ending a 14 day course of
Cipro for complicated UTI on [**2125-11-13**]. His daughter notes that
the patient has been admitted to several different hospitals in
the area recently for urinary tract infections.
Upon presentation to the [**Hospital1 18**] ED, vitals were: HR 74, BP 85/58,
O2Sat 98%. Had a RIJ sepsis line place as well as a 20g IV. Got
a total of 3 L NS in ED. Received 1 g Vancomycin and 4.45 g
Zosyn. CVP was 6 at time of signout to the ICU. Receiving 0.09
of levophed prior to transfer to the ICU. Urinalysis was
performed. Vitals prior to transfer to the unit were: T 97.3, HR
78, BP 115/51, RR 14, O2Sat 99% 3L NC.
ROS:
(+)ve: shaking chills, diarrhea, sweats, rhinorrhea
(-)ve: fever, nausea, vomiting, constipation, visual changes,
sore throat, myalgias, dysuria, abdominal pain
Past Medical History:
1) Diabetes mellitus
2) Coronary artery disease with missed IMI in [**2105**]
3) COPD
4) Pituitary adenoma resection [**2106**] and [**2108**] with resulting
hypopituitarism
5) OSA
6) Hypertension
7) Hyperlipidemia
8) Hypothyroidism
9) CKD baseline Cr in [**6-/2125**] was 1.4
10) Gout
11) Dementia
12) Syncope, recurrent since [**2101**]
- Tilt table testing negative x 2
- Holter monitor from [**7-/2125**]: SR 41 to 92, mean 52, APBs with 6
beat run @ 102
- Nuclear exercise stress test [**7-/2124**]: [**Doctor First Name **] 2'[**51**]", 5 mets, HR
54 to 70, SBP 90 to 130, no CP, no EKG changes, EF 49% with
inferior hypokinesis and moderate fixed inferior defect
- Cardiac cath [**4-/2121**]: mild LCA, collateralized 100% RCA,
calcified mild R fem stenosis
- Interim IMI by EKG in [**2105**]
Social History:
He receives his primary care at [**Location 1268**] VA with Dr. [**Last Name (STitle) 29697**].
He receives cardiology care with Dr. [**Last Name (STitle) 84073**] at [**Hospital1 2025**].
Tobacco: previously smoked for 80 pack-year history, quit 12
years ago (later stated he quit only months ago)
EtOH: Denies
Illicits: Denies
Family History:
NC
Physical Exam:
VS: T 98.3, HR 80, BP 140/61, RR 17, O2Sat 99% 3L NC.
GENERAL: NAD, occasional shaking chill
HEENT: PERRL, EOMI, oral mucosa slightly dry,
NECK: Supple, no [**Doctor First Name **], no thyromegaly
CARDIAC: RR, nl S1, nl S2, nl M/R/G
LUNGS: CTAB anteriorly
ABDOMEN: BS+, soft, NT, ND
EXTREMITIES: Warm and well-perfused, no edema or calf pain
SKIN: No rashes/lesions, ecchymoses.
NEURO: Oriented only to self, difficult to understand his
speech, BUE strength intact
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
.
[**2125-11-14**] 02:50AM WBC-8.7 RBC-3.71* HGB-11.2* HCT-34.5* MCV-93
MCH-30.3 MCHC-32.6 RDW-14.7
[**2125-11-14**] 02:50AM PLT COUNT-257
[**2125-11-14**] 02:50AM PT-14.1* PTT-31.8 INR(PT)-1.2*
[**2125-11-14**] 02:50AM GLUCOSE-171* UREA N-31* CREAT-1.7* SODIUM-137
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-17* ANION GAP-15
[**2125-11-14**] 02:50AM ALT(SGPT)-25 AST(SGOT)-25 ALK PHOS-65 TOT
BILI-0.2
[**2125-11-14**] 02:50AM LIPASE-17
[**2125-11-14**] 02:50AM ALBUMIN-3.2*
[**2125-11-14**] 02:59AM LACTATE-1.0
.
Cortisol stimulation test (last dose prednisone 15 mg on morning
of [**2125-11-16**])
--
[**2125-11-18**] Cortisol (5:37am) 1.1
--cosyntropin given at 6:17am
[**2125-11-18**] Cortisol (6:36am) 11.8
[**2125-11-18**] Cortisol (7:38am) 16.4
[**2125-11-18**] FSH: < 1
[**2125-11-18**] LH: < 1
[**2125-11-18**] TSH: 1.1
[**2125-11-18**] Free T4: 0.30
[**2125-11-18**] ACTH: pending
.
MICRO
[**2125-11-14**] Blood cx: Pending
[**2125-11-17**] Blood cx: Pending
[**2125-11-14**] Urine cx: negative
[**2125-11-17**] Catheter tip: negative
.
IMAGING:
.
Chest X ray [**2125-11-14**]: Appropriately positioned central venous
line with no
pneumothorax.
Brief Hospital Course:
82 yo M with history of multiple episodes of past syncope, CAD,
and hypopituitarism, who presented with rigors and hypotension.
#. Hypotension: He was admitted with hypotension requiring
pressor therapy with norepinephrine. He was afebrile without an
increased WBC count and was not tachycardic. He was started
empirically on antibiotics (cefepime, ciprofloxacin, and
vancomycin) for possible sepsis. He was also given an increased
dose of prednisone 15 mg daily for three days as stress dose
steroids given his chronic steroid use. He was aggressively
fluid resuscitated on admission and his blood pressure responded
well. It remained stable after his acute presentation. Cultures
from outside hospital were as follows: [**Last Name (un) 4199**] blood cultures
positive 2 out of 4 bottles for coagulase negative staph
(presumed contaminant), [**Location (un) 2251**] urine cx from [**10-19**] had GPC/GNR
but no other speciation. Patient's urine, blood, and CVL
catheter cultures from this admission yeilded no growth. Based
on these results it is unclear that his presenting hypotension
was at all related to infection. Patient was persistently
orthostatic throughout admission even after significant volume
resuscitation. At time of discharge patient's blood pressure
continued to drop with standing (< 20 points systolic) but was
without orthostatic symptoms. Patient is encouraged to continue
increased fluid intake to prevent orthostatic symptoms.
Patient's hypopituitarism (adrenal insufficiency,
hypothyroidism, and likely testosterone deficiency) was also
thought to contribute to his symptoms.
.
#. Panhypopituitarism: He had a recent decrease in his dose of
levothyroxine from 100 mcg daily to 25 mcg daily without
explanation. He had a normal TSH during this admission.
However, his Free T4 was found to be low at 0.30. Endocrine
Team was consulted and patient's dose of levothyroxine was
increased back to 100 mcg daily. Additionally, his prednisone
was increased from 5mg daily to 15 mg daily for a three day
course immediately after presentation. After this stress dose
steroid course patient underwent an attempted cortisol
stimulation test with cosyntropin on [**2125-11-18**] that revealed a
very low basal cortisol level (1.1). His concurrent undetectable
LH and FSH make adrenal insufficiency a likely diagnosis. The
Endocrine team also stated that patient likely suffered from
testosterone deficiency and that he may benefit from closely
monitored testosterone replacement therapy in the future. He
should continue his daily prednisone 5 mg po daily. He will
likely require stress dose steroids (15 mg po x 3 days) during
acute illness. It is very important that patient establish care
with an Endocrinologist to monitor these issues. Patient had
previously established care with Dr. [**Last Name (STitle) 41292**] at [**Hospital1 2025**]. Because he
has not been seen there in years he will need to reestablish
care. His records will be faxed to the [**Hospital 2025**] [**Hospital 1800**] clinic and
he will be contact[**Name (NI) **] to schedule an appointment. If he does not
hear from the [**Hospital 1800**] Clinic in 2 weeks please contact them at
[**Telephone/Fax (1) 84074**].
#. Diabetes: He had some hyperglycemia after admission, likely
related to his underlying diabetes and his increased dose of
steroids. He was managed with an insulin sliding scale and
finger stick blood glucose measurements qachs. Recommend
monitoring HbA1C in outpatient setting. Consider adding Januvia
to diabetic regimen if possible in the future.
#. COPD: Stable. He was continued on his home advair and
tiotropium.
.
#. CAD / Hypertension / Hyperlipidemia: He was continued on
simvastatin and aspirin. His lisinopril and metoprolol were
initially held due to hypotension and ultimately restarted at
home dose without complications.
#. Gout: He was continued on his home allopurinol.
#. Dementia: He was continued on donepezil
#. Prophylaxis: He was given SC heparin for DVT prophylaxis.
#. Access: He had a right IJ central line placed for central
venous access on [**2125-11-14**] which was discontinued [**2125-11-17**].
#. Communication: With patient and daughter, [**Name (NI) **]
([**Telephone/Fax (1) 84075**]; [**Telephone/Fax (1) 84076**])
#. Code Status: Full Code, confirmed with patient's daughter
.
#. Dispo: Rehab while awaiting [**Hospital3 **] bed assignment
Medications on Admission:
1) Aspirin 81 mg daily
2) Donepezil 10 mg daily
3) Metoprolol succinate 12.5 mg daily
4) Lisinopril 10 mg daily
5) Prednisone 5 mg daily
6) Trazodone 50 mg PO QPM
7) Omeprazole 20 mg daily
8) Allopurinol 100 mg daily
9) Advair 250/50 1 INH [**Hospital1 **]
10) Calcium carbonate 1250 mg [**Hospital1 **]
11) Wellbutrin SR 200 mg [**Hospital1 **]
12) Tiotropium bromide 1 INH daily
13) Levothyroxine 25 mcg daily
14) Metoclopramide 10 mg QACHS
15) Simvastatin 80 mg PO QPM
16) Senna 2 tabs PO daily
17) Cipro 500 mg Q12H (course ended on [**2125-11-13**])
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 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. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Insulin
Please continue humalog insulin sliding scale with qachs fsbs.
14. Synthroid 100 mcg Tablet Sig: One (1) Tablet PO once a day.
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 29393**] - [**Location (un) 2251**]
Discharge Diagnosis:
Hypotension
Hypopituitarism
Hypothyroidism
Diabetes Mellitus type 2
Hypertension
Discharge Condition:
Patient is hemodynamically stable, afebrile, tolerating po diet,
able to ambulate with minimal assistance
Discharge Instructions:
You presented to the Emergency Department with very low blood
pressure. You were treated with IV fluids, antibiotics, and
medications to increase your blood pressure. You were admitted
to the ICU and monitored overnight. Your symptoms improved and
you were transferred to the medicine floor. You underwent
several studies to evaluate the cause of your symptoms. The
exact cause of your symptoms on presentation was not determined.
Your hypopituitarism and dehydration are likely significant
contributors these recurrent symptoms of loss of consciousness
and low blood pressure. It is very important that you establish
care with an Endocrinologist to manage this condition.
.
The following changes were made to your home medications:
1) INCREASE levothyroxine (Synthroid) to 100 mcg tablet, 1
tablet daily
Followup Instructions:
Please follow up with your primary care provider within one week
of discharge.
It is very important that you establish care with an
Endocrinologist to manage your hypopituitarism and
hypothyroidism. The [**Hospital 84077**] clinic at [**Hospital3 2576**] [**Hospital3 **]
will be contacting you to schedule a follow up appointment. If
you do not hear from the [**Hospital 84077**] Clinic within two weeks
please contact [**Telephone/Fax (1) 84074**].
|
[
"599.0",
"250.00",
"244.9",
"585.9",
"253.2",
"412",
"274.9",
"255.5",
"V58.65",
"257.2",
"414.01",
"327.23",
"276.51",
"496",
"403.90",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11740, 11819
|
5219, 9639
|
291, 297
|
11944, 12052
|
4011, 4011
|
12911, 13368
|
3441, 3445
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10244, 11717
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11840, 11923
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9665, 10221
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12076, 12796
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3460, 3992
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12814, 12888
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232, 253
|
325, 2256
|
4027, 5196
|
2278, 3079
|
3095, 3425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,698
| 138,981
|
28614+57603
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-7-21**] Discharge Date: [**2165-7-30**]
Date of Birth: [**2096-8-6**] Sex: F
Service: NEUROLOGY
Allergies:
morphine
Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Hallucinations and possible seizure activity in the context of
presumed infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained from patient. 68F with PMH of neurogenic
bladder and recurrent resistant UTI's, pAF, HTN, HL, GERD, and
seizure disorder presenting with hallucinations. Per patient,
she was brought to the hospital by her sister because the place
where she is living "is full of evil." In support of this belief
she cites an occasion where she placed two glasses on either
side of a rosary and then asked someone at the facility to get
her a glass. They refused to pick up the glasses adjacent to the
rosary, which she attributes to them being afraid to go near the
rosary, as well as the fact that, if they picked up the glasses,
they would see that there is a spider inside. She is also
concerned about her sister because she has developed a dark spot
on her face, which is a sign of evil. She asks if I have ever
studied evil, and when I report that I have not, she becomes
tearful and states, "I really wish someone would." She
acknowledges that [**Last Name (un) 15025**] believes her and that it is likely that
I won't believe her either.
She denies dysuria or urgency, but does endorse frequency. She
denies fevers, chills, nausea, vomiting, or diaphoresis. She
states she feels well physically, only complaining of mild pain
in her low back which is chronic for her. She is constipated,
which is her baseline.
ROS: As noted above, otherwise a ten point review of systems was
performed and negative.
Past Medical History:
- Neurogenic bladder with chronic foley and recurrent urinary
tract infections
- Hypertension
- Anemia
- Hyperlipidemia
- Paroxysmal atrial fibrillation
- Gastroesophageal reflux disease
- Severe osteoarthritis of her left hip
- Small bowel obstruction s/p laparotomy in [**4-/2164**]
- Lumbar discectomy in [**2123**]. T6-9 laminectomy done in [**Month (only) 956**]
[**2158**] done due to residual fluid left in spinal canal. Non
ambulatory since
- seizure disorder
- UGIB [**12-20**] duodenal ulcer [**2-/2165**]
Social History:
-Home: She has been at Wyngate of [**Location (un) 583**] since discharge from
[**Hospital1 18**] on [**2165-5-13**]. Widowed. Has one child (son, slightly
estranged per sister as he is on parole). Very close with her
sister/HCP [**Name (NI) **].
-Occupation: No longer working.
-Tobacco: Previously smoked two packs per day for 40 years, but
quit eight years ago.
-EtOH: No alcohol use.
-Illicits: None.
Family History:
Per OMR: Father deceased at age 57 from a heart virus. Her
brother is alive but had leukemia as well as complications of a
brain bleed and he also had coronary artery disease status post
MI.
Physical Exam:
Physical Exam:
Vitals: T:98.2 P: 78 R:16 BP: 100/80 SaO2: 96% on RA
General: somnolent, cooperative with most commands prior to
ativan, too somnolent to follow commands after ativan
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Foley in place.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Podus boots on bilateralluy
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Knew her name and that she was in a hospital.
Unable to say the year. Knew she was her for a UTI and that she
was "very sick". Inattentive, requiring multiple requests for
her to follow commands. Language was halting but fluent. Pt
unable to cooperate with further language testing. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. Patient unable to cooperate fully with motor
exam but could lift [**Doctor Last Name **] 4 extremities off the bed, with some pain
limited motion at her L shoulder.
-Sensory: Pt withdrew all 4 ext to noxious stimulation (after
ativan given)
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: Patient unable to cooperate
-Gait: Deferred
DISCHARGE EXAM:
General: NAD, Awake, Alert, Cooperative
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Foley in place.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Podus boots on bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, Alert, Oriented to person, place, and
time. language fluent, with intact repetition. No paraphasic
errors noted, or neologisms. She shows no signs of impaired
cognition, memory, or lack of attention.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L * * * 5 5 5 5 5 2 2 2 2 3 3
R 5 5 5 5 5 5 5 5 2 2 2 2 3 3
* pain limits assessment of motor strength in these extremities
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 1 2 1 0
R 2 1 2 1 0
Plantar response was flexor bilaterally.
-Coordination: Finger-nose-finger bilaterally intact, unable to
cooperate with heel-to-shin
-Gait: Deferred
Pertinent Results:
[**2165-7-21**] 02:00PM URINE HOURS-RANDOM
[**2165-7-21**] 02:00PM URINE UCG-NEGATIVE
[**2165-7-21**] 02:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2165-7-21**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2165-7-21**] 02:00PM URINE RBC-7* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
[**2165-7-21**] 02:00PM URINE HYALINE-3*
[**2165-7-21**] 02:00PM URINE MUCOUS-RARE
[**2165-7-21**] 01:50PM LACTATE-2.2*
[**2165-7-21**] 01:35PM GLUCOSE-98 UREA N-20 CREAT-0.6 SODIUM-143
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-24 ANION GAP-13
[**2165-7-21**] 01:35PM estGFR-Using this
[**2165-7-21**] 01:35PM WBC-4.4 RBC-3.11* HGB-10.1* HCT-31.1*
MCV-100* MCH-32.5* MCHC-32.6 RDW-16.0*
[**2165-7-21**] 01:35PM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-1.4*
[**2165-7-21**] 01:35PM NEUTS-58.1 LYMPHS-31.4 MONOS-4.1 EOS-5.8*
BASOS-0.6
[**2165-7-21**] 01:35PM PLT COUNT-112*
[**2165-7-30**] 04:20AM BLOOD WBC-8.0# RBC-2.64* Hgb-8.8* Hct-27.0*
MCV-102* MCH-33.2* MCHC-32.5 RDW-17.0* Plt Ct-150
[**2165-7-30**] 04:20AM BLOOD Plt Ct-150
[**2165-7-30**] 04:20AM BLOOD PT-15.1* PTT-25.6 INR(PT)-1.4*
[**2165-7-30**] 04:20AM BLOOD
[**2165-7-30**] 04:20AM BLOOD Glucose-108* UreaN-17 Creat-0.5 Na-141
K-4.3 Cl-111* HCO3-23 AnGap-11
[**2165-7-27**] 04:25AM BLOOD ALT-15 AST-32 LD(LDH)-179 AlkPhos-186*
[**2165-7-30**] 04:20AM BLOOD Albumin-2.6* Calcium-7.7* Phos-2.0*
Mg-1.7
CXR [**Month/Day/Year **]: As compared to the previous radiograph, the
vertebral stabilization devices are in unchanged position. The
right PICC line has been removed. Most importantly, however, a
new parenchymal opacity has appeared at the bases of the left
lung. The opacities are alveolar in appearance and leads to
blunting of the contour of the left hemidiaphragm. The opacity
very likely reflects pneumonia. As an incidental finding,
luxation of the left shoulder is observed.
EEG [**Month/Day/Year **]:
ABNORMALITY #1: Occasional blunted triphasic waves were seen at
a frequency of [**11-19**] Hz involving the parasagittal head regions
bilaterally.
ABNORMALITY #2: Less frequent generalized sharp waves were also
seen.
ABNORMALITY #3: Background activity was reasonably
well-organized although
slow in the [**4-26**] Hz mixed theta and alpha frequency range.
BACKGROUND: As above.
HYPERVENTILATION: Was contraindicated.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: The patient remained awake throughout this recording
period.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate of 72 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of rare
generalized discharges, occasional blunted triphasic waves, all
superimposed on a slow background.
Brief Hospital Course:
Ms. [**Known lastname **] is a 68 year-old woman with past medical history of
neurogenic bladder with chronic foley, complicated by recurrent
antibiotics resistant UTIs (including vancomycin-resistant
enterococcus), paroxysmal atrial fibrillation, HTN, HL, reported
dementia and prior seizures in the setting of infections who
presented on this admission for a UTI and hallucinations.
# Neurologic:
Ms. [**Known lastname **] was placed on EEG monitoring, and found to be in
nonconvulsive status epilepticus for which she was transferred
to the neuro ICU. there she was started on Keppra and Vimpat
with good effect. Regarding the hallucinations and paranoia
which were noted on admission, our differential diagnosis
included medication effect vs. infection vs. psychiatric
illness. Per [**Hospital1 1501**] medication list, the patient has been receiving
Dilantin, which has been reported to cause her to experience
paranoia in the past. Unclear why this was re-started as an
outpatient after being held during her last admission. Given
recurrent UTI's this remains a concern, although patient was
still on Linezolid when her hallucinations developed. Held
further dilantin and hold antibiotics pending the results of her
urine culture.
Upon transfer to general neurology, the patient was noted to
have no further episodes concerning for seizure activity. She
was gradually weaned off of Vimpat while increasing Keppra
dosage to 2g b.i.d. Of note her gabapentin was increased from
600 mg t.i.d. to 900 mg t.i.d.
# Hematology:
Ms. [**Known lastname **] had an existing diagnosis of anemia with hematocrits
have ranged between 30 and 27 upon discharge. Guaiac of her
stool was performed which resulted as negative. Over the course
of her hospitalization, no leukocytosis was observed. Her
platelets were noted to be low ranging from 179 to 96, due to
unknown etiology.
On discharge, her platelet count was 150.
# Infectious Disease:
The patient was recently admitted for a urinary tract infection
in [**Month (only) 216**] for which a course of Linezolid it was prescribed.
Her urinalyses consistently revealed significant white blood
cell count greater than 182, and varying amounts of red blood
cells from [**6-10**] with minimal epithelial cells. ID was consulted
to evaluate the need for antibiotic therapy, with
recommendations to avoid antibiotics unless the patient
demonstrated other infectious symptoms including fever or
leukocytosis. on [**7-28**], the patient spiked a fever to
103.2??????F at which time she was pancultured. Chest x-ray was
performed which revealed a left parenchymal opacity in the left
lung. As a result, Ceftriaxone 1 g q24hours was started, with a
total course of 14 days. UTI results also came back positive
for greater than 100,000 yeast. As a result, Diflucan was
started for a total course of 14 days. Both of these
medications in their course of administration were approved by
infectious disease.
# Transitions of care:
- Antiepileptic medications should be continued until following
up in clinic
- The patient has followup scheduled with epilepsy clinic on
[**8-13**]
- She will be continuing rehabilitation at [**Hospital1 **]
- Midline IV access may be pulled at the end of antibiotic
therapy.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Hospital1 581**].
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/sob
2. Artificial Tears 2 DROP BOTH EYES TID
3. Ascorbic Acid 500 mg PO BID
4. Atorvastatin 40 mg PO DAILY
5. Baclofen 5 mg PO TID:PRN muscle spasms
6. Bisacodyl 5 mg PO DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Fondaparinux Sodium 2.5 mg SC DAILY
11. Gabapentin 600 mg PO TID
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheeze
13. LeVETiracetam 1500 mg PO BID
14. Milk of Magnesia 30 mL PO DAILY:PRN constipation
15. Mirtazapine 15 mg PO HS
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO DAILY
18. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
19. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
20. Polyethylene Glycol 17 g PO DAILY
21. Senna 1 TAB PO BID:PRN constipation
22. Simethicone 80 mg PO QID:PRN gas
23. Zinc Sulfate 220 mg PO DAILY
24. Fleet Enema 1 Enema PR DAILY:PRN constipation
25. Prochlorperazine 25 mg PR Q12H:PRN nausea
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/sob
2. Artificial Tears 2 DROP BOTH EYES TID
3. Ascorbic Acid 500 mg PO BID
4. Atorvastatin 40 mg PO DAILY
5. Baclofen 5 mg PO TID:PRN muscle spasms
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Fleet Enema 1 Enema PR DAILY:PRN constipation
9. FoLIC Acid 1 mg PO DAILY
10. Fondaparinux Sodium 2.5 mg SC DAILY
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheeze
12. Multivitamins 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
14. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
15. Polyethylene Glycol 17 g PO DAILY
16. Prochlorperazine 25 mg PR Q12H:PRN nausea
17. Simethicone 80 mg PO QID:PRN gas
18. Zinc Sulfate 220 mg PO DAILY
19. Senna 1 TAB PO BID:PRN constipation
20. Bisacodyl 5 mg PO DAILY:PRN constipation
21. Milk of Magnesia 30 mL PO DAILY:PRN constipation
22. Omeprazole 20 mg PO DAILY
23. Mirtazapine 15 mg PO HS
24. Gabapentin 900 mg PO TID
25. CeftriaXONE 1 gm IV Q24H
26. Fluconazole 200 mg PO Q24H
27. Acetaminophen 650 mg PO Q6H:PRN fever/pain
28. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
29. HYDROmorphone (Dilaudid) 0.125 mg IV Q4H:PRN pain
30. Levitracetam [**2152**] mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Village - [**Location 4288**]
Discharge Diagnosis:
Non-convulsive status epilepticus in the setting of urinary
tract infection / pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at [**Hospital1 69**] for
episodes which are concerning for seizure activity. On EEG
studies you were found to be having seizures for an extended
period of time which is a state we call 'non-convulsive status
epilepticus' for which we transitioned your anti-epileptic
medications to a stronger regimen.
We also identified two active infections which may have lowered
your seizure threshold. A chest x-ray identified a left lung
pneumonia which you will be receiving an IV antibiotic -
Ceftriaxone for another 11 days; once his course of therapy has
completed, your midline IV access may be discontinued. You also
will be receiving a course of 12 days of DiFlucan taken once a
day by mouth.
Because of concerns for your history of anemia and GI bleed, we
performed a number of complete blood counts as well as performed
a fecal occult blood test which was negative for any additional
GI bleeding.
Please follow-up with the appointments as scheduled below, and
complete the course of antibiotic therapy prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2165-8-1**]
9:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2165-8-1**] 9:30
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) 22698**] Phone:[**Telephone/Fax (1) 857**]
Date/Time:[**2165-8-13**] 9:45
Completed by:[**2165-7-30**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 11826**]
Admission Date: [**2165-7-21**] Discharge Date: [**2165-7-30**]
Date of Birth: [**2096-8-6**] Sex: F
Service: NEUROLOGY
Allergies:
morphine
Attending:[**First Name3 (LF) 65**]
Addendum:
The patient's discharge information did not include a
prescription for 2g [**Hospital1 **] Keppra. The addition of this medication
was phoned over to the rehabilitation center who would continue
its dosing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4227**] Village - [**Location 2708**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 66**] MD [**MD Number(2) 67**]
Completed by:[**2165-8-2**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
[]
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|
9936, 12888
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350, 357
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15897, 15897
|
7117, 9913
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2773, 2965
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14335, 15669
|
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5107, 5615
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229, 312
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385, 1795
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15912, 16024
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12909, 13188
|
1817, 2334
|
2350, 2757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,507
| 113,055
|
6189
|
Discharge summary
|
report
|
Admission Date: [**2112-12-24**] Discharge Date: [**2112-12-30**]
Date of Birth: [**2057-10-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 65 year old
gentleman with a history of positive Type 1 diabetes,
metastatic colon carcinoma, coronary artery disease,
hypertension, gastroesophageal reflux disease, anemia, and
laminectomy who presents with hematemesis, nausea, vomiting
and subsequently was found to be in diabetic ketoacidosis.
He was well until 10 and 12 days prior to admission at which
point his daughter noted him to be sick, he got nausea,
vomiting, chills, myalgias, nonproductive cough. He denies
shortness of breath, however, he does note temperatures to
101. He notes he did not get a flu shot this year. His
nausea persisted all week prior to admission. He awoke on
the morning of admission and had nausea, vomiting and
hematemesis, two cupfuls of "coffee ground." He had five
episodes since with a total of approximately one cup of
blood. He has had several of these before after getting
chemotherapy. His last chemotherapy was [**12-17**], last
esophagogastroduodenoscopy was three years ago. The patient
received nasogastric lavage in the Emergency Room. He denies
chest pain, shortness of breath, or diaphoresis. He does
note lightheadedness. He has not been checking his glucoses
frequently over the last four days. Yesterday his
fingerstick was 539. He continues with his Humalog. No
fingersticks were done on the day of admission. He came to
the Emergency Room with tachycardia, fingersticks in 800s,
bicarbonate was 9 and anion gap 20. He was given intravenous
insulin and started on an insulin drip, declined nasogastric
lavage.
PAST MEDICAL HISTORY: 1. Colon cancer diagnosed [**2112-6-28**],
low-grade mildly differentiated status post tumor resection,
liver mass on magnetic resonance imaging scan, 3 out of 14
nodes positive, he is on TPT 11, 5-FU, Leucovorin, now just
on TPT-11 complicated by nausea, vomiting and hematemesis.
2. Type 1 diabetes, followed by [**Last Name (un) **], Dr. [**Last Name (STitle) 24130**] and
complicated by gastroparesis. 3. Coronary artery disease,
had myocardial infarction in [**2112-6-28**]. Catheterization and
left circumflex on percutaneous transluminal coronary
angioplasty but no stent. 4. Chronic renal failure with
baseline 2.5. 5. Hypertension. 6. Gastroesophageal reflux
disease. 7. Esophageal ulcers. 8. Anemia. 9. Peptic
ulcer disease. 10. Status post laminectomy. 11. Chronic
right foot ulcer followed by Dr. [**Last Name (STitle) **] in Podiatry.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: He takes Protonix, Imdur,
Labetalol 400 t.i.d., Hydralazine 10 q.i.d., Ativan 1 prn
nausea, Loperamide, Humulin sliding scale, Glargine 36 units
q. AM.
FAMILY HISTORY: Father died of colon cancer.
SOCIAL HISTORY: Two packs per day times 20 years, quit 30
years ago. Rare alcohol. No drug use. Retired telephone
company worker, married with one daughter.
PHYSICAL EXAMINATION: Afebrile at 96, pulse 121, blood
pressure 129/65, respiratory rate 18, 99% on room air.
Examination significant for normal S1 and S2, lungs clear to
auscultation without crackles. Abdomen was soft, nontender.
No abdominal tenderness. Extremities were without edema and
right foot ulcer. Skin, dry and intact. The patient refused
rectal examination.
LABORATORY DATA: Laboratory data on the day of admission
revealed white count 6.2, hematocrit 35.1, platelets 153,
coags are normal. Chem-7 with sodium 127, potassium 6,
chloride 88, bicarbonate 9, BUN 86, creatinine 6.9, glucose
707, phosphorus 8.0, liver function tests normal.
Electrocardiogram, sinus tachycardia at 118, normal axis, ST
depression of .5 mm in lead 3, V4, V5, minimal ST elevation.
No significant change from [**11-11**].
HOSPITAL COURSE: 1. Diabetes - The patient was initiated on
insulin drip for diabetic ketoacidosis which was subsequently
weaned off over the next 36 hours. On [**12-27**], he had
difficulty with hypoglycemia from overlapping Glargine doses,
however, he subsequently maintained euglycemia. The patient
was taking minimal p.o.. At the time of discharge from the
Intensive Care Unit his Glargine dose was only 22 units.
2. Renal - His creatinine remained elevated throughout his
intensive care unit course. Renal Consult Team saw the
patient and felt his course to be consistent with acute
tubular necrosis and expected his renal function to continue.
At the time of discharge his creatinine was 5.5 and he had
good urine output. His electrolytes were normal and
acid-based status had improved.
3. Access - The patient was without intravenous access for
the day of [**2112-12-29**]. PICC line was placed by
Interventional Radiology.
4. Infectious disease - Patient with fevers, mild, and cough
without sputum which suggested influenza. Viral swabs were
negative and cultures were negative for six days on discharge
to the floor.
DISCHARGE DIAGNOSIS:
1. Likely influenza
2. Diabetic ketoacidosis
3. Acute and chronic renal failure
4. Coronary artery disease
5. Metastatic colon cancer
MEDICATIONS ON DISCHARGE:
1. Ascorbic mononitrate
2. Aspirin 325
3. Hydralazine 20 q.i.d.
4. Lantis 22
5. Humulin insulin sliding scale
6. Protonix prn
7. Reglan
8. Tylenol
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 2396**]
MEDQUIST36
D: [**2112-12-31**] 00:05
T: [**2112-12-31**] 20:24
JOB#: [**Job Number 24131**]
|
[
"530.7",
"276.5",
"197.7",
"584.5",
"250.61",
"196.2",
"403.91",
"250.11",
"250.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2850, 2880
|
5029, 5169
|
5195, 5624
|
2680, 2833
|
3883, 5008
|
3065, 3865
|
159, 1724
|
1747, 2653
|
2897, 3042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,502
| 151,584
|
42600
|
Discharge summary
|
report
|
Admission Date: [**2201-3-13**] Discharge Date: [**2201-3-25**]
Date of Birth: [**2131-11-22**] Sex: F
Service: SURGERY
Allergies:
Compazine
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2201-3-14**]:
Open ruptured AAA repair
History of Present Illness:
69 year old female who was transferred from OSH for ruptured
AAA. Patient reports the the pain began 3 hours prior to
presentation to OSH. Pain radiates to left flank. Patient
reports nausea but no vomiting. Patient reported an episode of
left arm wearkness/tingling that had resolved.
Past Medical History:
Past Medical History: HTN, hypercholesterolemia, right carotid
stenosis, subclavian steal syndrome on left
Past Surgical History: c-section, tonsillectomy
Social History:
EtOH: denies
Tob: Current smoker with < [**1-26**] ppd
Family History:
There is a family history of AAA
Physical Exam:
At time of discharge:
VS: 98.6 97.9 58 144/60 17 94 RA
Gen: resting comfortably
CV: RRR, nl S1, S2
Resp: CTAB
Abd: Soft, incision steristrips, dry, intack
Ext: warm well perfused
Pulses:
R p/d/d/d
L p/d/d/d
Pertinent Results:
[**2201-3-13**] 09:00PM BLOOD WBC-11.8* RBC-3.15* Hgb-9.5* Hct-28.5*
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.4 Plt Ct-173
[**2201-3-13**] 09:00PM BLOOD PT-12.2 PTT-33.4 INR(PT)-1.1
[**2201-3-14**] 12:51AM BLOOD Glucose-166* UreaN-15 Creat-0.7 Na-147*
K-3.2* Cl-109* HCO3-22 AnGap-19
[**2201-3-14**] 12:51AM BLOOD ALT-21 AST-29 LD(LDH)-234 CK(CPK)-87
AlkPhos-51 TotBili-0.9
[**2201-3-14**] 12:51AM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-3-14**] 07:53AM BLOOD CK-MB-4 cTropnT-<0.01
Renal US: [**2201-3-15**]
INDICATION: 69-year-old with status post AAA repair. Please
assess arterial
flow.
TECHNIQUE: [**Doctor Last Name **]-scale and color Doppler ultrasound images of the
kidneys were
obtained.
COMPARISON: Outside hospital CT of the abdomen and pelvis from
[**2201-3-13**].
FINDINGS:
The right kidney measures 10.9 cm without evidence of
hydronephrosis, stones,
or masses. There is normal arterial flow in the main renal
artery or the
upper, mid and lower pole renal arteries with resistive indices
(RIs ranging
from 0.64-0.74. The main renal vein is normal on the right side.
The left kidney measures 9.5 cm without evidence of
hydronephrosis, stones, or
suspicious masses. There is a 1.3 cm mid pole partially
exophytic cyst.
There is no flow to the left kidney including no flow in the
main renal artery
or the upper, mid, or lower pole renal arteries. The main renal
vein also
demonstrates no flow.
Bilateral pleural effusions and small amount of fluid
surrounding spleen. The
spleen is normal in size measuring 8.2 cm.
IMPRESSION:
No flow to or in the left kidney.
Bilateral pleural effusions. Small ascites.
[**2201-3-16**]:
INDICATION: 69-year-old female with left subclavian steal
syndrome
post-abdominal aortic rupture, evaluate for stroke.
COMPARISON: CTA head/neck from [**2201-2-3**] and outside hospital CT
head dated
[**2201-3-13**].
TECHNIQUE: Contiguous non-contrast axial images were obtained
through the
brain, and reconstructed at 5-mm intervals.
FINDINGS: There are new watershed infarcts in the left frontal
and parietal
regions, at the ACA/MCA and MCA/PCA boundaries. These have a
wedge-shaped
morphology with cytotoxic edema involving both [**Doctor Last Name 352**] and white
matter. There
is no evidence of hemorrhagic transformation.
The ventricles and sulci are prominent, consistent with
age-related
involutional changes. Multiple periventricular and subcortical
white matter
hypodensities persist, compatible with small vessel ischemic
disease. There
are dense calcifications in the bilateral cavernous carotid,
vertebral, and
basilar arteries.
Midline structures are preserved. There is no evidence of
herniation.
There is a mucus retention cyst in the left sphenoid sinus.
Mastoid air cells
and middle ear cavities are clear. There is mild cerumen in the
left external
auditory canal. Orbits and intraconal structures are intact.
IMPRESSION:
1. New watershed infarcts in the left frontal and parietal
regions. This was
called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2201-3-16**] at 6:48 p.m.
2. Chronic atrophy and microvascular disease.
[**2201-3-17**]:
Echocardiogram
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. There is no aortic valve 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 an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Pulmonary artery hypertension.
[**2201-3-17**]:
MR [**Name13 (STitle) **], MRA with out contrast
INDICATION: 69-year-old woman with status post urgent AAA
repair. Assess for
CVA.
COMPARISON: CT head dated [**2201-3-16**].
TECHNIQUE: Sagittal T1 and axial T1, T2, FLAIR, gradient echo,
and diffusion
with ADC map images were obtained without contrast.
FINDINGS: Scattered and confluent predominantly cortical based
areas of
restricted diffusion are seen involving the vascular territory
of the left
superior MCA division. Bilateral scattered acute infarcts are
moreover
identified involving the posterior circulation, notably the
bilateral medial
parietal and occipital lobes. Small scattered cortical foci of
restricted
diffusion in the right frontal lobe are too small to
characterize, yet likely
represent additional areas of infarct.
There is no evidence of hemorrhagic transformation and no mass
effect
associated with the infarct areas.
The cerebral sulci, ventricles, and extra-axial CSF-containing
spaces have
normal size and configuration. Flow voids of the major
intracranial vessels
are preserved. Extensive periventricular and deep white matter
FLAIR/T2
signal abnormalities are in keeping with sequela of small vessel
ischemic
disease.
The patient is intubated. There is fluid retention within the
sphenoid sinus.
Abnormal T2 hyperintensity is moreover seen within the mastoid
air cells.
MRI HEAD: When compared to the contralateral side, the flow
related signal in
the left intracranial ICA and MCA is mildly reduced which may
indicate a flow
limiting stenosis in the cervical portion of the left ICA.
In the presence of a right fetal origin, a focal right P1
segment stenosis is
not associated with flow reduction in the periphery of the right
PCA.
Besides the above mentioned global left sided flow reduction in
the anterior
circulation, the intracerebral internal carotid, vertebrobasilar
and anterior
and middle cerebral arteries are patent. There is no evidence of
additional
stenosis, occlusion, aneurysm, or arteriovenous malformation.
IMPRESSION:
1. Acute widespread infarcts involving the bilateral anterior
and posterior
circulation as detailed above. There is no associated vascular
occlusion, no
mass effect or hemorrhagic transformation. Relative global
reduction in flow
related enhancement of the left intracranial ICA and MCA may
indicate a flow
limiting stenosis in the cervical portion of the left ICA.
2. Extensive sequela of small vessel ischemic disease.
3. Fluid retention in the sphenoid sinus as well as bilateral
opacification of
the mastoid air cells, likely related to intubation.
[**2201-3-19**]:
Urine Cx
URINE CULTURE (Final [**2201-3-23**]):
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
The patient was admitted to the cardiovascular ICU after
undergoing emergent open AAA repair on [**2201-3-14**]. The patient
tolerated the procedure but was transferred to the CVICU in
critical condition after having an estimated blood loss of
7500cc, and getting transfused 14 U pRBC, 12 U FFP, 2 Plt.
Please see the separate operative note for full details of the
procedure.
Postoperatively the patient was transferred to the CVICU for
management of acute respiratory failure and hemodynamic
monitoring with strict control. During her stay in the ICU a
renal US was performed that showed no flow to her left kidney.
She was noted on POD 2 to not be movig her right upper
extremeity. A CT head was performed that showed subactue left
MCA/ACA and left MCA/PCA infarcts. Neurology was consulted who
thought this was mostly like hypotensive in nature and recommend
SBP [**Last Name (LF) 92158**], [**First Name3 (LF) **], statin, MRI for further evaluation. On POD 3
an MRI/MRA were performed (please see results section for full
read.) In brief the MRI shown left frontal, b/l parietal, b/l
occipital area of restricted diffusion. Patient was occasionaly
becoming tachycardiac for which she was treated with an
amiodorone infusion. On POD 4 the patient was extubated. She was
begun on diuresis to remove excess fluid. On POD 5 the patient
was started on cipro for a UTI. Patient was started on soft
foods, thin liquids at the recommendation of speech/swallow. On
POD [**7-2**] the patient was keep in the CVICU for occasional periods
of tachycardia that required amiodorone administration. On POD 8
the patient was transferred to the VICU. Cardiology was
consulted for continued trouble with tachycardia. The felt that
this was not atrial fibrillation but instead sinus tach with
APCs. The recommend anticoagulation with aspiring and lopressor
for heart rate control. On POD 9 patient was evaluated by
physical therapy who recommend rehab. Speech and swallow
revaluation removed all restrictions. On POD 10 patient's foley
was removed and patient voided without difficulty.
At time of discharge on POD 11 patient was tolerating a regular
diet, voiding without difficulty, pain was controlled on oral
pain medication, patient was able to get out of bed to chair
with assistance. Patient was discharged to [**Hospital 169**] Center
in [**Location (un) 1157**].
Medications on Admission:
Enalapril, [**Location (un) **] 325', HCTZ 25', metoprolol 100", simvastatin 40',
fish oil.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day: While non ambulatory. [**Month (only) 116**]
discontinue when patient ambulatory.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Ruptured Abdominal Aortic Anuerysm
B/L CVA
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
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-3**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-27**]
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
?????? You should get up every day, get dressed and walk, gradually
increasing 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 (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 [**2-27**] weeks for
follow up.
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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Please call Dr.[**Name (NI) 1392**] office ([**Telephone/Fax (1) 4852**] to schedule a
follow up appointment in 2 weeks.
Please call Dr.[**Name (NI) 5255**] office ([**Telephone/Fax (1) 22692**] to schedule a
follow up appointment in [**5-1**] weeks.
Completed by:[**2201-3-25**]
|
[
"599.71",
"401.9",
"433.10",
"518.51",
"276.2",
"349.82",
"458.29",
"599.0",
"305.1",
"041.3",
"441.3",
"272.0",
"997.02",
"427.89",
"434.91",
"E878.8",
"285.1",
"584.9",
"342.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12768, 12842
|
9563, 11924
|
285, 329
|
12929, 12929
|
1188, 9540
|
15818, 16101
|
911, 945
|
12067, 12745
|
12863, 12908
|
11950, 12044
|
13105, 15365
|
15391, 15795
|
797, 823
|
960, 1169
|
231, 247
|
357, 644
|
12944, 13081
|
688, 774
|
839, 895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,223
| 189,458
|
27008
|
Discharge summary
|
report
|
Admission Date: [**2147-2-10**] Discharge Date: [**2147-2-15**]
Date of Birth: [**2101-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
s/p stenting to LAD and biliateral iliac arteries
History of Present Illness:
46 y/o F w/ obesity, HTN, hypercholesterolemia, tobacco abuse,
who presented to [**Hospital3 3583**] after having episode of CP at
11:30pm after taking friend's SL NTG. Described pain as dull
ache/pressure with radiation to back and both arms. She noted
similiar sx last week that lasted for 3 hrs last week and less
severe sx all month. She denied SOB, diaphoresis, nausea, PND,
leg edema. She also reports pain in R leg w/ distance walking.
Pt presented to [**Hospital3 3583**] for evaluation of CP and had ST
elevations 2mm or greater in V1-V3. She was given ASA, SL NTG,
nitropaste, lopressor, heparin, integrillin, morphine and plavix
300mg PO x1 (though not confirmed). Initial vitals at [**Hospital1 3325**] were T 98.3, BP 200/114, HR 96, sats 98% on RA. Pt was
transferred to [**Hospital1 **] for cath. Cath revealed LAD 80% lesion that
was stented x2 (Cypher). Pt also noted to have R iliac disease
and had stenting of R iliac dissection and stenosed L iliac.
Venous sheaths pulled in holding area. Transferred to CCU for
further monitoring.
Past Medical History:
HTN
tobacco use
obesity
hypercholesterolemia
Pertinent Results:
CHEST - PORTABLE AP ([**2147-2-10**]): The heart size is within normal
limits for technique. The pulmonary vascularity is normal
without redistribution. Doubt the presence of effusions on the
supine study. No focal consolidations on the visualized lung
fields (left costophrenic angle excluded). There is slight
prominence of the superior mediastinum which may reflect supine
positioning.
.
Cardiac Catheterization ([**2147-2-10**]):
Right dominant circulation
LMCA: without angiographically apparent flow limiting disease
LAD: proximal 50% and then a hazy 80% stenosis with TIMI 2 fast
flow. The mid and distal LAD were without flow limiting disease.
D1, D2, and D3 were small vessels.
LCx: gave rise to a small AV groove Cx and a large branching
OM1. There were only mild luminal irregularities in these
vessels.
RCA: proximal 80% stenosis and then a serial 60% stenosis in the
mid segment. The R-PDA and R-PL were without any flow limiting
disease.
.
Resting hemodynamics: elevated right heart filling pressures and
moderate to severe elevation of left heart filling pressures.
There was moderate to severe pulmonary arterial hypertension.
The calculated cardiac output by the Fick method was 4.8 L/min
with a cardiac index of 2.4.
.
Transthoracic echocardiography ([**2147-2-10**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction. Overall left ventricular systolic function is
mildly depressed. Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Resting regional wall motion abnormalities
include mid to distal anteroseptal akinesis and apical
akinesis/hypkinesis (apex not fully visualized). Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a trivial/physiologic pericardial effusi**PRESSURES
.
Left cardiac cath [**2147-2-13**]
AORTA {s/d/m} 118/76/84
**CARDIAC OUTPUT
HEART RATE {beats/min} 67
RHYTHM SR
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 80
2) MID RCA TUBULAR 60
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 50
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 100
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
PTCA COMMENTS: Initial wire passage from the right CFA
access site
was difficult and dedicated flouroscopy showed that the distal
part of
the right iliac stent was underdeployed (likely due to being
deployed
within the sheath). With considerable difficulty, a Magic Torque
wire
was ultimately passed through the center of the udeployed part
of the
stent and then progressively dilated with a 3.0x40 mm Sailor
balloon, a
6.0x20 mm Agiltrac balloon and a 7.0x20 mm Diamond balloon.
Final
angiography showed no residual stenosis, no dissection and
normal flow.
We then turned our attention to the coronary arteries.
Bivalirudin was
given for anticoagulation. Initial angiography of the left
coronary
artery showed an interval occlusion of OM1 with fresh thrombus.
The
patient developed chest pain and ventricular bigeminy. In
retrospect,
thrombus was noted on the Magic Torque wire after the exchange
for the
JL4 catheter, potentially leading to an embolic occlusion of the
vessel.
At this point, Eptifibatide was started and the guide exchnaged
for a
XBLAD3.5, which provided good support. The lesion was crossed
with a PT
[**Name (NI) 9165**] wire and dilated with a 2.0x20 mm Voyager balloon at 8
atm,
restoring flow to the vessel. A very small lower pole of OM1 had
signficant residual thrombus but we elected to leave the branch
occluded
given its small caliber. Final angiography showed no residual
stenosis,
no dissection and TIMI 3 flow. The patient left the lab in
stable
condition.
Brief Hospital Course:
Patient presented to OSH with anterior STEMI with peak CK 815,
and was transferred to [**Hospital1 18**] for cardiac catheterization, which
was significant for the findings detailed above. In particular,
it demonstrated LAD and RCA disease. Two Cypher DES were placed
in the LAD with good angiographic results. The procedure was
complicated by right iliac artery dissection which was
successfully treated with stenting. A left iliac artery stent
was also placed for iliac artery stenosis. She was admitted to
the CCU post-procedure for monitoring. She did well, and was
called out to a monitored bed on HD #2. Her medication regimen
was optimized. She was continued on ASA and Plavix (started on
presentation to OSH). Lopressor and captopril were added, with
good control of her blood pressure. These were changed to once
daily formulations (Toprol XL and lisinopril) prior to
discharge. She was also started on a high dose statin, and
lifestyle modification--including tobacco cessation--encourged.
Transthoracic echocardiography during hospitalization was
significant for an ejection fraction of 50%, with anteroseptal
and apical akinesis / hypokinesis (results detailed above). On
HD3, she was taken back to the cath lab for intervention on her
RCA lesion. However, on access of the right iliac artery, the
right iliac stent was noted to be underdeployed. This was
dilated. However, on imaging of the coronary arteries, there
was noted to be interval occlusion of the OM1 with fresh
thrombus. The patient developed chest pain and ventricular
bigeminy, and on retrospect, it was felt that thrombus that had
developed on the lead wire had embolized to the OM1.
Integrillin was started, and the lesion was balloon dilated with
resolution of flow, and distal migration of residual thrombus to
a very small lower pole OM1. The patient was continued on
integrillin for 18 hours post-procedure with a peak CK of 1137
which resolved to 287 at time of discharge. She remained chest
pain free following cath and was discharged in good condition.
Medications on Admission:
paxil 40
xanax 0.5mg prn
"BP med"
"cholesterol med"
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take one as needed for chest pain; may repeat q 5 minutes x 2.
CALL 911 IMMEDIATLEY.
[**Hospital1 **]:*30 Tablet, Sublingual(s)* Refills:*2*
6. Paxil 40 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily) for 4 weeks: discuss refills with your
primary care doctor.
[**Last Name (Titles) **]:*28 Patch 24HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Anterior ST-Segement Elevation Myocardial Infarction
2. s/p stenting of Left Anterior Descending Artery
3. Two vessel coronary artery disease (LAD, RCA)
4. R Iliac Dissection s/p stenting; L iliac stenosis s/p
stenting
5. Hypertension
6. Hypercholesterolemia
Discharge Condition:
afebrile, hemodynamically stable, chest pain free
Discharge Instructions:
1. Please make sure to take each and every one of your new
medications every day. Please be sure to take aspirin and
plavix everyday as directed.
2. Please be aware that you will be called for an intervention
on the right coronary artery in the next 2 weeks. You will be
given specific instructions at that time, but you should not eat
or drink after midnight on the evening of the procedure except
to take your medications, and you should come in early on the
morning of the procedure.
3. Please call 911 should you develop any new chest pain,
shortness of breath, or any other serious symptoms.
It is HIGHLY recommended that you stop smoking.
Followup Instructions:
Please make an appointment to see your Primary Care Doctor
within 1-2 weeks. Please make sure you have your kidney function
and potassium checked at that visit. Please discuss with him a
referral to a cardiologist in your area.
In addition, as above, someone from the cardiology offices will
be calling you to schedule you for an additional heart
catheterization in the next 2 weeks. Please call [**Telephone/Fax (1) 66392**]
to inquire about this if you have not been contact[**Name (NI) **] in 2 weeks
time.
Completed by:[**2147-2-16**]
|
[
"272.0",
"410.91",
"410.71",
"305.1",
"414.01",
"997.1",
"278.00",
"401.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"39.50",
"36.07",
"00.66",
"88.56",
"00.42",
"00.48",
"88.48",
"88.55",
"00.33",
"00.41",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9352, 9358
|
5913, 7959
|
326, 402
|
9670, 9722
|
1570, 5890
|
10418, 10963
|
8061, 9329
|
9379, 9649
|
7985, 8038
|
9746, 10395
|
276, 288
|
430, 1483
|
1505, 1551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,906
| 106,234
|
50180
|
Discharge summary
|
report
|
Admission Date: [**2178-9-12**] Discharge Date: [**2178-9-18**]
Date of Birth: [**2126-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
51M with COPD recently discharged day prior to admission is
referred from [**Hospital 100**] Rehab with hypercarbic respiratory failure.
Pt noted to have increased tachypnea and WOB today x 4 hours
with episodes of desaturation to 50s. Minute ventilation per
report 14L on ventilator but ABG 7.12/99/69/32 o2 sat 86% on AC
RR25 40%FiO2 PEEP 10. There was concern for air leak by rehab
pulmonologist. Prior to transfer, T 97.8 BP 90/60 HR 70 RR 25
99%. FS 105. He was given 1 amp bicarb then transferred to [**Hospital1 18**]
for further eval.
.
In the ED, initial VS:Afebrile SBP 90s/60s. HR 60s-70s RR 20s.
Initial ABG 7.04/132/135 on 50% FiO2. Patient was given 3L NS
with persistent low BP, SBPs 70s-80s. Right femoral TLC then
placed and he was started on Levophed 0.09mcg/kg/min. ID was
called regarding antibiotics and he was given Tobramycxin 120mg
IV x 1 and vanco 1g IV x 1.
.
On the floor, pt is trached and sedated but opens eyes to voice
and tracks. He denies pain by shaking head and is intermittently
coughing with cuff leak evident and loss of approximately 100cc
with each Vt.
.
Review of systems: Unable to obtain secondary to tracheostomy
and mental status.
Past Medical History:
COPD on oxygen
Obstructive Sleep Apnea and obesity hypoventilation
Anxiety on klonopin
Morbid Obesity
Chronic LLE DVT
ARF [**3-9**] AIN, recent baseline Cr low-mid 2's
Pseudomonas VAP
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 104697**] UTI treated with fluc
Sacral decubitus ulcer right flank
Chronic pain of unclear etiology-trach site ulceration
Constipation
AF
Anemia
Social History:
Patient was living at home with mother but was recently
discharged to [**Hospital 100**] rehab. He denies any history of tobacco,
etoh, or drug use. He was using motorized chair for most
mobility but has been immobile.
Family History:
Noncontributory
Physical Exam:
On Admission:
General: Awakens and opens eyes to voice, tachypneic, grunting
and cuff leak evident with breathing.
HEENT: Trach in place with cuff fully inflated. Sclera
anicteric, MM slightly dry, oropharynx clear
Neck: supple, unable to appreciate JVP, no LAD
Lungs: Coarse vented rhonchorous BS occ exp wheezes B/L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. G
tube in place with dsg C/D/I
Ext: Warm, well perfused, 1+ pulses, trace edema, no clubbing,
cyanosis. Decub dsg. Right fem line with oozing. No erythema
Skin: Right flank sacral decub not observed but no s/s infection
per report
On discharge:
General: Awakens and opens eyes to voice, tachypneic, grunting
and cuff leak evident with breathing.
HEENT: Trach in place with cuff fully inflated. Sclera
anicteric, MM slightly dry, oropharynx clear
Neck: supple, unable to appreciate JVP, no LAD
Lungs: Coarse vented rhonchorous BS occ exp wheezes B/L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. G
tube in place with dsg C/D/I
Ext: Warm, well perfused, 1+ pulses, trace edema, no clubbing,
cyanosis. Decub dsg. Right fem line with oozing. No erythema
Skin: Right flank sacral decub not observed but no s/s infection
per report
Pertinent Results:
[**2178-9-11**] 02:36AM BLOOD WBC-8.1 RBC-2.91* Hgb-7.7* Hct-26.1*
MCV-90 MCH-26.5* MCHC-29.6* RDW-20.3* Plt Ct-109*
[**2178-9-11**] 02:36AM BLOOD PT-28.0* PTT-46.4* INR(PT)-2.7*
[**2178-9-11**] 02:36AM BLOOD Glucose-85 UreaN-41* Creat-2.5* Na-139
K-3.5 Cl-104 HCO3-27 AnGap-12
[**2178-9-12**] 09:58PM BLOOD ALT-16 AST-30 LD(LDH)-356* CK(CPK)-38
AlkPhos-81 Amylase-38 TotBili-0.2
[**2178-9-11**] 02:36AM BLOOD Tobra-2.8*
[**2178-9-11**] 01:34AM BLOOD Type-ART pO2-107* pCO2-69* pH-7.25*
calTCO2-32* Base XS-0
[**2178-9-12**] 09:58PM BLOOD WBC-12.8* RBC-3.28* Hgb-8.7* Hct-30.0*
MCV-92 MCH-26.3* MCHC-28.8* RDW-19.7* Plt Ct-136*
[**2178-9-14**] 09:25PM BLOOD Hct-23.5*
[**2178-9-16**] 12:08PM BLOOD Hct-25.7*
[**2178-9-16**] 03:51AM BLOOD PT-30.0* PTT-44.4* INR(PT)-3.0*
[**2178-9-16**] 03:51AM BLOOD Glucose-97 UreaN-47* Na-150* K-3.7
Cl-112* HCO3-29 AnGap-13
[**2178-9-14**] 02:47AM BLOOD ALT-12 AST-24 LD(LDH)-305* AlkPhos-77
TotBili-0.3
[**2178-9-14**] 02:47AM BLOOD Albumin-2.5* Calcium-8.8 Phos-5.7* Mg-2.2
[**2178-9-14**] 04:21PM BLOOD Tobra-3.6*
[**2178-9-15**] 06:29AM BLOOD Type-ART Temp-36.1 Rates-28/ Tidal V-520
PEEP-8 FiO2-40 pO2-69* pCO2-66* pH-7.26* calTCO2-31* Base XS-0
Intubat-INTUBATED Vent-CONTROLLED
[**2178-9-17**] 6:37 pm JOINT FLUID Source: Knee.
GRAM STAIN (Final [**2178-9-17**]): 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2178-9-20**]): NO GROWTH.
CT ABDOMEN AND PELVIS.
COMPARISON: [**2178-9-8**].
HISTORY: History of retroperitoneal bleed, on Coumadin, with new
hematocrit drop. Evaluate for worsening retroperitoneal bleed.
TECHNIQUE: CT axially acquired images through the abdomen and
pelvis were
obtained. No IV contrast was administered. Coronal and sagittal
reformats
were performed.
FINDINGS: Study is extremely limited due to extensive streak
artifact due to patient contact with gantry. Within the
limitations of a noncontrast exam, the lung bases demonstrate
severe ground-glass opacity with areas of focal consolidation,
most severe in the left lower lobe. Bilateral emphysematous
changes are also noted. this has worsened when compared to prior
exam. The spleen, liver, kidneys, adrenal glands, and pancreas
are unremarkable. The gallbladder contains high- density
material, which may represent small amount of sludge versus tiny
gallstones. There is no intrahepatic biliary dilatation. Small
bowel loops are normal in caliber. There is no free fluid or
free air. The patient is status post G- tube.
CT OF THE PELVIS: Again identified is expansion of the right
psoas and
iliacus muscle with high-density fluid consistent with a
retroperitoneal
hematoma. This measures approximately 9.6 x 17.8 cm (401B, 37)
and is
unchanged when compared to prior exam. No new areas of
retroperitoneal
hemorrhage are identified. A rectal tube is identified. The
rectum, sigmoid colon, and bladder are otherwise unremarkable.
Small foci of air within the bladder are noted and may be due to
recent Foley catheterization. The Foley catheter remains within
the bladder. There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
Degenerative changes of the thoracolumbar spine are noted.
IMPRESSION:
1. Stable appearance of large right iliacus and psoas muscle
retroperitoneal
bleed. No new areas of hemorrhage identified.
2. Bilateral lower lobe ground glass opacity with worsening
focal
consolidation of left lower lobe.
AP CHEST, 12:11 P.M. ON [**2178-9-16**]
HISTORY: COPD. Aspiration. Question pneumonia.
IMPRESSION: AP chest compared to [**9-3**] through [**9-14**].
Severe infiltrative pulmonary abnormality, probably largely
pulmonary fibrosis worsened only moderately since [**9-3**].
Aspiration pneumonia would not be appreciated. A component of
pulmonary edema, not necessarily cardiogenic is likely. Heart
size top normal, unchanged. Tracheostomy tube in standard
placement. No appreciable pleural effusion and no pneumothorax.
LENIs: No evidence of deep vein thrombosis in the left leg.
2-view knee: Study is limited due to difficulty in patient
positioning. There are no true AP or lateral views. Both of
these appear obliqued. Allowing for this, there are no
fractures. There is a knee joint effusion. There are
degenerative changes of the tibiotalar joint. No acute fractures
or dislocations are seen. There is some mild medial
compartmental joint space narrowing. If there is high clinical
concern for infection, MRI or joint aspiration should be
considered.
Brief Hospital Course:
This is a 51 y/o male with a history of severe mixed obstructive
and restrictive disease recently admitted with hypoxic and
hypercarbic respiratory failure, VAP and ARF now readmitted with
hypercarbic respiratory failure and elevated INR.
.
# Hypercabic respiratory failure: The patient has multifactoral
hypercarbic respiratory failure secondary to obstructive and
restrictive lung disease and obesity hypoventolation. The
patient had a tracheostomy placed [**2178-8-13**]. He presented to [**Hospital1 18**]
from [**Hospital 100**] Rehab with a rapidly worsening hypercarbia acidemia.
He had a audible sounds from his trach. Overall, the picture was
consistent with a cuff leak as the etiology of his worsening
hypercarbia. Upon arrival to the MICU the patient had loss of
100cc of tidal volumes due to the cuff leak. He had a
bronchoscopy on arrival and the trach was repositioned, which
led to a resolution of his cuff leak. He remained on AC
ventilation and albuterol, ipratroprium and beclomethasone. The
patient multiple ABG with goal PCO2 in the 70's. The patient had
a trial of pressure support, however, responded poorly with
tachypnea and anxiety. The patient was switched back to AC.
.
# Resistant pulmonary Pseudomonas VAP: The patient recently grew
resistant Pseudomonas on his sputum which persisted on a repeat
culture ([**2178-9-9**]) during a recent hospitalization. The culture is
sensitive to tobramycin and gent only. The patient currently is
being treated with tobramycin 150mg IV QOD. His course will end
[**2178-9-19**].
.
# Hypotension: The patient was initially normotensive on
presentation but became hypotensive with SBP to 70-80's in the
emergency department despite IVF. The etiology of his
hypotension was unclear. The patient did not have fevers or
leukocytosis which argued against infection, however, he had
many potential sources including Pseudomonas in his sputum,
decubitus ulcer and dirty UA. The patient also had a recent
psoas hematoma. His HCT was stable at admission and the patient
was not tachycardic. The patient was treated with levophed for a
goal of a MAP over 60 and was given fluid boluses as needed. The
patient was continued on his tobra. His hypotension resolved
with fluid boluses and levophed was stopped.
.
# Anemia: The patient had a falling hct during the
hospitalization of unknown etiology. During his prior admission
he was found to have a retroperitoneal bleed. He was transfused
a total of 2 units of pRBC and had a CT of his abdomen and
pelvis. The abdomen and pelvis scans showed a stable
retroperitoneal hematoma and no acute sources of bleed. The
patient had his coumadin stopped and vitamin K was given to
reverse his elevated INR. His hct was stablized during the
admission.
.
# Elevated INR: The patient had an INR of 7 which was likely
from an interaction from fluconazole and coumadin. The patient
was given vitamin K with a decrease in his INR to 2.4. His
coumadin was stopped due to his prior retroperitoneal hematoma
and hct drop during this hospitalization.
.
# Hypernatremia: Patient receiving D5W for hypernatremia. Will
adjustments to D5W IVF rate as needed.
.
# Renal failure: The patient had renal failure at his previous
admission. On admission his kidney function was resolving. Renal
was consulted and deferred dialysis due to improving kidney
function. The patient had his femoral HD line pulled without
complication.
.
# Atrial fibrillation: The patient developed intermittent Afib
during his last admission. Upon arrival he was normal sinus
rhythm and continued to be throughout the admission. The patient
was on metoprolol. His coumadin was stopped and not restarted
due to history of bleed.
.
# Left knee pain: The patient was noted to have L knee pain.
Three view x-ray were taken which failed to review etiology. The
joint fluid was aspirated and orthopedics was consulted. Ortho
thought unlikely to be septic joint, possible gout.
.
# H/O DVT: The patient had his coumadin stopped during this
admission. SC heparin was given.
.
# Constipation: The patient was continued on his home bowel
regimen.
.
# Code: Full code.
Medications on Admission:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*QS MDI* Refills:*2*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-20 Puffs Inhalation Q4H (every 4 hours).
Disp:*QS MDI* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*2*
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*QS * Refills:*2*
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*QS * Refills:*2*
6. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day).
Disp:*300 ML(s)* Refills:*2*
7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
Disp:*QS * Refills:*2*
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
9. Sodium Chloride 0.9% and heparin. Flush 10 mL IV PRN line
flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline and
heparin daily and PRN.
10. Pantoprazole 40 mg PO Q24H
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*QS Patch 72 hr(s)* Refills:*2*
14. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
15. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM.
Disp:*90 Tablet(s)* Refills:*2*
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash/puritis.
Disp:*QS * Refills:*0*
18. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
21. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation twice a day.
Disp:*QS MDI* Refills:*2*
22. Tobramycin: Dosed based on level
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SO or
wheezing.
Disp:*QS * Refills:*0*
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*QS * Refills:*2*
3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS * Refills:*2*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
Disp:*QS Patch 72 hr(s)* Refills:*0*
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 7500 (7500)
units Injection TID (3 times a day) as needed for DVT proph.
Disp:*QS * Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheeze.
Disp:*qs * Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*QS Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qS Tablet(s)* Refills:*2*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*QS * Refills:*2*
11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
Disp:*QS * Refills:*0*
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
Disp:*QS Tablet(s)* Refills:*0*
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**2-6**] Adhesive Patch, Medicateds Topical DAILY (Daily).
Disp:*QS Adhesive Patch, Medicated(s)* Refills:*2*
15. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*2*
16. Hydromorphone (PF) 1 mg/mL Syringe Sig: [**2-6**] Injection Q4H
(every 4 hours) as needed for pain.
Disp:*QS * Refills:*0*
17. Tobramycin Sulfate 40 mg/mL Solution Sig: Seven (7)
Injection ONCE (Once) for 1 doses: 280mg IV, To be given if
tobramycin level <2.
Disp:*QS * Refills:*0*
18. Outpatient Lab Work
Daily coag, CBC, chem 10. Results to be reviewed by MD.
19. Outpatient Lab Work
of D5W IVF.
20. Methadone 5 mg Tablet Sig: 2.5 Tablets PO four times a day:
total of 12.5 mg po QID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Inhalation Lung Injury
Hypoxic and Hypercarbic Respiratory Failure
Pseudomonas Pneumonia
Acute Renal Failure requiring Hemodialysis
Gastrointestinal Bleed
Atrial Fibrillation
Hypernatremia
L knee pain
Discharge Condition:
Fair
Discharge Instructions:
You were admitted to the MICU after experiencing respiratory
distress at your long term rehab facility. Upon admission, you
had a bronchoscopy which revealed poor placement of the
endotracheal tube. The tube was repositioned with immediate
improvement of your respiratory status. Because of your large
pain medication requirements, we change yor daily regimen to a
longer lasting medication called Methadone to be take three
times a day, with dilaudid to be given for breakthrough pain.
Lastly, your left knee pain appears due to bleeding into the
joint space. Aspiration of joint fluid showed no gout or
infection, and xray revealed no fracture. We've given you pain
medication to help with the pain, and we have reversed your
anticoagulation which should prevent further bleeding into the
joint space. Regarding your health issues prior to admission,
you sould continue on the ventilator for your respiratory
failure, uing the current Assist Control settings. These
settings may be weaned as tolerated. For your Pseudomonal
pneumonia, continue tobramycin for 3 more days. A tobramycin
level should be check prior to dosing, and a peak level should
be checked 1 hour after infusion stopped. His dose today will
be Tobramycicn 280mg IV if the tobramycin level comes back <2.
For your anemia, continue having hematocrit checked daily, and
transfuse for levesl less than 25. For your skin ulcerations,
continue current wound care. For hypernatremia, continue D5Wat
200cc/hr and check electrolytes [**Hospital1 **]. For renal failure,
continue to monitor urine output and BUN/Cr daily.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-10-13**] 2:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2178-11-24**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-12-14**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
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[
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"33.22",
"38.93",
"81.91",
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icd9pcs
|
[
[
[]
]
] |
17390, 17456
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8344, 12457
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355, 370
|
17710, 17717
|
3788, 8321
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19362, 19983
|
2247, 2264
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14870, 17367
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17477, 17689
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12483, 14847
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17741, 19339
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2279, 2279
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3038, 3769
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1512, 1576
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284, 317
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398, 1493
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2294, 3024
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1598, 1994
|
2010, 2231
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,350
| 141,625
|
44695
|
Discharge summary
|
report
|
Admission Date: [**2133-6-14**] Discharge Date: [**2133-7-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
abdominal pain, nausea and fatigue
Major Surgical or Invasive Procedure:
1. Dialysis Tunnel Catheter placement ([**2133-7-2**])
History of Present Illness:
85 y/o man with PVD, atrial fibrillation, severe diastolic
dysfunction and SSS s/p recent PPM implantation ([**6-8**]) who
presents with abdominal pain, nausea and fatigue.
.
He reports feeling well on the day of and after discharge, but
began to feel fatigued the next day. On the evening prior to and
the morning of admission, he began to have abdominal pain and
nausea. His PO intake and decreased as he has had no appetite.
He reports that the abdominal pain is located in his upper
abdomen. He denies fevers, chills, sweats or rigors. He denies
yellowing of the skin or eyes.
.
He denies chesrt pain and reports mild and improved DOE from
prior to the PPM implantation. On further review of symptoms, pt
reports some lightheadedness on Saturday and reports that after
micturition, his symptoms became much worse and he fell with
possible loss of consciousness.
Past Medical History:
# Diastolic Congestive Heart Failure: ECHO [**3-7**] EF of 50% &
severe LVH, in acute on chronic diastolic congestive heart
failure for past several months. LVH apparently adds component
of restriction per [**Doctor Last Name **].
# Atrial fibrillation on Coumadin, failed cardioversion with
complete heart block.
# Pacemaker, in [**6-7**] for complete heart block
# Peripheral vascular disease s/p right lower extremity bypass
# Hiatal hernia with intrathoracic stomach (confirmed by [**2133-6-16**]
CT)
# Hypertension
# Gout
# ?Prostate followed by Urology (denies symptoms of BPH)
# Chronic Kidney Disease ([**3-7**], Cr 2.2, stage III, est GFR 35)
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Patient's daughter had "kidney disease" and is
now s/p renal transplant. 2 sons and 1 daughter.
Physical Exam:
VS - T 96.1 BP 108/70 HR 72 RR 22-24 O2sat 95% 3LNC
Gen: Chronically ill-appearing man, in mild distress taking deep
breaths
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. CN II-XII intact.
Neck: Supple with JVP to jaw, likely 12 cm, + HJR.
CV: RR, soft S1, S2. Prominent S3, I/VI at LSB
Chest: no airmovement [**2-1**] right posterior lung fields with
dullness to percussion. Crackles at left base. Poor airmovement
throughout rest of lung including anterior lung fields
Abd: soft, distended, non tender, marked hepatomegaly (10-12 cm
in midclavicular line) with very firm liver edge, unable to
appreciate any splenomegaly or tappable ascites. + BS
Ext: gross anasacra with 2+ pitting edema: legs, arms, at hip,
cool extremities, 1+ DP, 1+ radial, no cynanosis. Sites of prior
IVs weeping serous fluid.
Skin: extensive ecchymoses on chest, upper abdomen, left arm,
left side of back. Skin tear left mid-back.
Neuro: CN II-XII intact, somnulent, intermittent jerks, few
tongue fasiculations, oriented to person, place, time, reason
for admission.
Pertinent Results:
[**2133-7-6**] 07:50AM BLOOD WBC-6.0 RBC-2.75* Hgb-9.0* Hct-28.4*
MCV-103* MCH-32.9* MCHC-31.9 RDW-18.9* Plt Ct-79*
[**2133-7-3**] 08:00AM BLOOD PT-14.9* PTT-34.8 INR(PT)-1.3*
[**2133-7-3**] 07:40AM BLOOD WBC-10.7 RBC-2.72* Hgb-8.9* Hct-28.3*
MCV-104* MCH-32.8* MCHC-31.5 RDW-18.6* Plt Ct-75*#
[**2133-7-2**] 05:16AM BLOOD WBC-10.1 RBC-2.63* Hgb-8.8* Hct-27.1*
MCV-103* MCH-33.2* MCHC-32.3 RDW-18.4* Plt Ct-48*
[**2133-7-3**] 07:40AM BLOOD Glucose-96 UreaN-37* Creat-4.2* Na-137
K-4.4 Cl-97 HCO3-28 AnGap-16
[**2133-7-2**] 05:16AM BLOOD Glucose-101 UreaN-29* Creat-3.5* Na-134
K-4.1 Cl-99 HCO3-28 AnGap-11
[**2133-7-1**] 05:40AM BLOOD Glucose-101 UreaN-44* Creat-4.3* Na-133
K-4.5 Cl-96 HCO3-27 AnGap-15
[**2133-6-24**] 09:41AM BLOOD LD(LDH)-235 TotBili-1.1 DirBili-0.5*
IndBili-0.6
[**2133-7-3**] 07:40AM BLOOD VitB12-GREATER TH Folate-7.2
[**2133-6-20**] 06:25AM BLOOD %HbA1c-5.9
[**2133-6-20**] 06:25AM BLOOD Triglyc-74 HDL-25 CHOL/HD-4.7 LDLcalc-78
ECG: V-paced at 60
.
2D-ECHOCARDIOGRAM performed on [**2133-6-8**] demonstrated:
The left atrium is dilated. Mild spontaneous echo contrast is
seen in the body of the left atrium. No mass/thrombus is seen in
the left atrium or left atrial appendage. Moderate to severe
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No spontaneous echo contrast or thrombus is
seen in the body of the right atrium or the right atrial
appendage. There is mild diastolic bowing of the interatrial
septum suggestive of elevated right atrial pressures. There are
complex (>4mm) atheroma in the aortic arch and descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
.
RENAL ULTRASOUND [**2133-6-9**]:
1. No evidence of hydronephrosis. Bilateral renal cysts.
2. Small amount of ascites around the liver and questionable
right pleural effusion.
.
CT ABD/PELVIS [**2133-6-16**]:
1. Abdominal and pelvic ascites. No secondary signs to
definitely suggest ischemic colitis, although this is a limited
examination secondary to lack of IV contrast administration.
2. Left diaphragmatic hernia with intrathoracic stomach. An
upper GI barium study would allow for evaluation of functional
impairment if clinically warranted. No definite evidence for
obstruction on CT examination.
3. Bilateral pleural effusions, right greater than left.
4. Sigmoid diverticulosis.
5. Small amount of pelvic ascites and small right inguinal
fluid-containing
hernia.
6. Anasarca.
.
CXR [**2133-6-18**]:
The heart is enlarged, the aorta is tortuous and the hilar
contours are normal. Bibasilar atelectasis is unchanged. There
is increasing moderate right pleural effusion. No pneumothorax.
The pacemaker device is in place. IMPRESSION: Increasing
moderate right pleural effusion.
.
CT HEAD [**2133-6-15**]: There is no hemorrhage, edema, mass effect, or
shift of normally midline structures. Vertebral artery
calcifications are identified. There is left cerebellar
encephalomalacia, chronic in nature. The white matter is normal
in attenuation. The ventricles and sulci are normal in size and
configuration. There is a right maxillary sinus mucus retention
cyst or polyp (2A:2). The visualized paranasal sinuses are
otherwise clear.
IMPRESSION:
1. No hemorrhage.
2. Left cerebellar encephalomalacia.
3. Vertebral artery calcifications.
4. Single Right maxillary sinus mucus retention cyst or polyp.
.
LIVER ULTRASOUND [**2133-6-15**]:
IMPRESSION:
1. Somewhat limited examination secondary to patient body
habitus. If
clinical concern persists, recommend CT imaging for further
evaluation.
2. Small ascites is seen.
3. Right-sided pleural effusion.
.
[**2133-6-18**]
ANCA: Negative By Indirect Immunofluorescence
ANTI-GBM: PENDING
HBsAg: Negative
HBs-Ab: Negative
IgM-HBc: Negative
HAV-Ab: Positive
HCV-Ab: Negative
Brief Hospital Course:
#GI Bleed/Anemia: During MICU stay pt experienced LGI Bld
requiring 1unit of pRBC. for the last week his Hct has remained
stable and his stools have been guaiac negative. Bld occurred
whilst pt had supra therapeutic INR. He will need an outpatient
colonoscopy.
#Acute on Chronic Renal Failure: Stage III CKD likely secondary
to chronic HTN. Pt developed acute on chronic renal failure
likely related to ICU status with pancreatitis. Patient now on
dialysis [**Month/Day/Year 766**], Wednesday, Friday access via tunnel catheter
(placed [**7-2**]).
#Diastolic Heart Failure: Prior to this admission, patient had
been experiencing increasing SOB and increasing girth. During
this admission patient developed worsening diastolic heart
failure managed by hemodialysis. Unclear if diastolic heart
failure is secondary to hypervolemic status following treatment
of pancreatitis or amyloidosis.
#Thrombocytopenia: Patient developed acute drop in platelets on
[**6-24**] 104->55 and dropped to 17, since then plt count has started
to trend up to 79. During work-up Protonix was discontinued, pt
was ruled out for Heparin Induced Thrombocytopenia.
Hematology/Oncology was also involved during work-up, ruled out
TTP, Myelodysplastic Syndrome.
#Fib:Pt has remained in sinus rhythm, rate controlled on
Amiodarone.
#Nutritional Status: Pt experienced decreased appetite and was
switched to regular PO intake, once his intake increases he will
need to be switched to a cardiac-renal diet.
#Acute Delirium: Pt experienced acute delirium whilst on
sleeping medications (Ambien, Trazodone, Olanzapine), according
to the family he sleeps well with regular Tylenol.
#Pancreatitis: Pt admitted to ICU initially for Pancreatitis
thought to be related to Amiodarone which pt started 1 week PTA.
Pt was followed clinically, pancreatitis resolved.
Medications on Admission:
MEDICATIONS ON TRANSFER
Amiodarone 200 mg PO BID
Pantoprazole 40 mg IV Q24H
Docusate Sodium 100 mg PO BID
Ferrous Sulfate 325 mg PO DAILY
Humalog Insulin Sliding Scale
Simethicone 40-80 mg PO QID:PRN
Lorazepam 0.5 mg IV Q8H:PRN
Zolpidem Tartrate 5 mg PO HS:PRN
Morphine Sulfate 1 mg IV Q2H:PRN
Ondansetron 4 mg IV Q8H:PRN
Senna 1 TAB PO BID:PRN
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Insomnia.
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Pancreatitis
Acute renal failure requiring dialysis
Congestive heart failure
GI bleed
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2133-7-24**] 11:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
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"577.1",
"600.01",
"428.33",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10771, 10851
|
7426, 9260
|
295, 351
|
10981, 10990
|
3379, 7403
|
11157, 11441
|
2063, 2242
|
9655, 10748
|
10872, 10960
|
9286, 9632
|
11014, 11134
|
2257, 3360
|
221, 257
|
379, 1247
|
1269, 1922
|
1938, 2047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,265
| 174,503
|
35501+58015
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-2-18**] Discharge Date: [**2181-2-28**]
Date of Birth: [**2119-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Name14 (STitle) 80860**] is a 61M with a PMH s/f CMML who is being
transferred from [**Hospital3 3583**] for continued management of
hypoxia. The patient was in his usual state of health when he
began to experience mild abdominal and rectal pain three weeks
ago. He saw his gastroenterologist and was told to complete a
course of ciprofloxacin and flaygl. He then went to [**Country 149**] on a
business trip, where he decided not to take the flagyl given its
disulfiram-like side effects. When he returned home, he
continued to have persistent rectal pain, with a new cough and
increasing shortness of breath and left-sided chest pain.
Specifically, his rectal pain was worsened with bowel movements
and associated with constipation and LLQ crampy pain, and he
noted scant red blood in his stools after bowel movements. His
chest pain was described as sharp and worsened with activity and
with coughing, but without nausea, vomiting, diaphoresis, or
radiation to the back or arms.
.
He presented to [**Hospital3 3583**] on [**2181-2-5**] where a CXR showed a
right sided pneumonia, for which he received levofloxacin,
zosyn, IV solumedrol (long smoking history and concern for
COPD), and nebulizers. A rectal exam revealed a new mass, which
was biopsied under general anesthesia, results are pending. A
CT abdomen and pelvis showed mild diverticulitis. On the fourth
hospital day, he had new, volumnious diarrhea, with 15 bowel
movements each night. Stool was sent for C. diff, which was
positive on the third set. PO vancomycin was started for this
rather than flagyl, based on renal recommendations. CXRs
cleared over the course of antibiotic therapy, and the patient
remained afebrile throughout his hospital course. His WBC count
climbed over his hospital course, however, from 40 on admission
to 109, in the setting of CMML, PNA, C. diff, and steroid
treatment. Heme-onc was consulted, and performed a bone marrow
biopsy, which [**Name8 (MD) **] MD sign-out showed "mild blasts on flow
cytometry"; however, it was felt that this was likely
demargination from steroids, C.diff, and PNA. He continued to
experience dyspnea, with worsening hypoxia, sating 70s on room
air, requiring a non-rebreather to maintain sats in the 90s. A
d-dimer was negative, though it was performed while the patient
was already started on empiric anticoagulation with heparin for
presumed PE, and a V/Q scan was indeterminate. The heparin was
stopped after the negative d-dimer. The patient is requesting
transfer for continued management of hypoxia.
Past Medical History:
#. Chronic metamyelocitic leukemia
-managed by Dr. [**Last Name (STitle) **] at [**Hospital1 2025**]
#. Nephrotic Syndrome with membranous nephropathy, bx proven per
report. Was treated with cyclophosphamide and prednisone.
-Baseline Cr 3.1
#. Hypertension
#. Diverticulosis
#. Colonic polypectomy
#. Status post right inguinal hernia
#. Vasectomy
#. Penile implant for erectile dysfunction
Social History:
He lives with his wife and quit smoking twelve years ago but has
a 2 to 3 pack-per-day history x 35 years. He drinks [**12-22**] glasses
of wine nightly. Regarding employment, he works as an insurance
broker. All four of his children live nearby.
Family History:
Father had lung cancer. No family history of hematological
malignancies.
Physical Exam:
T=98.4 BP=114/78 HR=75 RR=18 O2=94% 5L
.
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing ..... in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-22**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
EKG [**2181-2-11**]: NSR, HR 67, nl axis, nl intervals, no acute ST/T
wave abnormalities
.
CT Chest [**2181-2-8**] : borderline LNs in mediastinum, large spleen,
bilateral patches of feathery infiltrates, no consolidation,
small bilateral pleural effusion
.
CT Abd/Pelvis [**2181-2-5**]: inflammation posterior to proximal
descending colon with small fluid in pericolic gutter suggestive
of diverticulitis; mild splenomegaly; small AAA
.
CXR:
[**2181-2-5**]: limited exam, LLL infiltrate
[**2181-2-7**]: partial clearing of LLL infiltrate, small bilateral
pleural effusions
[**2181-2-11**]: no acute cardiopulm process
[**2181-2-14**]: no acute cardiopulm process
[**2181-2-15**]: no acute cardiopulm process
[**2181-2-18**]: new RUL airspace disease, minimal LUL airspace disease,
these findings consistent with pneumonia, lung bases are clear
.
Echocardiogram [**2181-2-8**]: LVEF 55%, 1+ TR, 1+ MR
.
V/Q scan [**2181-2-17**]: multiple subsegmental matched perfusion
defects, no unmatched perfusion defects, indeterminant result
.
Renal U/S [**2181-2-12**]: normal appearing kidneys
.
[**2-23**] MRI pelvis: IMPRESSION:
1. The anal tumor appears to extend into the distal-most rectum
for
approximately the anterior margin through the left lateral
margin. There
appears to be involvement of the levator muscle on the left as
well as
possibly the prostate.
2. 6-mm iliac chain lymph node.
3. Bone marrow signal abnormality likely reflecting the
patient's underlying
leukemia.
Brief Hospital Course:
Mr. [**Known lastname **] is a 61M with a PMH s/f [**Hospital 80861**] transfered to [**Hospital1 18**] for
further management of hypoxic respiratory distress.
#. Hypoxic respiratory distress: Possible etiologies for the
patient's hypoxia were thought to include pneumonia, PE,
noncardiogenic pulmonary edema, and leukostasis. He was
empirically started on vancomycin and zosyn, and though he had a
negative D-dimer and V/Q scan at [**Hospital3 3583**] an ECHO and
LENIs were attained and demonstrated no evidence of right heart
strain or DVT. A Broncoscopy was down and viral cultures were
RSV postive. He was also started on hydroxyurea to prevent
leukostasis, though the heme/onc service thought that this was
unlikely to be the etiology for his hypoxia and CXR infiltrates.
His respiratory status slowly imroved and pulmonary was
consulted to have determine when his pulmonary status had
improved enough to preceed to surgery for his anal cancer.
Pulmonary function test were performed which showed mild
restrictive and obstructive ventilatory defect and reduced
diffusing capacity. He was no longer on oxygen about 6 days
prior to discharge, and pulmonary felt that it was okay to
proceed on [**2181-3-5**].
#. Leukocytosis: Patient's WBC count increased from 40K on
admission to [**Hospital3 3583**] to 104K at time of transfer. This
was attributed to infection and steroid-effect causing massive
demargination in the setting of known CMML. Steroids were
discontinued and hydrea was started with improvement in his
white count to 30 at discharge. He was also continued on po
flagyl for C. diff. Blood cultures were negative. Please see
discussion below re: CMML.
#. C. diff: Diagnosed four days after starting antibiotics at
[**Hospital3 3583**] and treated with po vancomycin per renal reccs
by their consult service because of his renal insufficiency. He
was, however, converted to po flagyl upon admission to [**Hospital1 18**].
#. Rectal mass: Patient was found to have a rectal mass that
was biopsied by the surgical service under anesthesia (secondary
to significant pain) at [**Hospital3 3583**]. The mass was
concerning for squamous cell carcinoma per report and the biopsy
results are pending at the time of discharge. MRI of the pelvis
was performed and showed extension into the distal rectum,
levator muscle as well as iliac lymph nodes. The tumor was close
to obstructing the rectum. Multiple approaches to treatment were
discussed with hematologic malignancy, solid tumor, and surgical
experts. It was decided that the anal cancer took priority over
the CMML given the danger of obstruction. There it was decided
to pursue a diverting colostomy followed by chemo and radiation
which will be performed at [**Hospital6 33**] under the care
of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**]. The patient did not tolerate an anal
pap smear secondary to pain. We were unable to order HPV viral
load as an inpatient here. The patient underwent anesthesia
pre-op evaluation prior to discharge on [**2181-2-28**].
#. CMML: Diagnosed in [**2178**] and managed conservatively with close
monitoring. Has not previously received chemotherapy for this,
but started on hydroxyurea for leukocytosis as described above.
Incidentally, the etiology of the patient's CMML may be related
to her history of cyclophosphamide for membranous nephropathy. A
bone marrow was performed at [**Hospital3 **] and showed 19%
blasts, close to the 20% cut off for conversion to AML. Priority
was given to treating the anal cancer as explained above. The
CMML will be readdressed after chemo and radiation for the anal
cancer are completed. He will be discharged on hydrea 500mg [**Hospital1 **].
#. Nephrotic syndrome: Membranous nephropathy. Renally dosed
meds.
.
#. Thrush: started clotrimazole troches
CODE STATUS: full, discussed with patient
EMERGENCY CONTACT: Mrs. [**Name (NI) 1123**] [**Name (NI) 57495**], wife, Phone:
[**Telephone/Fax (1) 80862**], [**Name2 (NI) **] Phone: [**Telephone/Fax (1) 80863**]
Medications on Admission:
Levofloxacin 750 mg iv q48h
Zosyn 2.25 g iv q8h
Methyprednisolone 20 mg iv qd
Albuterol inhaler 2.5 mg q4h
Atrovent 0.5 mg q4h
Vancomycin 125 mg po q6h
Vitamin D 50,000 u po qSatruday
Megestrol 400 mg po qd
Hydrocortisone 2.5% apply topically tid
Hydromorphone 1-2 mg iv q3h
Lorazepam 0.5-1 mg iv q4h
Reglan 5-10 mg iv q6h
Acetaminophen [**Telephone/Fax (1) 80864**] mg po q6h
Diphenoxylate/atropine 1-2 tabs po tid
Colace 100 mg po bid
Loperamide 2 mg po prn diarrhea
Ranitidine 150 mg po bid
Senna 2 tabs po qd
Ambien 5 mg po qhs
Guaifenesin with codeine 50 cc po q6h prn cough
Lactulose 50 cc po qd
Magaldrate 10 cc po qid prn constipation
Milk of magnesia 30 cc po qd prn constipation
Lidocaine 1% as directed topically qid
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
2. Megestrol 400 mg/10 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
squamous cell carcinoma of the anus
CMML
RSV pneumonia
C diff colitis
.
nephrotic syndrome
Discharge Condition:
good
Discharge Instructions:
You were transfered to [**Hospital1 18**] for further treatment of your
hypoxia and high white blood cell count. You were found to have
a viral infection on broncoscopy called RSV. Your breathing
slowly recovered.
.
The biopsy of your rectal mass proved to be squamous cell
carcinoma. An MRI showed extension into your muscles and rectum.
It was decided that you will follow-up with [**Location (un) **] Atrius
in [**Location (un) **]. You will have surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] on
Monday, [**2181-3-5**]. You will be contact by her office
prior to this surgery for instructions.
.
Your bone marrow biopsy also showed poor markers for your CMML.
This disease will have to be further addressed after treatment
of the anal cancer is completed.
,
You were also treated with antibiotics for an infection in your
colon called c diff. You should continue to take Flagyl for the
next 4 days.
.
The following changes were made to your medication regimen:
Flagyl 500mg by mouth three times a day for the next 4 days
Megestrol 400mg by mouth daily to help increase your appetite
Hydroxyurea 500mg by mouth twice a day
.
Please follow up with your doctors as detailed below.
.
Please call your doctor or go to the emergency room for fevers,
chills, abdominal pain, diarrhea, severe constipation,
difficulty breathing, chest pain, or any other worrisome
symptom.
.
Surgery on Monday [**2181-3-5**].
-Dr.[**Name (NI) 3377**] secretary, [**Doctor First Name **], will call you on Friday to let
you know what time you need come arrive to the hospital on
Monday. Your surgery time will be sometime in the afternoon on
Monday, but NO SET time has been established.
-Please do not drink or eat after midnight on Sunday. NO bowel
preparation is required.
-Call Dr.[**Name (NI) 3377**] office with any concerns regarding your
bowels.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 61767**]
.
[**Location (un) **] Atrius Doctors:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], radiation oncology
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**], hematology oncology
.
You will be contact by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office
[**Telephone/Fax (1) 160**](colorectal surgery) prior to your surgery on monday
for additional instructions.
Name: [**Known lastname 12993**],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1046**] Unit No: [**Numeric Identifier 12994**]
Admission Date: [**2181-2-18**] Discharge Date: [**2181-2-28**]
Date of Birth: [**2119-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12206**]
Addendum:
The patient's anal mass was diagnosed as poorly differentiated
squamous carcinoma based on biopsies taken at [**Hospital3 **] on
[**2181-2-15**]. The slides were reviewed here as well. The pathology
report is as follows:
.
Anorectal biopsies, two ([**Hospital3 4121**]; S09-1629; [**2181-2-15**]):
A. Deep anal:
Fragments of invasive poorly differentiated squamous carcinoma
present in smooth muscle.
B. [**Last Name (un) **]-anal:
Fragments of invasive poorly differentiated squamous carcinoma
undermining rectal mucosa.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
[**Doctor First Name **] [**Last Name (NamePattern5) 12216**] MD [**MD Number(2) 12217**]
Completed by:[**2181-3-4**]
|
[
"V45.89",
"285.9",
"287.5",
"008.45",
"112.0",
"288.60",
"205.10",
"V10.49",
"581.1",
"V15.82",
"480.1",
"V12.72",
"E932.0",
"562.10",
"154.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
14805, 15009
|
6039, 10092
|
322, 328
|
11372, 11379
|
4527, 6016
|
13303, 14782
|
3614, 3689
|
10870, 11157
|
11258, 11351
|
10118, 10847
|
11403, 13280
|
3704, 4508
|
275, 284
|
356, 2916
|
2938, 3331
|
3347, 3598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 123,124
|
2543
|
Discharge summary
|
report
|
Admission Date: [**2125-12-1**] Discharge Date: [**2125-12-12**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Generalized weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 81 M with pmh of ESRD on HD, AFib, CHF, C diff
colitis, h/o klebsiella urosepsis, recent MRSA line infection
presented after slipping from his bed due to bilateral lower
extremity weakness. Patient had his last HD thursday where his
BP was low and experienced chills. He was recommended to go the
ED but refused. His BCx were drawn and was given 1 gram of
vancomycin according to nephrology notes. Yesterday he felt
generalized weakness and slipped out of his bed while trying to
get out. No truama and landed on his buttocks. He experienced
transient chest pain two days ago but unable to give any more
details about it. He had stool without knowing yesterday. No
diarrhea. Today he experienced abdominal discomfort transiently
which resolved without any intervention. He is unable to give
any more details about it. He again slipped today and his wife
was able to convince him to come to the Emergency Department.
He was sleepy since yesterday and this is a sign of him getting
sick per wife.
.
In the ED his vitals were T 96.9 BP 64/39 HR 93 RR 20 98% on
2L NC. His BP improved to 92/74 after 2LNS. His baseline blood
pressure is in 90s. He received 1 gram of vancomycin, zosyn 4.5
mg once, and aspirin 325 mg daily.
.
On arrival to MICU his vitals were T 96.8 HR 86 BP 80/53 to
93/54 without intervention 95% on 3LNC
He denies any fever, chills, nightsweats, current chestpain,
abdominal pain, nausea, vomitting, palpiatations, focal weakness
or numbness. He makes some urine and denies any dysuria,
hematuria. No blood in stool.
.
Past Medical History:
- Stage IV CKD
- Atrial fibrillation
- h/o GI bleed, diverticulitis
- C. Diff colitis
- h/o stroke 12 years ago w/ right-sided weakness; second stroke
5 years ago
- h/o nephrolithiasis w/ stent and nephrostomy tube
- CAD s/p MI
- sleep apnea not on cpap
- h/o klebsiella urosepsis, MRSA line infection
- depression
- PFTs [**2117**] with mild restrictive ventilatory defect
-Anemia with h/o iron deficiency
.
Social History:
Lives with wife [**Name (NI) **], daughter lives downstairs, h/o smoking
[**12-20**] PPD for 50 years, quit 20 years ago, occsional beer, none
recently, no drugs.
Family History:
non-contributory
Physical Exam:
Vitals: T 96.8 HR 86 BP 80/53 to 93/54 without intervention
95% on 3LNC
Gen: Pleasant gentleman, AOx3, in no apparent distress,
following commands.
HEENT: EOM-I, MMM, OP clear, JVP not elevated
Heart: S1S2 RRR, no MRG
Lungs: Bibasilar cracles, no wheezes
Abdomen: BS present, soft NTND, no appreciable
mass/organomegaly
Ext: WWP
Neuro: AOx3, CN III-XII grossly intact, strength 5/5 in
bilateral lower extremities, sensation is intact in BLE.
.
Pertinent Results:
EKG: afib with vent rate in 90s, LAD, PVC, no acute ST-T changes
compared to [**2125-10-22**].
.
CXR [**2125-12-1**]:
Low lung volumes, with no acute abnormalities.
.
[**2125-12-1**] CT abdomen/pelvis:
1. Enlarged gallbladder with a trace amount of pericholecystic
fluid. There is no cholelithiasis or choledocholithiasis.
Overall, these findings are equivocal for acute cholecystitis
and in the right clinical setting,
correlation with ultrasound is recommended.
2. Chronic dissection and aneurysmal dilation of the left common
and external iliac arteries.
[**2125-12-11**] HIDA Scan:
1. No evidence of cholecystitis. 2. Normal gallbladder function
and
ejection fraction.
[**2125-12-10**] Tunnelled Line Placement:
Successful placement of a 15.5 French tunneled dialysis catheter
with 23-cm tip-to-cuff length via left internal jugular vein
with the tip
positioned in the right atrium. The catheter is ready to use.
[**2125-12-7**] RUE U/S: 1. Findings consistent with acute right IJ
thrombosis.
[**2125-12-7**] Bilateral LE U/S:
Findings consistent with chronic left SFV thrombus. Nonocclusive
echogenic material within the right distal SFV, a son[**Name (NI) 493**]
appearance more consistent with old thrombus, but age
indeterminate.
[**2125-12-3**] RUQ U/S:
Distended gallbladder with sludge, and minimal wall thickening.
No definite evidence of acute cholecystitis.
Labs on Discharge:
[**2125-12-12**] 04:50AM BLOOD WBC-5.4 RBC-3.81* Hgb-10.5* Hct-33.2*
MCV-87 MCH-27.6 MCHC-31.6 RDW-16.8* Plt Ct-248
[**2125-12-12**] 04:50AM BLOOD Glucose-85 UreaN-22* Creat-2.8* Na-139
K-4.4 Cl-102 HCO3-31 AnGap-10
MICRO:
[**2125-12-1**] Blood culture:
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**Date range (1) 12910**] Blood cultures with no growth
Brief Hospital Course:
Mr. [**Known lastname 12731**] is an 81 yo male with pmh of ESRD on HD, AFib,
CHF,diverticulosis, h/o klebsiella and ecoli sepsis who was
admitted with generalized weakness and hypotension, found to
have recurrant E. coli sepsis.
1)Multi-drug resistent Ecoli sepsis: He was initially admitted
to the MICU as he was hypotensive with SBP 70's which improved
with IVF. He was initially treated with vanocomycin and
meropenam however vanc was stopped once culture data returned.
Etiology of recurrant ecoli sepsis unclear, however it appears
to be the same bacteria given that resistance profile is the
same. He was investigated for possible biliary source, however
this does not appear to be a potential source given his normal
HIDA scan. He had ultrasound to evaluate for possible infected
thrombus. He was found to have a right IJ thrombus. As a
result his right IJ tunnelled dialysis line was removed in order
to facilitate clot resolution. Culture of the dialysis line tip
was without growth. His urine culture was negative making
urinary source unlikely. He was treated with meropenam during
his hospitalization and then discharged on ertampenam to
complete a four week course, starting from his first negative
blood culture which was on [**2125-12-2**] with last day of therapy
[**2124-12-29**]. All further surveillance culturese were without
growth. His last day of ertapenam will be [**2125-12-16**]. He will
need evaluate of CBC with diff, Chem 7 and LFT's weekly at
dialysis while on ertapenam. Anticoagulation was considered and
briefly started however given his significant h/o diverticular
bleeding causing discontinuation of anticoagulation in the past
it was stopped. It was thought that his RIJ clot may dissolve
once line removed. He was scheduled for follow-up right upper
extremity ultrasound on [**2124-12-23**]. He was discharged on ertepenam
to complete antibiotic course, 500mg IM on non-dialysis days and
500mg IV on dialysis days, to be given at dialysis after he
completes his dialysis session.
2)Acute on Chronic heart failure - per recent echocardiogram
report appears consistent with cor pulmonale (? [**1-20**] long
untreated OSA), likely with current mild decompensation given
pulmonary congestion and left sided effusion new since
admission, likely [**1-20**] volume resuscitation. He was treated with
dialysis for fluid removal and was euvolemic by discharge.
3)ESRD/HD: dialysis schedule is T/Th/S, new left tunnelled line
placed on [**2125-12-10**]. Previous right IJ tunnelled line removed
given RIJ thrombus. He has plans for AV fistula by Dr.[**Last Name (STitle) 816**]
however concern is to determine source of recurrant bacteremia
before placing AV fistula. He will need ertapenam after
dialysis on dialysis days as well as weekly CBC with diff, chem
7 and LFT's while on ertapenam.
4)Sleep apnea: He was encouraged to use CPAP however refused
throughout his admission.
5) h/o CAD/PVD/CVA: no acute issues, he was continued on ASA 325
6) h/o Afib/flut: Currently in afib but rate controlled. He is
not on anticoagulation at baseline due to history of significant
diverticular bleeding. He was continued on ASA 325mg.
7) H/O Diverticulosis - no acute issues.
8) Code: Full Code
9) Contact: Wife, [**Name (NI) **] [**Name (NI) 12731**], h [**Telephone/Fax (1) 12911**], c [**Telephone/Fax (1) 12912**]
Medications on Admission:
Fluoxetine 10 mg daily
Atrovent HFA 1 inh q4h prn
Pantoprazole 40 mg daily
Tiotropium i puff daily
Tylenol prn
ASA 325 mg daily
Colace prn
Bisacodyl prn
MVI
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Ertapenem 1 gram Recon Soln Sig: Five Hundred (500) mg
Injection M,W,F,[**Doctor First Name **] for 18 days: Please inject 500mg IM on
non-dialysis days (Mon, Wed, [**Last Name (LF) **], [**First Name3 (LF) 1017**]). Last day of
antibioitics [**2124-12-29**].
12. Ertapenem 1 gram Recon Soln Sig: Five Hundred (500) mg
Intravenous at dialysis T,Th,Sat for 18 days: Please administer
500mg IV on dialysis days. Please give after dialysis. Please
mix with normal saline. Last day of treatment is [**2124-12-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Ecoli Bactermia
ESRD on Hemodialysis
h/o Diverticulosis
RIJ thrombosis
Discharge Condition:
stable, alert and oriented x3, no distress
Discharge Instructions:
You were admitted to the hospital because you were feeling light
headed and weak. You were found to have bacteria in your blood
stream. You had evaluation of your gallbladder which didn't
show any problem or cause for infection. You were found to have
a blood clot at the site of your right dialysis line. This may
be the source of bacteria so your right side dialysis line was
removed to help the blood clot dissolve. You will need a repeat
ultrasound to be sure that the clot does dissolve.
Medications:
1) You were started on an antibiotic to treat the blood stream
infection. You will need to complete four weeks.
None of your other usual medications were changed.
Please follow up as listed below.
Please call your doctor or return to the hospital if you
experience any worrisome symptoms including light headedness,
weakness, fevers, low blood pressure or other worrisome
symptoms.
Followup Instructions:
You have an appointment scheduled for an ultrasound of your
right arm/neck to evaluate the blood clot that was seen. The
appointment is on [**2124-12-23**] at 1:30. Please go to the [**Location (un) 470**] of
the [**Hospital Ward Name **] clinical center building. If you need to
reschedule please call [**Telephone/Fax (1) 327**].
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2126-1-9**] 2:10
Please follow up with Dr. [**Last Name (STitle) 4883**] in [**1-22**] weeks. Dr.[**Name (NI) 12913**]
office should contact you with an appointment. If you do not
hear from them please call [**Telephone/Fax (1) 60**].
|
[
"995.91",
"412",
"427.31",
"414.01",
"453.8",
"038.42",
"428.33",
"401.9",
"428.0",
"585.6",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.95",
"39.95",
"38.91",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
10254, 10348
|
5265, 8638
|
335, 341
|
10463, 10508
|
3074, 4455
|
11455, 12171
|
2568, 2586
|
8846, 10231
|
10369, 10442
|
8664, 8823
|
10532, 11432
|
2601, 3055
|
275, 297
|
4474, 5242
|
369, 1939
|
1961, 2372
|
2388, 2552
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,181
| 116,306
|
47127
|
Discharge summary
|
report
|
Admission Date: [**2183-9-26**] Discharge Date: [**2183-9-28**]
Date of Birth: [**2127-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
cocaine/opiate intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 56 yo man with h/o polysubstance abuse (heroin, crack
cocaine), depression/anxiety who presents with acute cocaine and
opiate intoxication. Patient went to the ED and reportedly
stated that "I took too much cocaine". Per report from the ED,
he took [**12-5**] ounce intranasally a couple hours before coming in.
He was reportedly very anxious and agitated as well as
diaphoretic. His initial vs were T 97.3, BP 180/120, HR 120-130s
and RR 35. He was given a total of 10 mg of IV ativan, 5 mg IV
haldol and 2 mg IV versed and was very sedated when he came to
the [**Hospital Unit Name 153**]. Initial vs in ICU were BP 134/73, P 91O2 sat 95% on
RA. Patient exhibiting periods of apnea which appears to be from
possible obstructive sleep apnea as he is trying to breathe
against a closed glottis.
Past Medical History:
1. Depression
2. Polysubstance abuse
3. Anxiety
4. BPH
5. h/o ARF after rhabdo [**1-3**] cocaine ingestion in [**2180**], needed to
be previously dialyzed. Last creatinine in [**2180**] was 1.9.
6. Hep B core ab positive on last admit and Hep C ab pos with
neg viral load
Social History:
smoker [**10-3**] ppd, occ etoh, h/o abuse in past. Uses cocaine
weekly. H/o IVDA but not now.
Family History:
non-contrib
Physical Exam:
GEN: sleeping, arousable with painful stimuli and sternal rub
HEENT: anicteric, pupils 2 mm and equally reactive, MM dry, OP
clear
NECK: no tenderness, suppple
SKIN: no lesions or track marks
CV: RRR no m/r/g
PULM: CTAB
ABD: soft, NT, ND, no masses or HSM, +bs
EXT: no cce, pedal pulses 2+ b/l
NEURO: DTRs 2+ and equal throughout, toes upgoing to babinski
but no [**Doctor Last Name 6671**], withdrew feet b/l, unable to assess strength or
cranial nerves
Pertinent Results:
[**2183-9-26**] 11:24AM URINE HYALINE-[**2-3**]*
[**2183-9-26**] 11:24AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2183-9-26**] 11:24AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2183-9-26**] 11:24AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2183-9-26**] 11:24AM PLT COUNT-189
[**2183-9-26**] 11:24AM NEUTS-89.0* LYMPHS-6.8* MONOS-3.3 EOS-0.7
BASOS-0.1
[**2183-9-26**] 11:24AM WBC-12.0* RBC-5.24# HGB-14.7# HCT-42.9#
MCV-82 MCH-28.0 MCHC-34.2 RDW-14.7
[**2183-9-26**] 11:24AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2183-9-26**] 11:24AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-9-26**] 11:24AM CK-MB-22* MB INDX-2.7
[**2183-9-26**] 11:24AM cTropnT-<0.01
[**2183-9-26**] 11:24AM LIPASE-17
[**2183-9-26**] 11:24AM ALT(SGPT)-28 AST(SGOT)-55* LD(LDH)-320*
CK(CPK)-823* ALK PHOS-85 AMYLASE-72 TOT BILI-0.9
[**2183-9-26**] 11:24AM GLUCOSE-98 UREA N-27* CREAT-1.4* SODIUM-142
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-17* ANION GAP-24*
[**2183-9-26**] 06:07PM OSMOLAL-297
[**2183-9-26**] 06:07PM CK-MB-22* MB INDX-2.2 cTropnT-<0.01
[**2183-9-26**] 06:07PM CK(CPK)-1011*
[**2183-9-26**] 06:13PM LACTATE-0.8
[**2183-9-26**] 06:13PM TYPE-ART PO2-82* PCO2-36 PH-7.40 TOTAL CO2-23
BASE XS--1
Brief Hospital Course:
56 year old with substance abuse, here s/p cocaine use and
resulting combativeness.
.
# Cocaine/opiate intoxication
-[**Doctor Last Name **] scale followed with 2 g ativan for [**Doctor Last Name **] > 10
-on day of discharge, pt. had not scored on [**Doctor Last Name **] scale, felt
well, VSS, eating, ambulatory.
.
# HTN - resolved after agitation was treated with benzos. Has no
previous history of HTN. Pt had 2 sets of negative cardiac
enzymes, refused the third. BP stable at time of d/c without
treatment.
.
# Elevated CK - initial ck 800. CK trended down to <300 at time
of d/c.
.
# Renal failure with AG acidosis- likely pre-renal on
presentation. Resolved with hydration. At time of discharge had
resolved, cr. normal.
.
# Depression- resumed home SSRIs and trazodone, hydoxyzine. At
time of d/c denied depressed mood, suicidality.
.
# BPH- resumed finasteride.
Medications on Admission:
Called pt.s pharmacy to confirm:
Hydroxazine 50 [**Hospital1 **] prn
Finasteride 5mg qday
Trazodone 100mg qhs
Cymbalta 40mg daily
Citalopram 20 mg daily
Discharge Medications:
No changes:
1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) as needed.
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Cocaine intoxication/overdose
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. Return to the [**Hospital1 18**]
Emergency Department for:
Chest pain
Suicidal thoughts
Lightheadedness
Followup Instructions:
Call your primary doctor for a follow up appointment within two
weeks of leaving the hospital:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 53457**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 14315**]
|
[
"970.8",
"790.5",
"965.00",
"311",
"305.91",
"586",
"728.88",
"796.2",
"E849.9",
"588.89",
"E850.2",
"E854.3",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5061, 5067
|
3532, 4410
|
343, 350
|
5141, 5150
|
2109, 3509
|
5341, 5555
|
1606, 1619
|
4615, 5038
|
5088, 5120
|
4436, 4592
|
5174, 5318
|
1634, 2090
|
276, 305
|
378, 1183
|
1205, 1478
|
1494, 1590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,527
| 155,091
|
22045
|
Discharge summary
|
report
|
Admission Date: [**2131-8-27**] Discharge Date: [**2131-10-3**]
Date of Birth: [**2068-10-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy w/ biopsy
History of Present Illness:
[**First Name8 (NamePattern2) **] [**Known firstname **] [**Known lastname 916**] is a 62-year-old woman with a history of
myelodysplasia, DVT, cellulitis, GVHD (diarrhea)presents with
worsening diarrhea. She was admitted on [**2131-1-11**] for allogenic
stem cell transplant per protocol DF05-279 and her conditioning
regimen consisted of photophoresis, pentostatin, and TBI. She
is now day 215 after transplant. [**Doctor First Name **] did very well in her
early posttransplant period; however, just after day 100, was
admitted with grade 3 GVHD of her GI tract. She had large
amounts of diarrhea. She has had two admissions for management
of this, C.diff negative.
Per the pt, she has [**3-4**] semi-formed, soft bowel movements per
day, non-bloody, no mucus, with mild cramping prior but
otherwise no abd pain. Pt denies any change or worsening of
diarrhea in the past several weeks. However, the pt's Hem/Onc
attending was concerned about worsening diarrhea as she had [**3-4**]
bowel movements in one hour at clinic. They report 10+ bowel
movements daily.
Past Medical History:
Hematologic Hx:
Severe MDS diagnosed in [**2130**].
Cytogenetics-->Initial bone marrow showed deletion 7 associated
with a poor prognosis. However, repeat cytogenetics performed on
[**2130-12-28**] at [**Hospital1 18**] show no such deletion.
Flow--> CD34-positive blasts are estimated at 5-6%
Biopsy/Aspirate-->From [**2130-12-28**]: The blast count on the aspirate
is 6%, and by CD34-immunostains is 6-10%, consistent with a
diagnosis of refractory anemia with excess blasts (RAEB-1) by
WHO criteria. While the cellularity was difficult to estimate
due to the aspiration artifact, the overall cellularity appears
decreased, which may be consistent with an hypoplastic
myelodysplastic syndrome.
.
Had sibling reduced-intensity Allogeneic Transplant [**2131-1-17**]
that she tolerated well with minimal transfusion requirements.
Bone marrow on [**4-27**] showed it was mildly hypocellular. There
were minimal dysplastic changes but of uncertain significance.
The patient's chimerism showed 99% donor.
.
Patient recently admitted to hospital (discharged on [**2131-6-10**])
with severe diarrhea from GVHD. Colonoscopy consistent with
GVHD. Diarrhea improved with increased immunosuppresents
.
PAST MEDICAL HISTORY:
.MDS - see history above
.Mitral regurgitation - Echo in [**12-6**] showed: Mitral valve
prolapse. Severe mitral regurgitation. Normal left
ventricular size and function.
.hypothyroidism - treated as outpatient on levothyroxine 50mcg,
last TSH 5.2 in [**3-7**]
pre-glaucoma - treated with travoprost
uterine polyps
GERD
hypercholesterolemia.
.
PAST SURGICAL HISTORY: Status post right breast lumpectomy for
benign cyst 35 years ago, multiple D&Cs, laser wart removal,
finger I&D.
Social History:
The patient is married; she has a son and a daughter. She has
two grandchildren. She retired this past [**Month (only) **] ([**2130**]) from
working as a cashier in the cafeteria of a local high school.
She smoked for approximately 4 years in high school, she does
not smoke and has stopped consuming alcohol, she has never used
illegal drugs.
Family History:
The patient has 2 siblings who are both living. Her brother has
a history of hypertension and an abdominal aneurysm that is
being watched; her sister has hypothyroidism and a history of
vascular surgery. Her father is deceased from throat cancer, her
mother is deceased from CVA. She had a maternal aunt with breast
cancer, and another maternal aunt with uterine cancer. She has
two children who are alive and well.
Physical Exam:
VS: 98.1 93% 4L, RR 16, HR 126 BP 103/78 on levophed 0.3
Gen: pale, elderly, NAD. Somewhat ill appearing
HEENT: MM dry. EOMI, PERRLA, anicteric. OP clear, left IJ in
place
Cards: Tachy, reg rate. no murmurs. no rub
Lungs: decreased BS at bases. no focal consolidation
Abd: BS+ NT ND soft, no rebound.
Ext: large tender, erythematous cellulitic region to left lower
extremity in upper thigh which extends to perineum and to the
posterior thigh. It is significantly tender to palp. there is
a 2x2cm area of local drainage but no obvious pocket of air or
fluid.
- distal pulses and [**Last Name (un) 36**] intact
NEURO: alert to person, place, situation. FROM, [**Last Name (un) 36**] intact
grossly
Pertinent Results:
.
Pathology of Nasal Turbinate [**2131-9-14**]:
Respiratory mucosa with mild chronic inflammation and fungal
forms consistent with aspergillus (GMS stain) seen.
.
[**2131-9-12**]:
1) Cholelithiasis without definitive evidence of acute
cholecystitis.
2) Unchanged small intra-abdominal ascites and right-sided
pleural effusion.
3) No evidence of portal vein thrombosis.
.
[**2131-9-10**]:
No evidence of bowel obstruction or ileus.
.
[**2131-9-7**]:
1. Tiny 3-mm nonobstructing right renal calculus. No
hydronephrosis.
2. Mildly increased renal echogensicity and evidence of cortical
thinning suggestive of underlying medicorenal disease. Correlate
clinically.
.
[**2131-9-4**]:
1. Cholelithiasis; no evidence of acute cholecystitis:
2. Small ascites and right-sided pleural effusion.
3. No evidence of a portal vein or hepatic vein thrombosis.
.
8/340 ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. The mitral
valve leaflets are elongated. There is moderate/severe mitral
valve prolapse. An eccentric, posterolaterally directed jet of
Moderate (2+) mitral regurgitation is seen. The timing of the
mitral regurgitation is late systolic. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
CXR [**9-1**]: relatively clear fields. Tip of left IJ in SVC
.
[**7-12**] DVT scan:
1. No evidence of right-sided DVT.
2. A similar extent of left-sided DVT extending from the right
common femoral
vein to the popliteal fossa with a slight reconstitution of flow
within the
right superficial femoral vein.
.
Colon bx [**5-7**]: GVHD
CMV Viral Load: CMV was not detected on [**6-25**], but on [**6-29**] was
22,100 copies/ml. Peaking on [**2131-7-3**] at 38,800 copies/ml.
[**2131-8-20**]: 1,600 copies/ml
.
MICRO:
blood cx this admit NGTD
[**2131-8-6**] wound cx: pseudomonas
C diff neg x3 since [**8-20**]
[**7-12**] urine w pseudomonas (cipro, tobra, gent res) and e coli
Brief Hospital Course:
62 year old female w/ allo SCT +>200 days, hx recent CMV
infection and GVHD diarrhea admitted for worsening diarrhea.
.
Cellulitis: Patient was transferred to the [**Hospital Unit Name 153**] for worsening
left thigh cellulitis. Concern for cellulitis vs. necrotising
fascitis. The patient had a prior history of pseudomonal
cellulitis on her left leg. On hospital day 6 she was developed
fevers to 101.8, rigors and became hypotensive to 70/40 which
did not respond to fluid boluses. Her left leg was noted to
look markedly cellulitis with erythema and tendernss. She was
placed on cefepime, flagyl and tobramycin given previous
pseudomonal sensitivities. She was transferred to the intensive
care unit where she was placed on pressors. The patient was
seen by sugery and the ID consult service. There was concern
that her leg infection might represent necrotising fasciitis.
CT scan of the left leg revealed extensive muscle edema but no
clear evidence of necrotising fasciitis but it was unclear what
type of inflammatory response the patient would mount given her
neutropenia. The patient's antibiotic coverage was broadened to
include meropenem, daptomycin and clindamycin and ultimately
switched to vancomycin and meropenem. The decision was made to
not take the patient to the operating room because the picture
was not entirely clear and it was felt that the patient would
not tolerate an extensive surgical procedure. Her cellulitis
slowly improved with broad spectrum antibiotics. She completed
a 21 day course of meropenem and vancomycin. Ultimately she
developed a well healing black eschar on the area, but never
fully resolved.
.
Sepsis: On hospital day 6 the patient developed rigors, fevers
to 101.8 and became hypotensive to the 70s systolic which was
not responsive to fluid boluses. At that time her leg was
markedly cellulitis with erythema, warmth and tenderness. Blood
and urine cultures were negative. CXR at that time showed no
evidence of infiltrate. It was felt that her sepsis was most
likely secondary to her leg wound. She was placed on broad
spectrum antibiotics per the infectious disease service as
described below. She required pressors for blood pressure
support. She received aggressive volume resucitation with IVF,
blood and albumin. She was weaned off pressors after the
initial 24 hour period but became hypotensive for a second time
and was placed back on pressors for an additional 72 hours.
Following this she was hemodynamically stable for the remainder
of her MICU course. She completed a 21 day course of meropenem
and vancomycin for her leg wound with slow clinical improvement.
Despite further aggressive care, she later developed both
aspergillosis in lungs and CMV viremia. Both were treated
aggressively and Infectious disease followed her throughout most
of her hospitalization. Ultimately, however, despite multiple
antibiotics, antifungals and antivirals, she did not overcome
her numerous infections and succumbed to massive sepsis.
.
Renal Failure: During her MICU course the patient developed
acute renal failure with her creatinine increasing from a
baseline of 0.4 to a peak of 1.3. Urine electrolytes were not
consistent with a prerenal etiology and her urine output was not
responsive to fluid boluses. Her urine sediment had many
granular casts. It was felt that her renal failure was most
likely secondary to ATN induced by her long period of
hypotension and pressor requirement. The patient was oliguric
for approximately one week and subsequently became severely
volume overloaded ultimately leading to intubation for
respiratory distress. The renal service was consulted who
recommended aggressive diuresis. Despite being on a lasix drip,
her renal function continued to decline. A discussion was held
with her family and the Renal team concerning further course of
therapy given that many of her medications were nephrotoxic and
she may need dialysis. Both her family and the Renal team
agreed with this course of action. In the last 24 hours of her
life, however, she had a rapid decline related to her
overwhelming sepsis and not renal function and never required HD
prior to death.
.
Invasive Fungal Infection: The patient was noted to have
aspergillus growing in her sputum on two samples. The
speciation of the mold suggested a non-pathogenic species but
the patient's fungal markers were significantly elevated. CT of
the chest did not reveal a clear fungal pneumonia. She
underwent MRI of the brain which showed an air fluid level in
the sphenoid sinuses. ENT biopsied a small ulcer in her middle
turbinate which ultimately came back positive for aspergillus
infection. She underwent debridement of her nasal septum and
turbinate on [**9-20**] and pathology results showed evidence of
angioinvasive fungal infection. She was treated initially with
posiconazole and ambisome with close monitoring of her liver and
kidney function. Her beta-glucan and galactomanan levels were
consistently monitored for signs of decreasing infection.
Despite aggressive therapy, the infection was ultimately
overwhelming.
.
Respiratory Failure: The patient was intubated on [**9-3**] for
respiratory distress secondary to pulmonary edema. Chest CT
showed bilateral pleural effusions but no clear evidence of
infection. Sputum cultures revealed aspergillus in two samples
(non fumagatus/[**Country 11730**]/flavus species). BAL with minimal mucous,
cultures negative. Despite aggressive diuresis she continued to
have poor NIFs and RSBIs. She ultimately underwent trachestomy
on [**9-20**] for prolonged respiratory failure. She continued on
trach AC until her death, never tolerating breathing on her own.
.
GVHD of the GI tract: The patient was originally admitted with
diarrhea felt to be secondary to GVHD. She underwent
colonoscopy which showed granularity consistent with GVHD.
Biopsy, however, was not definiative. She did have evidence of
CMV reactivation but CMV cultures from the colon were negative.
Stool cultures and clostridium difficile toxins were negative as
well. The patient was initially treated with increasing doses
of immunosuppresive agents including Solumedrol, cyclosporin and
cellcept. She also received one dose of IVIG when her IgG
levels were found to be low. She was started on TPN. When she
presented with sepsis her cellcept was discontinued and the
doses of her other immunosuppresives were reduced. For much of
her MICU course she had no evidence of stool production and
hypoactive bowel sounds. She also had persistently elevated
liver enzymes indicative of ongoing GVHD. Her steroids were
intermittently increased and then decreased given the fine
balance between managing her GVHD and controlling her multiple
infections.
.
Thrombocytopenia: Throughout her MICU course the patient has
had significant thrombocytopenia requiring platelet
transfusions. The etiology of this is unclear but has been felt
to be secondary to marrowsuppressive effects of her medications
including gancyclovir and cyclosporin. She was HIT negative.
DIC labs negative on multiple occassions. She did receive IVIG
on [**9-8**] with little improvement in her platelet count. She was
transfused as needed for platelet counts less than 30 or when
she developed oozing from her trach or sinuses after
debridement.
.
Anemia: The patient was also noted to have anemia throughout her
MICU course. She was found to have a decreased reticulocyte
count and an elevated ferritin consistent with an inflammatory
anemia. She received multiple red blood cell transfusions.
.
Embolic vs. Watershed infarcts: Patient noted to have three
small acute to subacute infarcts involving the right superiour
fontal lobe and right inferior cerebellum. Unclear etiology.
Concern that these represent fungal infection. She underwent
TTE which was inconclusive for fungal endocarditis. She had a
repeat MRI on [**9-23**] which was limited secondary to motion, but
ultimately read by Neuroradiology as no progression. No further
imaging was obtained, and she was never alert enough to perform
a meaningful neurological exam.
.
Sinus Bradycardia: Postoperatively the patient was noted to have
sinus bradycardia of unclear etiology but felt to be secondary
to post-operative sedation causing increased vagal tone. EKG
with no other significant changes. This resolved for almost 10
days until the last 24 hours of her life, when she progressively
had bradycardia until asystole.
.
Atrial Fibrillation: Patient with intermittent atrial
fibrillation with rapid ventricular response during this
hospitalization. Hemodynamically stable during this episodes.
She has been treated with digoxin on a number of occassions as
needed for rate control with good effect. She was not
anticoagulated given her thrombocytopenia and elevated IRN.
.
Elevated INR/Elevated total bilirubin: Throughout her MICU
course the patient has had fluctuating liver function tests, INR
and total bilrubin. Originally she was felt to have liver
function test abnormalities secondary to hypotension her
transaminases were never dramatically elevated. Her
transasminases have since normalized with a persistently
elevated alkaline phosphatase and total bilirubin. Multiple RUQ
ultrasounds have been negative for cholecystitis and portal
venous thrombosis. There was also concern that her LFT
abnormalities might be secondary to medications
(caspufugin/voriconazole/ambisome) or GVHD of the liver. Her
fungal coverage was switched from voriconazole to posaconazole
for decreased hepatic toxicity. Her IV steroids were decreased
to see if this would unmask GVHD of the liver. Her LFTs and
Tbili continued to rise, concerning for worsening GVHD, so her
steroids were increased. Towards the end of her life, her Tbili
indicated worsening damage and concern for uncontrolled GVHD
despite immunosuppresion. Heme-Onc followed her throughout her
stay, and their input was greatly appreciated.
.
CMV: Patient has had evidence of CMV infection throughout her
MICU course. Viral load trended up from 2960 to 49,000 and
finally started trending down when started on higher induction
doses of gancyclovir dosed for her creatinine clearance.
Ultimately, it began rising again and became uncontrolled. ID,
who was following her throughout her stay, had multiple
discussions with the family about the use of foscarnet given
that this may lead to complete renal failure. Her family was in
line with this decision making and she was started on it only
very briefly before she rapidly declined over the course of a
day and died from asystole.
.
MDS: The patient was status post-bone marrow transplant. Her
post-transplant course has been complicated by GVHD of the GI
tract and CMV infection. She currently is on reduced doses of
cyclosporin and solumedrol for GVHD treatment. Her last
chimerism showed 100% engraftment. Followed by Heme-Onc
throughout her inpatient stay.
.
DVT: CT of lower extremities from [**9-1**] shows bilateral DVTs.
Patient is thrombocytopenic so will not continue her on lovenox.
She has an IVC filter in place. No pneumoboots were used given
known DVT. Additionally, anticoagulation was held due to her
thrombocytopenia, anemia and oozing from multiple wound sites.
.
Hypothyroidism. Continue levothyroxine throughout her stay.
.
Hyperglycemia. Improved. Continue sliding scale with insulin
in TPN. Continue to follow nutrition recs. Goal per Heme/Onc is
for patient to be borderline hypoglycemic. She did well with
this during her stay.
.
Ultimately, given these multiple medical problems and
overwhelming infection, Mrs. [**Known lastname 916**] had a quick decompensation the
last 24 hours of her death signaled by progressive bradycardia.
Her family was called to her bedside given their wishes that she
be DNR. Early in the morning of [**2131-10-3**] she developed asystole
and was prounounced dead by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 483**].
Medications on Admission:
See prior discharge summary.
Discharge Medications:
None, expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis, Aspergillosis, CMV viremia, MDS
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
[
"038.43",
"284.1",
"996.85",
"117.3",
"570",
"480.8",
"790.29",
"427.31",
"238.75",
"574.20",
"998.11",
"518.81",
"285.1",
"995.92",
"293.0",
"078.5",
"276.6",
"682.6",
"584.5",
"785.52",
"434.91",
"453.8",
"599.0",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"22.63",
"22.60",
"21.22",
"33.23",
"99.14",
"22.52",
"99.04",
"22.2",
"21.69",
"38.93",
"99.05",
"22.19",
"99.07",
"99.15",
"31.1",
"96.04",
"96.56",
"96.72",
"21.61",
"22.50"
] |
icd9pcs
|
[
[
[]
]
] |
19297, 19306
|
7187, 19179
|
324, 347
|
19389, 19399
|
4701, 7164
|
19456, 19467
|
3544, 3961
|
19258, 19274
|
19327, 19368
|
19205, 19235
|
19423, 19433
|
3051, 3166
|
3976, 4682
|
276, 286
|
375, 1446
|
2684, 3028
|
3182, 3528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,812
| 114,731
|
16049
|
Discharge summary
|
report
|
Admission Date: [**2196-4-26**] Discharge Date: [**2196-5-3**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
male with prostate cancer recently hospitalized with
pneumonia who presents with fatigue. Since his
hospitalization he has been up and down per his family. Over
the last two days he has grown more fatigued per his
daughter. [**Name (NI) **] has gone three months without a transfusion and
often appears fatigue when he is due for a transfusion. His
po has decreased and he has not been sleeping at night. He
occasionally uses Ativan with resultant hypersomnolence and
confusion per his family. No reports of fevers, chills,
diarrhea, abdominal pain. He has pain when coughing from a
possible rib fracture sustained during a fall. Today he is
quite confused. Physical therapist saw him at home thought
he had deteriorated so his family brought him to see Dr.
[**Last Name (STitle) **] and this patient was admitted from clinic.
PAST MEDICAL HISTORY: Prostate cancer hormone refractory,
congestive heart failure, peptic ulcer disease, degenerative
joint disease, anemia transfusion dependent.
HOME MEDICATIONS: Renagel 800 t.i.d., Colace 100 b.i.d.,
hydrocortisone 20 b.i.d., Benzonatate 100 t.i.d.,
Ketoconazole 400 b.i.d., Toprol 25 b.i.d., Levaquin 250
b.i.d., Trazodone 50 q.h.s., Duragesic patch 15 micrograms
per hour q 32 hours, Percocet prn, Lasix 20 mg times one.
ALLERGIES: Ultram.
PHYSICAL EXAMINATION: Temperature 98. Heart rate 91. Blood
pressure 164/64. Respirations 24. O2 sat 97%. General, the
patient was alert, weak, chronically ill appearing. HEENT
ecchymosis over the left face. Tongue midline. Thorax clear
to auscultation bilaterally. Cardiac regular rate and
rhythm. Abdomen positive bowel sounds, nontender,
nondistended. Extremities no pitting edema. Neurological in
general, the patient was alert, but disoriented. Speech was
fluent. Cranial nerves II through XII are intact. Motor 5
out of 5 throughout upper and lower extremities.
LABORATORY: White blood cell count 2.8, hematocrit 25.3,
platelets 27.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2196-4-26**]. He was transfused to correct his anemia. The
patient was admitted to the Medicine Service. All narcotics
and sedatives were held. A CT scan was performed to evaluate
an old subdural hematoma sustained after a fall. Chest x-ray
was performed, which was negative. His Ketoconazole was
stopped. The patient was introduced to the neurosurgery
service for the purpose of draining his subdural hematoma. A
neurological checks q one hour were recommended. His
platelets were transfused to maintain platelets up above 100.
On [**2196-4-28**] a subdural drain was placed to allow drainage of
the subdural hematoma. Drainage was successful and the
patient continued to improve. On [**2196-4-30**] the drain was
removed. On [**2196-5-1**] the patient was discharged to the
regular floor where he received physical therapy and a
regular diet. He did well with both and physical therapy
recommended that the patient be allowed to go home with 24
hour supervision.
On [**2196-5-3**] the patient is being discharged to home. He will
have 24 hour supervision provided by his wife and daughter.
[**Name (NI) **] will also be sent home with VNA to provide home safety
evaluation checks, neurological checks, cardiopulmonary
checks and gait training. The patient is to follow up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1327**] in about one week for suture removal. The
patient is being discharged on Tylenol #3 for pain, Renagel
800 mg po t.i.d., Colace 100 mg po b.i.d., Hydrocortisone 20
mg po b.i.d. po, Toprol 25 mg po q 12, Trazodone 50 mg po
q.h.s. po, Duragesic patch 50 micrograms per hour q 72 hours,
Ranitidine 150 mg po q day. The patient is being discharged
in stable condition. He may observe a regular diet and ad
lib activity.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern4) 5919**]
MEDQUIST36
D: [**2196-5-3**] 12:05
T: [**2196-5-4**] 08:09
JOB#: [**Job Number 45925**]
|
[
"432.1",
"564.00",
"276.5",
"593.9",
"185",
"280.0",
"707.0",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
2157, 4246
|
1198, 1482
|
1505, 2139
|
147, 1013
|
1036, 1179
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,234
| 166,372
|
25240
|
Discharge summary
|
report
|
Admission Date: [**2153-6-5**] Discharge Date: [**2153-6-5**]
Date of Birth: [**2115-12-18**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37M w/ h/o bipolar and schizoaffective disorders and substance
abuse admitted with altered mental status. He initially came
into the emergency room apparently complaining of depression [**Doctor First Name **]
EMS accompanied with racing thoughts. Per report, patient
denied SI/HI.
.
In the ED, patient initially presented AO and eating food.
Within the hour began sweating and losing consciousness with
responsiveness only to sternal rub. Pupils WNL. FSBG 95.
Received 0.5 mg of flumazenil with return to alert state.
After, patient became agitated requesting to leave the ED. Was
section 12 by psychiatry for questionable suicidal ideations as
well as grossly imparied judgement and behavior. Urine tox
positive for benzos, amphetamines, and cocaine. Serum tox
positive for benzos but negative for EtOH. Other laboratory
data notable for leukocytoiss of 20.2 without bandemia and
normal white count distripution, as well as a thrombocytosis of
500. Vitals prior to transfer were T: 98.1, HR: 94, BP 124/80,
RR16 POx 96%.
.
On the floor, patient is AOx3 and calm. No acute distress.
When asked about recent cocaine use based on urine tox, denied,
although did admit to recent marijuana use.
.
Review of systems:
(+) Per HPI. Also reports 12 lbs weight gain since starting
risperidone 5 months ago.
(-) 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:
Past Medical History:
- h/o head trauma
- substance abuse
- bipolar disorder
- schizoaffective disorder
- hepatitis C genotype II
- hyponatremia
- polysubstance abuse incluidng cocaine, heroine
- chronic leukocytosis of unclear etiology.
.
PAST SURGICAL HISTORY:
1. Multiple trauma secondary to motor vehicle crash in [**2146**].
2. Bilateral rib fractures.
3. Jaw fracture, status post bilateral mandibular repair.
4. Status post splenectomy in [**2146**] secondary to motor vehicle
accident.
5. Right post tib-fib patellar repair.
6. Right shoulder surgery for dislocations, multiple times.
Social History:
Disabled secondary to his psychiatric
illness and does not currently work. Lives with a friend [**Name (NI) **]
[**Name (NI) **] [**Name (NI) **], his 61 yo roomate. Currently under a lot of
stress at home as having "misunderstandings" with his roomate.
Incarcerated from
[**2148**] to [**2150**] for assault and battery. Smoked 1 pack per day
since [**54**]. History of cocaine, heroin, and marijuana use.
Distant history of alcohol use.
Family History:
DM in both grandparents.
Physical Exam:
Vitals: T: 96.6 BP: 121/73 P: 57 R: 12 O2: 96%RA
General: Lethargic but Alert, oriented, no acute distress.
Diaphoretic
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
sluggishly reactive at 2mm bilaterally.
Neck: supple, no LAD.
Lungs: Coarse bronchial breath sounds thorughout without
definite wheezes or rhonchi.
CV: Bradycardic. Faint [**12-21**] murmur best auscultated at the Apex.
Normal S1 + S2, no rubs, gallops
Abdomen: Protuberant abdomen with midline scar. Nodular
postsurgical changes palpated in region underscar. Otherwise
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly. No HSM
appreciated.
GU: foley in place with clear urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Bilateral small scars noted around malleoli and tibial
regions.
Pertinent Results:
Admission Labs:
================
[**2153-6-5**] 05:51AM GLUCOSE-108* UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-28 ANION GAP-10
[**2153-6-5**] 05:51AM ALT(SGPT)-57* AST(SGOT)-34 LD(LDH)-162 ALK
PHOS-115 TOT BILI-0.2
[**2153-6-5**] 05:51AM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.5
MAGNESIUM-2.3
[**2153-6-5**] 05:51AM WBC-15.0* RBC-4.37* HGB-13.7* HCT-39.7*
MCV-91 MCH-31.3 MCHC-34.4 RDW-14.1
[**2153-6-5**] 05:51AM NEUTS-50.2 LYMPHS-36.9 MONOS-7.8 EOS-3.8
BASOS-1.2
[**2153-6-5**] 05:51AM PLT COUNT-531*
[**2153-6-5**] 05:51AM PT-14.1* PTT-32.7 INR(PT)-1.2*
[**2153-6-4**] 11:45PM URINE HOURS-RANDOM
[**2153-6-4**] 11:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-POS mthdone-NEG
[**2153-6-4**] 11:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2153-6-4**] 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2153-6-4**] 09:30PM GLUCOSE-84 UREA N-14 CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2153-6-4**] 09:30PM estGFR-Using this
[**2153-6-4**] 09:30PM ALT(SGPT)-66* AST(SGOT)-41* LD(LDH)-194 ALK
PHOS-118 TOT BILI-0.3
[**2153-6-4**] 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2153-6-4**] 09:30PM WBC-20.2* RBC-4.50* HGB-14.1 HCT-40.7 MCV-90
MCH-31.2 MCHC-34.6 RDW-14.0
[**2153-6-4**] 09:30PM NEUTS-56.5 LYMPHS-32.5 MONOS-7.0 EOS-2.0
BASOS-2.0
[**2153-6-4**] 09:30PM PLT COUNT-500*\
Discharge Labs
=================
Brief Hospital Course:
Assessment and Plan: 37M w/ h/o bipolar and schizoaffective
disorders and substance abuse admitted with oversedation from
presumed benzodiazepine overdose now resolving status post
flumazenil administration.
.
Sedation/Benzo Toxicity: patient presented on multiple sedating
medications. Medication list confirmed with patient and has
multiple redundant MOA's, including 3 different benzodiazepines,
antidepressants, AEDs, and Ultram. Urgent need for appropriate
medication reconciliation. Initially held sedating
medicationss.
Following morning patient more alert and oriented with physical
exam presentation concerning for developing manic episode.
Restarted AEDs (per Mood Disorder) and restarted Klonipin. Also
placed on CIWA with Diazepam given concern for acute
benzodiazepine withdrawal. He exhibited no signs of withdrawl
or seizures from flumazenil. Psychiatry consult suggested an
outpatient dual diagnosis program and stated that patient was
safe for discharge home.
Substance Dependence/Mood Disorder: patient initially had a
section 12 for impaired judgement and lack of insight into
current clinical presentation. Psychiatry consulted in ED.
Psych recs for aid in polysubstance abuse and polypharmacy
dependence suggested that patient follow-up in an outpatient
dual diagnosis program. Upon further psychiatric evaluation in
the AM, it was determined he was safe to go home. Patient was
thus discharged.
Medications on Admission:
- alprazolam 2mg QID
- bupropion ER 150mg [**Hospital1 **]
- clonazepam 1mg TID
- gabapentin 800mg QID
- ibuprofen 800mg TID
- lamotrigine 200mg [**Hospital1 **]
- omeprazole 20mg daily
- Trileptal, 300 mg [**Hospital1 **]
- polyethylene glycol 17gm daily PRN
- pregabalin 150mg TID
- selenium sulfide 2.5% [**Hospital1 **]
- temazepam 30mg QHS
- tramadol 50mg QID PRN
- triamcinolone 0.05% [**Hospital1 **] PRN
- docusate 100mg daily
- multivitamin
- nicotine patch
- senna
Discharge Medications:
1. alprazolam 2 mg Tablet Sig: Two (2) Tablet PO four times a
day.
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
6. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. polyethylene glycol Powder Sig: One (1) packet
Miscellaneous once a day as needed for constipation.
9. pregabalin 150 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. selenium sulfide 2.5 % Suspension Sig: One (1) application
Topical twice a day.
11. temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. triamcinolone acetonide 0.05 % Ointment Sig: One (1)
application Topical twice a day as needed for rash.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
15. multivitamin Tablet Sig: One (1) Tablet PO once a day.
16. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
18. Trileptal 600 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Anxiety
Likely benzodiazepene overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Patient adamantly denies suicidality
Discharge Instructions:
You were admitted to the intensive care unit after you were
unresponsive in the emergency room. We think that your
unresponsiveness was from dangerous combinations of your
prescription medications. You take many sedating medications,
and need to be extremely careful to not take more than
prescribed.
.
No changes were made to your medications. Please follow-up
closely with your outpatient psychiatrist and primary care
doctor.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2153-6-7**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAIN MANAGEMENT CENTER
When: THURSDAY [**2153-6-14**] at 2:00 PM
With: [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: [**Doctor Last Name **] PAIN MGMT CENTER
When: THURSDAY [**2153-6-14**] at 3:00 PM
With: PAIN PSYCHOLOGY [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"969.4",
"292.84",
"305.60",
"780.09",
"295.72",
"296.80",
"304.10",
"E853.2",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9140, 9146
|
5710, 7141
|
329, 336
|
9229, 9229
|
4120, 4120
|
9870, 10884
|
3210, 3237
|
7667, 9117
|
9167, 9208
|
7167, 7644
|
9417, 9847
|
2395, 2733
|
3252, 4101
|
1587, 2110
|
267, 291
|
364, 1568
|
4136, 5687
|
9244, 9393
|
2154, 2372
|
2749, 3194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,144
| 156,044
|
30619
|
Discharge summary
|
report
|
Admission Date: [**2141-10-24**] Discharge Date: [**2141-10-26**]
Date of Birth: [**2070-7-11**] Sex: F
Service: MEDICINE
Allergies:
Trileptal / Hydrochlorothiazide
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 y/o with h/o HTN, L MCA CVa in [**6-12**] with resudual language
impairment and seizures presents to [**Hospital1 18**] ED with a Na of 114.
Because of her seizures, she was recently started on Trileptal
[**2141-10-13**], and seen by Neuro [**2141-10-20**]. On [**2141-10-23**], her Na was noted
to fall from 139 on [**2141-10-13**] to 126 on [**2141-10-21**]. Her trileptal was
tapered and she received her last dose on [**2141-10-23**] and she was
started keppra. For hypertension, she was started HCTz 5 days
ago by her PCP. [**Name10 (NameIs) **], she presents with being very fatigued. No
fevers, chills, no nausea or vomiting no chest pain or shortness
of breath. Denied any headaches, blurred vision. She has been
drinking [**2-7**] glasses of water per day and has not eaten very
much per the patient. per her son in law, she been urinating
very much.
Past Medical History:
Ischemic stroke L MCA superior division [**6-12**]- mild Broca's
aphasia but no weakness on discharge, in follow up with Dr.
[**Last Name (STitle) **] in [**Month (only) **] he describes that she had "hesitant, broken,
frustrated speech. On the other hand, she can string together at
least six words, and she is coherent. She can follow multiple
different two-step commands. She can salute. She can repeat
various different phrases except she did have difficulties
saying [**State 350**] Institute of Technology." Work up showed
evidence of rheumatic disease on mitral valve, no carotid
stenosis, no arrhythmias on telemetry
-CAD s/p MI 5 yrs ago s/p stent
-High cholesterol
-Hypertension
-s/p basal cell ca resection [**5-13**]
-GERD
Social History:
Social History:
Lives with husband, very physically active, takes care of 4
horses; no tob, etoh, drugs. Has one son [**Doctor First Name **], one daughter.
Family History:
Family History:
No known early strokes in family.
Physical Exam:
On admission:
T- 96.3 BP- 149/66 HR- 56 RR- 13 O2Sat- 97% on RA
Gen: Lying in bed, NAD. SLowed speech, but appropriately
answering questions.
HEENT: NC/AT, dry mucosa
Neck: No tenderness to palpation, normal ROM, supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally. No RRW
aBd: +BS soft, nontender, nondistended
ext: no edema
skin: dry
Pertinent Results:
Labs on Admission:
[**2141-10-24**] 05:30PM BLOOD WBC-5.1 RBC-4.48 Hgb-14.2 Hct-38.6 MCV-86
MCH-31.6 MCHC-36.7* RDW-12.2 Plt Ct-258
[**2141-10-24**] 05:30PM BLOOD Neuts-73.9* Lymphs-17.2* Monos-7.6
Eos-0.8 Baso-0.5
[**2141-10-24**] 05:30PM BLOOD Plt Ct-258
[**2141-10-25**] 03:40AM BLOOD PT-11.3 PTT-26.7 INR(PT)-1.0
[**2141-10-24**] 03:59PM BLOOD ESR-14
[**2141-10-24**] 05:30PM BLOOD Glucose-116* UreaN-15 Creat-1.0 Na-114*
K-4.5 Cl-78* HCO3-26 AnGap-15
[**2141-10-24**] 05:30PM BLOOD CK(CPK)-93
[**2141-10-24**] 05:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-10-24**] 05:30PM BLOOD Calcium-9.8 Phos-3.5 Mg-2.0
[**2141-10-24**] 09:40PM BLOOD Osmolal-245*
[**2141-10-24**] 05:30PM BLOOD TSH-1.3
Brief Hospital Course:
72 y/o with h/o HTN, L MCA CVa in [**6-12**] with resudual language
impairment and seizures presents to [**Hospital1 18**] ED with slowed speech
and fatigue. Because of her seizures, she was recently started
on Trileptal [**2141-10-13**]. On [**2141-10-21**], her Na was noted to fall from
139 on [**2141-10-13**] to 126 on [**2141-10-21**]. Her trileptal was tapered and
she received her last dose on [**2141-10-23**] and she was started
keppra. For hypertension, she was started HCTz 5 days ago.
Today, she presents with being very fatigued with slowed speech.
She denied fevers, chills, nausea, vomiting, chest pain or
shortness of breath. Denied any headaches, blurred vision. She
has been drinking [**2-7**] glasses of water per day and has not eaten
very much - per the patient. Per her son in law, she been
experiencing increased urination over the past week.
.
In the ED:
- 80cc/hr of NS for a total of 500 cc - and her Na increased to
116.
.
Her Urine Sodium was 48, her serum Osm was 248 and her Urine Osm
was in the 432 consistent with SIADH. We also felt that she was
slightly hypovolemic. Hence she was treated with hypertonic
saline with a goal of increasing her Na ~ 8MeQ/24 hours. She
also received NS for volume repletion. Her trileptal was tapered
off by the Neurology sevice and transitioned over to keppra for
antiseizure prophylaxis. Also, her HCTZ was discontinued and her
BP remained in the 120s-130s in the ICU. Her Na gradually
improved to 134 by the morning of [**2141-10-26**]. The pt. remained
stable while in the ICU, showing no evidence of seizure
activity, and her mental status gradually improving. Per
request of the Neurology service she underwent an [**Date Range **] that on
prelim read showed slowing in the region of your old stroke -
however, the final read is pending at the time of your
discharge. On HD 3 the pt. Na had reached a normal level, she
was tolerating PO intake, was urinating without difficulty, was
ambulating without difficulty, and was ready for discharge.
Moreover, the pt. mental status was at baseline at the time of
discharge - A&O x3 and speaking in full sentences.
Medications on Admission:
keppra
HCTZ 25mg daily
Atenolol 50 mg [**Hospital1 **]
Zetia 10 mg qd
Nexium 40 mg qd
Aspirin 325mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Zetia 10 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.
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia due to trileptal/HCTZ
Discharge Condition:
AAO x 3. Speaking fluently.
Discharge Instructions:
You were admitted to the hospital because your Sodium level was
low. This was most likely related to taking Trileptal and
Hydrochlorthiazide, both of which can lower your Sodium levels.
Please STOP taking these medications.
.
Please also limit your fluid intake to 64 ounces per day = 2
quarts. This will also help your sodium level to improve.
.
Please go to Dr.[**Name (NI) 49335**] office on Friday to have your sodium
level checked. In addition, you will follow up with him on
Monday for an office visit.
Followup Instructions:
**It is very important that you make the following appointments.
Please call to confirm appointments**
.
You have an appointment at Dr.[**Last Name (STitle) **] office on Friday for a
blood draw for your Sodium level.
.
You have an appointment on Monday the 24th at Dr.[**Name (NI) 49335**]
office at 145pm for a follow up visit. Please bring a copy of
your discharge summary which we will provide for you for this.
.
Please call Dr.[**Name (NI) 17720**] office at [**Telephone/Fax (1) 2574**] for to arrange
for a follow up appointment.
.
You have an [**Telephone/Fax (1) **] test which is scheduled as below. This is to
follow up your stroke.
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 19105**] Date/Time:[**2141-10-31**] 3:00
|
[
"401.9",
"276.52",
"438.89",
"253.6",
"530.81",
"414.01",
"V45.82",
"E944.3",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6041, 6047
|
3348, 5481
|
307, 314
|
6126, 6156
|
2624, 2629
|
6713, 7467
|
2174, 2210
|
5635, 6018
|
6068, 6105
|
5507, 5612
|
6180, 6690
|
2225, 2225
|
255, 269
|
342, 1207
|
2644, 3325
|
1229, 1966
|
1998, 2142
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,959
| 112,254
|
35245
|
Discharge summary
|
report
|
Admission Date: [**2193-10-22**] Discharge Date: [**2193-10-24**]
Date of Birth: [**2114-12-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Fall out of bed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79F w/p mechanical fall from height of her bed; no LOC; head
CT @ OSH shows small amount of traumatic SAH and patient is
transferred to [**Hospital1 18**] for evaluation; she c/o mild h/a but denies
any neck pain, any abnormal strength or sensation in all
extremities (patient has MS).
Past Medical History:
MS
Social History:
NC
Family History:
NC
Physical Exam:
On admission:
BP: 121/55 HR: 86 R: 18 O2Sats: 10%
Awake, alert, Ox3, NAD, pleasant mood
Speech is intact
Perla, EOMI, face symetric, tongue midline;
Motor: Normal bulk and tone bilaterally. Strength full [**4-29**], with
only trace weakness in distal Left lower ext., at baseline per
patient (MS). No pronator drift
Sensation: Intact to light touch, propioception
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
On Discharge: A&Ox3, follows commads, PERRL, no drift, does have
h/o of MS and is at baseline stregth on L side which is a trace
weaker.
Pertinent Results:
[**2193-10-22**] 04:40AM BLOOD WBC-7.8 RBC-4.30 Hgb-13.9 Hct-40.2 MCV-94
MCH-32.3* MCHC-34.6 RDW-13.8 Plt Ct-243
[**2193-10-22**] 04:40AM BLOOD PT-13.5* PTT-29.5 INR(PT)-1.2*
CXR [**10-22**]: Calcified nodules project over the right mid and
upper lung, of unclear location and may be located in the chest
wall, breast, or lung.
Brief Hospital Course:
Pt was admitted to the ICU for close observation after suffering
a traumatic SAH and multiple facial fx. Opthamology and Plastics
saw the pt while in the hospital and their recommendations were
followed. She had stable head CTs and was neurologically stable.
She did c/o sl. cervicaltenderness however imaging of C-spine
was normal including MRI of c-spine which showed no ligamentous
injury. Cervical collar was removed.
Medications on Admission:
aspirin
Discharge Medications:
1. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed: Please do not drive or operated heavy machinery while
taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*0*
4. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours).
Disp:*45 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Very small foci of traumatic SAH
Left maxilla:
-Displaced, comminuted fx posterior wall
-minimally displaced fx anterior wall
-fx of inferior orbital wall
-minimally displaced fx of lateral orbital
-hemmorrage and fat herniating into left maxillary sinus with no
sinus of entrapment of inferior rectus muscle
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
Followup Instructions:
Neurosurgical Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Plastic Surgery Follow-up
Please call ([**Telephone/Fax (1) 2868**] to make an appointment with Dr.
[**First Name (STitle) 3228**] on Friday.
Please follow up with PCP for lung calcifications seen on chest
xray.
Completed by:[**2193-10-24**]
|
[
"E884.4",
"801.21",
"340",
"802.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2723, 2772
|
1697, 2120
|
337, 344
|
3125, 3149
|
1343, 1674
|
4125, 4619
|
723, 727
|
2178, 2700
|
2793, 3104
|
2146, 2155
|
3173, 4102
|
742, 742
|
1200, 1324
|
282, 299
|
372, 660
|
756, 1186
|
682, 687
|
703, 707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,079
| 154,859
|
7461
|
Discharge summary
|
report
|
Admission Date: [**2181-8-27**] Discharge Date: [**2181-8-28**]
Date of Birth: [**2096-1-3**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal pain, AAA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 27334**] is was seen in vascular
clinic today for follow-up of her known thoracoabdominal aortic
aneurysm. She had reported approximately 5 days of increased
abdominal pain and back pain which did not have any palliative
or
provocative symptoms. She does have baseline lower back pain
but
she feels that this is different from her normal pain. She has
not reported any changes in her appetite, nausea or vomiting, or
blood in her stool, urine or spit. She does have a known type
IV
with involvement of her celiac and inferior mesenteric artery
but
apparent sparing of her SMA, a "double-double" appearance. She
did report that her abdominal pain was slightly better after
being seen in clinic but in the ED, she does report some
increase
in her pain.
Past Medical History:
VASCULAR HISTORY: AAA: 5.9cm in [**2179**], non TEVAR candidate nor
operative at the time.
PAST MEDICAL HISTORY: hypertension, hearing loss, lupus,
depression, and recurrent UTI
PAST SURGICAL HISTORY: R retinopexy, open CCY
Social History:
denies smoking, etoh, illicits
Family History:
NC
Physical Exam:
Vital Signs: Temp: 97.4 RR: 18 Pulse: 83 BP: 122/83
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, abnormal: Palpable approximately 5.5cm
AAA palpable.
Rectal: Not Examined.
Extremities: No RLE edema, No LLE Edema, abnormal: Dusky feet
L>R.
Brief Hospital Course:
After being admitted for blood pressure control, a discussion
was had with the patient with regards to operative repair.
Because of anatomy, the patient is not a candidate for
endovascular repair and the patient does not wish for operative
repair. After ensuring adequate blood pressure control, the
patient was discharged home with instructions for more stringent
BP control.
Medications on Admission:
1. Quetiapine Fumarate 50 mg PO QHS PRN insomnia
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*6 Tablet Refills:*0
Discharge Medications:
1. Quetiapine Fumarate 50 mg PO QHS PRN insomnia
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
thoracoabdominal aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - walker
Discharge Instructions:
You were seen for a concern for rupture or dissection of your
thoracoabdominal aortic aneurysm. You had a CT scan which
showed that the aneurysm had increased in size slightly but
showed no evidence of rupture or dissection. You are not a
candidate for endovascular repair or open repair of this
abnormality. If you notice any severe increase in your
abdominal pain or any other problems, please contact your
primary care doctor or go to the nearest emergency department.
You should also see your primary care physician [**Last Name (NamePattern4) **] 1 months time
with repeat liver function tests as you had a slightly elevated
liver enzyme.
Followup Instructions:
Primary care physician, [**Name10 (NameIs) **] month
You do not need to follow up with Dr. [**Last Name (STitle) **], but can if
you have need, you may contact the office at [**Telephone/Fax (1) 2625**].
Completed by:[**2181-10-31**]
|
[
"441.7",
"401.9",
"311",
"710.0",
"789.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2807, 2813
|
1920, 2299
|
322, 329
|
2905, 2905
|
3722, 3959
|
1448, 1452
|
2566, 2784
|
2834, 2884
|
2325, 2543
|
3050, 3699
|
1360, 1384
|
1467, 1897
|
263, 284
|
357, 1136
|
2920, 3026
|
1271, 1337
|
1400, 1432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,611
| 129,665
|
44042
|
Discharge summary
|
report
|
Admission Date: [**2172-4-13**] Discharge Date: [**2172-4-29**]
Date of Birth: [**2090-5-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Tagged RBC scan
CTA abdomen
Central venous line placement
History of Present Illness:
Mr. [**Known lastname **] is an 81 y/o gentleman with CHF (EF 45%), porcine AV
replacement, severe MR/TR, AFib, pacemaker, diverticulosis s/p
bleed [**2171**], who was transferred from [**Hospital **] Hospital to [**Hospital1 18**]
yesterday ([**4-13**]) due to melena.
Initially, there had been plans for MVR/TVR in 3/[**2172**]. The pt
was admitted to [**Hospital **] Hospital from [**Date range (1) 94558**] w/ refractory
peripheral edema [**2-13**] chronic right sided heart failure and was
diuresed; he was also developed pneumococcal
pneumonia/bacteremia so was treated with two weeks of CTX which
he completed in rehab. While at rehab, warfarin was restarted
for Afib (this had been discontinued in [**5-/2171**] [**2-13**] a large
diverticular bleed) and 3 days later he had dark/tarry stools in
the setting of INR of 3.4 and hct of 27.5 (from 30 on [**2172-3-26**]). He was sent to [**Hospital **] Hospital on [**4-9**] where he was
found to have hct of 28.3 which dropped to 25.8 on repeat. INR
was 2.31. He was given at least 2 units of FFP and 10 mg vitamin
K which brought his INR down to 1.9. Per wife, pt received 1
unit pRBCs. He underwent EGD which showed only a small amount of
blood in the stomach and signs of congestive gastropathy with
multiple hemorrhagic changes. He was transferred to [**Hospital1 18**] on [**4-13**]
because his cardiac care has been here. On the cardiac surgery
service, GI was consulted given his recent GI bleed and plan
were made for colonscopy on [**4-15**]. He was also seen by vascular
surgery for his b/l LE ulcers. Per Cardiac Surgery, he is not a
candidate for surgery at this time due to GI bleed and various
other issues (see below) so a transfer to Medicine was
requested.
Past Medical History:
Hypercholesterolemia
CHF (EF 45% on [**2172-4-14**])
Atrial fibrillation (previously on coumadin until [**2171-5-12**])
GI bleed [**5-/2171**] with 6 unit transfusion d/t Diverticulosis
Decubitus ulcer
Anemia - baseline hct 28-30
Pacemaker [**2-/2170**] Dr. [**Last Name (STitle) 4455**]
Diverticulosis
Hemorrhoids
Hepatic cysts
Obesity
Colonic adenoma
Prostate cancer
Cataract
Acute on chronic renal insufficency - baseline Cr 1.6
Gout
PSH:
s/p Yag Laser Caps - OS [**2172-2-13**]
s/p cataract surgery
s/p Pacemaker for tachy-brady syndrome [**2170-2-23**]
Social History:
Most recently has been staying at [**Hospital 5682**] Nursing Home, prior
to [**Month (only) **] lived at home w/ wife. Pt is a retired court officer
security guard. Pt last smoked in the 60s (20-30 pack years),
and occasionally smokes a cigar. The patient w/ h/o drinking
moderate to heavily, with > 8 drinks per week.
Family History:
Non contributory.
Physical Exam:
ADMISSION EXAM:
VS: Tm98.2 Tc97.6 BP 89/64 (87-94/58-72) HR 90 RR 18 O2 sat 94%
General: Pleasant, alert, oriented, no acute distress, prominent
temporal wasting
HEENT: Sclera anicteric, MM dry, oropharynx clear, no scleral
lesions
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, III/VI holosystolic murmur heard
throughout precordium, but best in LLSB
Abdomen: soft, non-distended, bowel sounds present, liver
palpable 3cm below the costal margin, no tenderness to palpation
or percussion
Ext: wrapped w/ ACE bandages; fingers w/ some deformities
Neuro: CNs2-12 intact, motor function grossly normal
Skin: skin breakdown covered w/ dressings
DISCHARGE EXAM:
Gen: Chronically ill, cachectic man in NAD speaking in full
sentences, A+Ox3, appears to be SOB intermittently
HEENT: MMM, JVD to mandible
Heart: irregularly regular, 3/6 systolic murmur best LLSB
radiating into axilla, RV heave
Lungs: dim b/l base
Abdomen: BSx4, soft, non-tender
Ext: [**2-14**]+ pitting edema b/l LE
Skin: marked venous stasis ulcerations b/l LE
Neuro: Non-focal, AAO x3
Pertinent Results:
ADMISSION LABS:
[**2172-4-14**] 04:30AM BLOOD WBC-4.6 RBC-3.91* Hgb-9.4* Hct-32.0*
MCV-82 MCH-24.2* MCHC-29.6* RDW-21.4* Plt Ct-66*
[**2172-4-14**] 04:30AM BLOOD PT-22.2* PTT-35.5 INR(PT)-2.1*
[**2172-4-14**] 04:30AM BLOOD Glucose-108* UreaN-69* Creat-1.6* Na-140
K-3.0* Cl-102 HCO3-27 AnGap-14
[**2172-4-14**] 04:30AM BLOOD ALT-38 AST-43* LD(LDH)-351* AlkPhos-94
TotBili-1.5
[**2172-4-14**] 04:30AM BLOOD Albumin-2.6* Calcium-9.1 Phos-3.0 Mg-1.9
Iron-20*
[**2172-4-14**] 04:30AM BLOOD calTIBC-282 VitB12-GREATER TH Ferritn-84
TRF-217
[**2172-4-14**] 07:55AM BLOOD %HbA1c-6.0* eAG-126*
[**2172-4-14**] 04:30AM BLOOD TSH-3.8
STUDIES:
[**2172-4-21**] TTE: Left ventricular wall thicknesses are normal. The
left ventricular cavity is severely dilated. There is moderate
to severe reduction of the left ventricular ejection fraction at
least partially due to ventricular interaction (LVEF = 30 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular free wall is hypertrophied. The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. 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. The mitral valve
leaflets do not fully coapt. Severe (4+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is at least moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. There is no
pericardial effusion.
[**2172-4-14**] CXR: The left pectoral pacemaker lead terminates in the
region of the base of the right ventricle. There is severe
cardiomegaly with surrounding atelectasis. There is
opacification in the right lower lobe with air bronchograms that
likely represents pneumonia. There is no pulmonary vascular
congestion or pneumothorax. There are probably small pleural
effusions. IMPRESSION: Right lower lobe pneumonia.
[**2172-4-14**] TTE: The left atrium is markedly dilated. The right
atrium is markedly dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is severely dilated. There is mild to
moderate global left ventricular hypokinesis (LVEF = 45 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
markedly dilated with severe global free wall hypokinesis. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric, posteriorly directed jet of severe (4+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2172-4-15**] EGD: Mottled erythema (giraffe skin pattern) and atrophy
in the antrum compatible with atrophic gastritis (biopsy)
Fundic gland polyps Otherwise normal EGD to third part of the
duodenum.
[**2172-4-15**] Colonoscopy: Polyp at 65cm in the transverse colon
(polypectomy). Diverticulosis of the mid-ascending colon and
sigmoid colon. Otherwise normal colonoscopy to cecum and
terminal ileum.
[**2172-4-15**] Non-invasive arterial studies: 1. Mild inflow arterial
disease to the right lower extremity, likely located at the
iliac level. 2. No evidence of arterial insufficiency to the
left lower extremity.
[**2172-4-15**] Abd U/S: 1. Exaggerated phasicity within the portal vein;
dilated hepatic veins and IVC; pleural effusion and ascites;
findings all consistent with changes of congestive heart failure
and valvular regurgitation. 2. Gallbladder wall edema, also
compatible with congestive heart failure. 3. Left lobe hepatic
cyst.
[**2172-4-24**] GI BLEEDING STUDY:
Intermittent GI bleeding localized to the ascending colon, just
proximal to the hepatic flexure.
[**2172-4-24**] CTA Abdomen
FINDINGS:
1. Tortuous, rotated and atherosclerotic aorta was demonstrated.
2. Multiple digital subtraction angiograms from the superior
mesenteric artery did not demonstrate any active extravasation.
3. Inferior mesenteric artery was not identified.
IMPRESSION: Uncomplicated mesenteric arteriogram of the superior
mesenteric artery with no active extravasation demonstrated.
PATHOLOGY:
[**2172-4-15**] A) Antrum, biopsy: Fundic/antral mucosa with scattered
dilated gastric pits. Some of the fragments of tissue may
represent (portions of) fundic gland polyps. B) Colon,
transverse, polypectomy: Adenoma.
Brief Hospital Course:
81 yo M w/ h/o CHF (EF 45%), porcine AV replacement, severe
MR/TR, AFib, tachy-brady syndrome s/p pacemaker, diverticulosis
s/p bleed in [**2171**], transferred from [**Hospital **] Hospital to [**Hospital1 18**] on
[**4-13**] for evaluation of melena.
.
#) Goals of care:
During the course of Mr. [**Known lastname 94559**] hospitalization, the decision
was made to transition the goals of his care to focus on his
comfort. The decision was made after his second GI bleed.
Although an unsuccessful attempt was made to stop the bleed via
interventional radiology, the patient did not want to undergo a
repeat colonoscopy and it was felt that the risks of this
procedure in light of his comorbid conditions outweighed the
benefits. Multiple discussions were had with the patient, his
longtime girlfriend, and his sons, including his health care
proxy, and the decision was made to treat his GI bleed
conservatively and to transition his code status to "DNR/DNI".
The patient reported that he simply wanted to go home or at
least to a hospice setting. He will be continued on diuretic
therapy for comfort and is to be discharged to a hospice
facility.
#) GIB:
Pt had hx of melena with hct drop to 25 in setting of
anticoagulation with coumadin at rehab. EGD at OSH showed
congestive gastropathy, repeat EGD at [**Hospital1 18**] showed atrophic
gastritis. Colonoscopy showed diverticulosis of mid-ascending
colon and sigmoid w/o any active bleeding; a polyp was also
noted in the transverse colon which was removed, pathology c/w
adenoma. The GI team felt that given his history of large
amounts of bloody and black stool neither of these findings
might account for his bleed. His initial bleeding was ultimately
attributed to his gastritis/gastropathy in the setting of a
supratherapeutic INR. The patient again had a GI bleed on [**4-24**],
this time with BRBPR. He underwent a tagged RBC scan which
revealed a bleeding near the hepatic flexure, unfortunately IR
was unable localize the source for an intervention. A
colonoscopy was consider however, given the patients poor
functional status, significant comorbidities, and shift in the
patient's goals of care, the decision was made to treat his
bleed conservatively. He was given multiple transfusions and
his hematocrit gradually stabilized. He continues to have
maroonish stools.
#) Acute on chronic systolic congestive heart failure secondary
to severe MR [**First Name (Titles) **] [**Last Name (Titles) **]:
The patient was initially evaluated for the possibility of valve
replacement, however it was felt he was a very poor surgical
candidate. He had an episode of respiratory distress and
hypotension prompting transfer to the CCU. He was aggressively
diuresed with a lasix drip, and transitioned to oral torsemide.
He continues to have LE edema and slight pulmonary edema. The
patient is to continues on his diuretic regimen to comfort.
#) Severe Malnutrition:
The patient reported 70 pounds weight loss in the last 3 years
and is cachetic. He was evaluated by nutrition and began taking
supplements with his meals. He is to continue with these
supplements, but should be mindful of his total fluid intake
given his sCHF.
.
#) Atrial fibrillation:
The patient remained in atrial fibrillation throughout his
hospital stay. All of his anticoagulation has been stopped
given both his GI bleed and his new goals of care.
.
#) Coagulopathy:
Initialy was secondary to warfarin and was reversed at OSH with
FFP and vitamin K 10 mg from 3.4 to 1.9. Concern that
coagulopathy may be secondary to impaired hepatic function given
CHF with evidence of congestive hepatopathy on ultrasound. He
is no longer being anticoagulated as above.
.
#) Thrombocytopenia:
On admission to [**Hospital1 18**], plts were around 60. This was a drop from
baseline of 146 on [**4-9**] (160 in 12/[**2172**]). The plts had already
started to trend down by [**4-11**] when they were documented at 64 at
[**Hospital **] Hospital. During his hospitalization at [**Hospital1 18**], platelets
remained stable around 60. The etiology of the thrombocytopenia
was unclear but may have been reactive in the setting of illness
vs. related to evolving liver disease.
#) Acute on chronic kidney disease:
Pt with stage III CKD with baseline creatinine of 1.6. On
admission patient was at his baseline but creatinine bumped to
2.2 on [**4-17**] after several days of NPO status in setting continued
diuresis. Blood pressures also dropped in this setting so ATN
was a possible contributor. He was given fluids and creatinine
trend back to his baseline.
#) RLL infiltrate on CXR:
Pt found to have RLL infiltrate on CXR on admission. He was
recently treated with CTX and azithro for strep pneumo
pna/bacteremia in [**Month (only) 958**] so this was felt to be residual
infiltrate vs. new aspiration pneumonitis. Patient had no active
cough, fever or leukocytosis and antibiotics were not started.
#) LE ulcers:
Pt's ulcers were likely [**2-13**] blistering from chronic LE edema.
Pulses were intact so arterial disease was felt less likely to
be etiology. Vascular was consulted and ABIs performed which
showed low level R LE disease at iliac level. Vascular was not
concerned about mild arterial disease and patient was managed
with leg elevation, ABM foam dressings, and ACE wrap bandaging.
#) Unstageable sacral decub:
Pt with pre-existing sacral decubitus ulcer. Wound care was
consulted and made recommendations for management. Nutrition was
addressed as above and patient was frequently moved.
Medications on Admission:
Home Medications:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler 2 puffs inh prn
ALLOPURINOL 300 mg Tablet daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] 250 mcg-50 mcg/Dose Disk
with Device - 1 puff inh twice a day
FUROSEMIDE 80 mg po BID
METOLAZONE 2.5 mg Tablet po BID
POTASSIUM CHLORIDE 20 mEq 2 Tablet(s) by mouth three times
a day
SIMVASTATIN 20 mg Tablet daily
Coumadin - 4 mg daily - held [**4-7**]
ASPIRIN 81 mg Tablet daily
Tiotroprium 18 mcg daily
Omeprazole 20 mg daily
Mucinex 600 mg [**Hospital1 **]
Oxycodone 2.5 mg PRN
.
Medications on Transfer from [**Hospital1 **]:
Fluticasone 250 salmeterol 50
Lasix 40 mg PO daily
Mucinex 600 mg PO BID
Metolazone 2.5 mg Po daily
Omeprazole 20 mg [**Hospital1 **]
Potassium 20 mEq PO daily
Discharge Medications:
1. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
2. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
5. morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4
hours) as needed for pain/dypsnea.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for shortness of breath or wheezing.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] house
Discharge Diagnosis:
Primary:
Acute on chronic systolic congestive heart failure
Lower gastrointestinal bleeding
Secondary
Atrial fibrillation
Severe malnutrition
Acute on chronic kidney injury
Coagulopathy
Thrombocytopenia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking part in your care during this
hospitalization. You were admitted as you were bleeding in to
your intestines. You also had an exacerbation of your heart
failure. You were diuresed to help remove fluid from your lungs
and your body. You developed a second episode of bleeding in to
your intestines, which were were unable to stop. Upon
discussions with you and your family, it became clear that you
wished to transition to focus of your care to comfort. You are
being transferred to a hospice facilitiy. It was wonderful
meeting you.
Followup Instructions:
Please speak with the physician at the hospice facility within
1-2 days of your arrival
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12,831
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Discharge summary
|
report
|
Admission Date: [**2195-9-17**] Discharge Date: [**2195-10-8**]
Date of Birth: [**2112-5-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2195-9-23**]: Open transabdominal repair of infrarenal abdominal
aortic aneurysm with Dacron graft
[**2195-10-2**]: L-thoracentesis of pulmonary effusion
History of Present Illness:
The patient is an 83-year-old gentleman who was followed for an
infrarenal abdominal aortic aneurysm as well as a suprarenal
abdominal aortic aneurysm. The suprarenal component of his
aneurysm was stable without any change in size over a
significant period of time with monitoring. However his
infrarenal component increased in size to 6.7 cm. It was felt
that the patient was a poor candidate for an extensive
thoracoabdominal surgical repair for type 4 aortic aneurysm.
However due to the fact that his infrarenal component was
enlarging aneurysm, it was felt that he would benefit from
repair. He did have a normal segment of aorta in his visceral
segment and in the area of the renals. It was felt due to the
anatomy of his aneurysm that potentially an infrarenal clamp
would be able to be placed and we would be able to sew below the
renals. Therefore it was felt that he would most benefit from
an infrarenal abdominal aortic aneurysm repair with conservative
management of suprarenal aneurysm. He therefore presents today
for open repair of his infrarenal abdominal aortic aneurysm as
it did not make criteria for endovascular repair.
Past Medical History:
PMH: CAD, Afib, htn, hyperlipidemia, PVD, thoracoabdominal
aneurysm, benign positional vertigo, CKD baseline Cr 1.4
PSH: CABG x 4 '[**85**], L Renal artery stent
Social History:
lives at home with wife; has good family support
Family History:
n/c
Physical Exam:
Afebrile, vital signs stable, no apparent distress, comfortable
Abd: abdominal surgical incision intact and well healed; abdomen
soft, nondistended, obese, normal bowel sounds
Cardio: irregular rhythm, regular rate
Pulm: lungs clear to ascultation bilaterally
Neuro: alert and oriented x3, conversant, moving all extremities
to command
Pertinent Results:
[**2195-10-5**] 04:00AM BLOOD WBC-5.2 RBC-3.44* Hgb-10.5* Hct-31.8*
MCV-93 MCH-30.5 MCHC-33.0 RDW-14.5 Plt Ct-286
[**2195-10-8**] 04:57AM BLOOD PT-12.4 PTT-38.3* INR(PT)-1.1
[**2195-10-8**] 04:57AM BLOOD Glucose-104* UreaN-25* Creat-0.9 Na-137
K-4.7 Cl-105 HCO3-25 AnGap-12
[**2195-10-2**] 12:20AM BLOOD CK-MB-3 cTropnT-0.12*
[**2195-10-2**] 08:31AM BLOOD CK-MB-3 cTropnT-0.18* proBNP-3097*
[**2195-10-3**] 04:00AM BLOOD CK-MB-3 cTropnT-0.23*
[**2195-10-4**] 01:46AM BLOOD CK-MB-3 cTropnT-0.20*
[**2195-10-8**] 04:57AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1
[**2195-10-2**] 1:27 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT [**2195-10-8**]**
GRAM STAIN (Final [**2195-10-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2195-10-5**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2195-10-8**]): NO GROWTH.
MR HEAD W/O CONTRAST Study Date of [**2195-10-4**] 1:00 AM
FINDINGS: There is no evidence for acute intracranial
hemorrhage or mass. There is no acute ischemia. There is
prominence of ventricles and sulci suggesting volume loss for
age. Intracranial flow voids are maintained.
There is opacification of all the paranasal sinuses with also a
polypoid soft tissue density in the nasal cavity on the right.
Recommend further evaluation with CT of the sinuses when the
patient is clinically stable . There is opacification of the
right frontal sinus in a somewhat expansile fashion, cannot
exclude an early mucocele. Bilateral mastoid and middle ear
opacification is seen.
CT HEAD W/O CONTRAST Study Date of [**2195-10-2**] 6:12 PM
FINDINGS: Compared to the prior exam, there has been no major
interval
change. There is no evidence for acute intracranial hemorrhage,
large mass, mass effect, edema, or hydrocephalus. The basal
cisterns appear patent. There is preservation of [**Doctor Last Name 352**]-white
matter differentiation. Prominent ventricles and sulci suggest
age-related involutional changes. White matter hypodensity is
likely secondary to sequela of chronic small vessel ischemic
disease.
There is persistent partial opacification of the mastoid air
cells with
improved but residual partial opacification of the ethmoid air
cells, and
persistent complete opacification of the right frontal sinus
with an air-fluid level in the left frontal sinus, possibly
related to recent intubation. Chronic-appearing mucosal
thickening is seen in the maxillary and sphenoid sinuses
bilaterally.There is possible polyp in the right nasal cavity.
No acute bony abnormality is detected. Arterial calcifications
are seen.
Brief Hospital Course:
The patient was admitted to the [**Hospital1 18**] Vascular Surgery Service
for open repair of an abdominal aortic aneurysm (see operative
note for further details). The surgery was successful, but
complicated by hypotension and extensive blood loss (13 units).
He was subsequently placed in the Intensive Care Unit, intubated
and sedated, for approximately 13 days.
#Neuro
In the ICU he was initially unresponsive to verbal commands
after propofol and fentanyl had been discontinued 4-days
post-op, however he gradually improved to an alert and
conversant state. Concern for global cerebral ischemia
secondary to the intraoperative blood loss was explored with
head CT/MRI/EEG; the studies showed generalized encephalopathy
but no signs of acute ischemia/cerebral bleed. Neurology was
involved with this assessment. Gradually his mental status
improved but tended to wax and wane during this improvement.
#Cardio
On postop day 15 (day 2 on the floor), the patient became
tachycardic to the 100's and reported chest pain. Cardiac
biomarkers revealed an elevated troponin and normal CK and
CK-MB. Cardiology was consulted to manage the patient, and
their recommendations were observed. We initiated beta-blockade
to control heart rate, continued blood pressure management, and
trended cardiac enzymes. His chest pain resolved and his
cardiac enzymes ultimately trended downward. He had no further
issues with chest pain. All of his home meds were resumed on
discharge and Metoprolol was added to his daily regimen.
#Pulm
The patient was intubated and sedated in the ICU for
approximately 10days before being extubated in the unit. He had
no pulmonary issues and had adequate O2 saturation but after
being transferred to the floor was found to have a large left
sided pleural effusion. It was drained by Interventional
Pulmonology for approximately 1L of serosangenous fluid, which
was sterile on microbiological analysis.
#GI
The patient was placed on TPN for nutritional repletion while in
the ICU and on the floor. Consideration was given for a PEG,
but the patient subsequently passed a speech and swallow
assessment and his diet was advanced to ground solids and thin
liquids. The patient was able to tolerate PO intake but we
continued his TPN at half the initial rate because he was still
not taking in adequate nutrition (per caloric intake
monitoring). The rate of his TPN may need to be adjusted at the
Rehab in accordance with his PO intake. His speech and swallow
status will also need to be reevaluated to advance his diet. He
will
#GU
The patient received IV Lasix for diuresis until his volume
status was appropriate. He was clinically euvolumic on
discharge. Foley was in place on discharge, but should be
removed on day 1 at the Rehab center.
#Heme
The patient was on Coumadin prior to hospitalization; this was
discontinued postoperativly. He was resumed on his home dose of
Coumadin on the day of discharge, with no bridging therapy. He
was continued on subcutaneous Heparin on discharge to the rehab.
The patient was on cilostazol prior to admission; this was held
while in house, then resumed on discharge to the Rehab facility.
#Endocrine
The patient was placed on an Insulin Sliding Scale regimen.
#ID
Ceftriaxone-sensitive Pseudomonas was detected in both sputum
and urine cultures while in the ICU, and the patient was treated
with ceftriaxone; blood cultures were negative. The patient
developed oral thrush while on the floor and was treated with
Nystatin mouth swabs until he was able to perform Nystatin mouth
rinses/spit. He was discharged to the rehab with Nystatin oral
rinses and the oral thrush was improving.
The patient was in stable condition upon discharge from the
hospital. He does require assistance with feeding and voiding.
He reports he was not independently ambulatory prior to
hospitalization, and is still not ambulatory. He is able to get
out of bed to chair with assistance at this time and should work
with Physical Therapy at the Rehab Facility.
Medications on Admission:
asa 81', simvastatin 40', sotalol 40'', coumadin 5 qSaSuTuTh,
2.5 qMWF, diovan 160', cilostazol 100'', imdur 60qAM
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Albuterol Inhaler [**2-7**] PUFF IH Q2H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN NO BM
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Insulin SC
Sliding Scale
Fingerstick q 6 hrs
Insulin SC Sliding Scale using REG Insulin
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Metoprolol Tartrate 50 mg PO Q6H
hold for bp<90 systolic
10. Nystatin Oral Suspension 5 mL PO QID:PRN oral candidiasis
please use with a mouth swab and suction afterwards because
patient has failed speech/swallow
11. Simvastatin 80 mg PO DAILY
12. Valsartan 80 mg PO DAILY
13. Warfarin 5 mg PO [**Last Name (LF) **],[**First Name3 (LF) **],TU,TH
14. Warfarin 2.5 mg PO M,W,F
15. cilostazol *NF* 100 mg Oral [**Hospital1 **]
preadmission medication, resumed on discharge
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 **]
Discharge Diagnosis:
abdominal aortic aneurysm
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:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-12**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-6**]
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
?????? You should get up every day, get dressed and walk, gradually
increasing 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 (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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) 1391**] in clinic in [**3-8**]
weeks after discharge from the hosptial. You must call his
office to set up an appointment.
Dr. [**Last Name (STitle) 1391**]: ([**Telephone/Fax (1) 4852**]
Completed by:[**2195-10-8**]
|
[
"441.7",
"599.0",
"E942.6",
"276.2",
"585.3",
"410.71",
"E878.2",
"V45.81",
"V12.54",
"276.69",
"997.49",
"403.90",
"386.11",
"998.11",
"440.21",
"041.7",
"E937.9",
"287.49",
"511.9",
"427.31",
"293.0",
"473.9",
"482.1",
"518.52",
"458.29",
"272.4",
"112.0",
"349.82",
"723.5",
"441.4",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.00",
"34.91",
"99.15",
"96.72",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
10182, 10242
|
5106, 9138
|
330, 490
|
10311, 10311
|
2307, 5083
|
13091, 13368
|
1931, 1936
|
9304, 10159
|
10263, 10290
|
9164, 9281
|
10486, 12638
|
12664, 13068
|
1951, 2288
|
264, 291
|
518, 1662
|
10326, 10462
|
1684, 1849
|
1865, 1915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,931
| 109,646
|
8183
|
Discharge summary
|
report
|
Admission Date: [**2179-7-22**] Discharge Date: [**2179-8-11**]
Date of Birth: [**2104-3-14**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Neomycin
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
ankle, thigh, penile edema
Major Surgical or Invasive Procedure:
In CCU had SWAN catheter placement for hemodynamic monitoring
History of Present Illness:
75 year old male with a history of ischemic cardiomyopathy and
EF 10-15% with history of progressive ankle, thigh, penile edema
over past 2.5 weeks. Weight has increased from baseline of
151-154 lbs to 159 lbs. He has been admitted in the past for
treatment of his CHF, including monitoring with a swan ganz
catheter. He has been taking his medications. He denies
increased DOE, SOB at rest, orthopnea, nocturia, but does note
increased fatigue. He has DDD/ICD (BiV placement considered too
risky). Complicating factors include recent cessation of
amiodarone/statin due to concern for myopathy leading to
weakness, however treatment reinstated since holding did not
increase strength. Also has CRF with recent creatinine of 1.6
and chronic hypotension with SBP at 90 mmHg. Coronary artery
disease status post anteriolateral myocardial infarction in
[**2174**]. PCI with stent placement in LAD and D1 in [**2175**],
complicated by apical thrombus, emergent CABG. LV anterioapical
aneurysm. CHF with EF 14% from ETT-MIBI, Swan catheter in [**2175**]
had evidence of elevated left and right sided pressures. At
that time diuresed with IV lasix and milrinone with improvment
of pressures (to wedge less than 20, diuresed 18 liters). Echo
[**1-21**] LAE, LV dilatation, EF 10-15% severe global LVHK, severe
global RV free wall HK, 4+MR, 4+TR, mod Pulm HTN.
Past Medical History:
1. Coronary artery disease status post anteriolateral
myocardialinfarction in [**2174**]. PCI with stent placement in LAD
and D1 in [**2175**], complicated by apical thrombus, emergent CABG.
LV anterioapical aneurism.2. Congestive heart failure with
anejection fraction of 10 to 15%.3. Gastrointestinal bleed
secondary to small bowel AVMs.4. Atrial fibrillation status post
pacer DDD and AICD.5. Hypercholesterolemia.6. Hypertension.7.
Benign prostatic hypertrophy.8. Depression.9. Eczema.10. Anemia
with a baseline hematocrit of 27 to 32.11. Chronic renal failure
with a baseline creatinine of 2.0.12. MRSA colonization.13.
Status post stroke.14. Gastroesophageal reflux disease.15.
Status post appendectomy.
Social History:
The patient lives with his wife and his adopted son who is 8. He
has a fifty pack year history of smoking, but quit many years
ago. He drinks one to two glasses of alcohol per day.
Family History:
Non-contributory
Physical Exam:
Vitals T 95.5 P 75 BP 70/48 Resp 20 96%RA
Gen Alert, oriented, cooperative male in NAD
HEENT PERRLA, MMM, OP clear
Neck JVD at 15 cm, no lymphadenopathy or thyromegally
Thorax Scar on chest, crackles and wheezes at left base
CV RRR, S1,S2,S3, Systolic murmer at lt sternal base and apex
[**1-23**]
Abd Soft, slightly distended, no ascites, NT/ND +BS
Ext 3+ edema to just below the knee, no cyanosis
Neuro Intact
Pertinent Results:
[**2179-8-11**] 09:30AM BLOOD WBC-4.6 RBC-4.06* Hgb-11.2* Hct-35.3*
MCV-87 MCH-27.6 MCHC-31.7 RDW-17.2* Plt Ct-257
[**2179-8-11**] 09:30AM BLOOD Plt Ct-257
[**2179-8-11**] 09:30AM BLOOD Glucose-143* UreaN-25* Creat-1.3* Na-138
K-3.5 Cl-98 HCO3-27 AnGap-17
[**2179-8-11**] 09:30AM BLOOD Calcium-9.3 Phos-2.5* Mg-2.1
[**2179-7-23**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.06*
Brief Hospital Course:
1. CHF - This 75 year old male with a history of ischemic
cardiomyopathy EF 14% from ETT-MIBI presented with incresing
edema indicating acute CHF exacerbation. Upon admission
aggressive diuresis was started with the goal to get back to his
dry weight of 151-154lbs. Nesiritide drip was started and he
was stareted on Dopamine drip to maintain SBP >90. Upon further
evaluation it was determined that he would benefit from having
more tailored CHF therapy including monitoring with a SWAN
catheter. He was transferred to the CCU.
In the CCU a SWAN was placed and his initial readings were
PCWP 38, PA 56/24. He was continued on Dopamine and Nesiritide.
His ICD was interrogated and found to be working well, he was
being safety paced. After four days in the CCU he had diuresed
from 75 to 69.4 kg with Dopamine, Lasix, and Nesiritide.
Captopril and Altactone were started. The swan was dc'd and he
was transfered back to the floor for further management. His
swan ganz readings upon transfer to the floor were: CVP 12, PAP
51/18, CO 5.3.
Initially on the floor he was continued on Captopril,
Aldactone, Nesiritide, and bolus Lasix. He was converted from
Nesiritide and IV Lasix to Captopril and PO Lasix. After a few
days on the floor he had some increased edema and was more
aggressively diuresed with Dopamine and IV Lasix. His pressure
was very labile and it was difficult to stop the Dopamine, which
was maintaining his SBP >90. He was started on Sinemet for Dopa
stimulation and Aminophyline. As these medications were
titrated up we were able to wean off the IV Dopamine and he
maintained his blood pressure well. He was converted to oral
medications with his final regimen as below. He was on the
floor for a total of 14 days after transfer out of the CCU.
His discharge weight was 141 lbs. He had limited ankle edema
>1+ and no crackles on exam. He had no tremors from the
Aminophyline or Sinemet. Generally he is doing very well on
his current oral regimen.
2. CAD- He is s/p PCI with stent placement in LAD and D1 in
[**2175**], complicated by apical thrombus, emergent CABG. Since he
could not be on aspirin due to severe GI bleed he was not
treated with any. Initially his B-blocker and ACE-I were held
due to hypotension, but were restarted on the floor prior to
discharge. One set of enzymes was drawn which showed a troponin
of 0.6, this was felt to be demand ischemia due to fluid
overload.
3. Valves- He has severe 4+MR and 4+TR. An Echo here showed:
"The left atrium is markedly dilated. The right atrium is
markedly dilated. The left ventricular cavity is severely
dilated. There is akinesis of the septum. The is a posterior
apical aneurysm. There is hypokinesis of the remaining walls
with some preservation of the basal lateral and inferolateral
walls. Overall left ventricular systolic function is severely
depressed (ejection fraction 10%). A left apical thrombus
cannot be fully excluded. The right ventricular cavity is
dilated. The basal segment of the right ventricular contracts.
The aortic valve leaflets (3) are mildly thickened but
not stenotic. Severe (4+) mitral regurgitation is seen. Moderate
to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery
systolic hypertension. Mild to moderate pulmonic regurgitation
is seen.
Compared to the prior study of [**2179-2-10**] (tape not available for
review), there
has been a small increase in the pulmonary artery systolic
pressures. The
posterior apical aneurysm was not previously described." His
valve disease was unchanged from previous therefore ruling out
worsening valve disease as a cause of his acute exacerbation of
CHF.
4. CRI- His baseline creatinine is 1.6, we continued to monitor
his creatinine during his hospital stay and it was 1.2 at
discharge. His SBP was maintained greater than 90 throughout
his hospital stay to keep his kidneys adequately perfused.
5. GERD-He was continued on protonix for his GERD throughout his
hospital stay. He had no evidence of GI bleed.
6. Depression-He was continued on Zoloft throughout his hospital
stay. He was started on Olanzapine at night secondary to some
increased confusion and sundowning while in the CCU. It was
continued on the floor as it assisted with his sleeping and he
had no further episodes of confusion.
7. Atrial fibrillation: The patient has a pacemaker. He is
not on anticoagulation secondary to his chronic gastrointestinal
bleed.
8. Anemia: His HCT was stable throughout his hospital stay and
was 35.3 on discharge.
Medications on Admission:
1. Toprol XL 25 mg/day 2. Lasix 80mg BID3. Aldactone 12.5mg/day
4. Rabeprazole 20mg [**Hospital1 **] 5. Digoxin 0.125mg QD 6. Zoloft 200mg QD
7. MVI QD8. Procrit 30,000 units/week 9. Lisinopril 7.5mg/day
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO QD (once
a day).
4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QD (once a day) as
needed for heart failure.
14. Aminophylline 200 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
15. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
16. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
17. Carbidopa-Levodopa 10-100 mg Tablet Sig: Four (4) Tablet PO
QID (4 times a day).
18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
CHF (EF 10-15%) had less than 6 month life expectancy
CAD
A.flutter
HTN
Depression
GERD
Discharge Condition:
stable, same level of ability as prior to admission
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by > 3
lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 ml/day
Take all of your medications
Return to the hospital if you have any shortnes of breath, chest
pain, leg swelling
Followup Instructions:
Call to make appointment for Follow up with primary care doctor
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 29102**] in [**11-20**] weeks.
Call to make appointment for Follow up with Dr. [**First Name (STitle) 2031**] ([**Telephone/Fax (1) 24136**] in [**11-20**] weeks.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"427.31",
"428.0",
"414.8",
"397.0",
"458.9",
"530.81",
"424.0",
"401.9",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
9912, 9990
|
3586, 8128
|
316, 380
|
10122, 10175
|
3189, 3563
|
10480, 10888
|
2721, 2739
|
8382, 9889
|
10011, 10101
|
8154, 8359
|
10199, 10457
|
2754, 3170
|
250, 278
|
408, 1773
|
1795, 2507
|
2523, 2705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,252
| 158,920
|
53685
|
Discharge summary
|
report
|
Admission Date: [**2182-5-11**] Discharge Date: [**2182-5-20**]
Date of Birth: [**2145-3-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 yo M w/ history of epilepsy since childhood (GTG), Obesity,
who presented on [**5-9**] to OSH, diagnosed with pancreatitis and is
transferred to [**Hospital1 18**] given concern for worsening hemodynamic
instability.
Patient was in USOH until AM of [**5-9**], when after eating
breakfast, noted rapidly escalating epigastric pain, which
eventually radiated to below the umbillicus and down to
bilateral flanks. After several episodes of emesis, he drove
himself to OSH ED for an evaluation.
At OSH, initial VS were 97.8F 65 151/89 99% RA. He received
Zofran 12mg, Dilaudid 3mg, 1L NS. Labs were notable for lipase
of > 4000, and thus admitted to the floor for management of
pancreatitis. On the floor, he received NS at 1200cc bolus then
150cc/hr x 48hrs. Per patient, UOP has been declining over the
past two days, he has developed difficulty breathing and
pleuritic type chest pain. On day of transfer, he developed a
fever to 102.6F, HR increased to sustained 110s and RR to 20s on
RA.
At OSH, labs Lipase > 4000 -> [**2077**] , Amylase 363. Ca 9.7 -> 6.5,
Cr 1.1 -> 1.6, BUN 17 -> 36, Na 144 -> 138, Cl 107 -> 106, HCO3
23 -> 23, Alb 4.3 -> 2.8, AST/ALT 27/12, TG 98, HCT 55 -> 48,
WBC 14.7 -> 19K. UA SG < 1.005, Ket neg, pH 5, neg WBC/RBC. Ct
abd. was notable for fatty liver, edema at head and uncinate
process, no necrosis, peripancreatic [**Doctor First Name **] and mild bowel wall
thickening of 2/3rd portions of duodenum. Because of
tachycardia, fever and worsening UOP, patient was transferred to
[**Hospital1 18**] for further treatment.
In ICU, initial VS were 97.8F 114 139/68 22 98% 2L NC. Patient
appeared in NAD, he was c/o of abdominal pain, orthopnea,
pleuritic CP and concentrated urine. He notes that he consumes
only 1-2 drinks per week, denies FHx of pancreatitis, abdominal
cancers, gall stones. Has not taken any new medications or
ingestions.
Review of systems:
(+) Per HPI, otherwise negative in detail.
Past Medical History:
Epilepsy
Social History:
Lives on [**Hospital1 6687**]. Commercial driver, married, has 2 children.
- Tobacco - 1/2ppd
- EtOH - 1/wk
- Drug use - denies.
Family History:
No malignancy, no etoh abuse
CAD/CABG in mother in sixties.
Physical Exam:
Admission exam:
General: Obese, frustrated appearing man, alert, no acute
distress
HEENT: Sclera anicteric, Obese, dMM, oropharynx clear
Neck: supple, JVP 7, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: decreased breaths b/l, L > R.
Abdomen: Obese, diffusely tender to palpation in Lower quadrants
> upper quadrants, bowel sounds present, no organomegaly, no
rebound or guarding, but reports some tenderness with passive
movement of the bed.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented to place and time. MOYb intact.
EOMI, Face symmetric, palate elevates symmetrically, tongue is
midline. Moves all extremities antiresistance.
Discharge Exam:
VS: Afebrile, normal vitals
GEN: NAD
ABD: Soft, nontender, normal bowel sounds
Pertinent Results:
Admission labs:
[**2182-5-11**] 03:57PM BLOOD WBC-16.7* RBC-5.17 Hgb-16.4 Hct-47.7
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 Plt Ct-187
[**2182-5-11**] 03:57PM BLOOD Neuts-86* Bands-2 Lymphs-5* Monos-5 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2182-5-11**] 03:57PM BLOOD PT-15.9* PTT-34.0 INR(PT)-1.5*
[**2182-5-11**] 03:57PM BLOOD Glucose-93 UreaN-30* Creat-1.4* Na-139
K-4.4 Cl-102 HCO3-18* AnGap-23*
[**2182-5-11**] 03:57PM BLOOD ALT-20 AST-30 LD(LDH)-437* AlkPhos-41
TotBili-0.8
[**2182-5-11**] 03:57PM BLOOD Lipase-383*
[**2182-5-11**] 03:57PM BLOOD Albumin-3.1* Calcium-6.5* Phos-1.4*
Mg-1.8
[**2182-5-11**] 04:11PM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-44 pH-7.35
calTCO2-25 Base XS--1
[**2182-5-11**] 04:11PM BLOOD Lactate-2.1*
Discharge labs:
Imaging:
-RUQ US ([**2182-5-11**]): Extremely limited exam. No evidence of
cholecystitis or
intrahepatic biliary ductal dilatation. No gallstones
identified.
-CXR ([**2182-5-11**]): There are no old films available for comparison.
Lung volumes are slightly low. There are compressive changes at
both bases and small infiltrates can't be excluded. The heart is
mildly enlarged. The mediastinal silhouette is slightly
prominent, likely due to patient's size and AP technique. The
left hemidiaphragm is poorly visualized which could be due to
combination of overlying soft tissue, small effusion, volume
loss, or small infiltrate. A lateral film would be helpful when
the patient is able.
CT abdomen [**5-14**]
CT ABDOMEN: There is fat stranding surrounding the entire
pancreas with fluid
extending to the anterior pararenal space, lesser sac,
transverse mesocolon,
and root of the mesentary. There is no venous thrombosis or
evidence of
pancreatic necrosis.
There is bibasilar atelectasis and a small left pleural
effusion. The
visualized portions of the heart and pericardium are
unremarkable. The liver
is diffusely hypodense, consistent with fatty deposition. The
portal veins
are patent.
The gallbladder, spleen, and adrenals are normal. The kidneys
enhance
symmetrically and excrete contrast without evidence of
hydronephrosis or mass.
There is no nephrolithiasis. Several undigested pills are seen
in the fundus
of the stomach which is otherwise unremarkable. The small bowel
is normal.
CT PELVIS: The appendix is not visualized. The colon, rectum,
seminal
vesicles, prostate, and urinary bladder are normal. There is no
pelvic
lymphadenopathy or free fluid.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
suspicious for
malignancy.
IMPRESSION:
1. Findings consistent with acute pancreatitis with
peripancreatic effusions
but no evidence of pancreatic necrosis or venous thrombosis.
2. Fatty liver.
3. Bibasilar atelectasis and small left pleural effusion.
CXR: [**5-17**]
Cardiomediastinal silhouette and hilar contours are
unremarkable.
Lung volumes are low. An opacity projecting over the left
hemithorax can
correspond to atelectatic areas seen on CT on [**2182-5-16**]. The
right lung
also has areas of atelectasis, but no focal opacities concerning
for an
infectious process. No pleural effusion is noted on this
radiograph.
KUB:
Supine and upright abdominal radiographs demonstrate dilated
loops
of small bowel measuring up to 5 cm with air-fluid levels on
upright imaging.
There is residual gas and oral contrast throughout the colon and
rectum.
There is no evidence of free intraperitoneal air. Bibasilar
atelectasis is
again noted. The osseous structures are unremarkable.
IMPRESSION: Likely ileus.
Brief Hospital Course:
37 M with history of epilepsy since childhood, Obesity, who
presented on [**5-9**] to OSH, diagnosed with acute pancreatitis of
unclear etiology and was transferred to [**Hospital1 18**] given concern for
worsening hemodynamic instability, and clinically stabilzed.
# Acute pancreatitis, severe: Unclear etiology. Pt initially
admitted to the MICU given his severe pancreatitis and concern
for hemodynamic instability. On admission, APACHE II score 10
and approximately 10% TBW volume depleted. Etiology of
pancreatitis is unclear, minimal EtOH use, normal TG. No biliary
colic on history, and RUQ ultrasound negative for stone although
it was a limited study. He has not had exposures to common
medications that cause pancreatitis, nor has he had
hypercalcemia. Triglycerides were 131 at admission. Patient
was repleted with 5 liters LR overnight after admission, but
continued to have significant tachycardia. Pain was controlled
with IV Dilaudid. He was initially kept NPO and diet was
advanced and he tolerated a regular diet as of [**5-17**]. GI plans
on evaluating his biliary tree and pancreas within 4-6 weeks of
discharge. Given the fact that he has been a stable dose of
lamictal for over a year and it has effectively controlled his
seizures, we did not pursue switching this medication.
# Ileus: acute, found on KUB [**5-17**] done for leukocytosis and
increased abdominal girth. He is passing liquid stool and gas,
but appeared bloated. Pt kept NPO on [**5-17**] PM and advanced to
clears the following afternoon. Ileus resolved on [**5-18**] and his
diet was slowly advanced.
# Leukocytosis: WBC was 16 at admission, thought to be [**2-7**]
pancreatitis. BCx and UCx were sent which showed coag negative
staph, so vancomycin which was emperically started for GPCs on
the gram stain were stopped. However, his WBC continud to rise
to 24 on [**5-17**]. He had a clear CXR (other than atelectasis), a
negative UA, improving abdominal pain, and an abdominal CT on
[**5-14**] showing pancreatitis without findings suggestive of acute
infection, and negative Cdiff on culture. A potential source
includes a red and warm area from a prior peripheral IV site in
his R antecubital fossa, though there was no streaking,
purulence, or large area of cellulitis. Repeat cultures were
sent on [**5-17**] and were no growth to date at the time of
discharge. His WBC on discharge was 20.5
# Anion gap acidosis. Resolved after admission with aggressive
fluid resuscitation. Likely related to the mild lactate
elevation at admission, this is further supported by the fact
that his acidosis improved with volume resuscitation.
# [**Last Name (un) **]: Cr at admission was 1.4 and improved to baseline of
0.9-1.0 after fluid resuscitation. Likely pre-renal azotemia in
the setting of volume depletion from pancreatitis with
significant third spacing of fluid.
# Epilepsy: No seizures this admission, continued on home
Lamictal.
# Coagulopathy: INR 1.5 at admission and he is not
anticoagulated. Thought to be due to recent poor PO intake. No
evidence of bleeding on exam.
# Transitional issues:
[ ] GI outpatient follow-up
[ ] MRCP
[ ] Repeat CBC to make sure WBC normalizes
[ ] Follow-up final blood culture results
Medications on Admission:
Home:
-Lamictal 300mg [**Hospital1 **]
On transfer:
- Lamictal 300mg PO BID
- Dilaudid 1-2mg Q1H prn
- Zofran 4mg Q6H prn
- Tylenol
Discharge Medications:
1. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis, acute
Ileus
Hypokalemia
Acute renal failure
Epilepsy
Leukocytosis
Bacteremia (coag neg staph)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for pancreatitis. You were also found to
have ileus. Please avoid alcohol, [**Doctor First Name **] fatty foods.
Please continue to take all of your medications.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] G
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 54491**]
Phone: [**Telephone/Fax (1) 38070**]
Appointment: Thursday [**2182-5-23**] 10:00am
[**2182-6-17**] 03:45p [**Last Name (LF) **],[**First Name3 (LF) **] ([**Hospital1 **] GI)
[**Street Address(2) **] ([**Hospital1 **], MA), [**Location (un) **]
[**Hospital1 **] GI
|
[
"584.9",
"288.60",
"278.00",
"786.09",
"564.00",
"276.2",
"276.69",
"041.19",
"276.8",
"560.1",
"790.92",
"790.7",
"345.10",
"E936.3",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10442, 10448
|
6921, 10014
|
318, 324
|
10599, 10599
|
3389, 3389
|
10959, 11371
|
2490, 2551
|
10343, 10419
|
10469, 10578
|
10186, 10320
|
10749, 10936
|
4144, 6898
|
2566, 3274
|
3290, 3370
|
2251, 2295
|
264, 280
|
352, 2232
|
3405, 4127
|
10614, 10725
|
10037, 10160
|
2317, 2327
|
2343, 2474
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,598
| 131,654
|
34158
|
Discharge summary
|
report
|
Admission Date: [**2141-4-13**] Discharge Date: [**2141-4-19**]
Date of Birth: [**2058-10-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2141-4-14**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to
Ramus, SVG to OM1, SVG to Om2, SCG to RCA)
History of Present Illness:
82 y/o female who presented to OSH with chest pain. Ruled in for
an MI. Underwent cardaic cath which showed severe three vessel
coronary artey disease. Transferred to [**Hospital1 18**] for surgical
intervention.
Past Medical History:
Hypertension, Depression, Breast Cancer s/p Lumpectomy and Chemo
Social History:
Denies Tobacco or ETOH use.
Family History:
Father with MI at age 52. Son with MI at age 50.
Physical Exam:
VS: 60 16 155/77 60" 65kg
Gen: WD/WN female in NAD
Skin: Unremarkable
HEENT: EOMI/PERRL NCAT
Neck: Supple, FROM -JVD
Chest: CTAB
Heart: RRR -murmur
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2141-4-14**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is mild distal inferior wall hypokinesis. The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. There
are complex (mobile) atheroma in the descending aorta. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). POSTBYPASS: Preserved biventricular systolic
function. Thje study is otherwise unchanged from prebypass.
[**4-17**] CXR: In comparison with study of [**4-16**], the various tubes have
been removed and the right IJ sheath persist. Specifically, no
convincing evidence of pneumothorax. Atelectatic changes persist
at the left base.
[**2141-4-18**] 05:40AM BLOOD Hct-31.5* Plt Ct-112*
[**2141-4-17**] 03:45AM BLOOD WBC-11.0 RBC-3.71* Hgb-11.0* Hct-31.9*
MCV-86 MCH-29.7 MCHC-34.7 RDW-14.7 Plt Ct-82*
[**2141-4-16**] 03:52AM BLOOD PT-16.4* PTT-39.2* INR(PT)-1.5*
[**2141-4-17**] 03:45AM BLOOD Glucose-103 UreaN-18 Creat-0.8 Na-137
K-3.7 Cl-102 HCO3-29 AnGap-10
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 78737**] was transferred to [**Hospital1 18**]
after cath revealed severe coronary disease. She underwent usual
pre-operative work-up prior to going to the operating room. On
[**4-14**] she was brought to the operating room where she underwent a
coronary artery bypass graft x 5. Please see operative report
for surgical details. Within 24 hours she was weaned from
sedation, awoke neurologically intact and extubated. Pt.
required Inotropic support initially but was eventually weaned
off on post-op day two. She required blood transfusion
post-operatively due to low HCT. On post-op day two she was
started on beta blockers and diuretics and gently diuresed
towards her pre-op weight. On post-op day three her chest tubes
and pacing wires were removed and she was transferred to the
telemetry floor to begin increasing her activity level. Cleared
for discharge to rehab on POD #5. Pt. is to make all followup
appts. as per discharge instructions.
Medications on Admission:
[**Last Name (un) 1724**]: Atenolol 100mg qd, Aspirin 81mg qd, Norvasc 5mg qd, Benicar
40/25 qd, Vit B12, Calcium/Vit D
MAT: NTG gtt, Heparin gtt, Atenolol 100mg qd, Aspirin 325mg qd
Vit B12 1mg qd, Cozaar 50mg qd, HCTZ 25mg qd, Norvasc 5mg qd,
Protonix 40mg qd, Calcium/Vit D
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital
Discharge Diagnosis:
MI
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
PMH: Hypertension, Depression, Breast Cancer s/p Lumpectomy and
Chemo
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon or at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 3659**] in [**1-15**] weeks
Dr. [**Last Name (STitle) 27267**] in 2 weeks
Completed by:[**2141-4-19**]
|
[
"V10.3",
"410.91",
"311",
"414.01",
"401.9",
"285.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"36.15",
"36.14",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4678, 4761
|
2448, 3446
|
290, 404
|
4938, 4944
|
1113, 2425
|
5285, 5484
|
796, 846
|
3773, 4655
|
4782, 4917
|
3472, 3750
|
4968, 5262
|
861, 1094
|
240, 252
|
432, 646
|
668, 735
|
751, 780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,280
| 139,398
|
52723+59459
|
Discharge summary
|
report+addendum
|
Admission Date: [**2102-7-20**] Discharge Date: [**2102-8-6**]
Date of Birth: [**2051-1-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Tetracycline
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**2102-7-20**]: Angiogram with coiling of the R PCOMM aneurysm
[**2102-7-25**]: Angiogram with interarterial verapamil to BIL ACAs
History of Present Illness:
51 y/o F with history of hyperlipidemia presents after being
found down at home this morning. Patient's significant other was
able to provide history. He states that patient has been
complaining of headache for a couple days and this morning
patient was in bathroom when he heard a scream. He ran to the
bathroom where he found her laying on the floor in a pool of
emesis. He states that at that time patient was disoriented and
preservative. EMS was called and patient transported to [**Hospital1 18**].
Once at [**Hospital1 18**], head CT was done which revealed diffuse SAH. CTA
was done and a R PCOM aneurysm was seen. Neurosurgery was
consulted. Patient complained of pain at the base of the head.
Past Medical History:
significant other- hyperlipidemia
Social History:
Has a son and daughter, +tobacco, +ETOH
Family History:
no history of brain aneurysm
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 4 GCS E:4 V:5 Motor:6
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Pupils: 3-2mm bilaterally EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-4**] throughout.
Sensation: Intact to light touch.
Pertinent Results:
CT/CTA Head [**2102-7-20**]:
1. 5.6 x 3.3 mm saccular aneurysm arising from the right
posterior
communicating artery.
2. Extensive subarachnoid hemorrhage layering within the basilar
cisterns.
Crowding of the cerebellar tonsils at the level of the foramen
magnum
suggestive of a component of herniation.
3. Prominence of the temporal horns may indicate a component of
early
developing hydrocephalus for which close follow-up is
recommended
ECG [**2102-7-21**]:
Sinus bradycardia with sinus arrhythmia. Poor R wave
progression. Compared to the previous tracing of [**2102-7-20**]
irregular sinus bradycardia is new. The
QRS changes in leads V3-V4 could be due to lead placement.
QT/QTc: 480/457, Rate 47, PR 134, QRS 86, P 16, Axis: QRS 26, T
29
CT/CTA Head [**2102-7-23**]:
FINDINGS: There is interval evolution of the diffuse
subarachnoid hemorrhage. Redistribution of blood within the
ventricles. Multiple streak artifacts are seen in the
suprasellar cistern from the previously placed coils in the
right PCOM aneurysm. There is mild dilatation of the ventricles
as compared to the prior scan suggestive of mild communicating
hydrocephalus.
CTA HEAD: Intracranial and internal carotid arteries, vertebral
arteries,
basilar artery and their major branches are patent with no
evidence of
stenosis, occlusion, dissection or aneurysm. Multiple streak
artifacts are
seen from the previous coil embolization of right PCOM aneurysm.
There is mild vasospasm involving bilateral Anterior cerebral
arteries .
IMPRESSION:
Interval evolution of diffuse subarachnoid hemorrhage. Compared
to the
previous scan there is mild dilatation of the ventricles
suggestive of mild communicating hydrocephalus. There is mild
vasospasm involving bilateral anterior cerebral arteries.
ECHO [**2102-7-25**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
ECG [**2102-7-25**]:
Sinus bradycardia. Delayed precordial R wave transition as
recorded
on [**2102-7-21**]. The rate has increased. Otherwise, no diagnostic
interim change.
Rate 58, QT/QTc 426/422, PR 116, QRS 98, P 31, Axis: QRS 21, T
24
CT/CTA Head [**2102-7-25**]:
FINDINGS:
CT HEAD: Streak artifact from the coil pack in the right
posterior
communicating artery origin aneurysm slightly limits evaluation
at that level. There is decreased extent and density of
subarachnoid hemorrhage, with no new hemorrhage. There is stable
dilatation of the ventricles compared to [**2102-7-23**].
Intraventricular hemorrhage seen on [**2102-7-20**] has resolved. There
is no evidence of new acute major vascular territorial infarct.
The visualized portions of the paranasal sinuses and mastoid air
cells are clear. Osseous structures are unremarkable.
CTA OF THE HEAD: Compared to the two prior exams, there is
decreased caliber of the A1 and A2 segments of the anterior
cerebral arteries, and of the M1 segments of the middle cerebral
arteries, worse on the right. There is no change in the caliber
of the posterior circulation arteries. There is a dominant left
vertebral artery. Evaluation for residual filling of the
previously embolized right posterior communicating artery origin
aneurysm is limited by streak artifact from the coil pack.
IMPRESSION:
1. Expected evolution of subarachnoid hemorrhage. No new
hemorrhage.
2. Stable dilatation of the ventricles compared to [**2102-7-23**],
suggesting mild communicating hydrocephalus. Resolution of
intraventricular hemorrhage since [**2102-7-20**].
3. Progressive vasospasm of the A1 and A2 segments of the
anterior cerebral arteries and of the M1 segments of the middle
cerebral arteries, right worse than left.
[**2102-7-30**]: CT CTA
CT HEAD: There is no evidence of new hemorrhage, edema or mass
effect. Subtle hypodensty is noted in the posterior limb of
right internal capsule which is more prominent on the present
scan (se 2, [**Female First Name (un) **] 15) as compared to the previous scan, which
raises possibility of ischemia. Streak artifact from the coil
pack in the right posterior communicating artery aneurysm limits
the evaluation at this level. There is evolution of the
subarachnoid hemorrhage seen on prior studies. There is stable
dilatation of the ventricles. Visualized paranasal sinuses and
mastoid air cells are clear. Osseous structures appear
unremarkable.
CTA HEAD: The evaluation for residual filling of the previously
embolized
right posterior communicating artery aneurysm is limited by
streak artifact from the coil pack. There is decreased caliber
of M2 segment of the right middle cerebral artery which is
similar as compared to the previous study. There is decreased
caliber of A1 and A2 segments of bilateral anterior cerebral
arteries, worse on the right side, but is stable as compared to
the prior study. The posterior circulation arteries appear
normal. There is left dominant vertebral artery.
IMPRESSION:
1. Subtle hypodensty is noted in the posterior limb of right
internal capsule, which raises possibility of ischemia.
2. No evidence of new hemorrhage. Evolution of the subarachnoid
hemorrhage.
3. Stable dilatation of the ventricles.
4. Stable appearance of M2 segment of right MCA and stable
vasospasm of A1 and A2 segments of bilateral anterior cerebral
arteries, right greater than left.
[**2102-8-1**] LENIS:
IMPRESSION: No evidence of right or left lower extremity DVT.
[**2102-8-6**] CTA head:
Note is again made of trace subarachnoid hemorrhage and right
interal capsule hypodensity (2:16). Ventricular caliber is
unchanged as is the appearance of the intracranial vasculature.
The caliber of the ACA's is unchanged as are the MCA's. Notably,
the MCA's are improved in caliber when compared to [**0-0-0**].
Brief Hospital Course:
51 y/o F found down this morning by significant other in pool of
emesis. Patient was transported to [**Hospital1 18**]. Head CT showed diffuse
SAH and CTA was performed which revealed a 6mm R PCOM aneurysm.
Patient was admitted to neurosurgery and transported to the ICU
for close monitoring. She was taken to angiogram for coiling of
R PCOM aneurysm. There was no complications and she was taken
back to the ICU. Her sheath was pulled and she remained to have
good distal pulses. She remained on bed rest for six hours and
then was allowed to move around.
On [**7-21**], her exam remained stable. She was OOB with physical
therapy. On [**7-22**], she was bradycardiac but no intervention was
deemed needed. She continued to complain of headaches and a
steroid taper was started. Her headaches continued and a CTA
head was ordered on [**7-23**]. The CTA showed mild vasopsasm. She
was pressed to Systolic BP 160-200. Her exam remained
unchanged.
We repeated the CT/CTA on [**7-25**] which showed progressive
vasospasm and the patient was taken to angio and received a
total of 15mg of intra-arterial Verapamil to the bilateral ACAs.
Post-angio, her SBP was kept greater than 160 and her exam
remained stable. We started formal triple H therapy in the ICU
with pressors and fluids at a rate of 150cc/hr. Her exam
remained stable while on Vasospasm watch.
The morning of [**7-31**] she developed hypotension while on the
commode to sys of 108. She develped acute left facial assymetry
and slurred speech. She was placed back to bed in
trendelenburg. We pressed her sys BP to 170 and she had
resolution of her symptoms in about 10 minutes time. She
remained stable otherwise.
On [**8-1**], her SBP was liberalized to be greater than 150 without
any complication. On [**8-2**], her SBP was liberalized to be greater
than 120 and subsequently on [**8-3**] she was liberalized completely
to autoregulate at her baseline. No new neurological defecits
were appreciated.
She was transferred to the Step down unit on [**8-4**] with
telemonitoring. She remained stable medically and
neurologically on [**7-21**]. On [**8-6**] she got a CTA head which
showed a stable SAH and ventricular size. There was improvement
in the size of MCA.
At that time she was considered ready for discharge home.
Medications on Admission:
simvastatin 10mg QD, estrogen
patch, prometrium 100mg QD, ativan 0.5 prn, motrin prn
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
RIGHT POSTERIOR COMMUNICATING ARTERY ANEURYSM / RUPTURED
HEADACHE
CEREBRAL ARTERY VASOSPASM
UTI
DIPLOPIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What 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)
?????? 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
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks with an MRI/MRA with
and without contrast ([**Doctor Last Name **] Protocol). Please call [**Telephone/Fax (1) 4296**]
to make this appointment.
Name: [**Known lastname 17810**],[**Known firstname **] Unit No: [**Numeric Identifier 17811**]
Admission Date: [**2102-7-20**] Discharge Date: [**2102-8-6**]
Date of Birth: [**2051-1-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Tetracycline
Attending:[**First Name3 (LF) 40**]
Addendum:
Nimodipine 30 mg PO Q2H
Discharge Medications:
13. nimodipine 30 mg Capsule Sig: One (1) Capsule PO q2hr (every
two hours). Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2102-8-6**]
|
[
"599.0",
"784.69",
"368.2",
"041.04",
"427.89",
"435.8",
"305.1",
"348.39",
"272.4",
"784.59",
"784.0",
"458.29",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
13409, 13549
|
8443, 10741
|
298, 432
|
11037, 11037
|
2309, 4880
|
12656, 13252
|
1296, 1327
|
13275, 13386
|
10904, 11016
|
10767, 10854
|
11188, 11975
|
12001, 12633
|
1342, 1546
|
249, 260
|
460, 1164
|
1667, 2290
|
6397, 8420
|
11052, 11164
|
1186, 1222
|
1238, 1280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,612
| 107,502
|
23430
|
Discharge summary
|
report
|
Admission Date: [**2189-12-3**] Discharge Date: [**2189-12-10**]
Date of Birth: [**2140-7-14**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Transfer for liver failure.
HISTORY OF PRESENT ILLNESS: The patient is 49 year-old man
who was transferred to us from [**Hospital6 **] for
treatment of his liver failure and evaluation for liver
transplantation. Since he cannot give any history the
history is recorded from his records and reported by his
wife. [**Name (NI) **] is a 49 year-old man who by vocation is a car
salesman who is known to have hepatitis for about 15 to 19
years. He has been followed by his primary care physician
for this. Over the last six months to one year he has been
getting increasingly ill and has been complaining of
confusion, fatigue and mild jaundice. In the middle of
[**Month (only) **] approximately a month and a half ago he experienced
worsening confusion and some shortness of breath, which led
him to going to an outside hospital. At this hospital he was
found to be in liver failure acutely sick and was transferred
to [**Hospital6 **] for further care. His initial
evaluation raised the possibility of cholangitis along with
his primary liver failure from hepatitis. Given this
consideration he received an endoscopic retrograde
cholangiopancreatography and removal of stones and sludge
from his biliary tree. Despite endoscopic retrograde
cholangiopancreatography, however, his primary disease was
believed to be liver failure from his hepatitis, which was
the primary reason for his progression into kidney failure
officially given him the diagnosis of hepatorenal syndrome.
Due to his worsening hepatorenal syndrome and worsening
mental status he was transferred to [**Hospital1 190**] for further care and consideration for liver
transplantation.
PAST MEDICAL HISTORY: Hepatitis B and C, history of
intravenous drug abuse six years ago, history of ethanol
abuse in the distant past up to approximately ten years ago.
Gastroesophageal reflux disease. Status post laminectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Protonix, Lactulose, Lasix,
Clindamycin, Spironolactone.
MEDICATIONS ON TRANSFER: Levofloxacin, Flagyl, Lactulose,
Albuterol, Zantac.
FAMILY HISTORY: No history of cancer or liver failure.
Mother died of myocardial infarction at age 60.
PHYSICAL EXAMINATION: Temperature 97.2. Pulse 95. Blood
pressure 112/40. Respirations 31. O2 sat is 95 percent on
vent support. Intubated, sedated and jaundice frail looking
man with truncal obesity secondary to fluid. Heart
examination shows a regular heart. There is no
lymphadenopathy. There are no carotid bruits. There are no
oral lesions and the pupils are equal and reactive. Lung
examination shows decreased breath sounds in the right chest.
Abdominal examination shows a soft, but distended abdomen
without any incisions or apparent guarding. Rectal
examination shows rectal bag with melena. Extremity
examination shows jaundiced extremities with peripheral
deconditioning and mild edema. Pulse examination shows
palpable bilateral femoral radial and dorsalis pedis pulses.
LABORATORIES ON ADMISSION: White blood cell count 12.3,
hematocrit 27.9, platelet count 75, PT 19.8, PTT 44, INR 2.5,
fibrinogen of 134, potassium 5.9, sodium 153, BUN of 126,
creatinine of 4.4, glucose 126, alkaline phosphatase was 75,
total bilirubin of 34. Chest x-ray shows a right
hydrothorax.
HOSPITAL COURSE: The patient was transferred to the [**Hospital1 1444**] under conditions described
above in the history of present illness. On arrival he was
extremely confused, agitated and short of breath. This
required immediate intubation for control of his airway.
Immediate evaluation was begun for consideration for liver
transplantation. On arrival he received a head CT, which
showed no infarcts or hemorrhage. He received an ultrasound
of his liver, which showed patent vessels. He received a
Swan Ganz catheter for optimal hemodynamic management and a
dialysis access line for continuous dialysis. He also
required a right chest thoracentesis for huge right
hepatohydrothorax and a paracentesis for 6 liters for
increased abdominal girth. His neurological status upon
intubation was unresponsive, not following commands, moving
all four extremities, occasionally and withdrawing to pain
without reliability. After initial studies for consideration
of liver transplantation the patient also received an
esophagogastroduodenoscopy study secondary to melena, which
was noticed on transfer. The esophagogastroduodenoscopy
showed varices in the esophagus and dried blood in the
stomach, but no active bleeding. The [**Hospital 228**] hospital
course was prolonged and complicated and will be summarized
below by systems.
Neurologically, on arrival the patient was extremely agitated
and intermittently unresponsive requiring intubation for
protection of his airway. After intubation the best mental
status was occasional movement of all extremities, which over
the first 24 hours deteriorated to no response and no
withdraw to pain. Despite being off sedation from [**12-3**]
to [**12-10**] he did not regain any neurological signs of
alertness. He received a head CT scan on arrival, which was
negative for any hemorrhage or ischemia. At the end of his
hospital course once he was made comfort measures only he was
placed on intravenous morphine for comfort until his death.
Cardiovascular, the patient was found to be hypodynamic by
his heart rate and cardiac output on arrival. On his arrival
to [**Hospital1 69**] he received a right
internal jugular Swan Ganz line placement. During his
subsequent hospital course he was managed through his Swan
Ganz numbers to optimize his cardiac output and peripheral
resistance. He did not suffer from any instability during
the course, however, his blood pressure continued to remain
on the lower side with the systolics between to 100.
Eventually approximately five days into his hospital course
he required neo-Synephrine support to maintain his blood
pressure. Neo-Synephrine was continued in moderate doses
until it was determined that he will not be a candidate for a
liver transplantation.
Respiratory, the patient arrived with a large right
hepatohydrothorax in his right chest. This hydrothorax was
drained on arrival for 2700 cc of serosanguineous fluid. He
was managed on the ventilator with a goal PCO2 of 35 to
optimize his cerebral function. Over the course of his
hospital stay he reaccumulated the right hydrothorax
requiring higher PEEPS for support. This required right
sided pigtail catheter placement on [**2189-12-8**]. This
catheter was in place until the time of his death and
functioning properly.
Gastrointestinal, the patient presented with acute liver
failure with bilirubins of 34. This bilirubin progressed to
a level of 45 over his hospital course. He was treated with
Lactulose to minimize his hepatic encephalopathy. He was
considered for liver transplantation, however, given his
comorbidities and unstable status including an extremely poor
neurological status he was deemed non transplantable. The
patient also presented to our hospital with a
gastrointestinal bleed, which was presumed very likely to be
an upper gastrointestinal bleed. This was confirmed with
upper endoscope, which showed dried blood in the stomach and
esophageal varices. In the middle of his hospital course on
[**12-6**] he was noticed to have bright blood coming from
his nasogastric tube. This required progressive transfusions
and corrections of his coags. A scope was placed again and
multiple bands were performed again and the multiple bands
were placed for banding esophageal varices. Two days after
the banding procedure on [**12-8**] he developed an upper
gastrointestinal bleed again, which required placement of a
[**State **] tube with a gastric balloon for control of
hemorrhage. This tube was continued for 24 hours before its
discontinuation and subsequently later the patient was made
comfort measures only.
Infectious disease, the patient was treated with empiric
Vancomycin and Zosyn for prevention of infections, which may
lead to sepsis, which he will not tolerate given his tenuous
state. He was cultured routinely for surveillance cultures
and did not develop any sepsis by culture or physiology
during his course. His antibiotic levels were dosed
according to his renal function.
Renal, the patient presented to us in complete renal failure
with a diagnosis of hepatorenal syndrome. He was placed on
continuous hemodialysis through a right femoral hemodialysis
access line. He was maintained on this until [**2189-12-9**] when he was deemed non transplantable.
Hematology, the patient required continued transfusions of
platelets, fresh frozen platelets, and blood to maintain his
platelet level over 80, INR level less then 2 and hematocrits
about 28. Increasing amount of blood products were given
during his upper gastrointestinal bleed. On hospital day
four he was placed on an fresh frozen platelets drip to
support his coagulation status awaiting improvement in his
neurological status. Since this improvement did not come the
transfusions were stopped on [**12-10**] prior to his demise.
Endocrine, the patient maintained adequate blood sugar levels
during his course.
Social support, the patient was seen by our social workers
through the transplant office and the family was provided
with as much support as possible during this difficult time.
Code status, the patient failed to improve neurologically
over nine days of his hospital stay and continued to show no
signs of progress despite aggressive care. Eventually he
also developed significant gastrointestinal bleed, which
required aggressive support to maintain life. Given this he
was deemed to be a very poor candidate for liver
transplantation with almost no survival benefit should a
transplant be attempted. Given this he was deemed non
transplantable and the family was made aware of this. After
extensive discussions he was made comfort measures only on
[**2189-12-10**] and expired at 5:45 p.m. on [**2189-12-10**]. Morphine was started after comfort measures only code
status was implemented.
DISCHARGE DISPOSITION: Death.
DISCHARGE DIAGNOSES: Liver failure.
Renal failure.
Hepatitis B.
Hepatitis C.
Hepatic encephalopathy.
Gastroesophageal reflux disease.
Gastrointestinal bleed.
Hepatorenal syndrome.
Hepatic hydrothorax.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 22102**]
MEDQUIST36
D: [**2189-12-10**] 18:56:55
T: [**2189-12-11**] 09:41:30
Job#: [**Job Number 60077**]
|
[
"070.20",
"511.8",
"572.3",
"570",
"572.4",
"518.82",
"286.7",
"571.2",
"070.44",
"578.1",
"584.9",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"99.04",
"96.06",
"34.04",
"96.04",
"45.13",
"39.95",
"99.05",
"89.64",
"42.33",
"54.91",
"34.91",
"38.95",
"99.07",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10298, 10306
|
2280, 2368
|
10328, 10779
|
3486, 10274
|
2126, 2184
|
2391, 3179
|
173, 202
|
231, 1835
|
3194, 3468
|
2210, 2263
|
1858, 2104
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,815
| 150,497
|
54255
|
Discharge summary
|
report
|
Admission Date: [**2147-5-27**] Discharge Date: [**2147-7-3**]
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy
sigmoid colectomy with end colostomy
open cholecystectomy
central line placement
swan ganz catheter placement
History of Present Illness:
85F with CAD s/p CABG, paroxysmal atrial fibrillation & h/o
diverticulosis, who presented from PCP's office with abdominal
pain, fevers & rapid atrial fibrillation. Although she is a
poor historian, she c/o fatigue, some dizziness, epecially upon
standing, as well as recent diarrhea. No fevers, chills, CP,
SOB, or other associated complaints.
Past Medical History:
CHF
CAD s/p CABG [**2136**]
PAF
SDH s/p craniectomy & drainage
osteoarthritis
s/p appy
s/p TAH
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
temp 101.2, AF 147, 128/75, RR 19, 97%
poorly oriented, NAD
tachycardic, irregular
CTAB
Soft, obese, slight RLQ tenderness, no rebound
Guaiac negative
2+ pedal edema, no cyanosis
Brief Hospital Course:
Admitted [**5-27**] for serial exams. Her exam deteriorated through
[**5-28**], when she was brought to OR for exploratory laparotomy.
Please refer to op note for details. She was then sent to the
SICU for further care, which will be reviewed below in an organ
based fashion.
Neuro: minimal sedation with opiates & benzos and treated to
establish comfort.
CV: persistent rapid atrial fibrillation postoperatively.
CK/trop negative. TEE showed good ventricular fxn & no atrial
thrombi, but no concerted atrial movement. cards rec'd vs
cardioverting her (either electrically or chemically) secondary
to high clot risk.
Resp: Gradually deteriorated throughout her postoperative course
and had worsening ABG readings. In the background of her code
status the patient received nasal BiPAP, however did not
tolerate this well with frequent desaturations. She was then
tried on full face mask and seemed to tolerate this somewhat
better however her gas continued to worsen and she expired due
to respiratory failure on [**7-3**] at 5pm.
FEN: Large fluid requirement postop from septic, distributive
physiology. Eventually reached 110kg (about 30kg above dry
weight). Diuresed with lasix & diamox. Patient also tried on
acetazolamide with limited success. This was stopped due to her
worsening base deficit as her respiratory status also
deteriorated.
GI: Started on tube feeds POD2, ostomy functional soon
thereafter. LFTs began to rise about POD7, and ERCP was
consulted. No ductal dilatation on multiple RUQ US obstruction
vs congestive hepatopathy
Heme: thrombocytopenia of sepsis postop. HIT negative. Was
transfused appropriately throughout her hospital stay.
ID: prophylactic antibiotics were given as was fluconazole for
positive cultures for [**Female First Name (un) **]. There were no other positive
cultures to date.
Endo: Patient was maintained on a regular insulin sliding scale
and her blood sugars were noted to be well controlled
throughout.
Dispo: Patient expired in the surgical intensive care unit on
[**7-3**] at 5pm from respiratory collapse and exhaustion. Her
code status was followed throughout by all involved in her care.
Medications on Admission:
lasix 40', zestril 20", lopressor 50"
Discharge Medications:
none, patient expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
CHF
CAD s/p CABG
atrial fibrillation
h/o subdural hematoma s/p drainage
osteoarthritis
diverticulosis
sigmoid diverticulitis
cholecystitis
hemodynamic monitoring with PA catheter, A line, CVL
Discharge Condition:
good
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"584.5",
"562.11",
"428.30",
"518.5",
"997.4",
"707.03",
"427.31",
"287.5",
"511.9",
"401.9",
"038.9",
"995.92",
"574.10",
"567.8",
"576.8",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"99.07",
"97.55",
"96.72",
"88.72",
"96.6",
"51.87",
"51.22",
"46.11",
"45.75",
"51.85",
"99.04",
"34.91",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
3438, 3453
|
1139, 3304
|
228, 362
|
3689, 3695
|
3748, 3883
|
904, 921
|
3392, 3415
|
3474, 3668
|
3330, 3369
|
3719, 3725
|
936, 1116
|
174, 190
|
390, 737
|
759, 855
|
871, 888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,919
| 165,571
|
18200+56925
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-10-14**] Discharge Date: [**2181-10-24**]
Date of Birth: [**2149-10-1**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 31 year old male with
history of intravenous drug abuse with heroin, hepatitis B with a
recent admission from [**9-3**], to [**2181-9-30**] with a
right-sided tricuspid valve endocarditis complicated by septic
emboli to his lungs with Methicillin-sensitive Staphylococcus
aureus. He was initially treated with a combination of
Vancomycin and gentamicin secondary to a penicillin allergy but
was then changed to Oxacillin and Gentamicin for three weeks time
at which point he left Against-Medical-Advice and was changed to
p.o. Linezolid. He now returns with complaints of shortness of
breath and back pain. Mr. [**Known lastname 931**] originally presented on
[**9-3**], with four days of fever to 104, headache,
photophobia, nausea and vomiting and meningismus. 19 of 21
blood culture bottles grew Methicillin-sensitive Staphylococcus
aureus. He also had a left arm abscess at a heroin injection
site which grew Methicillin-sensitive Staphylococcus aureus and
Streptococcus milleri. Initial echocardiogram showed no
vegetations but a repeat transthoracic echocardiogram several
weeks into his hospital course had a large vegetation of the
tricuspid valve and 2+ tricuspid regurgitation. He initially was
treated with Vancomycin and Gentamicin but blood cultures
continued to be positive and therefore desensitization to
Oxacillin was performed in the Medicine Intensive Care Unit and
he was started on a combination of Oxacillin and Gentamicin with
resolution of his fevers and bacteremia. After three weeks
of treatment of Oxacillin the patient refused transfer to
[**Last Name (un) 9301**]. He finished a six week course of Oxacillin and he
left Against-Medical-Advice. He was given p.o. Linezolid
even though this was suboptimal treatment so that he would
have some antibiotic coverage and was discharged on [**2181-9-30**]. Of note, he also had multiple septic emboli to his
lungs on that admission. He was then seen in clinic on
[**10-10**] and still had sweat though no fevers and
significant pleuritic chest pain. Laboratory data showed an
increased white blood cell count, ESR and CRP. The patient
was notified and sent to the Emergency Department. The
patient reports no fevers since leaving the hospital but he
has had nightsweats requiring him to change his clothes up to
three times per night as well as sweats during the day. He
reports chills as well and reports intermittent shortness of
breath at rest that has been getting worse. He also has
pleuritic chest pain that has continued and Fentanyl patch
helps although only for a short while. He says he has been
taking the Linezolid as described. He also is complaining of
continuing low back pains which is chronic but then worsens
with discharge.
PAST MEDICAL HISTORY: 1. Intravenous drug abuse, heroin
last use [**2181-9-2**], per patient. 2. Hepatitis B.
3. Seizures. 4. Right-sided tricuspid
Methicillin-sensitive Staphylococcus aureus endocarditis,
partially treated with septic emboli to his lung. 5. Low
back pain since childhood.
ALLERGIES: Penicillin and Ampicillin both of which cause
rash and shortness of breath.
MEDICATIONS ON ADMISSION: Linezolid 600 mg p.o. b.i.d.;
Fentanyl patch 25 mcg that the patient reports he has been
changing every 48 hours.
SOCIAL HISTORY: He lives with his girlfriend/fiance and has
a ten year old son from a previous relationship. He has a
history of intravenous drug abuse and he reports his last use
of heroin on [**2181-9-2**]. He has also used cocaine in
the past and ethanol in the past, previously 30 cans of beer
per day, now only occasionally. He also smokes two to five
packs per day of cigarettes for many years, and he has
multiple tattoos.
FAMILY HISTORY: Only significant for alcoholism in a
brother, father and grandfather.
PHYSICAL EXAMINATION: Temperature 97.7, blood pressure
104/70, pulse 102, respiratory rate 20, sating 100% on room
air. The patient was lying comfortably in bed, watching
television, a pleasant thin man in no acute distress. Head,
eyes, ears, nose and throat, sclera were anicteric and his
mucous membranes were moist. Neck, he had no jugulovenous
distension or lymphadenopathy and he had 2+ carotid pulses
without bruit. Cardiovascular, regular rate and rhythm,
normal S1 and S2. No murmur appreciated. Lungs, clear to
auscultation bilaterally. He had no costovertebral angle
tenderness but he did have lumbar spinal tenderness. His
abdomen was soft, nontender, nondistended with positive bowel
sounds and no organomegaly. His extremities were warm and
well perfused with no edema. His neurological examination
was unremarkable. His skin examination showed no stigmata of
systemic emboli from endocarditis, namely no splinter
hemorrhages, no ossicular nodes or [**Last Name (un) 1003**] lesions.
LABORATORY DATA: Laboratory data on admission revealed white
count 12.0 with 60% neutrophils, 30% lymphocytes, 6%
monocytes, 4% eosinophils, hematocrit 36.9, platelets 188.
Chem-7 was unremarkable as were liver function tests. ESR
was 42. Toxicology screen was positive for ethanol but
otherwise negative and he was positive for hepatitis B. His
chest x-ray showed interval improvement in multiple cavitary
lesions in the right upper lobe and left lower lobe with no
new consolidation and new cavitary lesions noted.
Computerized tomography scan of the chest was negative for
pulmonary embolism but did show multiple nodular cavitary
lesions that had all decreased in size except for two in his
right apex, one of which was new. His electrocardiogram was
normal sinus rhythm in the 80s, normal axis and intervals and
[**Doctor Last Name 1754**] and no ST-T wave abnormality.
HOSPITAL COURSE: 1. Endocarditis - The patient has a known
tricuspid valve Methicillin-sensitive Staphylococcus aureus
endocarditis that was incompletely treated with optimal therapy
of Oxacillin due to his leaving the hospital Against-Medical-
Advice, and his symptoms have remained as well as elevated white
count and elevated ESR. Infectious Disease and Allergy were both
consulted and it was determined that the patient would need
another four week course of Oxacillin. He was initially started
on Vancomycin until transfer to the Medicine Intensive Care Unit
could be raised for his desensitization, which went well with no
complications and the patient was started on Oxacillin on [**2181-10-15**]. Blood cultures drawn on admission as well as the
following two days remained negative and so Gentamicin was not
included. Repeat transthoracic echocardiogram showed normal left
atrium and left ventricular ejection fraction of over 55% and the
tricuspid valve vegetation was currently smaller and now only
moderate in size, but his tricuspid regurgitation was now
moderately severe and therefore a little worse than the previous
echocardiogram. He continued to have mild pulmonary hypertension
with an estimated pressure of 30+ right atrial pressure.
Additionally since the patient came in complaining of worsening
low back pain, there was concern that he had a new epidural
abscess, so magnetic resonance imaging scan of his lumbar spine
was obtained that showed no abscess and some old L5-S1 disc
herniation. The patient did well during his hospital course
on Oxacillin and had no allergic reaction to it, and his
sweats improved.
2. Pain control - The patient had chest pain from his resolving
septic emboli as well as likely from some costochondritis. The
Pain Service was consulted in an effort to manage his pain, given
his history of opiate abuse. The patient came in on essentially
50 of Fentanyl patch because he was wearing two at a time. The
Pain Service recommended pain control with additional nonopiates,
none of which were very effective. Finally the patient was
switched from Fentanyl patch to Methadone 20 t.i.d. for a better
pain control. He will be closely followed for his Methadone use
by his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital 191**]
Clinic.
3. Hepatitis B - Currently the patient's liver function
tests are normal and stable, and no further workup or
treatment was done.
CONDITION ON DISCHARGE: Stable and improving from an
infectious disease perspective.
DISCHARGE DIAGNOSIS:
1. Methicillin-sensitive Staphylococcus aureus, tricuspid
valve endocarditis with septic lung emboli.
2. Intravenous heroin abuse.
3. Hepatitis B
DISCHARGE MEDICATIONS/FOLLOW UP PLANS/DISCHARGE STATUS: To
be dictated on an additional discharge summary addendum.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2181-10-24**] 11:02
T: [**2181-10-24**] 11:55
JOB#: [**Job Number 50289**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 9302**]
Admission Date: [**2181-10-14**] Discharge Date: [**2181-10-25**]
Date of Birth: [**2149-10-1**] Sex: M
Service: Medicine
ADDENDUM:
DISCHARGE STATUS: We had arranged for the patient to go to
[**Hospital1 1238**] for the last three weeks of his antibiotic course. After
these arrangements had been made, the patient refused to go to
[**Hospital1 1238**] and insisted that we take his PICC line out and allow
him to leave the hospital. The attending, Dr. [**Last Name (STitle) **], spoke with
him and made it clear that if he were to leave the hospital and
stop his antibiotic course he would be at serious risk of dying
from his endocarditis. Additionally, he made it clear that if
the patient was to stop his antibiotics and then restart any
penicillin including Oxacillin he would be at danger of
developing anaphylaxis. The patient clearly understood these
risks and insisted that we remove the catheter and allow him to
leave the hospital.
Throughout his hospital course, he understood the dangers of
discontinuing the therapy and we felt him to be capable of making
this medical decision. We respected his wishes, removed his PICC
line and he signed out AMA. While signing the papers, we again
reiterated the risks to him, namely of dying from infection or
dying from anaphylaxis should he restart his antibiotics and he
clearly understood them.
He left the hospital AMA, returning home. He was sent out on no
medications, neither his antibiotics nor methadone. The patient
was encouraged to follow-up with his primary care physician, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in the [**Hospital 112**] Clinic.
Additionally, during his hospital stay, he had been given the
business card of Dr. [**Last Name (STitle) 9307**] in Infectious Disease and was
encouraged to call and make an appointment and to follow-up with
him as well. The patient was told of the need for him to get
repeat echocardiograms to follow his valvular disease.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Last Name (NamePattern1) 827**]
MEDQUIST36
D: [**2181-10-25**] 02:01
T: [**2181-10-25**] 19:49
JOB#: [**Job Number 9308**]
|
[
"070.32",
"780.39",
"304.00",
"415.19",
"V14.1",
"421.0",
"733.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
3899, 3970
|
8492, 11392
|
3332, 3447
|
5879, 8384
|
3993, 5861
|
171, 2916
|
2939, 3305
|
3464, 3882
|
8409, 8471
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,472
| 195,734
|
44660
|
Discharge summary
|
report
|
Admission Date: [**2176-6-22**] Discharge Date: [**2176-7-16**]
Date of Birth: [**2126-3-21**] Sex: F
Service: VSURG
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Tramatic avulsion of right popliteal artery
Major Surgical or Invasive Procedure:
Right lower extremity exporation. Faciotomy. Right popliteal
artery repair with GSV interposition graft
removal external fixation and evaluation of right knee joint
under anesthesia [**2176-7-1**]
History of Present Illness:
fifty year old female who sustained a fall from her riding horse
with a pelvic fracture and cold right leg.Airflighted to [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) 95581**] and treatment.
Past Medical History:
Allergies: Penacilin
History of migrane
History of breasr cancer
s/p Csection x 2
Social History:
unknown
Family History:
unknown
Physical Exam:
GENERAL: intubated
Lungs : clear
Heart: RRR, sinus tachycardia
ABD: soft nontender, nondistended. Pelvis stable. Rectal: normal
tone stool guiac negative.
EXTREMITY: right leg rotated. mottled and cold to palpation
kwith absent pulses
below right femoral artey which palpable. Left leg pulse exam :
palpable pulses.
NEURO: intact
Brief Hospital Course:
[**2176-6-22**] Patient initally evaluated by trama team in the
emergency room and vascular consulted for ischemic right
leg.Abdominal Ct.,Chest xray and pelvic x rays wiere without
fracures. right [**Doctor First Name **] was noted to have a hematoma in posterior
patellar fossa.
On clinica exam with right calf compartment syndrome and
pulseless foot. Patient underwent emergent surgery with
exploration of popteal artery with intrposition graft with left
greater saphenous vein. and faciotomiesand external fixation of
knee. Patient was transfered to SICU for continued postoperative
care. urine for myoglobin and serial total CPK's were
monitered.CPK's peaked at [**Numeric Identifier **].Urine was alkinized and IV fluid
were continued.
Lovenox 30mgm [**Hospital1 **] was began.Tube feed were continued and
perioperative kefzol was continued.
[**2176-6-23**] POD#1 remained intubated in ICU.Transfuse two units
PRBC's . CPK down [**Numeric Identifier 95582**].
Foot warm with dopperable pedial pulses.
[**2176-6-24**] POD#2 extubated.HCT> remained stable at 29.7. nasogastric
tube was removed and diet was advanced as tolerated.
[**2176-6-25**] POD#3CPK's continue to show a downward trend.
[**2176-6-26**] POD#4 Bicarbonate IV drip discontinued CPK 9220.Patient
transfered to VICU .Physical thearphy consulted.Neurology
consulted for diminished right foot motoer and sensory function
Neurologyfelt patient had sustained sciatic injury and tramatic
streaching of peroneal and tibial nerves.Continued clinical
monitering and if no improvement consider EMG studies.
Antibiotic discontinued.Ct of neck and MRi of thigh obtained as
suggested by neurology. MRI demonstrated anterior and posterior
ligment rupture with medial collateral ligment injury. joint
effusion and ? lateral menescuc tear.
[**2176-6-27**] POD#5 temperature 101.8. wbc 11.4, chast xray negative
for pulmonary infiltrate, CVL line culture no growth.MRSA screen
negative.OOB to chair without knee flexion.Physical thearphy
recommendations rehab when medically stable.
[**2176-7-1**] POD# 9 s/p removal of external fixation and evaluation of
right knee under anesthesia.Knee reduced and placed in brace.
[**2176-7-2**] POD # [**8-23**] evaluated by ocupational theraphy for AFO. No
acute needs for occcupational thearphy.71yo with ESRD who has
been spiking fevers for last week. Has had permacath for 7d
now.lastic consulted for wound closure of faciotomy sites.
[**2176-7-3**] POD#[**9-24**] acute pain consulted for neuropathic pain.
Celebrex, oxycontin and diludid continued. Neurotin increased
400mgm HS,elavil 25mgm HS added
[**2176-7-4**] POD# [**10-25**] improvement in pain with regime adjustment.
[**2176-7-5**] POD#13/4 s/p Split thickness skin graft to faciotomy
siteswith VAC dressing placement. Orthopedic surgery defered
until [**Month (only) **] (4-6 weeks).
[**2176-7-6**] POD# 14/5/1 donor site open to air and zeroform dressing
intact.
[**2176-7-8**] POD# 16/7/3 Knee brace locked @ 30 degrees. [**Month (only) 116**] be oob
to chair ambulaated twenty minuets at time with leg dependant
position . Weight bearing touchdown only. Followup with Dr. [**First Name (STitle) 4304**]
[**Name (STitle) 284**] in mid [**Month (only) **] for orthopedic surgery.
[**2176-7-9**] POD#17/8/4 Vancomycin started for wound erythema.
[**2176-7-10**] POD#18/9/5 EMG: intact axonal continuity of tibial
nerve. No clear evidence of axonal continuallity of common
peroneal and it's branches but limited exam secondary to
dressings. Patient did extend foot breifly during exam. followup
EMG 2 months.Vac removed.With good take of her graft.
[**2176-7-12**] POD#20/11/7 wound erythema diminished.
[**2176-7-15**] POD# 23/14/10 cllinically continued to show improvement.
[**2176-7-16**] discharged to home with services
Medications on Admission:
axert
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Axert 12.5 mg Tablet Sig: One (1) Tablet PO once () as needed
for headache.
4. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
5. Rofecoxib 12.5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Hydromorphone HCl 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed for breaththrough pain.
9. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: 40mgm mgm
Subcutaneous Q12H (every 12 hours) for 4 weeks.
Disp:*56 syringes* Refills:*0*
10. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
15. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
17. Hydromorphone HCl 2 mg Tablet Sig: 1-4 Tablets PO Q3-4H ()
as needed for breakthrough pain.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
right popteal artery injury
Right knee dislocation injury
peroneal/tibial Nerve tramatic injury by EMG
neuropathic pain
Discharge Condition:
stable
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) **]. call for appointment. [**Telephone/Fax (1) 95583**]
f/up with Dr. [**Last Name (STitle) 284**] in Ortho/Trama for right knee repair.
Call for appointment.[**Telephone/Fax (1) 5499**]
f/up with Dr.[**Last Name (STitle) 95584**] Plastics service 1 week. call for
appointment @ [**Telephone/Fax (1) 274**]
f/up withDr. Raunor Neuromuscular Service re EMG [**Telephone/Fax (1) 44**]
for EMG and f/up
Completed by:[**2176-7-16**]
|
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icd9cm
|
[
[
[]
]
] |
[
"78.66",
"81.46",
"39.56",
"83.14",
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] |
icd9pcs
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[
[
[]
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230, 275
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958, 967
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,680
| 111,462
|
5593
|
Discharge summary
|
report
|
Admission Date: [**2159-4-4**] Discharge Date: [**2159-4-11**]
Date of Birth: [**2085-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
Transesophageal echo
History of Present Illness:
73 yo F with h/o poorly-controlled HTN, ESRD, and DM p/w SOB x1
day, started 1 day after regular HD session. SOB associated with
cough, white sputum for about a week. Pt attributes this to a
cold, although denies rhinorrhea, nasal congestion, sore throat.
+ sick contacts at dialysis center. Notes increased abdominal
girth for several days. Loose BM 3 days ago, passing flatus. +
subjective fever, low grade temp to 100.0 this morning. Slight
bleeding from fistula.
.
ED course: CXR with pulmonary edema, ? pneumonia - given ctx,
azithro. Recieved HD in preparation for CTA which was negative
for PE, + for pulmonary edema.
.
ROS: + low grade fever, no n/v/abd pain, + loose stools several
days ago, make urine, no dysuria or urinary frequency. +20 pound
weight loss over last 6 months
Past Medical History:
) Type 2 diabetes mellitus: Started insulin in [**2157**].
2) Hypertension: Poorly controlled with many admissions to
MICU/CCU for hypertensive urgency.
3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal
arteries, superior with question of stenosis and middle with
stenosis.
4) Hypercholesterolemia
5) ESRD on HD M/W/F. Followed by Dr. [**First Name (STitle) **]
6) Diastolic CHF
7) Osteoarthritis
8) Depression
9) Anxiety
10) Sickle cell trait
11) Hiatal hernia
12) Gastroesophageal reflux disease
13) Chronic constipation
14) History of mechanical falls.
15) Chronic anemia: Presumed secondary to renal failure.
16) Status post hysterectomy in [**2132**].
Social History:
Lives at home with her husband. Moved to the US in [**2124**].
Originally from Barbados, but lived in [**Location **] for 20 years as
well. She used to work as a medic in the PACU at [**Hospital1 18**], then
later as a recreational assistant at another facility. Denies
any alcohol use, no history of smoking, no IVDU. Has mother who
is sick in a hospital in Barbados.
Family History:
Mother alive at 89, with DM2, HTN. Father died of Alzheimer's
Disease. Brother with hypertension.
Physical Exam:
Vitals: T 98.8, BP 163/76, HR 110-120, RR 16, O2 sat 98% on RA
GEN: A&O x 3, pleasant, thin F sitting up in bed in NAD. No
accessory muscle use, talking in full sentences.
HEENT: EOMI, OP clear with MMM.
Neck: JVD to jaw
CV: irregular, tachycardic, nl S1/S2, II/VI SEM at LUSB
LUNGS: crackles at bases bilaterally, good air entry
ABD: soft, moderately distended, palpable hepatomegaly, 10cm
below costal margin, NT, +BS
EXT: tr pitting edema b/l, warm. L AVF with palpable thrill.
Pertinent Results:
[**2159-4-4**] 06:15PM HCT-28.8*
[**2159-4-4**] 01:30PM ASCITES TOT PROT-4.5 GLUCOSE-211 CREAT-4.2
LD(LDH)-119 AMYLASE-41 ALBUMIN-2.7
[**2159-4-4**] 01:30PM ASCITES WBC-261* RBC-[**Numeric Identifier 22475**]* POLYS-1*
LYMPHS-32* MONOS-54* MESOTHELI-3* MACROPHAG-10*
[**2159-4-4**] 06:35AM GLUCOSE-154* UREA N-33* CREAT-4.2* SODIUM-135
POTASSIUM-3.6 CHLORIDE-90* TOTAL CO2-33* ANION GAP-16
[**2159-4-4**] 06:35AM ALT(SGPT)-22 AST(SGOT)-30 LD(LDH)-215
CK(CPK)-55 ALK PHOS-123* AMYLASE-112* TOT BILI-0.5
[**2159-4-4**] 06:35AM LIPASE-141*
[**2159-4-4**] 06:35AM CK-MB-NotDone cTropnT-0.15*
[**2159-4-4**] 06:35AM TOT PROT-7.9 ALBUMIN-4.3 GLOBULIN-3.6
CALCIUM-9.7 PHOSPHATE-3.5 MAGNESIUM-2.1 IRON-67
[**2159-4-4**] 06:35AM calTIBC-231* FERRITIN-GREATER TH TRF-178*
[**2159-4-4**] 06:35AM WBC-10.3 RBC-4.41 HGB-10.4* HCT-33.0* MCV-75*
MCH-23.6* MCHC-31.5 RDW-21.8*
[**2159-4-4**] 06:35AM PLT COUNT-201
[**2159-4-4**] 06:35AM PT-17.1* PTT-30.4 INR(PT)-1.6*
[**2159-4-4**] 02:20AM CK(CPK)-57
[**2159-4-4**] 02:20AM CK-MB-NotDone cTropnT-0.14*
[**2159-4-3**] 04:15PM LACTATE-1.9
[**2159-4-3**] 04:00PM GLUCOSE-282* UREA N-29* CREAT-3.8* SODIUM-139
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-33* ANION GAP-17
[**2159-4-3**] 04:00PM estGFR-Using this
[**2159-4-3**] 04:00PM CK(CPK)-56
[**2159-4-3**] 04:00PM cTropnT-0.13*
[**2159-4-3**] 04:00PM CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2159-4-3**] 04:00PM CALCIUM-10.0 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2159-4-3**] 04:00PM WBC-9.0 RBC-4.32 HGB-10.5* HCT-32.5* MCV-75*
MCH-24.2* MCHC-32.2 RDW-21.8*
[**2159-4-3**] 04:00PM NEUTS-76.4* LYMPHS-14.2* MONOS-7.9 EOS-0.9
BASOS-0.6
[**2159-4-3**] 04:00PM HYPOCHROM-1+ ANISOCYT-2+ MICROCYT-3+
[**2159-4-3**] 04:00PM PLT COUNT-219 LPLT-1+
[**2159-4-3**] 04:00PM D-DIMER-1224*
.
Imaging:
.
[**4-3**] CXR: CHF, no PNA
.
[**4-3**] ABD XR: MPRESSION: Dilated loops of small bowel with
multiple "step-ladder" fluid levels, and paucity of large bowel
gas, highly concerning for small bowel obstruction; adynamic
ileus is less likely.
.
[**4-3**] CT Chest, ABD, Pelvis: IMPRESSION:
1) No pulmonary embolism or evidence of bowel obstruction.
2) Moderate amount of ascites.
3) Cardiomegaly with evidence of mild congestive heart failure
and passive hepatic congestion. Small right pleural effusion.
4) Coronary artery calcification.
5) Mild enlargement of the pulmonary arteries, suggestive of
pulmonary arterial hypertension.
6) At least one small cystic lesion in the head of the pancreas,
which appears likely to connect to the main pancreatic duct but
is not well evaluated on CT; this could be followed up in 6
months.
7) Adrenal lesions not well characterized on this study appear
consistent with adenomas on prior studies.
.
[**4-4**] RUQ U/S:
1. Liver Doppler findings consistent with right heart
failure/triscuspid regurgitation. Patent hepatic vasculature.
2. Hepatomegaly. No evidence of splenomegaly.
3. Limited evaluation of the gallbladder which may contain
stones.
.
[**4-4**] ECHO:
Conclusions:
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular ejection
fraction appears somewhat reduced. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen.
IMPRESSION: No left atrial or left atrial appendage clot, but
severe left atrial appendage spontaneous echo contrast
.
[**4-7**] CXR
IMPRESSION: Improvement in the congestive heart failure seen on
the prior examination.
.
Other Data:
.
HBcAb negative ([**1-6**])
HCV Ab negative ([**1-6**])
HEPATITIS BE ANTIBODY NON-REACTIVE ([**1-6**])
.
Ascitic Fluid [**2159-4-4**]
Cultures pending
WBC RBC Polys Lymphs Monos Mesothe Macroph
261* [**Numeric Identifier 22475**]* 1* 32* 54* 3* 10*
TotPro Glucose Creat LD(LDH) Amylase Albumin
4.5 211 4.2 119 41 2.7
.
SAAG greater than 1.1
Ascitic fluid total protein is 4.5 (greater than 2.5) indicating
a cardiac etiology for the ascites.
Brief Hospital Course:
This is a 73 yo F with DM II, HTN, ESRD on HD, who presented
with shortness of breath, found to have new onset atrial
fibrillation, cardiac ascites, course complicated by persistent
bleeding in the setting of attempted [**Numeric Identifier **] in
preparation for cardioversion, requiring transfer to the MICU.
.
On the floor patient underwent an abdominal CT scan which showed
moderate ascites as well as hepatomegaly. She also underwent
abdominal ultrasound as well as paracentesis with 800cc of fluid
removed, and ultimately it was thought that her ascites was c/w
cardiac ascites. Hepatology was consulted and agreed. Hepatitis
serologies have been negative.
.
She also had new onset atrial fibrillation, and patient was
started on a heparin gtt with the plan for TEE and subsequent
cardioversion. However, after TEE was performed, she had not yet
been dialyzed and it was thought that cardioversion would not be
successful in the setting of volume overload. Cardioversion was
postponed, and course was then complicated by continuous oozing
and bleeding, both from her nares as well as paracentesis site.
Topical thrombin was applied to paracentesis site which
eventually stabilized bleeding. The patient also had a
significant amount of epistaxis, which was eventually tamponaded
by ENT with packing and afrin. Paracentesis site again started
to ooze, and it was difficult to control bleeding on the floor.
Her hematocrit trended downwards over this course from 28 -->
23. She had been scheduled to receive blood transfusion with
dialysis, but HD would not accept her because she was bleeding.
Because nursing was not comfortable administering dDAVP on the
floor, the patient was transferred to the MICU. She received 1
unit of pRBCs prior to transfer to the unit.
.
Trauma surgery was consulted for persistent bleed, and it was
determined that she should no longer continue on a heparin gtt.
Heparin had not been supratherapeutic during this time, however,
she had been bleeding almost persistently despite this. She was
transfused one more unit of pRBCs with an appropriate
stabilization of her hematocrit.
.
# Bleeding: Initially patient was started on a heparin gtt and
Coumadin, was on ASA 325mg. In addition, she is a dialysis
patient and has platelet dysfunction at baseline. Heparin gtt
has been discontinued as well as Coumadin, and ASA was reduced
to 81mg given bleeding. Paracentesis site bleeding was initially
tamponaded and controlled with topical thrombin, but in the
setting of being on heparin gtt, bleeding has persisted,
requiring compression for >30minutes and dDAVP to control
bleeding. Epistaxis required ENT consult with nasal packing to
control. The patient received 2 u of pRBC with an appropriate
increase in her HCT and vital signs stable.
.
# Atrial fibrillation: No prior hx of AFib, prior EKG
interpreted as ? wandering atrial pacemaker. Pt is at risk for
developing AF in setting of stretched R atrium and ECG is
consistent with that. Unable to perform cardioversion as unable
to anticoagulate. Moderate to severe contrast echo seen in
atrium, representing likely very poor flow state, high risk for
thrombus formation. There are also complex (>4mm) atheroma in
the descending thoracic aorta. However, unable to anticoagulate
given high risk of bleeding. The patient will be treated with
aspirin 325mg po daily now that HCT is stable. For rate control
she is on metoprolol XL and verapamil SR. She had an episode of
tachycardia to the 140s during dialysis, likely due to the fact
that she was due for rate controlling medications. She has
outpatient follow up appointment with cardiology.
.
# Ascites: Patient is s/p paracentesis, ascitic fluid consistent
with portal hypertension from cardiac etiology. Abdominal
ultrasound also c/w liver enlargement from RHF, normal flow on
dopplers. Fluid cytology negative for malignancy. Appreciate
hepatology recommendations who also agree that ascites is most
likely from cardiac etiology.
.
# Diabetes Mellitus, type 2, well controlled: Glyburide
discontinued on admission, given renal failure. Likely should
not be continued as an outpatient. On admission was on lantus
45U qam and 15 units of lantus qhs. She had multiple episodes of
hypoglycemia during her admission and required a D10 gtt. Likely
hepatic impairment of gluconeogenesis as well as impaired renal
clearance are likely playing a role. [**Last Name (un) **] involved. Lantus
now decreased, made daily instead of [**Hospital1 **] dosing. The patient
was informed of insulin regimen changes for outpatient and to
continue to monitor blood glucose with fingersticks, primary
physician's direction.
.
# ESRD on HD: Renal failure likely secondary to DM and HTN. She
received hemodialysis while inpatient and also nephrocaps,
sevelamer, fluid restriction. Dr. [**First Name (STitle) 805**] is outpatient
nephrologist.
.
# Hypertension: Previously on regimen of labetalol, lisinopril,
nifedipine, hydralazine, clonidine, and isosorbide. We have
discontinued hydralazine, changed nifedipine to verapamil, and
decreased metoprolol, titrated down clonidine.
.
# Dyspnea: Likely a combination of fluid overload, atrial
fibrillation, mechanical stress of ascites. CTA negative on
admission for PE. No evidence of pneumonia on CXR. No evidence
of new coronary event, troponin at baseline. DFA for influenza
was negative. Continue dialysis for volume overload.
.
# Pancreatic lesion: ?cyst, consider MRI eval as outpatient.
Medications on Admission:
Labetalol 300 mg PO TID
Lisinopril 40 mg PO QD
Nifedipine 180 mg QD
Hydralazine 50 mg PO BID
Clonidine 0.3 mg PO BID
Isosorbide Mononitrate 90 mg Sustained Release PO DAILY
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg PO once a day.
Ferrous Sulfate 325 PO DAILY
Clonazepam 1 mg PO BID
Folic acid 1 mg daily
Insulin Lantus 45 units QAM, 15 units Qpm
glyburide 2 mg [**Hospital1 **]
MVI 1 tablet daily
B12 50 mcg po daily
Tylenol prn arthritis
Sevelemer 400 mg TID
ASA 325 mg daily
Rhinocort Acqua
Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous qam: Take as directed by your doctor. .
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*150 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
- Atrial fibrillation
- Diastolic congestive heart failure
.
Secondary diagnosis:
- Diabetes mellitus type 2
- Hypertension
- Hypercholesterolemia
- End stage renal disease on hemodialysis
- Osteoarthritis
- Gastroesophageal reflux disease
- Chronic anemia
Discharge Condition:
Atrial fibrillation on aspirin, respiratory status stable
Discharge Instructions:
You presented to the hospital with shortness of breath and were
found to have atrial fibrillation. You were originally treated
with [**Hospital **] (blood thinner) but due to increased
bleeding, the [**Hospital **] was held. You will need to go to
a follow up appointment with your cardiologist to reassess
[**Hospital **].
Please take all medications as directed. Some of your
medications have been changed:
a. Stop taking labetalol, nifedipine, hydralazine, glyburide.
b. New medications include metoprolol XL 150mg by mouth once
daily, verapamil SR 240mg by mouth once daily.
c. The doses have been changed on some of your medications.
- decrease clonidine to 0.2mg by mouth twice daily
- increase isosorbide mononitrate to 120mg by mouth once daily
- insulin glargine has been decreased to 20 units once each
morning. Do not take any insulin glargine (lantus) in the
evening.
Continue to check your blood sugar regularly and call your
doctor if your blood sugar is less than 60 or greater than 400.
Please attend all follow up appointments.
Continue to go to your regularly scheudle dialysis appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml per day.
If you develop fever, chills, shortness of breath, chest pain or
any other symptom that concerns you, call your primary doctor,
or if unavailable go to the emergency room.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 911**], MD Phone: [**Telephone/Fax (1) 22476**] Date/Time: [**2159-4-19**]
12:30
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2159-4-24**] 9:50
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 11595**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 19196**] Date/Time: [**2159-4-24**] 2:15pm
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] (you
will have already seen your cardiologist prior to this
appointment), your blood sugar, and discuss a pancreatic cyst
seen on imaging and MRI may be indicated for further evaluation.
|
[
"250.02",
"428.0",
"285.21",
"300.4",
"V58.67",
"715.90",
"403.91",
"998.11",
"272.0",
"553.3",
"428.32",
"789.5",
"V45.1",
"530.81",
"564.00",
"427.31",
"784.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"99.04",
"88.72",
"54.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14778, 14836
|
7326, 12792
|
342, 364
|
15156, 15216
|
2896, 7303
|
16692, 17399
|
2280, 2379
|
13341, 14755
|
14857, 14857
|
12818, 13318
|
15240, 16669
|
2394, 2877
|
276, 304
|
392, 1180
|
14958, 15135
|
14876, 14937
|
1202, 1878
|
1894, 2264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,837
| 162,198
|
55166
|
Discharge summary
|
report
|
Admission Date: [**2165-8-1**] Discharge Date: [**2165-8-9**]
Date of Birth: [**2091-2-16**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Melena and newly diagnosed colonic mass
Major Surgical or Invasive Procedure:
Intubation times 3
History of Present Illness:
HPI: 74F with PMH COPD on home O2 2L, CAD (+ stress test, not
cathed), HTN, hx DVT on coumadin presented to [**Hospital **] Hospital
on [**7-28**] with a CC of dark stools and foot pain. Dark stools
started in the 2 days prior to presentation and were associated
with fatigue and increased SOB. No fever, chills, abdominal
pain, BRBPR, n/v, hemoptysis, syncope or CP. She was found to
be guaiac + with a HCT of 22. No evidence of upper GIB on
endoscopy, but colonoscopy revealed an appendiceal/cecal mass
with an ulcerated center, bx: high grade dysplasia with no
definite adenocarcinoma. CT showed cecal wall thickening
corresponding to mass location, mildly proominent right hilar
lymphadenopathy of unclera significance, and no evidence of
metastatic disease. She received 2 u pRBC and HCT stabilized at
29. Given patient's high surgical and procedural risk, she was
transferred to [**Hospital1 18**] for further pre-operative assessment and
ultimately treatment of her colonic mass.
Upon transfer, patient's vitals were 112/42, 70, 18, 93% on 2L
NC. She reported only mild abdominal pain and her baseline SOB.
ROS otherwise negative.
Past Medical History:
- HTN
- HL
- COPD with chronic hypoxia on 2L NC home O2
- CAD- s/p DES to RCA in [**2159**], on Plavix
- AAA- Repaired in [**2147**], complicated by thrombus at site and
embolism to left leg in [**2150**] requiring left foot amputation. On
Coumadin.
- Left foot amputation [**2150**]
- GERD
- Left hip fx, s/p ORIF
- Carotid artery disease
- diastolic heart failure
Social History:
Lives alone with occasional help from HHA and help from
daughters, who live nearby. [**Hospital 8735**] hospital unit secretary.
Active smoker, now down to 1 pack/week from 1PPD x 30 years. No
alcohol or other drugs.
Family History:
Father died of old age. Mother died age [**Age over 90 **] in [**2154**]. Maternal
great aunt with [**Name2 (NI) 499**] ca. No family hx breast of GYN
malignancies.
Physical Exam:
ADMISSION EXAM:
Vitals: 112/42, 70, 18, 93% on 2L NC
General: pleasant elderly woman, NAD
HEENT: NC/AT, PERRL, EOMI, MMM, oropharynx clear
Neck: supple, no JVD or adenopathy
Pulmonary: Dry crackles at bilateral lung bases to mid-lung.
Good airmovement. No wheezes or rales. On 2L NC.
Cardiac: RRR, S1 S2, II/VI systolic murmur at RUSB, PMI
non-displaced
Abdomen: Midline surgical scar, soft, minimally tender to
palpation, with a 3x3cm firm left periumbilical mass (old that
is non-tender. +BS, no HSM appreciated.
Ext: No edema, L foot amputation,
Skin: Multiple ecchymoses
Neuro: A+O x 3, no focal deficits
DISCHARGE EXAM:
Deceased
Pertinent Results:
Admission labs:
[**2165-8-1**] 09:05PM BLOOD WBC-9.4 RBC-3.36* Hgb-9.7* Hct-31.3*
MCV-93 MCH-28.8 MCHC-30.9* RDW-15.7* Plt Ct-514*
[**2165-8-1**] 09:05PM BLOOD Neuts-74.7* Lymphs-14.1* Monos-5.5
Eos-5.4* Baso-0.3
[**2165-8-1**] 09:05PM BLOOD PT-10.9 PTT-32.8 INR(PT)-1.0
[**2165-8-1**] 09:05PM BLOOD Glucose-112* UreaN-17 Creat-0.9 Na-142
K-4.5 Cl-98 HCO3-40* AnGap-9
[**2165-8-1**] 09:05PM BLOOD ALT-12 AST-16 LD(LDH)-195 AlkPhos-81
TotBili-0.2
[**2165-8-1**] 09:05PM BLOOD Albumin-3.9 Calcium-9.9 Phos-4.6* Mg-2.1
Imaging:
CTA
FINDINGS: An endotracheal tube is in place, 3.6 cm above the
carina. An
enteric tube traverses inferiorly into the stomach out of view.
The aorta is normal in caliber without acute pathology. The
pulmonary arterial tree is well opacified to the subsegmental
level without filling defects to suggest pulmonary embolism.
The heart is normal in size without pericardial effusion.
Extensive multivessel coronary arterial calcifications are
present. A small 8mm penetrating aortic ulcer is present in the
arch distal to the left subclavian origin. There is a bovine
arch configuration of the arch vessels, compatible with normal
anatomic variation. Small hilar lymph nodes may be present,
nonspecific.
There is extensive biapical predominant centrilobular emphysema.
Note is made of subsegmental atelectasis of the lingula.
Abrupt attenuation of the
subsegmental and lower order branches of the bronchi supplying
the lingula (4, 85-88) could represent sequela of a prior
infection such as scarring (which could be correlated with prior
exam if available).
There is trace right dependent atelectasis. No obvious
pulmonary nodule or
mass.
There are wedge compressions involving T4-5 vertebral bodies,
status post vertebroplasty with hyperdense material within the
vertebral bodies. There is also wedge compression of what
appears to be T7 vertebral body, with a 30% loss of height, age
indeterminate.
Limited subdiaphragmatic evaluation demonstrates two exophytic
right renal
cysts, the inferior of which measuring approximately 20
Hounsfield units,
which could represent proteinaceous or hemorrhagic component,
but is
incompletely assessed.
There is diffuse moderate atherosclerotic disease throughout the
imaged
portion of the aorta, without aneurysm.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. 8-mm penetrating aortic ulcer in the aortic arch distal to
the arch vessel origins. Diffuse moderate atherosclerotic
disease.
3. Moderate diffuse centrilobular emphysema.
4. Subsegmental lingular atelectasis.
5. Probable right renal cysts, the inferior of which is
hyperdense. Consider ultrasound for further evaluation.
6. Severe multivessel coronary arterial disease.
TTE:
The left atrium is elongated. No right-to-left shunt is seen on
agitated saline injection at rest. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened (?#).
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**2-4**]+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Minimal aortic valve stenosis. Mild aortic
regurgitation. Mild-moderate mitral regurgitation.
Brief Hospital Course:
74F with PMH COPD on O2, CAD, HTN, DVT previously on coumadin,
presented to OSH with 2 days of melena and was found to be
anemic to HCT 22 with an appendical/cecal ulcerated mass.
#. COPD- During hospitalization, patient's COPD was initially
treated with Advair, Spiriva, and albuterol nebulizers as
needed. She was maintained on 2L of O2 by NC, which is also her
home dose. She was noted to become tachycardic and acutely
desaturated to 70% requiring emergent intubation by anesthesia.
She was subsequently transferred to the MICU for further
management. She was extenuated and initially fared well, though
the patient did experience acute episodes of shortness of
breath. She acutely desautrated to 60% on 2L and had to be
emergently intubated. The patient tolerated ventilation well and
was breathing more comfortably on the ventilator. She was
started on treatment for COPD exacerbation. In light of the
end-stage nature of her COPD, ongoing discussions were carried
out with the patient's daughter [**Name (NI) 15528**] her mother's goals of
care. The patient was subsequently extubated, but quickly
required re-intubation for respiratory distress and concern for
fatigue despite PPV. After patient's third intubation, the
decision was made by the patient's daughter with the help of
on-going discussions by palliative care to transition the
patient to comfort measures only. She expired.
Brief outline of on-going issues during patient's hosptalization
prior to be made CMO:
# GI bleed- Based upon colonoscopy at OSH, patient's ulcerated
appendiceal/cecal mass was felt to be the most likely source.
Her bleeding had stopped by the time of transfer to [**Hospital1 18**] and
her HCT was trending up, from a nadir of 22 at OSH to 31 on
hospital day 2 at [**Hospital1 18**]. She also remained hemodynamically
stable and was restarted on her Metoprolol for BP control. An
active type + screen was maintained and patient was monitored on
telemetry. In spite of the fact that patient had stopped
bleeding, we continued to hold her Coumadin and Plavix given
that we did not have source control.
# Colonic mass- Patient's 2cm, ulcerated appendiceal/cecal mass
had been biopsied during colonoscopy at OSH and pathology
revealed high grade dysplasia concerning for malignancy. A
rectal polyp was also removed with pathology showing a
tubulovillous adenoma with high grade dysplasia. GI at [**Hospital1 18**] was
consulted and felt that mass could not be managed or excised
with an endoscopic approach, so colorectal surgery was
consulted. Given patient's COPD and CAD, she is a very high risk
surgical candidate. Surgery was not purused given her
respiratory status.
# HTN- Home antihypertensives Lisinopril and Metoprolol were
held at OSH in the setting of patient's GI bleed. Upon transfer
to [**Hospital1 18**], patient was hemodynamically stable and telemetry
demonstrated occasional PVC's, so Metoprolol was restarted.
# UTI- Patient was diagnosed with a UTI at OSH. She received a
total of 6 days of Levaquin. Upon transfer to [**Hospital1 18**], patient
denied urinary symptoms and Levaquin was discontinued. Her urine
culture showed enterococcus 10,000-100K CFU. She was initially
started on Ampicillin based on sensitivities, but this was then
discontinued.
# AAA repair c/b embolism to Left Leg and Left Foot Amputation-
Patient's Coumadin was held given recent GI bleed.
# CAD - Patinet has a history of drug eluting stent placement
in her RCA in [**2159**]. She is still on Plavix. Presumably, her
Plavix was not discontinued after stent placement but we were
unable to clarify the indication for Coumadin with patient and
with her outside records. Her Plavix was held in the setting of
GI bleed.
# Hypercholesterolemia- Patient's home dose of simvastatin is 70
mg daily. While in house, she was continued on simvastating 40
mg daily. Upon discharge, please consider switching to a higher
potency statin.
# GERD- Patient was continued on ranitidine
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH notes;
patient cannot recall med list. .
1. Amitriptyline 25 mg PO QAM
2. Amitriptyline 50 mg PO QHS
3. Symbicort *NF* (budesonide-formoterol) 150/4.5 Inhalation
[**Hospital1 **]
4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 1
tablet Oral daily
5. Clopidogrel 75 mg PO DAILY
6. Foradil Aerolizer *NF* (formoterol fumarate) 1 inhalation
Inhalation Q4H:PRN shortness of breath
7. Furosemide 20 mg PO EVERY OTHER DAY
8. Gabapentin 300 mg PO QAM
9. Gabapentin 600 mg PO QPM
10. Isosorbide Mononitrate 30 mg PO DAILY
11. Lisinopril 10 mg PO QPM
12. Lorazepam 0.5 mg PO QPM
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Ranitidine 150 mg PO QAM
15. Simvastatin 70 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. TraMADOL (Ultram) 50 mg PO BID
18. Warfarin 3 mg PO DAILY
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"578.1",
"V45.82",
"518.81",
"V46.2",
"285.1",
"599.0",
"V58.61",
"V12.51",
"569.82",
"530.81",
"496",
"V49.73",
"569.9",
"401.9",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11790, 11799
|
6773, 10746
|
315, 335
|
11850, 11859
|
2983, 2983
|
11915, 12061
|
2145, 2312
|
11758, 11767
|
11820, 11829
|
10772, 11735
|
11883, 11892
|
2327, 2938
|
2954, 2964
|
236, 277
|
363, 1504
|
3000, 6750
|
1526, 1894
|
1910, 2129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,425
| 120,766
|
45935
|
Discharge summary
|
report
|
Admission Date: [**2120-6-2**] Discharge Date: [**2120-6-24**]
Date of Birth: [**2056-10-16**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Shellfish / OxyContin / Codeine / Acetaminophen
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
nausea, vomiting and abdominal pain
Major Surgical or Invasive Procedure:
Central line placement
Hemodialysis
Tunnelled HD line [**2120-6-18**]
PICC line placement [**2120-6-10**] on Right side
History of Present Illness:
63 year old woman with HTN, Asthma, fibromyalgia/chronic pain,
h/o breast cancer in remission ([**2102**]), lung SCC (resected in
[**2116**]), tracheal cancer ([**4-/2119**] s/p chemoXRT and
radiation induced esophagitis), who presents with bilateral
upper abdominal pain with nausea and vomitting. Her g-tube
removed last week, she says she has been gaining weight. Denies
fever/chills.
In the ED, initial vitals were: 98F 92 162/98 16 100% RA.
Oxygen saturations dropped and she required 8L via venti-mask.
Combivent was given. She received 500cc IVF. Labs were notable
for newly elevated AST/ALT (2-3K), [**Last Name (un) **] (Cr 1.4 from baseline
0.9), metabolic acidosis (AG 24 with lactate 4.8), trop 0.03.
CT torso showed multifocal opacities suggestive of pneumonia
(possible aspiration) without acute intra-abdominal process.
She was given vancomycin and zosyn. She was found to be in new
afib with RVR with rates 150 and LBBB. Subsequently she
received 20mg IV diltiazem with rates dropping to 90s. RVR
recurred prompting another 10mg IV dilitiazem. Blood pressure
was stable with SBP 130-140s throughout ED stay. She also
received 10mg morphine for pain, reglan 5mg and zofran 8mg for
nausea. Peripheral IV access could not be obtained, therefore
R. femoral CVL was placed.
On arrival to the MICU, Pt is in NAD, she has some difficulty
answering questions and ignore certain questions. She has a
non-labored breathing pattern while lying flat.
Past Medical History:
ONCOLOGIC HISTORY:
1) Breast cancer stage II (T2N0M0), [**2102**]: treated with
lumpectomy, XRT, and CMF. No evidence of recurrent disease.
2) Lung SCC stage IA (T1bN0M0), [**2116**]: Resected on [**2117-11-16**].
Without evidence of recurrence.
3) Tracheal cancer diagnosed in [**4-/2119**]
- [**2119-6-22**]- [**2119-7-20**]: Received weekly [**Doctor Last Name **] and txol with
concomittent XRT
- [**2119-7-24**]: CT without evidence of tumor
- [**2119-7-24**] to [**2119-8-1**] Admitted for esphagitis, dehydration.
Started TPN.
- [**2119-7-27**] HELD W6 carboplatin paclitaxel for esophagitis and
excess toxicity.
- [**2119-8-1**] Completed 6000 cGy to the tumor and involved LNs
- Admitted for odynophasia ([**8-15**] - [**8-27**])- radiation-induced
esophagitis vs. [**Female First Name (un) **], previously on TPN and completed a
10-day course of Fluconazole with improvement of this problem
- [**Name (NI) **] negative staph Bacteremia - 3 of 4 bottles positive on
[**8-14**]. Portacath was removed [**8-17**] but tip culture results were
negative. Treated with Vanco IV x 2 weeks (750 mg iv q12h
through [**2119-8-31**])
- Admitted [**Date range (3) 97801**] for odynophagia, dysphagia -
radiation-induced esophagitis, bx neg for [**Female First Name (un) **]/CMV/HSV, tx
for [**Female First Name (un) **] without improvement
PAST MEDICAL HISTORY:
- Fibromyalgia / chronic pain syndrome (due to osteoarthritis
and rheumatoid arthritis). Status post multiple immunomodulatory
agents (including methotrexate) and courses of steroids.
Currently on chronic opiates.
- Asthma with bronchospasm, bronchomalacia and chronic
rhinosinusitis with previous exacerbations requiring steroids
attacks) with need of steroids.
- Hypertension
- Depression
- Hyperlipidemia
- Obesity
- Migraine
- GERD
- bilateral carpal tunnel syndrome w/ hand weakness
- spondylolisthesis of L4-5, radiculopathy w/stenosis
- Right total shoulder arthroplasty [**10/2114**]
- Right total knee arthroplasty
- Left shoulder replacement
- Possible sundowning on admission [**9-2**] - [**9-8**] for COPD
exacerbation
Social History:
Widowed. Lives alone but with considerable support from her
children, who are trying to convince her to move in with them.
Smoking since later in life. Continues to smoke 2 cigs/day. No
alcohol or illicits.
Family History:
Daughter with metastatic breast cancer. Mother also with breast
cancer but died of MI.
Physical Exam:
Admission exam:
Vitals: T: 97.7 BP: 153/94 P: 120 R: 37 O2: 90%
General: Alert, oriented, no acute distress
[**Month/Year (2) 4459**]: Sclera anicteric, MMM, oropharynx clear, EOMI, [**Month/Year (2) 2994**]
Neck: supple, no LAD
CV: Tachycardia rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Wheezes bilaterally
Abdomen: soft, TTP R side> L, non-distended, bowel sounds
present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge exam:
Pertinent Results:
IMAGING:
PORTABLE ABDOMEN [**2120-6-22**]
Reason: evaluate for bowel obstruction, large amount of stool.
No air-filled dilated loops of small or large bowel are
identified. However, there is a relative paucity of gas
throughout the abdomen and the possibility of some fluid-filled
loops, including dilated fluid-filled loops, cannot be entirely
excluded. There is a large amount of stool in the rectal vault.
Multiple calcifications overlie the lower pelvis. On the
left, some of these lie above the iliac spine. IMPRESSION:
1) Relative paucity of gas within most of the bowel, of
uncertain clinical
significance. If there is high clinical suspicion for
obstruction, then
further assessment with CT would be recommended.
2) Large amount of stool in the rectal vault.
CHEST (PORTABLE AP) [**2120-6-22**]
A right-sided PICC line is present, tip overlying mid/distal
SVC. A
left-sided dual-lumen catheter is present, tips overlying SVC/RA
junction and RA. No pneumothorax is identified. There are low
inspiratory volumes. There is cardiomegaly with vascular
plethora and vascular blurring, though these findings are likely
accentuated by low inspiratory volumes. There is increased
opacity at the right base, which could represent a combination
of pleural fluid, elevated hemidiaphragm,
and underlying collapse and/or consolidation. There is also
pleural
thickening and/or fluid at the right lung apex. Sutures noted
about the right hilum. The left costophrenic sulcus is clear.
Compared with [**2120-6-15**], findings at the right base are
similar. There is slightly less opacity at the right apex. The
CHF findings may be slightly
worse.
TUNNELED DIALYSIS LINE PLACEMENT [**2120-6-18**]
Successful placement of tunneled hemodialysis line through the
left
external jugular vein. The left internal jugular vein was found
to be
occluded. Withdrawal of right-sided temporary hemodialysis line.
LOWER EXTREMITY ARTERIAL NONIVASIVES AT REST [**2120-6-17**]
REASON: Ischemic toes.
FINDINGS: Doppler waveform analysis reveals triphasic waveforms
at the right common femoral, popliteal, and DP. There are
mono/biphasic waveforms at the PT. The right ABI is 1.2. On
the left, there are triphasic waveforms at the common femoral,
popliteal, and mono/biphasic waveforms at the DP and PT. The
left ABI is 1.2. Pulse volume recordings demonstrate
preservation of the dicrotic notch down through the metatarsal
level bilaterally. IMPRESSION: Mild bilateral tibial arterial
disease.
MR HEAD W/O CONTRAST; MR INCOMPLETE STUDY [**2120-6-11**]
Limited examination, the patient became unstable and the study
was discontinued, only diffusion-weighted images and sagittal
images were
obtained. There is no evidence of diffusion abnormalities to
indicate restricted diffusion or acute/subacute ischemic
changes. Prominent ventricles and sulci remain unchanged since
the prior MRI of the
brain dated [**2119-12-27**]. There is no evidence of acute
intracranial hemorrhage or mass effect
CT HEAD W/O CONTRAST [**2120-6-9**]:
There is no hemorrhage, edema, mass effect, or territorial
infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns are patent. [**Doctor Last Name **]-white matter
differentiation is preserved. There is no fracture. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. IMPRESSION: No acute intracranial process.
CT CHEST W/O CONTRAST [**2120-6-9**]:
COMPARISON: [**2120-3-19**]. Coronal and sagittal reformats were
then obtained. FINDINGS: There is a central line with its tip
in the cavoatrial junction. There is an endotracheal tube and a
NG tube in situ. There are no abnormally enlarged mediastinal,
hilar or axillary lymph nodes. There has been prior surgery to
the right breast and there are dystrophic calcifications within
the right breast and architectural distortion within the soft
tissues of the right axilla, likely post-surgical. There is
triple three-vessel coronary artery calcification. The heart is
enlarged. The pericardial space is clear. There is also
enlargement of the main pulmonary artery, measuring 3.3 cm.
There are small bilateral pleural effusions, larger on the
right. The patient has had a prior right upper lobectomy. The
minimal soft tissue
thickening around the trachea is unchanged in appearance. Also
unchanged is the tracheal pseudodiverticulum, 2 cm above the
carina. There is confluent airspace opacity with air
bronchograms within the superior segment of the right lower
lobe. There is fibrosis within the right middle lobe, stable and
likely post surgical. Confluent airspace opacity is also seen
throughout the left upper and lower lobes. Ground glass
centrilobular nodules are also seen within the lower lobes
bilaterally. Visualized upper abdomen is grossly unremarkable.
There are no suspicious bony abnormalities. Evidence of prior
right thoracotomy and right shoulder replacement. IMPRESSION:
There has been interval development of diffuse patchy multifocal
airspace opacity. There are small bilateral pleural effusions.
Overall, in an acute setting, this is likely infectious, but
pulmonary edema or hemorrhage are not excluded. Clinical
correlation is required.
RENAL ULTRASOUND [**2120-6-4**]:
The right kidney measures 9.8 cm and the left kidney measures
10.0
cm. There is no hydronephrosis. No perinephric fluid
collection is
identified. No cyst or stone or solid mass is seen in either
kidney. A foley catheter is noted within the urinary bladder.
IMPRESSION: No hydronephrosis is identified. Unremarkable
renal ultrasound.
TTE [**2120-6-4**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
septal dyssynchrony, likely related to left bundle branch block.
The remaining segments contract normally (LVEF = 50%). The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild regional left ventricular systolic
dysfunction, likely secondary to left bundle branch block. Mild
mitral regurgitation. Moderate pulmonary hypertension.
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOP ABD/PEL LIMITED)
[**2120-6-3**]
There are no focal hepatic lesions. The portal vein is patent
with normal
hepatopetal flow. There is no intra- or extra-hepatic biliary
dilatation with the common bile duct measuring 3 mm. The
gallbladder is normal. The hepatic veins, hepatic artery, main,
right and left portal vein branches are patent with normal
waveforms. The relative degree of arterial flow appears
prominent. Portal waveforms are moderately pulsatile. There
are occasional premature cardiac beats seen among arterial
spectral waveforms. There is no ascites. There is however a
small right-sided pleural effusion. IMPRESSION: Patent hepatic
vasculature. No focal hepatic lesions. Normal gallbladder. Small
right-sided pleural effusion. Few premature cardiac beats.
CHEST (PORTABLE AP) [**2120-6-3**]: Compared to the previous
radiograph, the upper lung opacity on the right has
substantially increased in severity and extent. The opacity is
located at the region of former right upper lobectomy. The
short time course of the changes suggests infection rather than
a neoplastic recurrence. The pre-existing opacity on the left,
located in the lung apex, unchanged. Unchanged size of the
cardiac silhouette. Mild retrocardiac atelectasis.
CT ABD & PELVIS WITH CONTRAST [**2120-6-2**]:
Ground glass nodular opacities in both lung bases are consistent
with
aspiration or small airways infection. Small bilateral
nonhemorrhagic
effusions. No evidence of any acute process within the abdomen
or pelvis.
ECG [**2120-6-3**]:
Sinus rhythm. Left bundle-branch block. Left atrial abnormality.
No major
change compared to previous tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 130 132 446/472 52 -24 160
ECG [**2120-6-4**]: Atrial fibrillation with rapid ventricular
response. Incomplete left bundle-branch block. Probable left
ventricular hypertrophy. Compared to the previous tracing the
findings are similar.
Rate PR QRS QT/QTc P QRS T
117 0 126 362/461 0 -25 167
CT Abd and Pelvis: IMPRESSION: 1. Ground glass nodular
opacities in both lung bases are consistent with aspiration or
small airways infection. Small bilateral nonhemorrhagic
effusions. 2. No evidence of any acute process within the
abdomen or pelvis.
MICRO/PATH LABS:
[**2120-6-2**] Blood Culture, Routine: NO GROWTH
[**2120-6-3**] MRSA SCREEN: No MRSA isolated
[**2120-6-3**] 07:36AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-
POSITIVE
[**2120-6-4**] Rubella IgG/IgM Antibody: POSITIVE
[**2120-6-4**] RAPID PLASMA REAGIN TEST: NONREACTIVE.
[**2120-6-4**] RUBEOLA ANTIBODY, IgG (Final [**2120-6-5**]): POSITIVE BY EIA
[**2120-6-4**] 01:25AM BLOOD HIV Ab-NEGATIVE
[**2120-6-4**] VARICELLA-ZOSTER IgG SEROLOGY (Final [**2120-6-4**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
[**2120-6-4**] CMV IgG ANTIBODY (Final [**2120-6-4**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
118 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2120-6-4**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
[**2120-6-6**] IgM HBc-NEGATIVE IgM HAV-NEGATIVE, [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS
VCA-IgG AB-POSITIVE BY EIA, [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG
AB-POSITIVE BY EIA, [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB- NEGATIVE
<1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV
INFECTION. In most populations, 90% of adults have been infected
at sometime with EBV and will have measurable VCA IgG and EBNA
antibodies. Antibodies to EBNA develop 6-8 weeks after primary
infection and remain present for life. Presence of VCA IgM
antibodies indicates recent primary infection.
[**2120-6-6**] WOUND CULTURE (Final [**2120-6-6**]): No significant
growth.
[**2120-6-7**] HCV VIRAL LOAD (Final [**2120-6-7**]):
HCV-RNA NOT DETECTED.
[**2120-6-11**] GRAM STAIN (Final [**2120-6-9**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2120-6-11**]):
RARE GROWTH Commensal Respiratory Flora.
ADMISSION LABS:
[**2120-6-2**] 07:30PM BLOOD WBC-11.4* RBC-3.04* Hgb-10.0* Hct-31.2*
MCV-103* MCH-32.9* MCHC-32.1 RDW-17.9* Plt Ct-230
[**2120-6-2**] 07:30PM BLOOD Neuts-91.5* Lymphs-7.0* Monos-1.3*
Eos-0.1 Baso-0.2
[**2120-6-2**] 11:40PM BLOOD PT-20.3* PTT-38.3* INR(PT)-1.9*
[**2120-6-2**] 07:30PM BLOOD Glucose-108* UreaN-38* Creat-1.4* Na-132*
K-4.7 Cl-87* HCO3-26 AnGap-24*
[**2120-6-2**] 07:30PM BLOOD ALT-2490* AST-3867* LD(LDH)-5725*
AlkPhos-75 TotBili-1.4
[**2120-6-3**] 03:44PM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.3 Mg-1.7
[**2120-6-4**] 01:26AM BLOOD calTIBC-222* Ferritn-[**Numeric Identifier **]* TRF-171*
[**2120-6-4**] 07:32AM BLOOD Triglyc-241*
[**2120-6-4**] 01:26AM BLOOD AMA-NEGATIVE
[**2120-6-4**] 01:26AM BLOOD CEA-3.1 AFP-3.0
[**2120-6-3**] 03:39AM BLOOD Type-[**Last Name (un) **] pO2-26* pCO2-55* pH-7.34*
calTCO2-31* Base XS-0
[**2120-6-2**] 07:56PM BLOOD Lactate-4.8*
DISCHARGE LABS:
[**2120-6-24**] 04:05AM BLOOD WBC-13.2* RBC-2.90* Hgb-9.0* Hct-27.2*
MCV-94 MCH-31.0 MCHC-33.1 RDW-18.0* Plt Ct-400
[**2120-6-24**] 04:05AM BLOOD Plt Ct-400
[**2120-6-24**] 04:05AM BLOOD
[**2120-6-24**] 02:17PM BLOOD Glucose-201* Na-126* K-3.7 Cl-91* HCO3-22
AnGap-17
[**2120-6-24**] 04:05AM BLOOD Glucose-85 UreaN-25* Creat-3.2* Na-130*
K-3.5 Cl-93* HCO3-27 AnGap-14
[**2120-6-24**] 02:17PM BLOOD Calcium-8.1* Phos-1.9* Mg-2.2
Brief Hospital Course:
63 year old woman with HTN, Asthma, fibromyalgia/chronic pain,
h/o breast cancer in remission ([**2102**]), lung SCC (resected in
[**2116**]), tracheal cancer ([**4-/2119**] s/p chemoXRT and radiation
induced esophagitis), who presents with bilateral upper
abdominal pain with nausea and vomitting; found to be in acute
liver and anuric renal failure and altered mental status
requiring dialysis who had improving liver function at the time
of discharge but still requiring dialysis.
#HCAP, VAP: Pt was initially treated with IV vancomycin and
Zosyn for presumed HCAP based on radiographic infiltrates. Blood
and urine cultures did not grow any organisms. As pt's mental
status declined, pt required intubation for airway protection.
Pt was stable on the ventilator and was weaned off the
ventilator on Hospital Day 6. As pt's mental status did not
improve and pt became tachypneic, she was reintubated on Day 8.
CT chest was done which revealed a multifocal pneumonia. She was
then treated with a 7-day course of vancomycin and Zosyn for
ventilator associated pneumonia. She was extubated for the
second time on Day 12. Her respiratory status remained stable
without oxygen requirements during the rest of her stay in the
ICU.
#AMS: Pt has had fluctuating MS suggestive of delerium or
over-sedation. She has been noted to have poor motor effort and
persistant myoclonic jerks. Over the course of her
hospitalization she required intubation for airway protection
given her poor mental status. After she was extubated for the
second time her mental status cleared back to baseline and she
was A+Ox3 with a nonfocal neurological exam. She then developed
waxing and [**Doctor Last Name 688**] mental status. Her dilaudid was held, and her
gabapentin was decreased to qHD. An ABG did not show
hypercarbia. Neurology was following early in her stay and felt
that a large amount of her altered mental status was due to
narcotic overuse. Her mental status improved with less
narcotiics and avoidance of deliogenic medications.
#A fib w/ RVR: Pt developed atrial fibrillation with RVR upon
admission and was rate controlled without anticoagulation
initially due to her thrombocytopenia. Her CHADS score is 1, and
she was not started on anticoagulation given her
thrombocytopenia initially and that she as an allergy to
aspirin. She was difficult to acheive rate control and
ultimately was controlled on high dose metoprolol and diltiazem
and appeared to be in aflutter with 4:1 conduction with rates in
the 70s. She was started on digoxin with good improvement in
her rate. Serial EKG's were perfromed each day for potential
digoxin toxicity. Her digoxin was held with resultant increase
in her heart rate. She was then restarted on digoxin and placed
on digoxin M/W/F/Sa with great improvement in her arrhythmia.
#Acute liver failure: Pt presented with extremely elevated LFTs
and was screened for acute viral infections including hepatitis,
EBV and CMV, all of which were negative in terms of acute
exposure/infection. Pt was on fluconazole, but this would not be
expected to cause a transaminitis this severe. It's possible
that the patient had shock liver, but she was rarely hypotensive
and tended toward hypertensive in the MICU. Tylenol toxicity was
considered, and she received a course of NAC. Liver service also
recommended lactulose to evaluate whether altered mental status
was primarily hepatic encephalopathy. Pt was given lactulose
yielding adequate amounts of stool, but marginal improvement in
mental status was observed. Pt's LFTs trended down on their own.
After an extensive workup with the liver team to exclude drug
toxicity vs autoimmune vs infectious hepatitis, a definitive
etiology for acute liver failure could not be found.
#Acute anuric kidney failure requiring hemodialysis: Cr
progressively worsened during hospital stay from 1.2 to 5.5
during her first 4-5 days in the ICU, and she eventually became
anuric. Nephrology was consulted and concluded that renal
failure was likely multifactorial: prerenal/hypotension,
hepatorenal, contrast induced, and possible DIC. Hemodialysis
was commenced on [**6-6**], and she had repeat HD sessions throughout
her hospital course. She had a tunnelled dialysis line placed on
[**6-18**].
On [**2120-6-18**] and [**2120-6-19**] she made approximatly 300cc of urine. She
remained dialysis dependent while in the MICU. A PPD was placed
on [**2120-6-19**] on her Left forearm and was read as negative on
[**2120-6-23**]. On hospital day 14 erythema was noted around her
hemodialysis port. Interventional radiology was consulted and
placed a tunneled hemodialysis catheter.
#Elevated INR, thrombocytopenia: Pt's INR peaked at 2.8.
Hematology was consulted, and they believed that the pt had TTP
vs DIC, with schistocytes on peripheral smear, thrombocytopenia,
and elevated PT and PTT. DIC was thought to be more likely, and
no treatment was necessary, as pt did not have active bleeding.
INR normalized by Hospital Day 10 and platelets trended upwards,
reaching >100 during this time as well. Thrombocytopenia was
most likely due to liver failure and possible DIC and resolved
during her hospital course
#Pain: Pt has an extensive pain history and was on copious doses
of narcotics preadmission including 120mg/day of morphine. Pt's
pain was initially controlled with fentanyl, which was thought
to be the best choice in the setting of acute renal and liver
failure. She had problems with [**Name2 (NI) 97802**] on narcotics and
therefore Pain serivce was consulted to find nonsedating
medications to control her pain and she was started on
gabapentin. Her altered mental status made accurate assessments
difficult. She did complain of right shoulder pain. An xray of
this joint showed a normal appearing total shoulder replacement.
Her final pain regimen was gabapentin 200qHD, dilaudid 0.25 IV
q4hPRN for breakthrough pain, and 1mg PO dilaudid q4hPRN. She
still has waxing and [**Doctor Last Name 688**] sedation with this regimen.
#Hypertension: Pt has a history of hypertension and was on
metoprolol, Lasix, and lisinopril at home. Her lisinopril was
discontinued due to the renal failure. The Lasix was held, as
she was anuric, and her fluid status was managed via dialysis.
The patient was continued on metoprolol for HTN and rate
control, and the diltiazem was added for rate control as
described above. Hydralazine was added for BP control during her
MICU stay, but it was taken off when metoprolol and diltiazem
were increased and before digoxin was started.
#Anemia: Pt came in with a HCT of 31, but her HCT trended down
to as low as 20.2. There was no known source of bleeding.
Decreased HCT may have been due to hemolysis. The patient was
given several units of PRBCs during her admission to keep her
HCT above 21.Her HCT stabilized throughout her stay and she no
longer required any transfusions.
#Ischemic toes: Pt's toes were noted to be blackened and lacking
adequate capillary refill. Unsure of the etilogy the ischemic.
Pressors were given for a short duration. Vascular was consulted
and recommended arterial-brachial index which showed good distal
perfusion. There was no sign of wet gangrene or infection.
Vascular is concerned she may lose several toes. She will need
follow up for this issue with vascular, however no acute
management changes are needed.
#Hyponatemia: On [**2120-6-21**] she was noted to be hyponatremic. She
should be placed on a 1.5L fluid restriction moving forward, and
will need close monitoring given her autodiuresis as her kidney
recovers.
Transitional Issues:
- will need Liver f/u
- will need Renal f/u
- will need Vascular f/u
- will need cardiology f/u
- Hepatitis serologies negative except for HAV antibody
-1,25 OH Vit D pending
-Free water restriction
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. PredniSONE 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Lidocaine 5% Patch [**11-20**] PTCH TD DAILY
on for 12 hours, off for 12 hours
5. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
6. Metoprolol Succinate XL 250 mg PO DAILY
7. Senna 1 TAB PO QID
8. leflunomide *NF* 20 mg Oral daily
9. Ranitidine 300 mg PO BID
10. Montelukast Sodium 10 mg PO DAILY
11. Furosemide 20 mg IV DAILY:PRN swelling
12. Multivitamins 1 TAB PO DAILY
13. morphine *NF* 60 mg Oral [**Hospital1 **]
extended release
14. Oxycodone-Acetaminophen (5mg-325mg) [**11-20**] TAB PO Q4-6H PRN
pain
do not take more than 11 pills in 24 hours
15. fluticasone-salmeterol *NF* 230-21 mcg/actuation 2 puffs [**Hospital1 **]
16. esomeprazole magnesium *NF* 40 mg Oral [**Hospital1 **]
extended release
17. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral [**Hospital1 **]
18. Potassium Chloride 10 mEq PO DAILY:PRN when you take Lasix
extended release
19. Albuterol Sulfate (Extended Release) 2.5 mg PO Q6H:PRN
asthma symptoms
2.5mg/3mL (0.083%) - 1 solution inhaled by nebulizer every 6
hours as needed for asthma
20. albuterol sulfate *NF* 90 mcg 2 puffs Q4H: PRN asthma
symptoms
21. cholecalciferol (vitamin D3) *NF* 800 units Oral daily
22. Fluconazole 200 mg PO Q24H Duration: 13 Days
23. Ensure *NF* (food supplement, lactose-free) 1 can Oral TID
Discharge Medications:
1. Lidocaine 5% Patch [**11-20**] PTCH TD DAILY
on for 12 hours, off for 12 hours
2. Senna 1 TAB PO QID
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
4. Digoxin 0.125 mg PO M/W/F/SA
On dialysis days, please give AFTER dialysis.
RX *digoxin 125 mcg 1 tablet(s) by mouth m/w/f/sa Disp #*15
Tablet Refills:*0
5. Diltiazem 90 mg PO QID
hold for sbp < 100 and HR < 60
RX *diltiazem HCl 90 mg 1 tablet(s) by mouth four times a day
Disp #*60 Tablet Refills:*0
6. Gabapentin 200 mg PO QHD
please give after dialysis
RX *Neurontin 100 mg 2 capsule(s) by mouth qhd Disp #*30 Tablet
Refills:*0
7. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Breakthrough pain
RX *hydromorphone 2 mg/mL (1 mL) 0.25mg q4hprn Disp #*5
Milliliter Refills:*0
8. HYDROmorphone (Dilaudid) 1 mg PO Q4H:PRN pain
Hold for RR<10/ Sedation
RX *hydromorphone 2 mg 0.5 (One half) tablet(s) by mouth q4h prn
Disp #*10 Tablet Refills:*0
9. Metoprolol Tartrate 100 mg PO QID
hold for SBP <100, HR <55
RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth four times a
day Disp #*15 Tablet Refills:*0
10. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 capsule(s) by mouth daily Disp #*15 Tablet
Refills:*0
11. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *Alophen 5 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipatiion
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth daily
Disp #*15 Unit Refills:*0
14. Quetiapine Fumarate 25 mg PO HS:PRN agitation
Hold for sedation
RX *quetiapine 25 mg 1 tablet(s) by mouth qhs PRN Disp #*15
Tablet Refills:*0
15. albuterol sulfate *NF* 90 mcg 2 puffs Q4H: PRN asthma
symptoms
16. Albuterol Sulfate (Extended Release) 2.5 mg PO Q6H:PRN
asthma symptoms
2.5mg/3mL (0.083%) - 1 solution inhaled by nebulizer every 6
hours as needed for asthma
17. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral [**Hospital1 **]
18. cholecalciferol (vitamin D3) *NF* 800 units Oral daily
19. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
20. Ensure *NF* (food supplement, lactose-free) 1 can Oral TID
21. Esomeprazole Magnesium *NF* 40 mg ORAL [**Hospital1 **]
extended release
22. fluticasone-salmeterol *NF* 230-21 mcg/actuation 2 PUFFS [**Hospital1 **]
23. Montelukast Sodium 10 mg PO DAILY
24. Multivitamins 1 TAB PO DAILY
25. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Doctor Last Name **]
Discharge Diagnosis:
Pneumonia
Acute Kidney Injury
Acute Liver injury
Ischemic necrosis of toes
Altered Mental status
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:
Dear Ms. [**Known lastname 20893**],
You were treated at [**Hospital1 18**] for Pneumonia and found to have liver
and kidney injury. We do not know the cause of this, however you
are improving. Your blood pressure was low and you required
medications to boost your blood pressure, which caused you to
have a blockage of the blood to your feet. Vascular surgery saw
you and stated that there was no surgical treatment necessary,
and your toes will fall off on their own. While you were here,
you needed dialysis because your kidneys were not working. Your
kidneys appear to be improving, however you will likely need to
continue dialysis and be evaluated by a nephrologist in the
future. You were also very confused and unable to protect your
airway while you were here and required a breathing tube
temporarily and are doing well after that was removed.
You also had significant pain and required pain medicine,
however you frequently had changes in your mental status due to
the use of these medications. Your doctors [**Name5 (PTitle) **] need to balance
your pain medications with your sleepiness from those
medications.
Your heart rate also became elevated and irregular while you
were here, and you required three different medications to keep
your heart rate low. Please continue these medications and
follow up with cardiology about this in the future.
You have multipel follow-up as per below
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
You will see a nephrologist during your dialysis on Tuesdays,
Thursdays and Saturdays. If you wish to establish care with one
of our nephrologists at [**Hospital1 18**] if your dialysis is finished, you
can call our nephrology deparment at [**Telephone/Fax (1) 721**].
Department: CARDIAC SERVICES
When: WEDNESDAY [**2120-7-3**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: TUESDAY [**2120-7-16**] at 2:30 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,003
| 183,036
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28115
|
Discharge summary
|
report
|
Admission Date: [**2173-11-2**] Discharge Date: [**2173-11-7**]
Date of Birth: [**2108-5-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Percocet / Lasix / Keflex / Wellbutrin / Sulfa (Sulfonamide
Antibiotics) / Dilantin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache, Nausea, Vomiting
Major Surgical or Invasive Procedure:
[**11-3**]: Right Craniotomy for mass resection
History of Present Illness:
65 y.o. man with a known history of metastatic melanoma who
comes in to the [**Hospital1 18**] ED today with a chief complaint of
headaches and vomiting. Per the patient's wife and son, who are
with him today, he was diagnosed with melanoma 2
years ago when he found a lesion on his right anterior neck. He
then underwent excision and biopsy of this lesion and has
subsequently had chemotherapy x 2 and high-dose IL-2. Since this
time he had undergone regular disease surveilance, and has been
found to have metastatic disease to the lungs and abdomen. Over
the past few months he has been feeling well. However, he has a
been having b/l frontal headaches over the past week, which have
been minimally relieved with OTC pain meds. At 1:30 AM on [**11-2**]
he woke up and vomited 3-4 times and complained of excrutiating
pain in the back of his head and neck. He was then taken to an
OSH for evaluation and found to have an intracranial lesion on
CT. He was transferred to [**Hospital1 18**] for further evaluation. His wife
and son
deny any recent behavioral or mental status changes, recent
memory loss, or motor weakness. They do, however, report some
imbalance and unsteady gait. Of note, he had an MRI of the brain
in [**2173-5-27**] that did not show any intracranial masses.
Past Medical History:
Melanoma (metastatic), BPH, HL, COPD
Social History:
Lives at home with his wife. [**Name (NI) **] 3 sons and 1 daughter. [**Name (NI) 1403**]
part-time as a dispatcher for trucking company. Smokes 1ppd x
20yrs. Occasional ETOH use.
Family History:
Non-Contributory
Physical Exam:
On Admission:
T: 99.3 BP: 123/73 HR:55 R 16 O2Sats 96 on RA
Gen: Sedated appearing man in NAD. Appropriate appearance for
stated age.
HEENT: Pupils: pinpoint and minimally reactive b/l EOMs: full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Asleep, but arousable with verbal stimulus,
minimally cooperative with exam. Appears very sedated. Affect -
the patient appears indifferent to his status.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils are pinpoint, but equally round and reactive to
light,Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-31**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2
Left 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
On Discharge:
XXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2173-11-2**] 03:50PM BLOOD WBC-9.2 RBC-4.03* Hgb-13.0* Hct-35.5*
MCV-88 MCH-32.2* MCHC-36.5* RDW-14.3 Plt Ct-188
[**2173-11-2**] 03:50PM BLOOD Neuts-62.9 Lymphs-29.0 Monos-4.2 Eos-3.3
Baso-0.6
[**2173-11-2**] 03:50PM BLOOD PT-13.4 PTT-27.9 INR(PT)-1.1
[**2173-11-2**] 03:50PM BLOOD Glucose-96 UreaN-16 Creat-0.9 Na-129*
K-4.0 Cl-98 HCO3-23 AnGap-12
Labs on Discharge:
XXXXXXXXXXX
Imaging:
Head CT([**11-2**]):
IMPRESSION:
New 3 cm hyperdense lesion within the right temporoparietal
region highly
consistent with a melanoma metastasis. Mild associated mass
effect as
described.
MRI(Head) [**11-3**]:
MPRESSION:
1. Large relatively acutely hemorrhagic lesion in the posterior
right
temporoparietal region. This has surrounding zone of vasogenic
edema and
slight mass effect with evidence of "trapping" of the temporal
[**Doctor Last Name 534**] of the
ipsilateral lateral ventricle. There is melanin, or perhpas,
more subacute
hemorrhage at the dorsal aspect of the lesion, with only a faint
"blush"
of enhancement, anteriorly. The overall appearance is suggestive
of
hemorrhagic melanoma metastasis.
2. Appearance of at least partial "trapping" of the temporal
[**Doctor Last Name 534**] of the
ipsilateral lateral ventricle.
3. No other hemorrhagic or enhancing focus.
CT Torso([**11-3**])
Multiple pulmonary nodules are little changed from [**2173-10-1**] except
for slight
increase in size of posterior right lower lobe nodule.
Pleural-based nodules on the right are decreased in size. No new
focus of metastatic disease is seen. Interval substantial
improvement in paraaortic retroperitoneal fat stranding and soft
tissue density compared to [**2173-10-1**]. Colonic diverticulosis.
Brief Hospital Course:
The patient is a 65M who presented to [**Hospital1 18**] emergency department
following a period of time feeling ill with heache and vomiting.
He has PMH significant for known metastatic melanoma. Head CT
was performed in the emergency department revealing a right
sided temporal mass. Given the location of the mass, he was
admitted for observation to the ICU pending further evaluation.
He was subsequently seen by neuroncology who agreed with
neurosurgery to pursue the resection of his mass. On [**2173-11-4**],
he underwent a right sided craniotomy to resect the mass. He
was monitored overnight in the ICU. Post-operative head CT
revealed expected post-operative changes.
The patient was transferred to the general floor on POD 1 and
began tolerating a regular diet. His pain was well controlled
initially with IV, and then PO pain medication. His Foley
catheter was removed on POD 1. On POD 1, an MRI was obtained and
showed "resection of right temporal mass with mild residual
enhancement." There was no evidence of acute infarction and
there was a small amount of blood products seen at the surgical
site.
The patient was ambulating, taking in food PO and voiding
without difficutly prior to discharge. He was instructed to
follow-up as necessary with all of the physicians who are caring
for his cancer needs. He was sent home with a steroid taper down
to 2mg [**Hospital1 **]. The patient was oriented x 3, full strength and
sensation throughout. He was stable upon discharge.
Medications on Admission:
Flomax, Lipitor, ASA 81, Vicodin,
Ativan
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid () for 3
doses: Then take 2mg twice daily until follow-up appointment.
Disp:*50 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**5-2**]
hours: No driving while on narcotics.
Disp:*50 Tablet(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Temporal Mass
Discharge Condition:
Neurologically Stable
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 have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
-Please return to the office in [**8-5**] days for removal of your
sutures and a wound check. Please call ([**Telephone/Fax (1) 88**] to
schedule an appointment.
-Please call the Brain [**Hospital 341**] Clinic on Tues. to schedule the
first available appointment [**Telephone/Fax (1) 1844**]. You will NOT need an
MRI at that time. Tell them that you had brain surgery recently
with Dr. [**Last Name (STitle) **].
You also have the following appointment scheduled pertaining to
you tumor follow up:
1. Dr. [**Last Name (STitle) 3929**](Radiation Oncologist): for radiation planning
on [**11-22**], and first treatment on [**11-23**]. Please call ([**Telephone/Fax (1) 54862**] if you need to reschedule.
Completed by:[**2173-11-7**]
|
[
"V10.83",
"253.6",
"600.00",
"272.4",
"348.4",
"198.89",
"197.0",
"492.8",
"198.3",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.04",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
7626, 7632
|
5245, 6740
|
374, 424
|
7696, 7720
|
3507, 3512
|
9278, 9804
|
2008, 2026
|
6831, 7603
|
7653, 7675
|
6766, 6808
|
7744, 9255
|
2041, 2041
|
9815, 10052
|
3470, 3488
|
308, 336
|
3898, 5222
|
452, 1734
|
2651, 3456
|
3526, 3879
|
2314, 2635
|
1756, 1794
|
1811, 1992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,341
| 129,945
|
22841
|
Discharge summary
|
report
|
Admission Date: [**2168-6-15**] Discharge Date: [**2168-7-19**]
Date of Birth: [**2105-3-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Myocardial infarction
Major Surgical or Invasive Procedure:
[**2168-6-17**] - Coronary artery bypass grafting x4 with the left
internal mammary artery to the left anterior descending artery
and reverse office vein. Vein grafts to the first obtuse
marginal artery, third obtuse marginal artery, posterior
descending artery.
[**2168-6-20**] - Flexible bronchoscopy, bronchoalveolar lavage of left
lower lobe.
[**2168-6-25**] - Percutaneous Cholecystostomy
[**2168-6-27**] - 1)Coil embolization of left sided rectal arteries.
2)Coil embolization of perineal branches of the left internal
iliac artery. 3)Coil embolization for right internal iliac
artery
[**2168-6-28**] - Exploratory Laparotomy, Rectal Resection, End
Colostomy, Cholecytectomy, Placement of G-Tube
[**2168-7-7**] - Uncomplicated ultrasound and fluoroscopically guided
dual lumen PICC line placement via the right basilic venous
approach. Final internal length is 37 cm, with the tip
positioned in the SVC.
History of Present Illness:
This is a 63-year-old male with morbid obesity, severe
osteoarthritis on methotrexate and sleep apnea, who has a
history of coronary artery disease. He underwent a stent of his
left anterior descending artery a year ago. He now presents with
chest pain and workup eventually revealed 3-vessel coronary
artery disease. He had an ejection fraction of 50%. He is now
transferred from [**Hospital **] Hospital for surgical management.
Past Medical History:
HTN
CHF
Myocardial infarction
Hyperlipidemia
CAD with past PTCA/Stenting
Type I DM
Rheumatic fever as child
OSA (CPAP at noc)
Rheumatoid arthritis
Chronic LBP, disc issues
BPH
GERD
Diverticulitis
Social History:
Lives with wife in [**Name (NI) 1110**]. Quit smoking [**2152**].
Obese. Works in data entry.
Family History:
(+) FHx CAD
Physical Exam:
97.1 97 SR 90/60 92% RA sats
WDWN, NAD
A+Ox3, MAE
CTAB, good resp effort, no wheeze, crackles or rales
Distant heart sounds, RRR, no m/r/g
soft, nt, nd, nabs, small umbilical hernia
LE warm, Distal DP/PT pulses 2+
Carotids 2+ pulses, no bruits.
Neuro: nonfocal
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2168-7-18**] 03:18AM 21.2* 3.29* 9.7* 28.6* 87 29.5 33.8 16.5*
138*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos Promyel NRBC Other
[**2168-7-11**] 02:53AM 75* 0 7* 5 1 0 1* 9* 2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-7-18**] 03:18AM 199* 20 0.7 130* 4.3 95* 26 13
[**2168-6-17**] ECHO
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
Regional left
ventricular wall motion is normal. There is mild global left
ventricular
hypokinesis. Overall left ventricular systolic function is
mildly depressed.
2.Right ventricular chamber size and free wall motion are
normal.
3.The ascending aorta is mildly dilated. There are simple
atheroma in the
descending thoracic aorta.
4.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen. Central jet with a wide base. Vena
contracta is 4mm.
Post Bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine.
1. Biventricular systolic function is unchanged.
2. Mitral regurgitation persists.
3. Aorta intact post decannulation.
[**2168-6-20**] Lower Extremity Ultrasound
Extremely limited study due to patient's body habitus and
central line with overlying dressings obscuring the common
femoral veins. There is no evidence of deep venous thrombosis in
the proximal and mid SFV, or the popliteal veins.
[**2168-6-20**] ECHO
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is
moderately depressed. Right ventricular chamber size is normal.
There is mild global right ventricular free wall hypokinesis.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is a
large pericardial effusion. The effusion appears loculated and
is dustrubuted along the inferiro and posterior walls of the
left ventricle. There are no echocardiographic signs of
tamponade.
[**2168-6-21**] Liver Ultrasound
Secondary to subcutaneous gas from recent surgical procedure, no
ultrasound evaluation can be made of the intra-abdominal organs.
[**2168-6-25**] CT Guided Cholecystostomy
Status post successful percutaneous cholecystostomy under CT
guidance.
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2168-7-16**] 10:34 AM
CT CHEST W/CONTRAST
Reason: r/o mediastinitis
Field of view: 38
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with s/p cabg, open chest for decreased CO, WBC
63K
REASON FOR THIS EXAMINATION:
r/o mediastinitis
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT of the chest.
INDICATION: 63-year-old male status post CABG, presenting with
increased white blood cell count of 20,000 today. Assess for
mediastinitis.
COMPARISONS: [**2168-7-3**].
TECHNIQUE: Following the administration of 75 cc of Optiray
intravenous contrast, MDCT axial images were acquired from the
thoracic inlet to the upper abdomen. Coronal reformatted images
were then obtained. 1.25-mm thin sections through the chest were
also obtained.
CT OF THE CHEST WITH IV CONTRAST: The patient is status post
median sternotomy and CABG. There are associated postoperative
changes in the anterior chest. There are several foci of air
along the superficial aspect of the anterior chest. No air is
present within the mediastinum. However, on today's examination,
just anterior to the heart, there appears to be a low- density
area with diffuse fat stranding, particularly along the inferior
margin which is suspicious for inflammatory. This area extends
superiorly along the anterior aspect of the pericardium. The
heart is enlarged. There are diffuse atherosclerotic
calcifications of the right coronary, left anterior descending,
and left circumflex arteries respectively. There are multiple
prominent lymph nodes in the prevascular space, the largest of
which measures 11 mm in short-axis dimension (4:64). New on
today's examination within the left upper lobe are several
fluid-attenuation collections. The largest collection is located
superiorly and measures 6.2 x 3.5 cm and has a mildly denser
rim. There is a possible communication with a more superiorly
located posteromedial simple-attenuation collection which
measures 3.7 x 2.7 cm (2:12). There is a small-to-moderate left
pleural effusion which may contain some proteinaceous material
as it is higher in attenuation than simple fluid. There is
associated mild compressive atelectasis. The left lower lobe
pleural effusion is not significantly changed compared to the
previous examination. There is right lower lobe atelectasis
which also appears unchanged compared to the previous
examination. There is a small, 3-mm pulmonary nodule within the
right middle lobe, lateral aspect (3:34).
Limited views of the lung bases again demonstrate bilateral
adrenal nodules which are incompletely imaged. The largest is
located within the left adrenal gland and measures approximately
1.7 x 1.3 cm. A right-sided nodule measures approximately 1.3 x
1.0 cm. A tube can be seen within the stomach. There is at least
one calcification within the head of the pancreas. Limited non-
contrast views of the liver and spleen are unremarkable.
IMPRESSION:
1. No foci of air within the mediastinum to suggest
mediastinitis. However, there is increased fluid-soft tissue
density material within the anterior mediastinum amidst multiple
surgical clips that appears new compared to [**2168-7-3**]. Clinical
correlation is recommended.
2. New, two simple-appearing fluid collections in the superior
aspect of the left upper lobe with associated pleural thickening
consistend with a left upper lobe loculated pleural effusion.
Persistent moderate left pleural effusion and associated
atelectasis versus consolidation.
3. Persistent right lower lobe atelectasis.
4. Bilateral adrenal nodules, unchanged compared to [**2168-7-3**].
Followup is recommended in [**3-22**] months if these do not meet
criteria for adenoma by CT.
5. A 3 mm right middle lobe nodule should be evaluated in [**3-22**]
months to confirm stability.
Findings were discussed with Dr. [**Last Name (STitle) **] by Dr. [**First Name (STitle) 7747**] over the
telephone at approximately 12:00 p.m. on [**2168-7-16**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2618**] [**Doctor Last Name **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Brief Hospital Course:
Mr. [**Known lastname 59042**] was admitted to the [**Hospital1 18**] on [**2168-6-15**] via transfer
from [**Hospital6 **] for surgical management of his
coronary artery disease. He was worked-up in the usual
preoperative manner and deemed suitable for surgery. On [**2168-6-17**],
Mr. [**Known lastname 59043**] was taken to the operating room where he underwent
coronary artery bypass grafting to four vessels. Please see
operative note for details. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. Given the
length and complexity of Mr. [**Known lastname 59043**] hospital course, the
remainder of the summary will be broken down into systems.
Cardiac:
As his cardiac index was low, he remained intubated and sedated
on pressors and inotropes postoperatively. An Echo was performed
on postoperative day one which showed normal valves and good
right and left heart function. He was transfused to maintain a
hematocrit above 30%. He developed atrial fibrillation which was
treated with amiodarone and cardioversion. As Mr. [**Last Name (Titles) 59044**]
hemodynamics were poor an echocardiogram was obtained which
showed some pericardial effusion. The decision was then made to
open his chest on [**2168-6-21**]. His hemodynamics improved and his
chest was left open with ioban coverage. As he continued to
improve from a cardiac standpoint, his chest was successfully
closed on [**2168-6-25**]. As he fully weaned from pressors and
inotropes, beta blockade was resumed. He was continued on a
statin and aspirin as well. Mr. [**Known lastname 59042**] required aggressive
diuresis for fluid overload. Subcutaneous heparin was used for
DVT (deep vein thrombosis) prophylaxis.
Nutrition:
Tube feeds were started while he remained intubated for
nutritional support. TPN was started to help maintain his
nutritional status. Free water blouses were used to correct
hypernatremia. When he extubated, he was able to advance his
diet to regular.
Respiratory:
From a respiratory standpoint, Mr. [**Known lastname 59042**] [**Last Name (Titles) 59045**] with
acidosis, hypoxemia and failure to wean from the ventilator. On
postoperative day four, he developed ventilator associated
pneumonia. He underwent several bronchoscopies to clear thick,
purluent secretions. Culutures revealed pseudomonas aeruginosa
for which cefepime was started. Mr. [**Known lastname 59042**] developed
subcutaneous emphysema after his chest closure and chest tubes
were positioned accordingly with slow resolution of his
emphysema. On [**2168-7-8**], Mr. [**Known lastname 59042**] was successfully extubated.
Infectious Disease:
Vancomycin was used prophylactically postoperatively. The
infectious disease service was [**Known lastname 4221**] and followed Mr. [**Known lastname 59042**]
throughout his hospital stay. Mr. [**Known lastname 59043**] was treated for
pseudomonas Ventilator Acquired Pneumonia(VAP) with intravenous
cefepime. Flagyl was started empirically for C. Diff prevention.
With time, his chest x-ray and respiratory status improved. A
blood culture from [**2168-7-2**] grew vancomycin resistent
enterococcus and a catheter tip grew gram negative rods. At the
same time, a swab from his lower portion of his sternal wound
grew enterococcus as did a blood culture. Linezolid was added
for treatment and his lines were changed. As Mr. [**Known lastname 59046**]
infectious disease issues stablized, flagyl was discontinued.
Fifteen days of cefepime was recommended for complete treatment
of his VAP which was completed on [**2168-7-6**]. On [**2168-7-10**] he drew
gram negtive rods on his central line tip and cefepime was
resumed. The cefipime was then d/c'd on [**7-15**] and ID recommended
a 4 week course of Linezolid.
Wound Care:
As Mr. [**Known lastname 59042**] developed some skin breakdown and ulcers from
being incapacitated. The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] who
followed him throughout his postoperative course. Aquacell was
used on the open portions of his sternotomy. The colostomy nurse
was [**Last Name (Titles) 4221**] who cared for his sigmoid colostomy following his
bowel surgery. He also had lower sternal drainage and the lower
portion of his wound was opened. He is currently on a VAC dsg.
for this.
Renal:
Mr. [**Name14 (STitle) **] developed postoperative renal failure. The renal
service was [**Name14 (STitle) 4221**] for assistance with his care. Slowly his
renal function began to improve. He responded well to diuretics
and is currently on Lasix 80 [**Hospital1 **].
Endocrine:
Stress dose steroids were used postoperatively. His blood sugars
were aggressively managed with insulin.
Gastrointestinal:
Mr. [**Known lastname 59042**] abdomen was distended postoperatively in the presence
of rising liver enzymes and leukocytosis. The general surgery
service was [**Known lastname 4221**] and followed Mr. [**Known lastname 59042**] throughout his
hospital stay. A right upper quadrant ultrasound was performed
but was inconclusive. A CT scan showed a fecoloaded rectum and
an elarged gallbladder with pericholecystic fluid. Given these
findings, it was elected to perform a CT guided percutaneous
cholecystostomy on [**2168-6-27**]. 150cc'c of bilious fluid was drained
which did not grow any organisms. On [**2168-6-27**], Mr. [**Known lastname 59042**]
developed extensive gastrointestinal bleeding. He was transfused
with multiple blood products. He was taken to the
catheterization lab for an angiogram where successful coil
embolization of left sided rectal arteries and successful coil
embolization of perineal branches of the left internal iliac
artery was performed. He continued to bleed however and returned
for an re-look angiogram which showed the right internal iliac
artery with two branches, one superior and one inferior that
still fill the bleeding site. He was subsequently taken to the
operating room on [**2168-6-28**] where he underwent a exploratory
laparotomy with rectal resection, cholecystectomy, an end ostomy
and J-Tube placement. As his tube migrated up into the stomach,
the tube was repositioned by endoscopy. He is currently on TF at
night and can take PO, but does not take enough to meet his
nutritional needs.
General:
The physical and occupational therapy services worked with him
daily. He continued to make steady progress and was discharged
to [**Hospital1 **] Rehab.Hospital on POD #34. He will
follow-up with Dr. [**Last Name (STitle) **], his cardiologist, his primary care
physician and the infectious disease service as an
outpatient.Pt. is to return to [**Hospital 409**] Clinic on [**Hospital Ward Name 121**] 2 on Wed.
[**7-27**] to have all wounds checked.
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
3. Gabapentin 300 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO TID (3
times a day).
4. Prednisone 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
7. Tolterodine 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
8. Ezetimibe 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
9. Lisinopril 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
10. Sertraline 50 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO DAILY
(Daily).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
[**Month/Year (2) **]: Two (2) Tablet Sustained Release 24HR PO QAM (once a day
(in the morning)).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
[**Month/Year (2) **]: One (1) Tablet Sustained Release 24HR PO HS (at bedtime).
13. Alprazolam 1 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2 times a
day).
14. Alprazolam 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO NOON (At
Noon).
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
2. Atorvastatin 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
5. Bupropion 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
6. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Month/Year (2) **]: Five
(5) ML PO TID (3 times a day).
7. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
Inhalation Q6H (every 6 hours) as needed.
11. Prednisone 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily).
12. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
13. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
14. Ibuprofen 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8
hours) as needed.
15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
17. Linezolid 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours) for 2 weeks.
18. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
19. Lasix 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
20. Metoclopramide 10 mg IV Q6H:PRN nausea/vomiting
21. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
22. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: 25 units units
Subcutaneous q AM: 80 units q PM.
23. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
unit Subcutaneous four times a day: RISS:
BS: Units SC:
110-140 4
141-170 6
171-200 8
201-240 10
241-280 12.
Discharge Disposition:
Extended Care
Facility:
NE [**Hospital1 **] of [**Hospital1 336**]
Discharge Diagnosis:
CAD s/p CABGx4
NSTEMI
Hyperlipidemia
HTN
Obstructive sleep apnea
Diabetes
Rheumatoid arthritis
Morbid obesity
Acute renal failure
Atrial fibrillation
Ventilator Acquired Pneumonia
Sepsis
Pressure ulcer
Tamponade
Hypoxemia/Respiratory failure
Cholecystitis/Enlarged gall bladder/Pericholecystic fluid
collection
GI Bleed
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for infection. These include redness, drainage
or increased pain. Please contact the [**Name2 (NI) 5059**] with any wound
issues. ([**Telephone/Fax (1) 1504**]
2) Report any fever greater then 100.5
3) Weigh yourself daily. Report any weight gain of greater then
2 pounds in 24 hours.
4) No lifting greater then 10 pounds for 10 weeks from date of
surgery. No driving for 1 month.
5) You should wash or shower daily. No lotions, powders or
creams to incisions. No swimming until wound has healed.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**First Name (STitle) 1075**] in 2 weeks.
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 32996**] in 2 weeks.
Completed by:[**2168-7-19**]
|
[
"E878.8",
"518.0",
"714.0",
"998.59",
"998.81",
"414.01",
"995.92",
"420.90",
"996.62",
"V58.65",
"278.01",
"V09.80",
"997.1",
"707.11",
"038.3",
"327.23",
"996.72",
"707.05",
"427.31",
"482.1",
"575.11",
"578.9",
"518.5",
"584.5",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"88.73",
"38.95",
"96.6",
"38.93",
"51.22",
"33.24",
"45.13",
"88.72",
"88.47",
"97.03",
"39.61",
"39.95",
"00.14",
"48.62",
"51.01",
"34.03",
"99.04",
"46.32",
"99.07",
"36.15",
"39.79",
"96.72",
"99.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
20038, 20107
|
9354, 13112
|
311, 1223
|
20471, 20480
|
2344, 5288
|
21044, 21351
|
2031, 2044
|
17505, 20015
|
5325, 5393
|
20128, 20450
|
16099, 17482
|
20504, 21021
|
2059, 2325
|
239, 273
|
5422, 9331
|
13124, 16073
|
1251, 1683
|
1705, 1903
|
1919, 2015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,799
| 150,926
|
5761
|
Discharge summary
|
report
|
Admission Date: [**2137-4-11**] Discharge Date: [**2137-4-23**]
Date of Birth: [**2072-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2137-4-12**] Aortic Valve Replacement ([**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical
valve), Aortic Root Enlargement with pericardial patch, Septal
Myomectomy
History of Present Illness:
64 y/o female with known h/o aortic stenosis. Referred for
cardiac cath which revealed severe aortic stenosis. Further
work-up included an echocardiogram which also revealed
progression of her AS. Referred for surgical replacement of her
aortic valve.
Past Medical History:
Aortic Stenosis, Paroxysmal Atrial Fibrillation, Hypothyroidism,
Hyperlipidemia, Hypertension, h/o Scarlet fever
Social History:
The patient worked as a school volunteer. Married with 3 kids.
She denies any history of smoking, alcohol or drug use.
Family History:
Rheumatic fever in her mother s/p valve replacement and ?
arrhythmia
Physical Exam:
VS: 51 20 140/47 5'6" 184lbs
General: NAD
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, ?murmur
Chest: CTAB -w/r/r
Heart: RRR, +4/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, trace edema, -varicosities, 2+ pulses
throughout
Neuro: MAE, A&O x 3, non-focal
Pertinent Results:
[**2139-4-11**] CNIS: 40-59% right carotid stenosis. Less than 40% left
carotid stenosis.
[**2137-4-12**] Echo: Prebypass: 1.No atrial septal defect is seen by 2D
or color Doppler. There is severe 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%). 2. Right
ventricular chamber size and free wall motion are normal. 3.The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. There are simple atheroma in
the descending thoracic aorta. 4. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Moderate (2+) aortic regurgitation is seen. 5.The
mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. Mild to moderate ([**2-5**]+) mitral
regurgitation is seen. 6.The tricuspid valve leaflets are mildly
thickened. 7. There is a small pericardial effusion. Post
Bypass: 1. Patient is being AV paced and receiving an infusion
of phenylephrine. 2. Biventricular systolic function is
unchanged. 3. Mechanical valve seen in the aortic position.
Leaflets move well and the valve appears well seated. No aortic
insufficiency seen. Mean gradient across the aortic valve is 8
to 11 mm Hg. 4. Trace to mild mitral regurgitation present. 5.
Aorta intact post decannulation.
Brief Hospital Course:
Ms. [**Known lastname 22930**] was admitted prior to surgery d/t patient
requiring Heparin secondary to being on Coumadin for Atrial
Fibrillation. She underwent pre-operative work-up as well which
included carotid ultrasound. On [**2137-4-12**] she was brought to the
operating room where she underwent a aortic valve replacement.
Please see operative report for surgical details. Following
surgery she was transferred to the CSRU for invasive monitoring
in stable condition. Later on op day she was weaned from
sedation, awoke neurologically intact and was extubated. On
post-op day one her chest tubes were removed. On post-op day two
her epicardial pacing wires were removed and she was transferred
to the telemetry floor. On post-op day three a PICC line was
placed secondary to difficulty with obtaining intravenous
access. She remained on vancomycin for a right antecubital
phlebitis, some sternal erythema and a fever. Also on this day
Coumadin was started with a Heparin bridge, until her INR was
therapeutic for a mechanical aortic valve. Vancomycin was
started for phlebitis which resolved quickly. When her INR was
within a therapeutic range, her heparin was discontinued. Ms.
[**Known lastname 22930**] continued to make steady progress and was discharged
home with a visiting nurse on [**2137-4-23**]. She will follow-up with
Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as
an outpatient. Her Coumadin will be followed by Dr. [**Last Name (STitle) **] for
atrial fibrillation as per preoperatively.
Medications on Admission:
Coumadin, Levoxyl 50mg qd, Norvasc 10mg qd, Enalapril 20mg [**Hospital1 **],
Labetelol 200mg [**Hospital1 **], Lipitor 40mg qd, Paxil
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day) for
10 days.
Disp:*80 Capsule, Sustained Release(s)* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
11. Levoxyl 50 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
2 days: please take 5mg [**3-26**] and [**3-27**] then have INR checked with
further dosing by Dr [**Last Name (STitle) **] .
Disp:*60 Tablet(s)* Refills:*0*
13. Outpatient [**Name (NI) **] Work
PT/INR as needed - goal INR 2.5-3.5
results to Dr [**Last Name (STitle) **] office #[**Telephone/Fax (1) 1260**]
first draw [**4-25**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Paroxysmal Atrial Fibrillation, Hypothyroidism,
Hyperlipidemia, Hypertension, h/o Scarlet fever
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, 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
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 1260**]) please call for appointment
Dr [**Last Name (STitle) **] in [**3-9**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
[**Telephone/Fax (1) **]: PT/INR for coumadin dosing first draw [**4-25**] with results to
Dr [**Last Name (STitle) **] (goal INR 2.5-3.5 for AVR)
Completed by:[**2137-4-23**]
|
[
"999.2",
"451.82",
"998.89",
"780.6",
"244.9",
"272.4",
"401.9",
"424.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61",
"37.33",
"38.93",
"35.39"
] |
icd9pcs
|
[
[
[]
]
] |
6372, 6429
|
2917, 4464
|
296, 485
|
6618, 6624
|
1429, 2894
|
7090, 7652
|
1054, 1124
|
4648, 6349
|
6450, 6597
|
4490, 4625
|
6648, 7067
|
1139, 1410
|
237, 258
|
513, 766
|
788, 902
|
918, 1038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
157
| 110,545
|
27280
|
Discharge summary
|
report
|
Admission Date: [**2106-5-17**] Discharge Date: [**2106-5-26**]
Date of Birth: [**2025-12-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Succinylcholine / Aspirin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Found down with subdural hematoma on CT
Major Surgical or Invasive Procedure:
Left sided craniotomy for subdural hematoma evacuation X2
History of Present Illness:
80 y/o male transferred from outside hospital with subdural
hematoma. Mr [**Known lastname 30119**] is a 80 y/o gentleman who was found down
by a friend this morning,? tripped over rug. However friend of
patient reports change in mental status the last 24 hours
driving
was off while driving to Foxwoods. His friend asked him to call
him when he got home but he didn't so friend went and checked on
him and found him down on the floor. He was found to have an INR
of 1.6 at outside hospital. Mr [**Known lastname 30119**] relates a fall
approximately 1 month ago when he hit his head on the corner of
the stove and had a LOC.
Past Medical History:
Diabetes not being treated, Paget Disease
Social History:
Lives alone in an apartment in [**Hospital1 392**], MA. Divorced, has nephew
and brother in local area, children in other states.
Former smoker
NO alcohol
Family History:
Non contributory
Physical Exam:
T:98.0 BP:143/75 HR:80 R18 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-11**] EOMs full
Neck: in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Bruise on right leg, poor toe nails, Warm and
well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: To name and hospital, date [**2077-3-9**]
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming impaired. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
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. Right sided drift
UE [**5-14**] (Bicep/Tricep) hands are arthritic lower extremities IP
[**5-14**] AT [**Last Name (un) 938**] 3+/5 G [**4-14**] bilaterally
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+ 2+
Left 2+ 2+
Pertinent Results:
[**2106-5-17**] 08:20AM PT-14.3* PTT-30.5 INR(PT)-1.3*
[**2106-5-17**] 08:20AM PLT SMR-NORMAL PLT COUNT-169
[**2106-5-17**] 08:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2106-5-17**] 08:20AM NEUTS-48* BANDS-1 LYMPHS-12* MONOS-38* EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2106-5-17**] 08:20AM WBC-5.1 RBC-4.10* HGB-12.8* HCT-36.2* MCV-88
MCH-31.2 MCHC-35.4* RDW-16.3*
[**2106-5-17**] 08:20AM CK-MB-13* MB INDX-3.7 cTropnT-0.06*
[**2106-5-17**] 08:20AM CK(CPK)-348*
[**2106-5-17**] 08:20AM GLUCOSE-102 UREA N-14 CREAT-0.5 SODIUM-142
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
Brief Hospital Course:
Mr [**Known lastname 30119**] was admitted to the Trauma ICU on the Trauma
service. After discussion with the patient and his nephew it
was felt having a craniotomy to evacuate his large left sided
subdural would be in his best interest.
On [**5-18**] he went to the OR and had left sided craniotomy, he was
extubated post operatively and had a subdural drain in place.
He was moving all extremities with good strength however less
strenght on the right sided he continued to be disorientated at
time.
On POD#1 He has a CT which showed evacuation of the chronic
portion with some reaccumulation of the acute blood but overall
improved. He received 1 unit of blood for crit 27. He was
transferred to the step down unit, he had some agitation after
transfer however, a second CT was stable, repeat crit was 31.
On POD#3 he was noted have some increase lethargy, a repeat CT
showed an interval increase of acute subdural blood he was
brought to the OR for a repeat subdural evacuation of
craniotomy. He spent overnight in the PACU, his exam he was
having difficulty speaking (which was similar post his first
surgery) slightly weaker on the right side though moving all
extremities. He had an MRI Slow diffusion in the left posterior
frontal region indicative of an acute infarct. He continued to
follow one step commands, slightly weaker on the right.
On [**5-26**] his drain was removed and a repeat head CT showed
continued evidence for a mixture of acute and chronic blood
products, as well as gas within the left frontal-temporal
subdural hemorrhage. Additionally, there is slight widening and
a somewhat biconvex contour to what may be an epidural
collection of gas subjacent to the craniotomy flap.
Neurologically he was awake alert, following commands but
continued with some aphasia though had no difficulty swallowing
or eating. His right side appeared weaker than the left.
On [**5-27**] he appeared brighter following commands trying to speak
a few words. He continues to move the right arm less than the
left. He does have motor strength in that arm. His appetite is
excellent.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
13. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep incision clean and dry. Have staples removed on [**2106-6-3**]
Watch incision for redness, drainage, swelling, bleeding or
fever greater than 101.5 call Dr[**Name (NI) 4674**] office
Also call for any mental status changes such as lethargy
Followup Instructions:
Have staples out on [**2106-6-3**] at Dr[**Name (NI) 4674**] office or at
nursing facility
Have sutures on left side of head removed [**2106-5-28**]
Follow up with Dr [**Last Name (STitle) 739**] in 4 weeks with head CT at that
time
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2106-5-26**]
|
[
"E885.9",
"852.22",
"998.11",
"293.9",
"785.0",
"790.92",
"790.01",
"285.9",
"784.3",
"432.1",
"731.0",
"276.51",
"250.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"01.24",
"99.07",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
6719, 6798
|
3401, 5504
|
330, 390
|
6860, 6884
|
2700, 3378
|
7179, 7538
|
1303, 1321
|
5559, 6696
|
6819, 6839
|
5530, 5536
|
6908, 7156
|
1336, 1608
|
251, 292
|
418, 1048
|
1901, 2681
|
1623, 1885
|
1070, 1114
|
1130, 1287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,652
| 103,471
|
38368
|
Discharge summary
|
report
|
Admission Date: [**2106-6-25**] Discharge Date: [**2106-6-30**]
Date of Birth: [**2082-2-28**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
s/p assault on [**2106-6-24**] with SAH, large sugaleal hematoma, and
multiple facial fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24 year old male who was attacked by multiple assailants and
struck on his head and to his chest on [**2106-6-24**]. He was discovered
by a [**Hospital3 **] who notified 911. Because of somnolence on
arrival to ED, he was given 2mg of narcan by EMS. Following this
he became agitated and combative. On arrival the patient was
combative and agitated with clear signs of narcotic withdrawal.
He became combative and was given ample doses of haldol as well
as Fentanyl so he could settle down for necessary exams/testing.
Past Medical History:
Unknown--pt poor/unreliable historian
Social History:
Self reported abuse of heroin and prescriptive medications over
the past three years or so. Possibly participating in a needle
exchange program (card was found in his pocket but not sure
where this was from). Possible ETOH abuse. Smokes 1 PPD x past
10 years. Parents did have a formal restraining order in the
recent past so he could not come to the house but they did have
that lifted recently. He has been in prison in the past, has
gone through rehab programs and was living in a halfway house in
the past. He has recently been homeless and living on the
streets with a girlfried named 'KiKi' who witnessed the assault,
fled the scene, and then waited 12 hours to call his parents to
let them know what happened.
Family History:
non-contributory
Physical Exam:
P/E:
VS: 99.4 99.4 77 120/54 11 99% RA
NPO; 640cc urine/6 hours; 615 IVF
GEN: WD/WN M obtunded and unable to cooperate w exam; in
restraints [**1-19**] intermittent agitation; rousable to sternal
rub/noxious stimuli
HEENT: moving eyes without identifiable deficit upon arrival to
hospital per ED; 2cm lateral supra-orbital lac w suture repair;
presently with ecchymosis and peri-orbital edema L>R; pupils
pharmacologically dilated by ophtho
CV: RRR
PULM: CTA B/L
ABD: S/NT/ND
EXT: No edema
Pertinent Results:
[**2106-6-25**] 11:05AM GLUCOSE-125* UREA N-11 SODIUM-142
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-32 ANION GAP-13
[**2106-6-25**] 11:05AM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2106-6-25**] 11:05AM WBC-9.6 RBC-4.47* HGB-13.5* HCT-39.8* MCV-89
MCH-30.2 MCHC-33.9 RDW-14.0
[**2106-6-25**] 11:05AM PLT COUNT-400
[**2106-6-25**] 03:06AM GLUCOSE-199* LACTATE-2.0 NA+-141 K+-3.1*
CL--96* TCO2-28
[**2106-6-25**] 03:00AM UREA N-11 CREAT-1.0
[**2106-6-25**] 03:00AM estGFR-Using this
[**2106-6-25**] 03:00AM LIPASE-21
[**2106-6-25**] 03:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-6-25**] 03:00AM WBC-14.2* RBC-4.59* HGB-13.4* HCT-40.9 MCV-89
MCH-29.2 MCHC-32.8 RDW-14.0
[**2106-6-25**] 03:00AM PLT COUNT-340
[**2106-6-25**] 03:00AM PT-11.7 PTT-21.7* INR(PT)-1.0
[**2106-6-25**] 03:00AM FIBRINOGE-391
.
RADIOLOGY
Final Report
HISTORY: Trauma.
.
AP RADIOGRAPH OF THE CHEST. AP RADIOGRAPH OF THE PELVIS.
.
COMPARISON: None.
.
CHEST: Lung volumes are low. The cardiac silhouette and hilar
contours
appear normal. The mediastinum is likely exaggerated by supine
technique. No pneumothorax or pleural effusion is present.
Osseous structures appear
intact.
PELVIS: Evaluation is limited by underlying trauma backboard.
The pubic
symphysis appears intact. There are no obvious pelvic fractures.
Evaluation of the right sacroiliac joint is limited but appears
normal.
IMPRESSION: Limited examination, but no evidence for traumatic
pathology.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 85446**]
Reason: H/O ASSAULT. EVAL
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with h/o assault
REASON FOR THIS EXAMINATION:
?head trauma
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Wet Read: JMGw FRI [**2106-6-25**] 3:31 AM
large left sided soft tissue swelling and temporal-parietal
subgaleal
hematoma.
.
Depressed zygomatic arch fx. fxs of the lateral and anterior
maxillary sinus walls, inferior and lateral left orbital wall
fx, possible inferior right orbital wall fx. globes and lenses
appear intact. no intracrainal injury.
.
Final Report
1HISTORY: 20-year-old man with assault.
CT HEAD: Axial imaging was performed through the brain without
IV contrast
administration. Sagittal and coronal reformats were prepared.
COMPARISON: None.
FINDINGS: There is hyperdense material layering along the corpus
callosum
compatible with a SAH (4001b:59). There is no edema, mass
effect, or evidence for acute vascular territorial infarction.
[**Doctor Last Name **]-white matter differentiation is well preserved and there is
no shift of normally midline structures.
There is marked soft tissue swelling along the region of the
left orbit, left temporal, and left parietal bones with a large
10 mm thick left
temporoparietal subgaleal hematoma.
There is a depressed zygomatic arch fracture with overriding
ends. The
zygomatic arch may be fractured at two sites (3:7). There is a
comminuted
medially displaced fracture of the medial orbital wall. There is
a depressed fracture of the inferior orbital wall with blood and
bone fragments in the left maxillary sinus. There is a depressed
comminuted fracture of the lateral and anterior walls of the
left maxillary sinus. There is a depressed fracture of the right
inferior orbital wall, which may be chronic.
Hypodense fluid compatible blood is seen within the left
maxillary sinus.
Remaining paranasal sinuses, mastoid and ethmoid air cells are
well aerated.
IMPRESSION:
1. Hyperdense material layering along the corpus callosum
compatible with a SAH.
2. Depressed zygomatic arch fracture. Fracture of the lateral
and anterior
left maxillary sinus walls. Inferior and lateral left orbital
wall fracture. Possible right inferior orbital wall fracture.
Globes and lenses are intact.
3. Large left-sided temporoparietal subgaleal hematoma with soft
tissue
swelling extending to the orbits.
If indicated, facial bone CT could be performed for better
evaluation of these fractures.
Finding of the subarachnoid hemorrhage was communicated to Dr.
[**First Name8 (NamePattern2) 7656**] [**Name (STitle) **] at 9:45AM.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 85447**]
Reason: S/P ASSAULT. ? FX.
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with h/o assault
REASON FOR THIS EXAMINATION:
?spine injury
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Wet Read: JMGw FRI [**2106-6-25**] 3:31 AM
no traumatic injury
.
Final Report
HISTORY: 20-year-old man after assault.
CT C-SPINE: Helical imaging was performed through the cervical
spine without IV contrast administration. Sagittal and coronal
reformats were prepared.
COMPARISON: CT head performed same day.
FINDINGS: There is no fracture or malalignment. Vertebral body
height and
alignment appears normal. There is no prevertebral fluid. The
visualized
outline of thecal sac appears normal; however, CT is unable to
provide
intrathecal detail comparable to MRI. Incompletely assessed is a
complex
fracture involving the left maxillary sinus, which is filled
with hyperdense fluid, likely blood. The visualized lung apices
are clear.
IMPRESSION:
1. No traumatic injury to the cervical spine.
2. Incompletely visualized complex left maxillary sinus
fracture.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~~~~
CT ORBIT, SELLA & IAC W/O CONT Clip # [**Clip Number (Radiology) 85448**]
Reason: bilateral to further define fracture
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man s/p assult to right face
REASON FOR THIS EXAMINATION:
bilateral to further define fracture
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Provisional Findings Impression: CXWc FRI [**2106-6-25**] 4:11 PM
PFI:
1. Left lateral facial fractures, including an extensively
comminuted
fracture involving the left inferior orbital wall and left
lateral maxillary sinus wall and the zygomatic arch, with
displacement at the zygomaticofrontal suture, compatible with a
tripod fracture. A bony fragment impinges upon the left lateral
rectus muscle, concerning for entrapment.
2. Fragmentation of the right inferior orbital wall, with fat
herniating
through the defect into the right maxillary sinus, but there is
only minimal mucosal thickening in the right maxillary sinus. In
the absence of prior imaging, this is an age-indeterminate
fracture.
Final Report
INDICATION: 28-year-old man status post assault.
COMPARISON: Head CT obtained approximately 10 hours earlier.
TECHNIQUE: Non-contrast axial images were obtained through the
facial bones. Multiplanar reformatted images were generated.
FINDINGS: There are multiple comminuted and displaced fractures
along the
left lateral face involving the zygomaticomaxillary complex. The
left orbital floor demonstrates an extensively comminuted
fracture extending into the lateral wall of the left maxillary
sinus, which is nearly filled with hyperdense material, with an
air-fluid level and some aerosolized contents. The lateral wall
of the left maxillary sinus is depressed medially. Fracture
fragments extend upward through the lateral wall of the left
orbit, with relatively large fracture fragments displaced
medially along the lacrimal gland and muscles. In particular, a
bony fragment impinges upon the left lateral rectus muscle,
which is concerning for entrapment. Additionally, a large
fragment impinges upon the left lacrimal gland, which is
displaced posteromedially. There is no evidence of retrobulbar
hemorrhage. The lens is in place. The globe demonstrates normal
signal intensity. Overlying this constellation of fractures is
extensive subcutaneous stranding and edema.
Additional fractures involve the left zygomatic arch.
Thezygomaticofrontal
suture is separated and displaced medially. The zygomatic
fracture fragments are overriding by several millimeters.
The floor of the right orbit demonstrates bony fragmentation
with a small
amount of fat herniating caudally into the right maxillary
sinus. However,
there is only a small amount of mucosal thickening or
intermediate density
fluid layering in the dependent portion of the sinus. In the
absence of prior studies, this is an age-indeterminant fracture.
On the right, there is no retrobulbar hemorrhage. The right
globe and lens are appropriately
positioned. Mild soft tissue swelling overlies the right orbit.
No other fractures are identified. There is mild mucosal
thickening of the
ethmoid air cells, with trace mucosal thickening in the right
sphenoid air
cell. Mastoid air cells are normally aerated. Frontal air cells
are normally pneumatized and aerated.
IMPRESSIONS:
1. Comminuted and displaced left lateral face fractures
involving the left
zygomaticomaxillary complex. A bone fragment impinges upon the
left lateral rectus muscle, concerning for entrapment.
Separation and displacement of the zygomaticofrontal suture
displaces the left lacrimal gland posteromedially.
2. Bony discontinuity of the floor of the right orbit contains a
small amount of fat herniating into the right maxillary sinus,
with minimal mucosal thickening or fluid in the sinus. In the
absence of prior films, this is an age-indeterminate fracture.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~~
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 85449**]
Reason: assess interval change
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man s/p assult to face
REASON FOR THIS EXAMINATION:
assess interval change
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Provisional Findings Impression: CXWc FRI [**2106-6-25**] 4:27 PM
PFI: No new abnormality. Decreased conspicuity of small amount
of blood
along the corpus callosum. No new hemorrhage. Left subgaleal
hematoma
stable. Left facial fracture is better delineated on the
dedicated facial
bone CT.
.
Final Report
INDICATION: 28-year-old man status post assault. Assess interval
change.
COMPARISON: Head CT obtained approximately 10 hours earlier.
TECHNIQUE: Non-contrast axial images were obtained through the
brain.
FINDINGS: Since the prior study, there has been no acute change.
A small
amount of hyperdense material layering along the surface of the
corpus
callosum is slightly decreased in conspicuity. There is no new
area of
intracranial hemorrhage. There is no edema, shift of normally
midline
structures, or evidence of acute major vascular territorial
infarct.
Ventricles and sulci are normal in size and configuration. The
[**Doctor Last Name 352**]-white
matter differentiation is preserved. The basilar cisterns are
symmetric.
Assessment of bony structures demonstrates extensive left facial
fractures, better delineated on the concurrently obtained facial
bone CT. Mastoid air cells are well aerated. No calvarial
fractures are identified.
A left subgaleal hematoma is unchanged, with associated
subcutaneous tissue edema. Right-sided subcutaneous tissue edema
is also unchanged.
IMPRESSION:
1. Slight interval decrease in conspicuity of blood layering
along the corpus callosum.
2. Left facial fractures, better evaluated on the concurrently
obtained
facial bone CT ([**Numeric Identifier 85450**]).
3. Unchanged left subgaleal hematoma and bilateral scalp edema.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Patient was immediately assessed by Trauma Team in the Emergency
Department (ED). Stat labs were obtained and sent. He was sent
for CT Orbit/Sella*IOC which showed multiple facial fractures,
CT spine was negative, CT head showed SAH and a large left-sided
temporoparietal subgaleal hematoma. A left brow laceration was
thoroughly washed out and then sutured while in the ED by Trauma
staff. Patient was evaluated by Ophthalmology service who found
no evidence of muscle entrapment or open globe or intraocular
involvement. Patient was evaluated by Neurosurgery service who
initially had trouble with exam due to sedation and recommended
patient be transferred to Trauma ICU (TICU) for Q1h neurochecks.
Patient was evaluated by Plastic Surgery service who felt that
facial fractures, specifically the left ZMC and orbital floor
fractures, needed surgical repair. Patient was started on
Unasyn and maintained on sinus precautions and facial fracture
repair was planned for the morning of [**2106-6-30**]. Social Work
became involved with the yet unidentified patient at the time on
[**2106-6-26**]. Patient became progressively more communicative and
alert during the day on [**2106-6-26**] and was eventually tranferred
out of ICU onto the floor. He was able to identify who he was
to the staff. In addition, patient's sister [**Name (NI) **] was able to
call the floor and identify herself as the patient's family.
Patient was then placed on 'Privacy Alert' for protection as
circumstances of assault remained unknown. Patient's mental
status continued to improve over the next few days and patient's
family very involved and present. Patient working with Physical
Therapy to improve steadiness of gait. Patient had a repeat
head CT on [**2106-6-27**] which was stable and showed stable SAH and
subgaleal hematoma. Neurosurgery signed off and cleared patient
for facial fracture repair. On the evening of [**2106-6-29**] patient
was all cleared for surgical repair on the morning of [**2106-6-30**]
and he was aware and in agreement with this plan. He was given
Benadryl for sleep for complaints of insomnia. He was NPO after
midnight. At about 2am on [**2106-6-30**] began requesting that he be
allowed to leave the hospital and stating that he did not intend
to pursue surgery in the morning. The risks of not getting the
surgery were explained to patient and he said he understood
those risks. The RN Supervisor was called and the on-[**Name6 (MD) 138**]
Plastics MD [**First Name (Titles) **] [**Last Name (Titles) 18**] Security. Patient told staff that he was
not 'a section-12' and therefore he couldn't be held against his
will. [**Hospital1 18**] Police confirmed this. Patient signed out of
hospital Against Medical Advice (AMA) but refused to sign AMA
paperwork.
Medications on Admission:
None
Discharge Medications:
None---signed out AMA
Discharge Disposition:
Home
Discharge Diagnosis:
Patient signed out AMA
Discharge Condition:
Patient signed out AMA
Discharge Instructions:
Patient signed out AMA
Followup Instructions:
Patient signed out AMA
Completed by:[**2106-7-8**]
|
[
"305.51",
"802.4",
"307.9",
"296.90",
"293.0",
"873.49",
"300.00",
"799.23",
"852.06",
"802.8",
"E968.9",
"802.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
16705, 16711
|
13808, 16604
|
411, 417
|
16777, 16801
|
2327, 3998
|
16872, 16924
|
1778, 1796
|
16659, 16682
|
11893, 11928
|
16732, 16756
|
16630, 16636
|
16825, 16849
|
1811, 2308
|
276, 373
|
11960, 13785
|
445, 967
|
4578, 6725
|
989, 1028
|
1044, 1762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,362
| 168,483
|
46374
|
Discharge summary
|
report
|
Admission Date: [**2104-6-23**] Discharge Date: [**2104-6-26**]
Date of Birth: [**2038-7-13**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Procardia / Bactrim DS /
Atovaquone
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo M with HIV (CD4 244, 16%, VL 99 copies/ml) on
Darunavir-rit-truvada, CAD, HTN, hyperlipidemia, diverticulitis,
urethral stenosis with multiple UTIs, who presented to the ED
with fever. He reported that 3 days prior to presentation, he
began to notice cough which had become more productive. His
sputum had mostly slightly whitish and small volume, but in the
ED he had thicker sputum which was sent for culture. Aside from
cough he also endorsed diffuse muscle aches including some neck
aches and flank pain a few days prior to presentation which had
improved. He had also had loose stools (1BM/d) for the last few
days. He has had intermittent fevers and has shaking chills x 1
on the day prior to presentation. He had mild headache in the
ED which resolved with tylenol. He denied shortness of breath.
He had not had any dysuria, frequency or any other symptoms that
he usually gets with UTI/pyelonephritis.
In ER: Triage Vitals: 101.4 --> 102.4 77 162/85 20 97% RA. He
had 4 attempts at lumbar puncture none of which were successful.
He received ceftriaxone, azithromycin, dapsone. A CXR was
without infiltrates or edema.
REVIEW OF SYSTEMS:
Positive per HPI. All other systems reviewed and negative.
Past Medical History:
1. HIV: He was diagnosed in [**2080**] after a sexual partner had
misrepresented his status to him. He has had no opportunistic
infections since diagnosis, and his lowest CD4 count was last
year (118 in [**2102-8-17**]). He was hospitalized for pneumonia in
[**2081**] that was presumed to be PCP pneumonia and is currently not
on PCP prophylaxis as his CD4 >200.
2. Diverticulitis: Was hospitalized for diverticulitis
(presented with fever & LLQ abdominal pain) in [**2098-4-16**] which
was L-sided and treated with Cipro/Flagyl - no
abscess/perforation. Since then, he has had sporadic LLQ
abdominal pain and has been treated outpatient for presumed
diverticulitis. Was also hospitalized in [**2102-4-17**] for
diverticulitis (again no abscess, no perforation) and treated
with Cipro/Flagyl. Takes Metamucil regularly.
3. CAD: He experienced angina 12 years ago, has never had an MI
or any revascularization procedures. He was found to have
moderate partially reversible perfusion defect in the inferior
and inferoseptal myocardium on [**9-/2102**] exercise MIBI. He
initially was started on nitroglycerin but had headaches and is
now on isosorbide dinitrate.
4. Hypertension: Difficult to control, is currently on 4 agents
for BP control.
5. Past infection with Hepatitis B ([**2071**]) - was hospitalized for
acute treatment and has not had any issues since. HBsAb & HBsAg
negative in [**8-/2102**], HBcAb positive.
6. Past infection with syphilis in [**2081**]
7. Multiple UTIs due to urethral stenosis (Last urethral
dilation in [**8-/2102**], urethrotomy in 04/[**2099**]).
8. Appendicitis in [**2062**]
9. Hyperlipidemia
10. Multiple ear infections (R>L) and ?perforation of eardrum
Social History:
Never smoked tobacco, no history of drug or alcohol abuse. rare
EtOH. Patient is a retired kindergarten teacher and lives alone
in [**Location (un) **]. He formerly used to be in the artillery. The
patient is able to perform ADLs independently. He exercises
regularly by walking miles a day. He had a long-term male
partner who passed away in the [**2072**]. He is currently not
sexually active.
Family History:
There is no family history of premature coronary artery disease,
unexplained heart failure, or sudden death. His father died of
MI at the age of 66 and his mother died of MI at the age of 70.
Sister also has angina but has not had an MI. No family history
of HIV, colon cancer, or diverticulosis.
Physical Exam:
On Admission:
T 101.3 P 72 BP 150/83 RR 18 O2Sat 95% No drop in O2 with
ambulation
GENERAL: well-nourished, pleasant, non-toxic appearing,
mentating well
Eyes: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
GU: no flank tenderness
Skin: flushed cheeks, no rashes or lesions noted. No pressure
ulcer
Extremities: 1+ pitting edema L ankle, trace edema on RLE, 2+
radial, DP and PT pulses b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted.
Psychiatric: pleasant and interactive
On Discharge:
VS: ambulatory saturation 96% without dyspnea, 99% on RA at rest
Exam notable for resolution of lower extremity edema, and only
mild scattered rhonchi on R>L. Otherwise unchanged from
admission exam and essentially normal.
Pertinent Results:
===================
LABORATORY RESULTS
===================
Labs on Admission:
WBC-5.6 RBC-4.44* HGB-15.0 HCT-41.9 RDW-13.2 PLT COUNT-179
-- NEUTS-66.8 LYMPHS-19.8 MONOS-6.9 EOS-5.5* BASOS-1.0
GLUCOSE-118* UREA N-17 CREAT-1.2 SODIUM-139 POTASSIUM-3.0*
CHLORIDE-99 TOTAL CO2-28
UA: COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2104-6-23**] 12:00AM
URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2104-6-23**] 12:00AM
URINE RBC-1 WBC-56* BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-<1
On Discharge:
[**2104-6-26**] 07:59AM BLOOD WBC-3.2* RBC-4.47* Hgb-14.8 Hct-42.5
MCV-95 MCH-33.1* MCHC-34.7 RDW-12.5 Plt Ct-181
[**2104-6-26**] 07:59AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
==============
MICROBIOLOGY
==============
Blood Cx *4: NGTD
Urine Culture [**2104-6-23**]:
URINE CULTURE (Final [**2104-6-25**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Sputum Culture [**2104-6-23**]:
GRAM STAIN (Final [**2104-6-23**]):
[**9-9**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2104-6-25**]):
SPARSE GROWTH Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2104-6-24**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
Rapid Respiratory Virus Screen:
Respiratory Viral Antigen Screen (Final [**2104-6-24**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Legionella urine ag: neg
Cryptococcal serum ag: neg
C. dif toxin assay from stool: neg
Respiratory Viral Culture, Lyme and anaplasma serologies:
Pending
==============
OTHER STUDIES
==============
CXR [**2104-6-22**]:
IMPRESSION: No radiographic evidence of acute cardiopulmonary
process.
CT HEAD W/O CONTRAST [**2104-6-22**]:
IMPRESSION: no acute process
CTA CHEST [**6-23**]:
1. No evidence for PE.
2. Small lung nodules in a tree-in-[**Male First Name (un) 239**] configuration in the
lower lobes
bilaterally consistent with small airways disease are concerning
for
aspiration. Differetial diagnosis would include other infectious
or
inflammatory process.
TTE [**6-24**]:
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
>55%). Right ventricular chamber size and free wall motion are
normal. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: No PFO or ASD. Normal global and regional
biventricular systolic function.
Brief Hospital Course:
65 yo M with HIV (CD4 244, 16%, VL 99 copies/ml) on
Darunavir-rit-truvada, CAD, HTN, hyperlipidemia, diverticulitis,
urethral stenosis with multiple UTIs presented with fever,
myalgias, diarrhea, productive cough with no radiographic
evidence of pneumonia and then developed hypoxia/hypotension
requiring MICU transfer.
1) Pneumonia, acute bacterial vs viral: Patient's presentation
with fevers and productive cough certainly reasonable for acute
bacterial pneumonia and he was treated for this in ED. After
transfer to MiCU for hypoxia decision was made to continue this
course with ceftriaxone/ azithromycin and add on vancomycin.
Given all bacterial cultures remained negative, however,
infectious disease with high suspicion of viral process but
viral antigen screen negative. Vancomycin was stopped on day
prior to discharge with ID input given no gram positive
organisms isolated. Pt will be switched from
ceftriaxone/azithromycin to levofloxacin at discharge to
complete a total of seven days of therapy. Of note, cough did
improve with antibiotic and bronchodilator therapy. Of note,
legionella and cryptococcal antigen studies were negative and
PCP not seen on sputum immunofluorescence.
2) Hypoxia: Patient did not require supplementary O2 in the ED
or on the floor but then acutely de-satted to 83% on room air
when getting up to ambulate. He was transferred to the MICU on
6 L by nasal cannula with stabilization of his sats. He was
empirically treated for PCP with clindamycin/primaquine.
Hypoxia was worked up by CT chest that showed no PE and very
minimal infiltrate that would likely not cause his degree of
hypoxia. TTE with bubble study did not reveal a shunt. His O2
progressively improved over the first 24 hours in the ICU. ID
was consulted and given rapidly improving hypoxia and the fact
that pattern not consistent with PCP and patient's CD4 not <200
they recommended stopping PCP treatment, which was done on
[**2104-6-24**]. By time of transfer out of the unit on [**6-24**] patient
was off supplementary O2 and was able to ambulate without
dyspnea. Possible patient developed viral reactive airway
disease and transient obstructive component conributed to
hypoxia though never really significant wheezing. He will be
discharged on bronchodilator as this seemed to help with cough,
and was instructed in the use of the MDI prior to discharge.
3) Hypotension: The patient was transiently hypotensive on
transfer to the ICU with SBP's in the 80s. These pressures
improved to the low 100's after one liter NS, which is still
quite low for this patient who is usually on five
anti-hypertensives. He remained stable throughout the 9th and
on [**6-25**] atenolol and lisinopril were restarted as SBP's in
150's. He tolerated this well. Likely etiology of hypotension
was dehydration and volume depletion in context of illness,
increased losses due to fever, and multiple anti-HTN meds. EF
was stable on echo during this hospitalization.
4) Fever: Presumed due to pulmonary infection, viral vs
bacterial. Unfortunately unable to obtain CSF to r/o meningitis
but never a great deal going for this but headache. Urine
culture results difficult to interpret. No abdomen specific
symptoms such as tenderness to suggest diverticulitis flare and
blood cultures remained negative. Fevers had resolved as of
[**6-25**].
5) Hypertension, benign: Patient initially hypotensive then
became hypertensive on [**6-25**] (which is his baseline). He was
restarted on lisinopril and atenolol on [**6-25**] and isosorbide and
1/2 dose HCTZ on [**6-26**]. He preferred to hold the nifedipine
pending PCP and cardiology followup, given his concern that this
[**Doctor Last Name 360**] could be causing or contributing to LE edema and fluid
weight gain. His SBP was 130 - 140 on discharge. He was to
restart full dose lisinopril, atenolol, isosorbide, and HCTZ on
[**6-27**], as well as his potassium supplementation.
6) HIV: Reports perfect adherence to his HAART regimen of
Dar-rit-truv. Continued HAART in house.
7) CAD, native vessel: He had no chest pain or signs of ACS.
Echo was benign. He was continued on his ASA, statin, cardiac
diet and beta blocker restarted after BP's improved.
8) Urethral stricture: The patient has a urethral stricture
associated with multiple UTI's. He was scheduled for follow up
with Dr. [**Last Name (STitle) 770**] prior to discharge. Urine culture in house
failed to reveal a clear causative organism for UTI though it
was extensively contaminated. Treatment regimen for pneumonia
should also reasonably cover empiric UTI treatment as well.
9) BPH: Patient had been on doxasosin but wasn't taking
regularly. This was held in the context of his hypotension.
Discussed with the patient to speak with his PCP and
cardiologist to check his BP closely, if he does feel the need
to restart this [**Doctor Last Name 360**].
10) GERD: He was continued on his home PPI
Transitional Issues:
-Mr [**Known lastname **] has follow up with his PCPs NP to follow up on
results of anaplasma and lyme serologies
-He will follow up with Dr. [**Last Name (STitle) 770**] regarding further work up of
his urethral stricture
-Respiratory viral screen and final blood cultures still pending
at time of discharge
-Patient provided with MDI for potential bronchospasm, and
teaching. [**Month (only) 116**] require further use of this medication if reactive
airway disease persists.
-BP check will be needed, to ensure that his BP is stable off
the nifedipine, and that further adjustments to the remaining
agents are made. The patient is aware of the need to call his Dr [**Name (NI) 98547**] office sooner, if his BP is elevated on home checks.
Medications on Admission:
darunavir 800 mg daily
ritonavir 100 mg daily
truvada 1 tab daily
doxazosin 2mg qhs -- hasn't been taking for six months.
HCTZ 25mg daily
atenolol 150mg daily
lisinopril 40mg daily
imdur 30mg daily
nifedipine 30 mg daily
rosuvastatin 10mg daily
ASA 81mg daily
lorazepam 1mg qhs takes PRN, which is rare
hydrocortisone rectal cream
omeprazole 20mg daily
potassium chloride 60 mEq daily
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day for 1 weeks: use four
times a day regardless of symptoms for one week then decrease to
as needed.
Disp:*1 inhaler* Refills:*1*
3. darunavir 400 mg Tablet Sig: Two (2) Tablet PO once a day.
4. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
6. atenolol 50 mg Tablet Sig: Three (3) Tablet PO once a day.
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Three (3) Tablet, ER Particles/Crystals PO once a day.
14. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
15. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Pneumonia (Acute Bacterial vs Acute Viral)
Hypoxia
Hypotension
Secondary Diagnoses:
HIV
Native vessel CAD
Hypertension
Urethral Stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to care for you during your admission. As you
know, you were admitted with cough and fever. We think that
this was due to a pneumonia, which is an infection of your
lungs. This may have been a bacterial infection or a viral one.
This likely caused your fevers and may have directly caused
your low oxygen levels or by making your airways get tight. You
improved with antibiotics and medicines to help open up your
lungs. You will be discharged on these medications to complete
your recovery.
Your medications have been changed:
-You have been started on levofloxacin (LEVAQUIN) an antibiotic,
you will complete an additional three days of treatment for
this.
-You have been started on albuterol, an inhaler to help keep
your lungs more open and improve your breathing as you recover
from the infection.
-Your nifedipine is being held on discharge given your report of
leg swelling, and request that you speak with Dr [**Last Name (STitle) **] before
restarting this medication. You should call Dr[**Name (NI) 29254**] office
if you notice blood pressures at home greater than 150-160/90
prior to your scheduled appointment.
Followup Instructions:
Department: DERMATOLOGY
When: MONDAY [**2104-6-30**] at 3:45 PM
With: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,NP [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2104-7-2**] at 10:10 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] None
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2104-8-4**] at 9:00 AM
With: STRESS TESTING [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please see Dr [**Last Name (STitle) 770**] at the following appointment to follow-up
on your urethral strictures.
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2104-7-10**] at 1:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"276.51",
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"401.9"
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icd9cm
|
[
[
[]
]
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|
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[
[]
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,828
| 107,386
|
43381
|
Discharge summary
|
report
|
Admission Date: [**2125-10-22**] Discharge Date: [**2125-10-31**]
Date of Birth: [**2084-6-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
intubation
bronchoscopy
History of Present Illness:
41 F with history of asthma, recently initiated treatment for
atypical pneumonia, now represents to ED for severe pneumonia
and respiratory failure requiring intubation. Patient seen on
[**10-19**] for R sided chest pain, shortness of breath and cough.
Discharged from ED on azithromycin after CXR showing atypical
pneumonia. Normal O2 per ED notes from that visit. Did not
improve at home and represented to ED yesterday evening. Per EMS
report, O2 sat 65% upon their arrival.
.
In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of
hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L
NS given, also vanc, levoflox, cefepime, bactrim. Tachypneic to
40-50s; intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8
70% FiO2 prior to arrival to floor.
Past Medical History:
asthma
depression
ethanol abuse
Social History:
- Has one daughter age 22
- Lives alone on disability for a vague histoy of brain damage
approximately six years ago, which she is not very clear of the
details.
- Smokes half pack per day for 30 years.
- Uses alcohol several times per week, does not know more
specifically. h/o withdrawal.
- Depression, on fluoxetine.
Family History:
non-contributory
Physical Exam:
Tmax: 36.9 ??????C (98.5 ??????F), Tcurrent: 36.9 ??????C (98.5 ??????F), HR: 84 (84
- 92) bpm, BP: 102/68(81) {102/68(81) - 102/68(81)} mmHg, RR: 25
(25 - 27) insp/min, SpO2: 98%, Heart rhythm: SR (Sinus Rhythm),
Height: 65 Inch
Gen Appearance: Well nourished, No acute distress, Overweight /
Obese, on vent
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, No cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic), distant
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), Breath Sounds:
Bronchial: No Wheezes, Rhonchorous
Abdominal: Soft, Non-tender, Bowel sounds present, Not
Distended, Obese
Extremities: Right: Absent, Left: Absent
Skin: Not assessed, No Rash: , No Jaundice.
RUE well healed horizontal scars.
Neurologic: Follows simple commands, Responds to: Not assessed,
Movement: Not assessed, Sedated, Tone: Not assessed, follows
commands when not sedated
Pertinent Results:
[**2125-10-21**] 10:30PM BLOOD WBC-15.1* RBC-3.72* Hgb-11.3* Hct-32.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-14.5 Plt Ct-442*
[**2125-10-30**] 05:43AM BLOOD WBC-19.5* RBC-4.30 Hgb-12.7 Hct-37.5
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.5 Plt Ct-559*
[**2125-10-21**] 10:30PM BLOOD Neuts-84.7* Lymphs-10.8* Monos-3.8
Eos-0.4 Baso-0.2
[**2125-10-21**] 10:30PM BLOOD PT-13.1 PTT-27.4 INR(PT)-1.1
[**2125-10-28**] 03:00AM BLOOD PT-15.0* PTT-25.6 INR(PT)-1.3*
[**2125-10-22**] 05:17AM BLOOD WBC-15.7* Lymph-10* Abs [**Last Name (un) **]-1570 CD3%-80
Abs CD3-1252 CD4%-58 Abs CD4-905 CD8%-22 Abs CD8-342 CD4/CD8-2.7
[**2125-10-21**] 10:30PM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-138
K-3.6 Cl-103 HCO3-24 AnGap-15
[**2125-10-30**] 05:43AM BLOOD Glucose-179* UreaN-20 Creat-0.7 Na-136
K-4.7 Cl-100 HCO3-26 AnGap-15
[**2125-10-21**] 10:30PM BLOOD ALT-17 AST-34 LD(LDH)-740* CK(CPK)-109
AlkPhos-105 TotBili-0.3
[**2125-10-28**] 03:00AM BLOOD ALT-18 AST-17 LD(LDH)-456* AlkPhos-72
TotBili-0.5
[**2125-10-21**] 10:30PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1388*
[**2125-10-22**] 05:17AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2125-10-22**] 05:17AM BLOOD Calcium-6.7* Phos-2.5* Mg-1.8
[**2125-10-30**] 05:43AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
[**2125-10-26**] 03:52AM BLOOD VitB12-807
[**2125-10-27**] 01:53PM BLOOD Ammonia-31
[**2125-10-26**] 03:52AM BLOOD TSH-0.43
[**2125-10-24**] 12:11PM BLOOD ANCA-NEGATIVE B
[**2125-10-30**] 03:30PM BLOOD HIV Ab-PND
[**2125-10-21**] 10:36PM BLOOD Lactate-1.5
[**2125-10-27**] 03:10PM BLOOD Lactate-1.3
[**2125-10-22**] 01:22AM BLOOD Type-ART Rates-0/20 Tidal V-400 PEEP-8 O2
Flow-100 pO2-162* pCO2-57* pH-7.19* calTCO2-23 Base XS--6
-ASSIST/CON Intubat-INTUBATED
[**2125-10-27**] 03:10PM BLOOD Type-ART pO2-77* pCO2-48* pH-7.49*
calTCO2-38* Base XS-11 Intubat-NOT INTUBA
[**2125-10-24**] 03:03PM BLOOD IGE-Test
[**2125-10-24**] 11:39AM BLOOD IGE-Test
[**2125-10-22**] 10:22AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2125-10-22**] 10:22AM BLOOD B-GLUCAN-Test
.
BAL ([**2125-10-22**]): no bacterial growth, no legionella, no
pneumocystis, no fungus, no acid fast bacilli, no respiratory
viruses (adeno, parainfluenza 1, 2, 3, influenza A and B, RSV
Urine ([**2125-10-22**]): negative legionella antigen, negative bacteria
Blood cultures ([**2125-10-22**] and [**2125-10-27**]): negative
Nasopharyngeal aspirate ([**2125-10-23**]): negative for viruses
RPR ([**2125-10-23**]): negative
Catheter tip-IV ([**2125-10-28**]): negative
.
BAL ([**2125-10-22**] am): clear with 12% eosinophils
BAL ([**2125-10-22**] pm): Negative for malignant cells. 35cc prurulent
fluid. no eos.
.
EKG ([**2125-10-21**]): Moderate artifact in lead V1. Probably within
normal limits. Compared to the previous tracing of [**2125-8-28**] no
diagnostic interim change.
.
Imaging:
CXR ([**2125-10-21**]): Bilateral diffuse airspace opacities in a
perihilar distribution, left greater than right. The
differential diagnosis includes viral, atypical, and fungal
etiologies.
.
CXR ([**2125-10-22**]): Severe bilateral airspace opacity suggesting
ARDS or
severe viral infection. Satisfatory placement of ETT.
.
Chest CT w/o contrast ([**2125-10-22**]): 1. Diffuse bilateral alveolar
and interstitial process with a somewhat upper lobe
predilection. The appearance is somewhat nonspecific and
etiologies can include noncardiogenic pulmonary edema (given
normal heart size and lack of pleural effusions, cardiogenic
pulmonary edema is considered less likely), infectious
etiologies such as viral pneumonia or possibly mycoplasma,
eosinophilic pneumonia (particularly given the 12% eosinophils
on original BAL) including acute eosinophilic pneumonia or
Loffler syndrome, or vasculitis. 2. Exophytic soft
tissue-density structure arising from the upper pole of the left
kidney. Ultrasound evaluation is recommended. 3. Nasogastric
tube tip terminating in the esophagus, which per report has been
subsequently advanced.
.
CXR ([**2125-10-26**]): Cardiomegaly is stable. The ET tube is in
standard position. NG tube tip is out of view below the
diaphragm. Right IJ catheter remains in place. There is no
pneumothorax. There are no enlarging pleural effusions.
Bilateral diffuse ground glass opacities are unchanged.
.
Head CT w/o contrast ([**2125-10-26**]): No change since [**2123-6-12**].
No evidence of hemorrhage or infarction.
.
CXR ([**2125-10-27**]): In comparison with the study of [**10-26**], the
patient has taken a somewhat better inspiration. The lungs
remain essentially clear and the tubes remain in place.
.
CXR ([**2125-10-29**]): Interval removal of nasogastric tube and right
internal jugular central venous catheter. Slight rounding of the
cardiac silhouette, which should be followed on subsequent
radiographs.
Brief Hospital Course:
41yoF with history of asthma, EtOH abuse, psych history;
admitted to MICU with respiratory failure requiring intubation
with severe pneumonia on CXR and high O2 requirements.
.
1. Acute eosinophilic pneumonia and respiratory failure:
admitted with hypoxemic respiratory failure, intubated on
hospital D#1, underwent two BALs. CT scans showed bilateral
pulmonary infiltrates, with BAL cell counts showing abundant
eosinophils (prior to steroids), in addition to elevated serum
IgE - both suggestive acute eosinophillic pneumonia. ANCA and
infection workup negative. Patient completed 7-day course of
levofloxacin for possible CAP. Patient was initiated on
steroids upon initial diagnosis of AEP, then down titrated on
[**10-27**] to solumedrol 60 Q12hrs, and on [**10-30**] to prednisone 60mg
on [**10-28**]. Extubation occurred on [**10-26**]. She was initiated on
bactrim given anticipated prolonged steroid course. Patient was
followed by pulmonary consult after transfer to the medicine
floor. She is being discharged on oral prednisone 60mg until
follow up with pulmonology to evaluate her improvement. Likely
she will need several months of prednisone. Due to high blood
sugars (low 300s) after starting prednisone, she will also be
discharged with metformin 500mg PO qday while she is on
steroids.
.
2. Mental status changes: Per daughter, patient has history of
anoxic brain injury as well as peripheral neuropathy due to
alcohol, reportedly lives/functions at home alone. Patient was
extubated on [**10-26**], showed some delerium post-extubation for 36
hours, requiring 2 doses of flumazenil and PO lactulose down NGT
(no labs or signs of liver failure, but empiric for gut
cleansing). Patient's delirium resolved, transferred to floor
with complete awareness and orientation.
.
3. Fever: Had temp to 101 on [**10-27**], no evidence of new
infiltrate on CXR. Urine and blood cultures were negative,
thought [**1-13**] atelectasis given positioning and lethargy at that
time. No recurrence of fevers. Leukocytosis likely secondary to
initiating steroids rather than infectious etiology.
.
4. Coffee ground emesis: Had one episode on [**10-26**] after dry
heaving; likely [**Doctor First Name **] [**Doctor Last Name **] vs. past OGT trauma; had
self-limited course with stable hct.
.
5. Depression: continued on home prozac dose.
.
6. Ethanol abuse: per family, also chronic pancreatitis per
imaging. Last drink thought to be [**10-20**] or [**10-21**]. Was on benzos
during intubation which would have masked any withdrawal; no
symptoms after extubation. Social work saw her while on the
floor.
.
7. Renal cyst: cyst seen on upper pole of left kidney on CT
scan. Follow up ultrasound showed exophytic 2-cm left upper pole
simple cyst.
.
8. HIV status: patient consented and was tested for HIV, given
association of acute eosinophil pneumonia with HIV. Results
pending at time of discharge. Results were negative and patient
was phoned by the medical team with these results.
Medications on Admission:
MVI daily
Prozac 60 mg daily
Zithromax Zpack
Percocet 1-2 tabs TID prn.
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take three tablets once per day.
Disp:*90 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute eosinophilic pneumonia
steroid induced hyperglycemia
Discharge Condition:
Stable, improved, satting well at rest and with ambulation on
room air
Discharge Instructions:
You were admitted to the hospital with respiratory distress that
required intubation. You had two bronchoscopies, which ruled
out infectious causes for the pneumonia, but did show eosinophil
inflammatory cells, consistent with acute eosinophilic
pneumonia. You recieved antibiotics and are being discharged on
steroids to treat the pneumonia.
.
Please take all your medications. New medications include
Prednisone 60mg daily and Metformin 500mg each morning daily
(take this medicine only as long as you are on prednisone) as
well as Bactrim three times a week for as long as you are on the
prednisone.
.
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 19039**]
as instructed below. At the time of discharge, your HIV test
result is still pending. You will get the result at your follow
up pulmonology appointment. If you need to cancel the
appointment, please phone the pulmonology office at
([**Telephone/Fax (1) 3554**] to get your result.
.
Return to the hospital if you have shortness of breath,
worsening cough, or any other concerning symptoms.
Followup Instructions:
Primary Care at [**Hospital **] Clinic: Dr. [**Last Name (STitle) 93374**]. Date/Time: [**2125-11-30**]
8:00. [**Telephone/Fax (1) 15982**].
.
Pulmonology at [**Hospital1 18**]: Dr. [**Last Name (STitle) 2168**]. Date/Time: [**11-7**] 2:40.
[**Telephone/Fax (1) 612**].
|
[
"518.81",
"577.1",
"357.5",
"E932.0",
"493.90",
"578.0",
"V58.65",
"305.00",
"593.2",
"311",
"518.3",
"249.00",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11152, 11158
|
7510, 10517
|
345, 370
|
11261, 11334
|
2774, 7487
|
12487, 12761
|
1580, 1598
|
10640, 11129
|
11179, 11240
|
10543, 10617
|
11358, 12464
|
1613, 2755
|
278, 307
|
398, 1171
|
1193, 1226
|
1242, 1564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,236
| 175,566
|
49913
|
Discharge summary
|
report
|
Admission Date: [**2177-6-23**] Discharge Date: [**2177-7-3**]
Service: MEDICINE
Allergies:
Valium / Elavil / Niaspan / Zithromax / Levaquin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
1. Central line placement - R IJ
History of Present Illness:
89 yo male with a history of CLL s/p multiple treatments, most
recently pentastatin (last dose [**2177-3-17**]) complicated by F+N so
stopped and reassessed [**2177-5-16**](no further treatment at that time
and acyclovir/aerosolized pentamidine started for ppx) chronic
hypogammaglobulinemia(treated intermittently w/ IVIG, last
[**2177-3-19**]) who was admitted [**2177-6-23**] for febrile neutropenia.
Relevant admission history included productive cough at home,
two recent falls without apparent loss of consciousness,
progressive weight loss, recurrent aspirations, strep viridans
bacteremia (as below) and ongoing diarrhea.
.
Of note, recent admission [**Date range (1) 104260**], diagnosed with strep
viridans bacteremia treated with broad spectrum abx and GCSF for
neutropenia. TEE was negative for vegetations. Prior to d/c,
antibiotics changed to clindamycin according to sensitivities,
and he was discharged to rehab to complete a 14 day course. He
was a known aspiration risk at that time (failed video swallow)
but refused PEG. He was continued on thickened liquids with
aspiration precautions. Patient signed himself out of rehab. It
is unclear whether he completed a complete course of
antibiotics.
.
Patient was seen by PCP [**Last Name (NamePattern4) **] [**6-23**] for chills, cough, s/p mult falls
(no LOC) and was referred to ED. In the ER, he was found to have
a T 100.3, HR 109, and O2 sat of 91% RA 94% on o2. CXR showed a
?RLL pna and he was started on levaquin 750mg.
.
On the floor, antibiotics were broadened to cefipime and SBP's
were running 110's. In the am of [**6-24**], the patient had a syncopal
episode while in the bathroom and BP was found to be in the
70's. Aggressive IVF's were started and BP returned to 100's.
Then, that afternoon, BP back to 80's despite IVF's. ECG
unremarkable. Repeat CXR demonstrated no infiltrates. ABG
7.34/34/60 on 2 liters oxygen. Patient was admitted to the ICU.
.
In the ICU, SBP dropped to 70s and temp spiked to 104.6.
Antibiotics were broadened to cefipime/vancomycin/flagyl. A
central line was placed and patient required dopamine x 36 hours
which was eventually weaned off [**6-25**]. No culture data could be
obtained to guide treatment. C diff negative x 3 ([**6-24**], [**6-26**],
[**6-28**]). Blood cxs [**6-24**] and [**6-26**] pending. Urine xc [**6-24**] and [**6-26**]
negative. Sputum from [**6-25**] grew OP flora. However, source
presumed to be aspiration pna. Heme/Onc consulted and
recommended giving IVIG at 400 mg/kg and GCSF at 300 mg sc QD.
Received treatment [**6-26**](per Heme/Onc should receive Q4-5 wks). A
Doboff was placed for tube feeds. Also transfused 1 unit PRBCs
on [**6-27**] for Hct 21 (-> 25). Also complained of RUE swelling/pain.
RUE u/s and XR both unremarkable. Vancomycin d/c'ed [**6-27**].
Intermittently required IV lasix 20 mg for volume overload with
good response. At the time of transfer, BPs had stabilized off
pressors, fever curse declining on broad spectrum antibiotics
(but off vanco), and ANC improving on GCSF.
.
Currently, patient feels breathing is improved. Denies any
chest pain, SOB, fevers, chills, abdominal pain. Resting
comfortably.
Past Medical History:
# CLL-
- s/p induction with chlorambucil at 6 mg/day x 3 weeks in
[**8-22**].
- s/p cycle of maintainence chlorambucil 24 mg /day x 5 days in
[**10-22**] (--> low counts).
- s/p 4 cycles maintainence chlorambucil at 24 mg/daily, for
five days/month starting in [**2173-12-6**].
- s/p 2 cycles of maintainence chlorambucil at 12 mg/day for 5
days every months in [**1-24**] and [**2-24**].
- intermittently on pentostatin, re-started on [**2177-2-7**]
following approx 2 month hiatus.
# CAD
- s/p cath in [**3-23**] with PTCA and PCI of LAD and D2.
# Hyperlipidemia
# Anemia
# BPH
# Osteoarthritis
# Diverticulosis
# Dementia
# h/o chronic low back pain
# Prostate ca
- s/p TURP
# recurrent aspiration pneumonitis
# s/p appy
# s/p tonsillectomy
# s/p b/l inguinal hernia repair
# Anxiety
# h/o malaria
Social History:
Lives alone in [**Location (un) 3146**]. Widowed with four children.
Family History:
non contributory
Physical Exam:
T: 98.2 BP: 112/58 HR: 84 RR: 24 O2 97% 3LNC
Gen: chronically ill appearing gentleman, laying flat in bed,
NAD
HEENT: No conjunctival pallor. Dry MMs. OP clear. Doboff in
place
NECK: Supple. Bilateral cervical adenopathy. No JVD. R IJ in
place. CDI
CV: RRR. nl S1, S2. [**1-25**] holosys murmur at apex
LUNGS: bibasilar crackles, L>R
ABD: NABS. Soft, NT, ND. No HSM
EXT: WWP. 1+ RUE swelling. Trace LE edema. No splinter
hemorrhages, Osler nodes, [**Last Name (un) 1003**] lesions
SKIN: multiple ecchymoses on forearms
NEURO: Alert. Oriented x3. CN 2-12 grossly intact. Preserved
sensation throughout. Moving all extremities.
Pertinent Results:
[**6-28**] R humerus XR:
No fracture detected involving the right humerus. Although
subtle marrow involvement might not be detected
radiographically, no obvious evidence for marrow involvement or
osteolysis is detected.
.
[**6-27**] UE u/s: No evidence of right upper extremity DVT.
.
[**6-24**] CXR: Allowing for technical differences, there has been no
significant change since the previous study of [**2177-6-23**].
Heart size is normal with tortuosity of the thoracic aorta and
coronary artery stent in situ. No definite pulmonary
consolidation or pleural effusions. Slight prominence of the
right hilum, likely vascular related to the relatively high
position of the right hemidiaphragm.
IMPRESSION: No evidence for pneumonia.
.
[**6-23**] CXR: The cardiomediastinal silhouette is unchanged. The
lungs are clear. No pleural effusions or pneumothoraces are
identified. The hilar structures are normal. The aorta is
unfolded.
IMPRESSION: No acute cardiopulmonary process identified.
.
[**2177-6-23**] 08:50PM BLOOD WBC-15.3* RBC-2.95* Hgb-10.0* Hct-30.9*
MCV-105*# MCH-33.9* MCHC-32.4 RDW-15.9* Plt Ct-282#
[**2177-6-24**] 01:23PM BLOOD WBC-8.9 RBC-2.56* Hgb-9.2* Hct-26.3*
MCV-103* MCH-35.8* MCHC-34.8 RDW-15.6* Plt Ct-223
[**2177-6-25**] 05:20AM BLOOD WBC-12.4* RBC-2.65* Hgb-9.1* Hct-27.9*
MCV-105* MCH-34.4* MCHC-32.7 RDW-15.7* Plt Ct-207
[**2177-6-26**] 04:57AM BLOOD WBC-6.2 RBC-2.26* Hgb-7.8* Hct-23.3*
MCV-107* MCH-34.4* MCHC-32.1 RDW-15.4 Plt Ct-174
[**2177-6-28**] 04:08AM BLOOD WBC-8.9 RBC-2.35* Hgb-8.0* Hct-23.8*
MCV-101* MCH-34.0* MCHC-33.6 RDW-16.8* Plt Ct-134*
[**2177-6-30**] 05:35AM BLOOD WBC-13.4* RBC-2.49* Hgb-8.4* Hct-25.1*
MCV-101* MCH-33.7* MCHC-33.3 RDW-17.0* Plt Ct-111*
[**2177-7-1**] 05:29AM BLOOD WBC-17.4* RBC-2.40* Hgb-8.4* Hct-25.1*
MCV-105* MCH-34.9* MCHC-33.4 RDW-16.5* Plt Ct-95*
[**2177-7-2**] 05:45AM BLOOD WBC-21.6* RBC-2.35* Hgb-8.0* Hct-24.7*
MCV-105* MCH-34.1* MCHC-32.5 RDW-16.5* Plt Ct-93*
[**2177-6-23**] 08:50PM BLOOD Neuts-3* Bands-3 Lymphs-88* Monos-1*
Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2177-6-25**] 05:20AM BLOOD Neuts-9* Bands-4 Lymphs-79* Monos-3 Eos-0
Baso-0 Atyps-3* Metas-2* Myelos-0
[**2177-6-27**] 03:00AM BLOOD Neuts-5* Bands-0 Lymphs-92* Monos-1*
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2177-6-24**] 07:50AM BLOOD PT-13.0 PTT-25.4 INR(PT)-1.1
[**2177-6-24**] 07:50AM BLOOD Gran Ct-1020*
[**2177-6-27**] 03:00AM BLOOD Gran Ct-520*
[**2177-6-28**] 04:08AM BLOOD Gran Ct-780*
[**2177-6-30**] 05:35AM BLOOD Gran Ct-970*
[**2177-6-23**] 08:50PM BLOOD Glucose-164* UreaN-18 Creat-1.0 Na-137
K-4.3 Cl-102 HCO3-26 AnGap-13
[**2177-6-24**] 01:23PM BLOOD Glucose-110* UreaN-22* Creat-1.0 Na-142
K-4.6 Cl-108 HCO3-24 AnGap-15
[**2177-6-27**] 03:00AM BLOOD Glucose-94 UreaN-24* Creat-1.0 Na-139
K-3.4 Cl-112* HCO3-21* AnGap-9
[**2177-6-29**] 05:23AM BLOOD Glucose-119* UreaN-20 Creat-0.9 Na-144
K-3.3 Cl-112* HCO3-26 AnGap-9
[**2177-7-1**] 05:29AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-146*
K-4.2 Cl-112* HCO3-29 AnGap-9
[**2177-6-24**] 01:23PM BLOOD ALT-8 AST-12 CK(CPK)-39 AlkPhos-66
TotBili-1.9*
[**2177-6-24**] 01:23PM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-6-24**] 07:50AM BLOOD calTIBC-282 Ferritn-562* TRF-217
[**2177-6-27**] 03:00AM BLOOD Hapto-174
[**2177-6-27**] 03:00AM BLOOD Cortsol-14.6
[**2177-6-24**] 12:37PM BLOOD Type-ART pO2-62* pCO2-34* pH-7.43
calTCO2-23 Base XS-0
[**2177-6-23**] 08:56PM BLOOD Lactate-2.0
[**2177-6-24**] 12:37PM BLOOD Lactate-3.5*
[**2177-6-24**] 08:44PM BLOOD Lactate-1.5
Brief Hospital Course:
89 yoM w/ a h/o CLL s/p multiple treatments, h/o
hypogammaglobulinemia (intermittently treated with IVIG), CAD
who p/w febrile neutropenia attributed to presumed aspiration
pna, admitted to the MICU for hypotension, now on broad spectrum
antibiotics without clear source of infection.
.
# febrile neutropenia: neutropenic and febrile on admission.
Possible sources include aspiration pneumonia, bacteremia
(unknown if completed course for strep viridans), C diff (given
diarrhea post clindamycin), skin(given small decub), SBE, UTI,
CNS infection. Pulmonary source seems most likely given cough
although no culture data guiding treatment currently. C diff
negative x 3. Decub only small so unlikely source. Urine
negative. SBE unlikely w/ negative blood cultures and no
stigmata of endocarditis. Vanco d/c'ed [**6-27**]. No evidence to
support CNS infection. Neutropenia resolved with Filgastrim
treatment and Filgastrim d/c'ed. Patient received a dose of IVIG
per Heme/Onc recs. Afebrile on broad spectrum antibiotics.
Patient completed a 10 day course of cefepime/flagyl and was
changed to cefpodoxime and flagyl oral at the time of discharge
to complete 4 more days. As described elsewhere, it was decided
by the patient and family that he would go to rehab with an
eventual goal of going home with hospice once services were in
place. He was continued on Acyclovir until discharge and was
then discontinued to minimize po medications.
.
# hypotension: presumed secondary to sepsis in the setting of
aspiration pna. Briefly required pressors in MICU but
stabilized on broad spectrum antibiotics and was weaned off. AM
cortisol normal. BPs otherwise remained normal for the
remainder of admission.
.
# CLL: s/p multiple treatment regimens. Near neutropenic at
baseline and was neutropenic on admission. Patient had a h/o
hypogammaglobulinemia, intermittently treated with IVIG. As
above, he was treated with IVIG and Filgastrim. Per Heme Onc
there were no other treatments available for his CLL.
.
# h/o aspiration: failed speech and swallow last admission but
refused PEG placement. He had a Doboff placed in the ICU and
received tube feeds. However, after discussions with the family
it was clear that the patient wanted to leave the hospital with
a focus more on comfort measures. He continued to refuse a PEG
tube. It was decided that patient would be discharged to rehab
with a goal of going home with hospice. Therefore, the Doboff
was removed for patient comfort and a a soft solid, thickened
liquid diet was started to allow feeding for comfort and patient
happiness.
.
# RUE swelling: unclear cause. Per family, fell and hit that
arm. Possibly secondary to trauma with fall. U/S and XR
unrevealing. Improved during course of admission.
.
# agitation: agitation in ICU requiring restraints. Per family,
patient has a history of sundowning. Seroquel started.
Alprazolam weaned down. However, once goals of care were focused
more on comfort, family requested increasing patient's Xanax
which was done. He was continued on Seroquel and Zyprexa to
help aid with continued evening agitation throughout admission.
.
# CAD: No active issues. Continued on his aspirin and beta
blocker throughout and remained asymptomatic.
.
# anemia: baseline Hct high 20s to low 30s. Transfused 1 unit
PRBCs for Hct 21 with appropriate resonse while in the ICU. His
hematocrit then remained stable.
.
# thrombocytopenia: patient initially had significant drop in
his platelets soon after admission. However, did not become
thrombocytopenic until more than a week after admission.
However, given concern for potential HIT, all heparin products
were stopped and a HIT antibody was sent but was pending at the
time of discharge. His platelets were 97 at discharge which is
stable.
.
# FEN: tubefeeds via Doboff then discontinued and restarted on
soft solid, thickened liquids for comfort.
.
# PPx: heparin sc until platelets dropped. Heparin d/c'ed and
pneumoboots placed.
.
# CODE: DNR/DNI, do not transfer to ICU, No central lines, no
pressors following meeting with healthcare proxy on [**2177-6-30**].
PLAN FOR COMFORT MEASURES WITHOUT REHOSPITALIZATION.
Medications on Admission:
Aspirin 81 mg Daily
Acyclovir 400 mg Q8H
Finasteride 5 mg DAILY
Folic Acid 1 mg DAILY
Benzonatate 100 mg TID prn
Alprazolam 0.25 mg TID as needed for anxiety.
Albuterol Sulfate 0.083 % Q 8H
Ipratropium Bromide 0.02 % Solution Sig: One Q8H
Clindamycin HCl 150 mg Q6H for 7 days.
Fluconazole 100 mg Q24H for 14 days.
Aranesp
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times
a day.
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution Sig:
Two Hundred (200) mg PO twice a day for 4 days.
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. aspiration pneumonia
2. neutropenia
Secondary:
1. CLL
2. CAD
3. Anemia
4. Dementia
5. anxiety
Discharge Condition:
Stable O2 sats on room air. Vitals stable. Aspirating on
minimal soft solids and thickened liquids. Agitated at times at
night improved with Zyprexa.
Discharge Instructions:
Please continue to take all medications as prescribed. Please
note that your Acyclovir, folic acid, fluconazole, and aranesp
have been discontinued. You have been started on Quetiapine and
you have been given Olanzapine to be used as needed for
agitation. You should also continue taking oral antibiotics for
the next 4 days.
Please continue to work with rehabilitation until you are ready
to return home.
Followup Instructions:
Please follow up with your Primary Physicians as needed.
Completed by:[**2177-7-3**]
|
[
"300.00",
"V45.82",
"787.2",
"995.92",
"272.4",
"008.45",
"507.0",
"276.51",
"204.10",
"038.9",
"799.02",
"284.1",
"112.0",
"276.0",
"294.8",
"424.0",
"785.52",
"518.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"38.93",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14069, 14163
|
8611, 12770
|
267, 301
|
14314, 14467
|
5117, 8588
|
14923, 15010
|
4434, 4452
|
13144, 14046
|
14184, 14293
|
12796, 13121
|
14491, 14900
|
4467, 5098
|
215, 229
|
329, 3506
|
3528, 4331
|
4347, 4418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,071
| 167,953
|
46267
|
Discharge summary
|
report
|
Admission Date: [**2127-4-4**] Discharge Date:
Service:
AGE: 84.
DATE OF DISCHARGE: [**Hospital **] rehabilitation bed.
CHIEF COMPLAINT: Lung nodule.
HISTORY OF THE PRESENT ILLNESS: The patient is an
84-year-old male with a history of CAD, CRI, diabetes
mellitus type 2, who was admitted to the Medical Service on
[**2127-4-4**] for rule out PB protocol. He had a known right
superior segment lower lobe lung nodule, which had been seen
on several chest x-rays and CT scans. He was admitted to GMH
on [**2127-4-4**], post admission to [**Hospital1 188**] for CHF exacerbation. He was transferred back to the
[**Hospital1 69**] because of concerns of
TB were raised. He was admitted to the Medical Service for
rule out TB. All tests here were negative and the rule out
was completed on [**2127-4-14**]. He was transferred to the
Surgical Service on [**2127-4-15**] status post mediastinoscopy with
VATS, right wedge resection, right superior segment right
lower lobe.
PAST MEDICAL HISTORY:
1. CHF.
2. CAD, status post CABG 2?????? years ago, with an ejection
fraction of greater than 55% and a diastolic dysfunction.
3. CRI baseline creatinine 2 to 2.5.
4. CVA one year ago.
5. Type 2 diabetes mellitus, noninsulin dependent.
6. Hypertension.
7. Hypercholesterolemia.
8. Gout.
9. Nephrolithiasis.
MEDICATIONS AT HOME:
1. Aspirin.
2. Plavix.
3. Lopressor.
4. Lipitor.
5. Neurontin.
6. NPH 22 AM and 40 PM.
7. Aricept.
8. Primidone.
9. Bumex.
ALLERGIES: Allergies are unknown.
HOSPITAL COURSE: The patient was admitted to the ICU for
postoperative monitoring after undergoing mediastinoscopy
with VATS, right wedge resection with right superior segment
right lower lobe. He was stable overnight. On postoperative
day #1, chest tube was discontinued. He was weaned off his
nitroglycerin drip and by the evening of [**2127-4-16**] he was
ready for transfer to the regular floor. He has been stable
here today on [**2127-4-17**]. He is ambulating. Pain is under
good control with oral analgesics. He is ready for discharge
to a rehabilitation facility when a bed is available.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg b.i.d.
2. Protonix 40 mg q.d.
3. Heparin 5000 units subcutaneously b.i.d..
4. Primidone 50 mg q.h.s.
5. Donepezil 5 mg q.h.s.
6. Neurontin 200 mg b.i.d.
7. Lipitor 10 mg q.h.s.
8. Bumex 1 mg q.d.
9. Colace 100 mg b.i.d.
10. Senna one p.o.q.d.
11. Tylenol 650 mg q.4h. to 6h.p.r.n.
12. Percocet one to tablets 4h. to 6h.p.r.n.
13. NPH insulin 22 units in the AM and 14 units in the PM;
regular insulin sliding scale.
FOLLOW-UP CARE: The patient is to followup with Dr. [**Last Name (STitle) 175**]
in one to two weeks.
CONDITION ON DISCHARGE: Stable.
The patient was discharged to a rehabilitation facility.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2127-4-17**] 16:10
T: [**2127-4-17**] 16:20
JOB#: [**Job Number 47261**]
|
[
"593.9",
"250.00",
"515",
"162.5",
"428.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.22",
"32.29"
] |
icd9pcs
|
[
[
[]
]
] |
2152, 2703
|
1538, 2126
|
1351, 1520
|
152, 991
|
1013, 1330
|
2728, 3075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,638
| 114,606
|
52689
|
Discharge summary
|
report
|
Admission Date: [**2153-7-26**] Discharge Date: [**2153-8-1**]
Date of Birth: [**2073-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
CHEST PAIN
Major Surgical or Invasive Procedure:
CABG x5 (Lima->Lad, SVG->OM1&2/RCA/PLV)
History of Present Illness:
80yo M with history of DMII now with exertional CP and positive
stress test referred for outpt. stress test.
Past Medical History:
HTN
Hyperlipidemia
DMII
h/o increased LFTs
HOH
Social History:
quit tobacco 30-40yo
ETOH:2-3 beers/day
retired [**Hospital1 **] carpenter
Family History:
denies CAD
Physical Exam:
ADMISSION PE:
VSS: 5'7", 183Lbs, RR-18,P-78,142/80
General: NAD
HEENT: WNL
Lungs: CTA (B)
CVS: RRR
ABD: soft/NT/ND + BS
EXT: warm, N0 C/C/E
Pertinent Results:
[**2153-7-31**] 06:35AM BLOOD WBC-8.6 RBC-3.25* Hgb-10.4* Hct-29.4*
MCV-90 MCH-31.9 MCHC-35.2* RDW-15.1 Plt Ct-190#
[**2153-7-26**] 12:30PM BLOOD WBC-4.1 RBC-3.32* Hgb-10.8* Hct-30.4*
MCV-92 MCH-32.4* MCHC-35.4* RDW-14.8 Plt Ct-137*
[**2153-7-28**] 03:40AM BLOOD PT-15.4* PTT-36.9* INR(PT)-1.4*
[**2153-7-26**] 12:30PM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.3*
[**2153-7-31**] 06:35AM BLOOD Glucose-110* UreaN-18 Creat-0.7 Na-140
K-3.5 Cl-103 HCO3-28 AnGap-13
[**2153-7-26**] 12:30PM BLOOD Glucose-136* UreaN-17 Creat-0.6 Na-139
K-4.0 Cl-107 HCO3-23 AnGap-13
[**2153-7-26**] 12:30PM BLOOD ALT-38 AST-49* CK(CPK)-59 AlkPhos-131*
Amylase-11 TotBili-0.9 DirBili-0.3 IndBili-0.6
[**Known lastname **] [**Known lastname 108702**],[**Known firstname **] [**Medical Record Number 108703**] M 80 [**2073-7-16**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2153-7-29**]
10:14 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2153-7-29**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 108704**]
Reason: s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with
REASON FOR THIS EXAMINATION:
s/p ct d/c
Final Report
HISTORY: Status post DC of chest tube.
CHEST, SINGLE AP VIEW.
Compared with [**2153-7-27**], multiple lines and tubes have been
removed, including a
left-sided chest tube. Still seen is a right IJ sheath tip over
proximal SVC.
The patient is status post sternotomy, with enlarged
cardiomediastinal
silhouette, which is stable. There is patchy opacity in the left
perihilar
region and left base, improved compared with [**2153-7-27**]. Minimal
atelectasis or
scarring is present at the right base.
No pneumothorax is identified. However, subtle pneumothorax
might be obscured
on this view due to the overlying first rib.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: SUN [**2153-7-29**] 2:41 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] [**Known lastname 108702**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 108705**] (Complete)
Done [**2153-7-27**] at 11:22:32 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2073-7-16**]
Age (years): 80 M Hgt (in): 67
BP (mm Hg): 130/70 Wgt (lb): 180
HR (bpm): 60 BSA (m2): 1.94 m2
Indication: Coronary artery bypass grafting
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2153-7-27**] at 11:22 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
Poor Transgastric windows
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
No LV aneurysm. Moderate regional LV systolic dysfunction. No LV
mass/thrombus. Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in ascending aorta. Normal aortic arch diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. No MS. Physiologic MR
(within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. No left ventricular
aneurysm is seen. There is moderate regional left ventricular
systolic dysfunction with moderate hypokinesis mid and distal
segments of anteriior, anteroseptal and lateral walls.. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is moderately depressed (LVEF=30
%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Physiologic mitral
regurgitation is seen (within normal limits).
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person of the results on [**Known firstname 449**] [**Last Name (NamePattern1) 108706**] at 8:30AM.
Post-Bypass:
Normal RV systolic function.
Overall LVEF 45%.
Thoracic aortic contour is intact.
Mild AI.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname **] is an 80yo M taken to the Operating room on
[**2153-7-27**] with Dr.[**Last Name (STitle) 914**] and underwent a CABGx 5 with Lima
grafted to the LAD, SVG to the Diag1/2, OM, and PLV. BPT=116
min, XCT=96min. Please refer to Dr[**Last Name (STitle) 5305**] Operative report
for further details. He was transferred to the CVICU intubated,
requiring low dose levophed. Otolaryngology was consulted
postoperatively for bleeding from the oropharynx.
Reccommendations were followed/appreciated, and Mr.[**Known lastname **] [**Known lastname **] was
placed on Bactraban and nasal spray. He was extubated and weaned
off drips in a timely fashion. On POD #2 he remained in the
CVICU due to pleasant confusion and the need for close neuro
assesment. On POD#3 he was transferred to the floor, tubes and
lines were dc'd, beta-blockade and an ACE-I was instituted as
soon as BP allowed. The remainder of his postoperative course
was essentially uneventful with mental confusion improved with
low dose haldol. He was ready for discharge on POD#5 to rehab.
Medications on Admission:
Toprol XL 25(1)
Lisinopril 10(1)
Metformin 1000(2)
Glipizide 10(1)
Lipitor 20(1)
ASA 325(1)
NTG sl prn
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: wean over a week .
Disp:*14 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
12. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
s/p CABG x5
HTN
DM
Dyslipidemia
HOH
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. [**Last Name (STitle) 171**] (cardiology) in 2 weeks ([**Telephone/Fax (1) 9410**] please call
for an appointment.
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (NamePattern4) 108707**] (PCP) in 2 weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2153-8-1**]
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28,161
| 169,787
|
33517
|
Discharge summary
|
report
|
Admission Date: [**2179-3-30**] Discharge Date: [**2179-4-24**]
Date of Birth: [**2136-6-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Alcoholic hepatitis, mental status change, GIB
Major Surgical or Invasive Procedure:
Intubation
EGD
History of Present Illness:
42 yo M w/[**Hospital **] transferred from [**Hospital 48910**] Hospital on [**3-30**]. Pt's MS
was altered at presentation, so his medical history is unclear
and may include cirrhosis and hepatorenal syndrome, as well as
ETOH abuse. Per report, his brother was [**Name (NI) 653**] the first
night and stated that diarrhea was the pt's chief complaint and
[**First Name8 (NamePattern2) **] [**Last Name (un) 48910**] records the pt was noted to have liquid red stools.
At [**Last Name (un) 48910**] he was given 1 uPRBC and FFP, protonix and had a hct
24. He was transferred here b/c they had no ICU beds.
.
Per notes, in the [**Hospital1 **] ED, the patient was unable to give much
history due to MS changes. This was thought to be [**2-27**] to
encephalopathy and he was given PO lactulose. Initially his SBP
was 114 and then 92. An NGT was placed and bilious material was
lavaged. Per liver recs the patient was given 1 gm ceftriaxone,
and started on an octrotide gtt.
Past Medical History:
unknown
Social History:
Lives with his mother, has one brother who was also a heavy
drinker and died during patients current hospitalization due to
his alcoholic liver disease. Patient has a 20 year history of
drinking.
Family History:
NC
Physical Exam:
PE: T 99.4 BP 108/68 HR 88 RR 24 o2 93/4L
General: jaundiced male, not oriented, in NAD
HEENT: COP, NG tube in place
Heart: tachycardic, no m/r/g/
Lungs: decreased BS at bases,
Abdomen: distended, nt, tympanic
Extremities: RUE 2+ edema, LE 1+ equal
Pertinent Results:
Pertinent lab results:
[**2179-3-30**] 10:09PM BLOOD WBC-11.3* RBC-2.48* Hgb-9.0* Hct-27.7*
MCV-112* MCH-36.3* MCHC-32.5 RDW-23.5* Plt Ct-117*
[**2179-4-23**] 05:20AM BLOOD WBC-6.3 RBC-2.52* Hgb-9.0* Hct-27.6*
MCV-110* MCH-35.8* MCHC-32.7 RDW-18.6* Plt Ct-405
[**2179-3-30**] 10:09PM BLOOD Neuts-71.3* Lymphs-23.0 Monos-4.3 Eos-1.2
Baso-0.2
[**2179-4-12**] 04:11AM BLOOD Neuts-71.5* Lymphs-17.5* Monos-7.1
Eos-3.4 Baso-0.5
[**2179-3-30**] 10:09PM BLOOD PT-18.9* PTT-38.9* INR(PT)-1.7*
[**2179-4-22**] 06:10AM BLOOD PT-15.2* PTT-33.3 INR(PT)-1.3*
[**2179-3-30**] 10:09PM BLOOD Glucose-92 UreaN-29* Creat-2.8* Na-131*
K-4.6 Cl-100 HCO3-18* AnGap-18
[**2179-4-23**] 05:20AM BLOOD Glucose-93 UreaN-3* Creat-0.6 Na-136
K-4.1 Cl-107 HCO3-21* AnGap-12
[**2179-3-30**] 10:09PM BLOOD ALT-137* AST-146* AlkPhos-264*
TotBili-7.5*
[**2179-4-22**] 06:10AM BLOOD ALT-57* AST-89* LD(LDH)-376* AlkPhos-118*
TotBili-2.1*
[**2179-4-1**] 03:19AM BLOOD Lipase-122*
[**2179-4-2**] 06:20AM BLOOD Lipase-80*
[**2179-4-10**] 06:27PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-3-30**] 10:09PM BLOOD Albumin-1.8* Calcium-7.4* Phos-4.7*
Mg-2.2
[**2179-4-23**] 05:20AM BLOOD Albumin-2.6* Calcium-8.6 Phos-2.8 Mg-1.7
[**2179-4-3**] 06:10AM BLOOD Hapto-42
[**2179-4-8**] 04:29AM BLOOD Triglyc-188*
[**2179-4-12**] 04:11AM BLOOD Triglyc-125
[**2179-3-31**] 04:14AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2179-3-30**] 10:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12.6
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-3-31**] 04:14AM BLOOD HCV Ab-NEGATIVE
[**2179-4-2**] 10:14AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test Name
[**2179-4-2**] 10:14AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
[**2179-4-2**] 10:14AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Yhsv
Brief Hospital Course:
In the MICU, the patient had an NG lavage, which was clear. He
had an EGD on [**2179-3-31**] and was found to have 3 non-bleeding ulcers
in the first part of the duodenum (one of which was thought to
have recently bled and was clipped), [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear and
portal hypertensive gastropathy. His octreotide gtt was stopped
and he was continued on a protonix gtt. Diagnostic paracentesis
was negative. While in the ICU he received 2 units of PRBCs and
his hct has been stable for the last two days. He did receive
valium yesterday for alcohol withdrawal.
Then patient was transferred to the floor:
His course was unremarkable on the floor until the morning of
[**2179-4-7**] when he triggered for low urine output (143cc over 4
hours). The patient was noted to be tachypneic to the 40s and
had a new oxygen requirement 91% on 4L NC (whereas before he had
been 100% on RA). He received a bolus of 500cc of NS, followed
by another 250cc. UOP showed marginal improvement. He received
20mg IV lasix X 2. He also received nebulizers. CXR showed RML
and RLL collapse which was unchanged since [**4-5**]. However there
was left lower lobe collapse and left pleural effusion which was
new. By 6:30 AM UOP had improved to 175 cc/night. The patient
again triggered at 1:15pm. He was tachypneic to 24-30 and O2
sats were 94 - 95 % on NRB. His abdomen was noted to be
distended. He also had hypoactive bowel sounds. Abdominal
ultrasound showed bowel dilatation. An NGT was placed and the
patient felt better. A considerable amount of bilious material
was drained immediately. However he continues to be tachycardic
to the 110s. His O2 sat was 89% on RA, thus requiring the NRB.
Given the dilated loops of bowel, the patient was started on
empiric coverage with cipro and flagyll, and transferred to
MICU:
In the MICU he was intubated for respiratory distress and
treated with vanc/zosyn for presumed PNA although there was
never any growth from sputum culture other than oropharygngeal
flora. The completed a 10 day course of zosyn. He continued to
have an 02 requirement after transfered back to the floor. He
underwent an uncomplicanted therapeutic paracentesis with
removal of 2L for ascites, his diuretics were also increased.
Both acted to decrease pulmonary edema and increase his baseline
low lunch volumes. The patient was gradually weaned off 02
until he was able to ambulate independently in the [**Doctor Last Name **].
He was discharged home after being cleared by PT with liver
transplant follow up for ongoing monitoring. He will have his
kidney funtion and electrolye followed there for now as he has
no insurance or PCP and he has been started in many new
medications, including diuretics.
On day of discharge pt was able to ambulate and complete ADLs
independently. He was pain free with stable vital signs, off
supplemental 02. Hematocrit stable with no further evidence of
bleed. He will complete a 2 week course for treatment of
presumed h. pylori infection in the setting of symptoms and
presence of duodenal ulcer without history of NSAID use.
Medications on Admission:
none
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*2 inhalers* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours
for 14 days.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): hold for >4 bowel movements per day.
Disp:*2700 ML(s)* Refills:*2*
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
12. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Once daily dosing
should be started after completing 2 weeks of twice a day
dosing.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed, duodenal ulcer
Pneumonia
Cirrhosis
Discharge Condition:
Good, off 02, ambulating independently.
Discharge Instructions:
You were admitted with an upper GI bleed, you were found to have
an ulcer in your stomach. You should complete the 2 week course
of protonix and antibiotics you have been prescribed for
treatment of this. While you were hospitalized you developed
respiratory stress due to a pneumonia which was treated with a
course of antibiotics.
Because of your underlying severe liver disease it is very
important that you continue to get enough nutrition. Please
adhere to the prescribed diet to ensure you are taking in enough
protein and calories.
You have been started on several new medications for your reflux
disease/ulcer as well as for your liver disease. You will need
to follow up closely either with a new PCP or your liver doctors
here at [**Name5 (PTitle) 18**] to have your labs monitored while on these new
medications.
Please take all medications as prescribed. Please attend the
recommended follow up appointments.
Call your doctor or return to the emergency room if you
experience fevers or chills, worsening shortness of breath,
abdominal pain or confusion of for any other concerning
symptoms.
You will need to call Pharmacare (number on your prescriptions)
and give them your address and they can mail you refills of your
protonix and lactulose.
Followup Instructions:
You have an appointment with Dr. [**Name (NI) **] at the Liver Center
on [**2179-4-30**] at 10am. Please call [**Telephone/Fax (1) 673**] with questions of
if you need to reschedule.
Please schedule a visit with a new primary care provider as soon
as possible, ideally within the next 2 weeks.
|
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"33.23",
"99.04",
"54.91",
"96.6",
"38.93",
"96.72",
"96.04",
"99.15",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8586, 8592
|
3706, 6851
|
363, 380
|
8687, 8729
|
1931, 3683
|
10035, 10334
|
1642, 1646
|
6906, 8563
|
8613, 8666
|
6877, 6883
|
8753, 10012
|
1661, 1912
|
277, 325
|
408, 1382
|
1404, 1413
|
1429, 1626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
236
| 151,459
|
25207
|
Discharge summary
|
report
|
Admission Date: [**2134-10-4**] Discharge Date: [**2134-10-15**]
Date of Birth: [**2081-12-5**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Admitted for orthotopic liver transplant secondary to Hep C
Cirrhosis with HCC treated in past with RF ablation.
Major Surgical or Invasive Procedure:
OLT [**2134-10-4**]
Takeback for biliary leak requiring biliary reconstruction with
Roux-en-Y hepaticojejunostomy
History of Present Illness:
Admitted for OLT in the setting of Hep C, HCC with RFA in [**4-5**].
Feeling well recently. MELD score 25 for HCC exception
Past Medical History:
Hep C positive (Bx proven 4 years ago)
HCC with RFA in [**4-5**] for lesions in segment V and VIII
DVT
cryoglobulinemia
kidney stones
depression
lumbar spine laminectomy
Left partial orchiectomy
Social History:
Lives with wife and 1 son in single family home
smokes cigarettes
No ETOH since [**2128**]
Remote Hx IV heroin use
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: 97.4, 74, 127/81, 20, 100% RA
Gen: In NAD
Lungs: CTA Bilaterally
Card: RRR, S1, S2, no M/R/G
Abd: Soft, NT, minimally distended, hepatomegaly with palpable
liver
Extr: warm, 2 + pulses bilaterally
Pertinent Results:
On Admission:
[**2134-10-4**] 02:10AM GLUCOSE-92 UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2134-10-4**] 02:10AM ALT(SGPT)-28 AST(SGOT)-42* ALK PHOS-150* TOT
BILI-0.6
[**2134-10-4**] 02:10AM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-1.9
[**2134-10-4**] 02:10AM WBC-4.9 RBC-3.82* HGB-11.8* HCT-34.0* MCV-89
MCH-30.9 MCHC-34.8 RDW-18.8*
[**2134-10-4**] 02:10AM PLT COUNT-91*
[**2134-10-4**] 02:10AM PT-13.0 PTT-30.5 INR(PT)-1.1
[**2134-10-4**] 02:10AM FIBRINOGE-187
[**2134-10-4**] 01:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2134-10-4**] 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
Brief Hospital Course:
Patient admitted for OLT from brain dead donor.
Surgical procedure: Deceased donor liver transplant with
piggyback
portal vein-to-portal vein anastomosis, celiac axis to
gastroduodenal artery, common hepatic artery branch patch,and
common bile duct-to-common bile duct anastomosis. Patient was
stable and transferred, extubated to SICU.
On the morning of postoperative day 1, his drain began putting
out approximately 50 cc per hour of bile. Patient returned to
the OR on POD 1 for surgical correction of a biliary leak with
biliary reconstruction with Roux-en-Y hepaticojejunostomy.
Patient was stable post surgery and returned to the SICU. Liver
U/S done on POD 1 showing Liver transplant with patent vessels,
no biliary dilatation or intrahepatic collections, a very small
subhepatic fluid collection, and a small right pleural effusion.
Patient was started on a solumedrol taper.
POD2: Patient extubated. Prograf started and diuresis performed.
On POD3 patient transferred out of SICU to transplant surgery
floor. Cellcept was started.
On POD4 ([**2134-10-8**]), Physical exam suggested patient had a swollen
right arm. Duplex Doppler showed no evidence of DVT within the
right upper extremity.
[**2134-10-9**]: LFTs rose and liver US was performed, demonstrating
increased velocity at distal main portal vein of uncertain
significance. Based on patient's lack of abdominal pain and no
new symptoms, conservative management was chosen. Solumedrol
taper completed; patient started on prednisone taper.
On [**10-11**], LFTs continued to rise. Roux study was performed and
demonstrated a widely
patent anastomosis. HIDA scan was performed, showing 1) Good
uptake, but very slow clearance of tracer by the liver;
concerning for impaired hepatic function. 2) Some activity in a
tubular structure consistent with jejunum. 3) Two foci of
tracer collection inferior to the left lobe of the liver in the
region of an indwelling drain, which could represent a leak.
Delayed images recommended to further assess the possibility of
leak. US was done to mark liver for biopsy location. Patient
was given pre-procedure Zosyn.
On [**10-12**], cholangiogram through existing PTC showed no biliary
leak and no portal vein stenosis, and no portal vein pressure
gradient was observed. Liver biopsy was performed and was
indeterminate for acute rejection but showed no evidence of
acute biliary tract obstruction. Patient was given mucomyst and
bicarb prior to procedures.
On [**10-13**] LFTs began down-trending and continued to do so until
discharge. On day of discharge, patient was ambulating, eating
a regular diet, having regular bowel movements. His pain was
well-controlled, and all JP drains had been d/c'd.
Blood sugars will continue to be monitored at home, teaching
done, this will be followed in clinic.
Medications on Admission:
Nexium 40', Lactulose 30 cc's b.i.d.,
Aldactone 150', Lasix 40', quinine 325 hs
Cipro 750 mg once a week, Nadolol 20' FeSO4 325', folic acid 1
mg'
Discharge Medications:
1. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Ten (10)
ML PO DAILY (Daily).
Disp:*qs ML(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO ONCE (Once).
Disp:*60 Capsule(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take as long as you are taking narcotics. [**Month (only) 116**] continue as
needed.
Disp:*60 Capsule(s)* Refills:*2*
8. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Taper prednisone per Transplant recommendations.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
Taper dose as pain level improves.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day:
MD will review continued use at transplant office visit.
Disp:*30 Tablet(s)* Refills:*0*
11. one touch test strips
Dispense 2 bottles
Refills 5
12. Lancets
Dispense 2 bottles
Refills 5
Discharge Disposition:
Home With Service
Facility:
vna of R.I.
Discharge Diagnosis:
s/p liver transplant [**2134-10-4**] for HCC
Takeback for biliary leak requiring biliary reconstruction with
Roux-en-Y hepaticojejunostomy [**2134-10-5**]
Discharge Condition:
Stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if you experience any of the following
symptoms: fever,chills, nausea, vomiting, diarrhea or inability
to eat.
Also report pain over the incision site or liver, jaundice, an
increase in abdominal girth or any other symptoms concerning to
you.
Monitor incision site for redness or drainage and report to
Transplant office.
Have labs drawn every Monday and Thursday and have them faxed to
Transplant office at [**Telephone/Fax (1) 697**].
CBC, Chem 10, AST,ALT, Alk Phos, Albumin, T Bili and trough
Prograf Level
Do not drive if you are taking narcotics.
Check Blood sugar 4 times daily for the first week and record.
Bring record to Transplant office visit
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2134-10-21**] 3:20
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2134-10-28**] 1:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2134-10-28**]
1:20
Completed by:[**2134-10-19**]
|
[
"273.2",
"155.2",
"070.70",
"V13.01",
"576.8",
"401.9",
"305.1",
"V12.51",
"570",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"88.64",
"00.93",
"50.59",
"87.54",
"51.37",
"38.93",
"99.05",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
6480, 6522
|
2058, 4875
|
393, 508
|
6722, 6731
|
1296, 1296
|
7469, 7901
|
1028, 1046
|
5072, 6457
|
6543, 6701
|
4901, 5049
|
6755, 7446
|
1061, 1061
|
241, 355
|
536, 661
|
1311, 2035
|
683, 880
|
896, 1012
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,129
| 118,393
|
49652
|
Discharge summary
|
report
|
Admission Date: [**2173-6-30**] Discharge Date: [**2173-7-6**]
Service: Medicine
CHIEF COMPLAINT: Chief complaint was increased swelling,
change in mental status, and acute renal failure.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
woman with congestive heart failure with an ejection fraction
of 20%, atrial fibrillation, and anasarca who presented with
acute renal failure, mental status changes, and swelling in
the extremities.
The patient is on a chronic diuresis for her anasarca. On
[**2173-6-21**], her creatinine was noted to be 1.7 and had
progressively increased to 4 on [**2173-6-30**]. During this
period, the patient did not have a Foley catheter in place,
raising the possibility of urinary retention. The change in
mental status was reported by her primary care physician
(Dr. [**Last Name (STitle) **], but when the patient herself denied feeling
confused. The patient denied chest pain. The patient admits
to shortness of breath which was no different from her
baseline. She normally sits upright in bed at all times,
even at night when she sleeps. The patient denies fever,
cough, chills, nausea, vomiting, diarrhea, dysuria, or
abdominal pain.
PAST MEDICAL HISTORY:
1. Congestive heart failure with an ejection fraction
of 20%.
2. Atrial fibrillation.
3. Chronic hypotension.
4. Home oxygen of 2 liters via nasal cannula.
5. Status post left above-knee amputation for squamous cell
carcinoma.
6. Peripheral vascular disease.
7. Status post hemicolectomy in [**2165**] secondary to bowel
strangulation.
8. Guaiac-positive in [**2168**].
9. Venous stasis disease.
10. Hypothyroidism.
11. Status post cholecystectomy in [**2154**].
12. Status post ventral hernia repair in [**2165**]
13. Chronic constipation.
14. Osteoarthritis.
15. History of cellulitis.
16. History of [**Last Name (un) **] syndrome.
MEDICATIONS ON ADMISSION: Medications included
Synthroid 25 mcg p.o. q.d., captopril 6.25 mg p.o. b.i.d.,
Lasix 120 mg p.o. q.d., enteric-coated aspirin 325 mg p.o.
q.d., Aldactone 50 mg p.o. b.i.d., lactulose 30 cc p.o. q.d.,
Senokot two tablets p.o. q.h.s., Miconazole powder topically
b.i.d., Protonix 40 mg p.o. q.d., Colace 100 mg p.o. b.i.d.,
K-Dur 20 mEq p.o. q.d.
ALLERGIES: Allergy to CIPROFLOXACIN, BIAXIN, ERYTHROMYCIN,
and DUODERM (reaction unknown).
SOCIAL HISTORY: The patient is retired. She has a daughter
in [**Name (NI) 86**]. Lived in [**Hospital3 2558**] for the last two weeks.
She denies tobacco or drinking alcohol.
FAMILY HISTORY: Family history is significant for coronary
artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, temperature was 96.3, pulse was 80, blood
pressure was 89/59, respiratory rate was 25, oxygen
saturation was 94% on 2 liters. In general, the patient was
an obese elderly Caucasian female in no acute distress;
slightly tachypneic. Head, eyes, ears, nose, and throat
revealed pupils were equal, round, and reactive to light.
The fundi were unremarkable. Mucous membranes were slightly
dry. The oropharynx was benign. The neck revealed no
cervical lymphadenopathy. Jugular venous distention about
12 cm. No thyromegaly. No carotid bruits bilaterally.
Heart was irregularly irregular rhythm. First heart sound
and second heart sound were normal. Distant heart sounds.
Lungs revealed bibasilar rales in the lower half of the
lungs. No wheezes or rhonchi. Gastrointestinal revealed
positive bowel sounds, soft, and obese. No masses.
Extremities revealed left above-knee amputation, 2+ edema
bilaterally in the lower extremities. The patient had a
3-cm X 3-cm ulcer on the anterior aspect of the distal right
lower extremity. There was also a 2-cm X 2-cm on the medial
aspect of the distal right lower extremity; this ulcer had a
clean base, not erythematous, with no discharge or pus. The
patient also had an ulcer on the left buttocks and the right
thigh. Neurologically, alert and oriented times three.
Cranial nerves II through XII were intact. No gross loss of
tactile sensation. Deep tendon reflexes were 2+ throughout.
Dermatologic examination revealed decreased skin turgor.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed a white blood cell count of 10.1, hematocrit
was 25.3, platelets were 100. Differential revealed
75 polys, 3 lymphocytes, and 10 bands. Sodium was 137,
potassium was 4.7, chloride was 95, bicarbonate was 33, blood
urea nitrogen was 56, creatinine was 4.1, blood glucose
was 124. Arterial blood gas revealed pH of 7.43, PCO2 of 59,
PO2 of 76. Urinalysis was negative except for large blood
and trace leukocyte. Microbiology urinalysis showed red
blood cells of greater than 50, white blood cells equaled 3.
Negative for eosinophils. Urine sodium was 57. Urine
creatinine was 72. FENa was approximately 2.2%.
RADIOLOGY/IMAGING: A chest x-ray showed increased density
in the left cardiac region; could represent atelectasis,
effusion, or pneumonia. There was increased pulmonary
bilaterally hilar opacity; represent pulmonary edema.
Electrocardiogram was unchanged from previous
electrocardiogram. There was atrial fibrillation with a
heart rate of 121 beats per minute, QRS interval of 164.
HOSPITAL COURSE: This is an 86-year-old female with a past
medical history of congestive heart failure with an ejection
fraction of 20%, atrial fibrillation, and anasarca who
presented with worsening congestive heart failure and acute
renal failure.
The most likely cause of her acute renal failure was prerenal
based on her physical examination and laboratories. Also,
secondary to over-aggressive diuresis with Lasix and
decompensated congestive heart failure. On the morning of
[**2173-7-2**] at 4 a.m., the patient had hypotension with a
blood pressure of 60/30 with decreased oxygen saturations to
below 70% on 7 liters. With mask oxygenation, the patient's
vital signs were back to normal range. Blood pressure was up
to 85/43 and oxygen saturation of 100%.
The patient went on to have a similar episode of hypotension.
At this time, the medical team agreed to send the patient to
Medical Intensive Care Unit for further evaluation.
In the Medical Intensive Care Unit, the patient was treated
with dobutamine, dopamine, an intravenous fluids; but the
patient showed little improvement in terms of oxygenation and
bilateral maintenance.
After a long discussion with the patient's primary care
doctor, and also her attending doctor, and the family members
including her daughters and grandsons we decided to send her
back to the floor for comfort measures on [**2173-7-4**].
It was a very difficult decision to make the patient do not
resuscitate/do not intubate with the primary goal of comfort,
but the family of the patient and the medical team also
agreed that this was the appropriate step to take.
When the patient was transferred back to the floor on
[**2173-7-4**], she was kept on comfort measures which
included only morphine intravenously and oxygenation through
nasal cannula to keep the patient comfortable. It was a very
difficult to make the patient do not resuscitate/do not
intubate the patient without monitoring except for morphine
and oxygenation.
The patient passed away two days later, on the morning of
[**2173-7-6**]. The family members and the attending were
notified at 2:30 a.m. Our grievance and sympathy go out to
the [**Known lastname **] family.
1. CARDIOVASCULAR: The patient had decompensated
congestive heart failure with an ejection fraction of 20%
with reduced forward flow and pulmonary edema as evidenced by
a chest x-ray and fistulogram.
On the second day of hospitalization, the patient developed a
dry cough but was afebrile. The cough was likely due to
pulmonary edema. Reduced afterload was limited due to a
history of hypotension. Anatrophic agents such as digoxin
did not help her in the past, according to her primary care
doctor. Diuresis is limited due to acute renal failure.
Therefore, very minimal intravenous fluids were used
throughout the hospital stay, and Lasix was withheld due to
the acute renal failure.
2. RENAL: The patient acute renal failure with a creatinine
of 4 and a fraction excretion of sodium of 2.2 which
suggested prerenal secondary to third space and possible
acute tubular necrosis in progression. The patient had
negative urinary eosinophils, which suggests that renal
interstitial disease was unlikely. The patient also had low
urine output on [**2173-7-1**] of around 15 cc per hour.
In the Medical Intensive Care Unit after the Medical
Intensive Care Unit admission, the patient was anuric. The
patient did not put out any urine.
When the patient came back to the floor on [**2173-7-4**],
transferred back from the Medical Intensive Care Unit, the
patient anuric. Because the patient was on comfort measures
only, no blood work or other monitoring was done.
3. PULMONARY: The patient had baseline shortness of breath.
Her shortness of breath progressively worsened throughout her
hospitalization. Although the patient was on high percentage
of oxygen nasal cannula (up to 10 liters), the patient's
oxygen saturation sometimes fell to the lower 70s. The most
likely cause of her low oxygen saturation was due to
worsening congestive heart failure.
4. INFECTIOUS DISEASE: The patient had a negative
urinalysis with no fever or symptoms of dysuria. Thus,
urinary tract infection was unlikely. The patient had a dry
cough which was most likely caused by pulmonary edema due to
worsening congestive heart failure.
5. HEMATOLOGY: The patient's hematocrit was in the low 20%;
however, this was her baseline. Transfusion was limited due
to the worsening congestive heart failure. Therefore, the
decision was to withhold blood transfusion in her case.
CONDITION AT DISCHARGE: The patient expired on [**2173-7-6**].
DIAGNOSES: The patient had worsening congestive heart
failure and worsening acute renal failure.
[**First Name11 (Name Pattern1) 8207**] [**Last Name (NamePattern4) 8208**], M.D.
[**MD Number(1) 8209**]
Dictated By:[**Name8 (MD) 38662**]
MEDQUIST36
D: [**2173-7-6**] 19:18
T: [**2173-7-10**] 05:28
JOB#: [**Job Number 103827**]
|
[
"443.9",
"428.0",
"682.6",
"427.31",
"584.9",
"244.9",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2549, 5240
|
1911, 2351
|
5258, 9827
|
9842, 10251
|
110, 201
|
230, 1201
|
1224, 1884
|
2368, 2531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,351
| 124,318
|
19075
|
Discharge summary
|
report
|
Admission Date: [**2170-7-17**] Discharge Date: [**2170-7-22**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman with a history of coronary artery disease, type 2
diabetes mellitus, and cryptogenic cirrhosis who was
transferred from [**Hospital6 33**] with a massive variceal
hemorrhage.
He presented on the day of admission ([**7-17**]) complaining of
two days of melena. No nausea, vomiting, or hematemesis.
The patient was hemodynamically stable on arrival to the
Emergency Department. Hematocrit was 25, and his INR was
1.3.
The patient was sent for esophagogastroduodenoscopy which
revealed grade IV varices with active bleeding at the
gastroesophageal junction in the mid/distal esophagus and
portal hypertensive gastropathy. Sclerate was injected into
the distal esophagus. As the scope was withdrawn, the
patient suffered massive hematemesis with a decreased blood
pressure to 60/40, heart rate was 60, and decreased oxygen
saturation to 84% on 6 liters. The patient was intubated, [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 406**] [**Last Name (NamePattern1) **] tube was inserted, and the patient was started on
dopamine. He was transfused 2 units of packed red blood
cells. Octreotide was started. The dopamine was weaned, and
the patient was transferred to [**Hospital1 188**] via medical flight.
On arrival, the patient's hematocrit was 38 status post 4
units of packed red blood cells. A chest x-ray on admission
demonstrated the [**First Name4 (NamePattern1) 406**] [**Last Name (NamePattern1) **] tube was coiled in the esophagus
with the gastric balloon inflated and a widened mediastinum.
The [**First Name4 (NamePattern1) 406**] [**Last Name (NamePattern1) **] tube was removed by the Liver Service. The
patient remained hemodynamically stable and was transferred
to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft times five.
2. Type 2 diabetes mellitus for 10 years.
3. Cryptogenic cirrhosis with ascites times one year.
4. History of varices (on propanolol).
5. No known prior bleeding history.
MEDICATIONS ON ADMISSION: The patient's medications on
admission included Lipitor, metformin, Actos, Glyburide,
Lasix, and Aldactone.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient had a rare history of alcohol
use. He has never smoked. He walks two miles per day.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient was an intubated, sedated,
obese, elderly gentleman. Vital signs revealed temperature
was 94.2, blood pressure was 106/54, heart rate was 69,
respiratory rate was 14, and oxygen saturation was 100% on
0.6 FIO2. His ventilator settings were AC 650 X 12/0.6/5.
Skin examination revealed anicteric. The extremities were
cool. Positive spider angiomata. Head, eyes, ears, nose,
and throat examination revealed normocephalic and atraumatic.
Opened eyes to voice. Pupils were equal, round, and reactive
to light. The neck was supple. No lymphadenopathy. No
jugular venous distention. The lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed normal first heart sounds and second heart sounds.
Regular rate and rhythm. A [**3-1**] harsh systolic murmur at the
right upper sternal border. The abdomen was obese, soft, and
nontender. Bowel sounds were present. No organomegaly
appreciated. Extremity examination revealed no edema. The
hands and feet were cool. Neurologic examination revealed
the patient was moving all extremities purposely. Responded
to simple questions.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
hematocrit on 11 a.m. at [**Hospital6 33**] was 24.9. At 7
p.m. at [**Hospital1 69**] his hematocrit
was 38.6. All other laboratories were normal. His arterial
blood gas was 7.35/30/226/265 in FIO2 60s, positive
end-airway pressure was 5, lactate 2.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray demonstrated the
[**First Name4 (NamePattern1) 406**] [**Last Name (NamePattern1) **] tube in the wrong position and a widened
mediastinum.
Electrocardiogram demonstrated a sinus rhythm at 68, primary
atrioventricular conduction delay (PRO 0.29). No ST-T wave
changes.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL BLEED ISSUES: The patient was
hemodynamically stable on admission but was continued with
intensive monitoring in the Medical Intensive Care Unit.
Serial hematocrit levels were drawn with a goal of keeping
his hematocrit above 30 given his history of coronary artery
disease. The patient was on a high dose of intravenous
Protonix and also was receiving octreotide at 50 mg per hour.
An esophagogastroduodenoscopy on [**7-19**] demonstrated grade
III varices in the middle third of the esophagus and lower
third of the esophagus. They were not actively bleeding.
Six bands were placed successfully. The
esophagogastroduodenoscopy also demonstrated a mosaic
appearance in the fundus which was compatible with portal
gastropathy. The patient received 1 unit of packed red blood
cells following his esophagogastroduodenoscopy. Twice per
day hematocrit levels continued to be checked, but the
patient did not require any further transfusions prior to
discharge. He was discharged on sucralfate, Nadolol,
Protonix, and lactulose. His octreotide was discontinued
prior to discharge.
The patient's stools continued to become progressively less
dark to the normal brown level. The patient was instructed
to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in the Liver Service
following discharge for a follow-up
esophagogastroduodenoscopy in two weeks.
2. CIRRHOSIS ISSUES: The patient came in with a diagnosis
of cryptogenic cirrhosis. Prior records of his liver disease
were not obtained. It was suspected that the patient has
non-alcoholic steatohepatitis given his history of diabetes.
The patient did not have any demonstrable ascites. The
patient was started on antibiotics for prophylaxis against
spontaneous bacterial peritonitis. He was given levofloxacin
500 mg once per day. As noted above, the patient was to
follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in the Liver Clinic for
continued management of his cirrhosis.
3. CORONARY ARTERY DISEASE ISSUES: The patient has an
extensive history of coronary artery disease, status post
coronary artery bypass graft. His cardiovascular medications
were held on admission. He did have some tachycardia, but
this was thought to be secondary to his hypotension at [**Hospital6 3622**], and this decreased during his admission. The
patient had evidence of conduction disease on his
electrocardiogram, and this was monitored. There was no
evidence of ischemia; although enzymes were cycled to rule
out myocardial infarction.
4. DIABETES ISSUES: The patient's oral hypoglycemics were
held on admission. He received a sliding-scale of insulin.
On discharge, he was started on his regular medications;
which were Glyburide, Actos, and metformin. The patient was
instructed to follow up with his primary care physician.
5. AIRWAY ISSUES: The patient was extubated prior to his
esophagogastroduodenoscopy and did not require oxygen.
6. CODE STATUS: The patient was full code.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good. He was not bleeding further. He did not require
further transfusions following the 1 unit after his
esophagogastroduodenoscopy.
MEDICATIONS ON DISCHARGE:
1. Metformin 500 mg by mouth four times per day.
2. Glyburide 5 mg by mouth four times per day.
3. Actos 30 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
5. Nadolol 20 mg by mouth once per day.
6. Pantoprazole 40 mg by mouth once per day.
7. Lactulose 30 by mouth twice per day.
8. Sucralfate 1 g by mouth every day.
9. Multivitamin one tablet by mouth once per day.
10. Simethicone 40 mg to 80 mg by mouth as needed (for gas).
11. Levaquin 500 mg by mouth q.24h. (times a 7-day course).
12. Lasix 20 mg by mouth once per day.
13. Aldactone 50 mg by mouth twice per day.
DISCHARGE DIAGNOSES:
1. Variceal bleed.
2. Cirrhosis.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 52071**]
MEDQUIST36
D: [**2170-8-16**] 13:40
T: [**2170-8-25**] 05:41
JOB#: [**Job Number 52072**]
|
[
"572.3",
"571.5",
"456.20",
"424.1",
"276.2",
"789.5",
"426.11",
"518.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
2484, 4359
|
8266, 8595
|
7632, 8245
|
2203, 2350
|
4393, 7413
|
7428, 7605
|
121, 1896
|
1918, 2176
|
2367, 2466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,047
| 162,073
|
27991
|
Discharge summary
|
report
|
Admission Date: [**2153-6-27**] Discharge Date: [**2153-7-3**]
Date of Birth: [**2102-9-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
50 yo female with ETOH abuse, seizures, depression who was found
by BF after falling out of bed yesterday. Presented to OSH
hypoxic, lethargic. CT head small SAH. Neurologically intact,
MAE.
CKs at OSH 14,000.
Past Medical History:
Depression
ETOH abuse
seizures
neuropathy
T2DM
asthma
Social History:
ETOH abuse. Lives with boyfriend.
Family History:
NC
Physical Exam:
at discharge:
AFVSS
NAD, A&Ox4
NCAT PERRLA EOMI
RRR CTAB
S/NT/ND +BS
MAE with mild tremulousness
Pertinent Results:
[**2153-6-27**] 08:37PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2153-6-27**] 08:37PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2153-6-27**] 08:37PM FIBRINOGE-577*
[**2153-6-27**] 08:37PM PT-11.6 PTT-18.6* INR(PT)-1.0
[**2153-6-27**] 08:37PM PLT COUNT-218
[**2153-6-27**] 08:37PM WBC-11.0 RBC-5.20 HGB-17.0* HCT-50.3* MCV-97
MCH-32.7* MCHC-33.8 RDW-14.0
[**2153-6-27**] 08:37PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2153-6-27**] 08:37PM URINE HOURS-RANDOM
[**2153-6-27**] 08:37PM ASA-4 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS
barbitrt-NEG tricyclic-NEG
[**2153-6-27**] 08:37PM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-1.8
[**2153-6-27**] 08:37PM CK-MB-5 cTropnT-<0.01
[**2153-6-27**] 08:37PM CK(CPK)-5489*
[**2153-6-27**] 08:37PM GLUCOSE-142* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
[**2153-6-27**] 09:49PM freeCa-1.03*
[**2153-6-27**] 09:49PM K+-3.6
[**2153-6-27**] 09:49PM TYPE-ART TEMP-36.6 PO2-89 PCO2-35 PH-7.36
TOTAL CO2-21 BASE XS--4 INTUBATED-NOT INTUBA
Brief Hospital Course:
50 yo female with ETOH abuse, seizures, depression who was found
by BF after falling out of bed. Presented to OSH hypoxic,
lethargic. Hypoxia improved with supplemental O2. CT head small
SAH. Neurologically intact, MAE. CKs at OSH 14,000. Pt was
admitted to SICU where a repeat CT of the head showed no change
in SAH size, no mass effect and the patient's mental status
cleared. She was transferred to the floor and evaluated by PT
and OT who found her safe for discharge home providing she had
close supervision from family members. Initially, family was not
eager to have patient return home without pt having acute [**Hospital **]
rehab (which was offered to patient but she refused), but
ultimately patient's boyfriend agreed to provide supervision.
Medications on Admission:
Trazodone 100 qhs, Depakote 500 [**Hospital1 **], Cyclobenzaprine 25 TID,
Lyrica 75 [**Hospital1 **], Effexor XR 150 qhs, orphenadrine 100 [**Hospital1 **], Moban
5mg TID, Singulair 10, metformin 500, cholordiazepoxide 25 TID,
Albuterol inhaler.
Discharge Medications:
1. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. Molindone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
6. Effexor XR 150 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO at bedtime.
7. Albuterol Inhalation
8. Medication check
You MUST see your primary physician [**Name Initial (PRE) 176**] 48 hours to confirm
your medication list and doses.
Discharge Disposition:
Home
Discharge Diagnosis:
1. subarachnoid hemmorhage
Discharge Condition:
Good, cleared by PT, with agreement from boyfriend to help
supervise patient.
Discharge Instructions:
Please take all medications as prescribed. Please attend all
followup appointments. Please seek medical attention for fever,
chills, seizures, nausea, falls or unsteadiness, chest pain,
vomiting, headache, or with other concerns.
You should be supervised at all times for your safety.
Followup Instructions:
Please followup with your regular doctor within 2 days. You
should call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 68161**] to schedule this
appointment.
Please followup in Trauma Clinic in 2 weeks. You must call ([**Telephone/Fax (1) 68162**] to schedule this appointment.
|
[
"311",
"780.39",
"852.00",
"E884.4",
"496",
"250.00",
"278.01",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
3777, 3783
|
2044, 2800
|
323, 331
|
3854, 3934
|
851, 2021
|
4268, 4558
|
715, 719
|
3096, 3754
|
3804, 3833
|
2826, 3073
|
3958, 4245
|
734, 734
|
748, 832
|
273, 285
|
359, 571
|
593, 648
|
664, 699
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,060
| 171,645
|
23575
|
Discharge summary
|
report
|
Admission Date: [**2178-5-27**] Discharge Date: [**2178-6-30**]
Date of Birth: [**2122-5-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
56M w/ colitis s/p lap total abd colectomy, end ileostomy
[**11/2177**] now with abd pain, no output, bilious emesis
Major Surgical or Invasive Procedure:
1. On [**2178-6-3**] to OR for laparoscopy, parastomal hernia repair,
and LOA
2. On [**2178-6-5**] to OR for Laparotomy and [**Hospital Ward Name **] tube placement.
3. On [**2178-6-25**] to OR for Dehisced laparotomy, Open abdomen, Loss
of abdominal domain, Multiple pulmonary emboli.
History of Present Illness:
56M with colitis s/p lap total abdominal colectomy end ileostomy
[**11/2178**] now with abd pain, bilious emesis, no ostomy output and
chills. Admitted for further management.
Past Medical History:
# Indeterminate colitis - Followed by GI here. reportedly
diagnosed ~5yrs ago. Max prednisone was 60mg. Has been
hospitalized 3 times since diagnosis.
# MSSA bacteremia
# T10 diskitis as consequence of bacteremia
# Multiple spine surgeries: Fusion T6-T12, Multiple thoracic,
laminetomies, partial vertebrectomy of T10-T11
# Pulmonary embolism - post/op complication from spine surgery
# HTN
# cholesterolemia
# Hemochromatosis - required phlebotomy in past but now
reportedly iron deficient and on iron supplementation.
# s/p arthroscopic knee surgery
# hx of C. Diff colitis
Social History:
Currently on disability after losing job in [**2175**]. Was
previously a safety manager at plant that produces insulation
for electrical wire. Lives with wife and middle son. [**Name (NI) **] 3
kids in total. Has lots of support from family. Pt is under
lots of stress recently: wife has [**Name2 (NI) **] and pt is unable to help
much with her work or everyday tasks b/c of his colitis.
EtOH: None currently. Had drank ~7-8beers/week prior to [**2174**].
CAGE negative.
Tobacco: Quit smoking in [**2161**]. Was 1ppdx25 yrs before that.
Illicits: Denies.
Family History:
Father - passed away from colon CA @ 62yo
Mother - passed away from MI @ 61 yo
2 brothers - one has hepatitis C requiring a transplant and the
other is alive and well.
Physical Exam:
On admission to the ED
T 97.3 HR 77 BP 143/96 RR 18 96% RA
Gen: NAD, somewhat uncomfortable
CVS: RRR
Pulm: CTA b/l
Abd: soft, mild distended, mildly tender, active bowel sounds,
small hernia at medical aspect of stoma
Guiaic negative, no output
.
At Discharge:
Vitals: T-100.8, HR-99, BP-112/62, RR-16, 96% on RA
Gen: NAD, A/Ox3
CV: RRR
RESP:CTAB
ABD: +BS, soft, ND, appropriately TTP
Incision: Midline incision with internal retention sutures (6
yellow buttons), 3 bilateral sides of incision. Midline incision
with vacuum sponge dressing to suction. CDI. [**First Name9 (NamePattern2) **] [**Hospital Ward Name **] tube
coiled, and secured with tape and gauze. RLQ ostomy stoma beefy
red and viable with liquid brown effluence. Ostomy appliance
intact.
Extrem: Right wrist erythematous with mild edema. Other extrems
no c/c/e
Pertinent Results:
[**2178-6-30**] 06:20AM BLOOD WBC-11.8* RBC-3.32* Hgb-8.9* Hct-27.8*
MCV-84 MCH-26.6* MCHC-31.9 RDW-18.4* Plt Ct-273
[**2178-6-21**] 05:40AM BLOOD WBC-23.3*# RBC-4.01* Hgb-10.6* Hct-32.7*
MCV-82 MCH-26.5* MCHC-32.4 RDW-18.8* Plt Ct-646*
[**2178-6-5**] 05:42PM BLOOD WBC-39.3*# RBC-4.80 Hgb-11.3* Hct-36.8*
MCV-77* MCH-23.6* MCHC-30.8* RDW-15.2 Plt Ct-207
[**2178-5-27**] 04:45PM BLOOD WBC-11.5* RBC-5.09 Hgb-11.6* Hct-37.0*
MCV-73* MCH-22.8*# MCHC-31.3 RDW-14.5 Plt Ct-301
[**2178-6-7**] 01:22AM BLOOD Neuts-95.6* Bands-0 Lymphs-3.4*
Monos-0.6* Eos-0.1 Baso-0.2
[**2178-6-5**] 01:30AM BLOOD Neuts-78* Bands-20* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2178-5-27**] 04:45PM BLOOD Neuts-83.6* Bands-0 Lymphs-12.6*
Monos-3.2 Eos-0.4 Baso-0.2
[**2178-6-30**] 06:20AM BLOOD PT-21.1* PTT-36.9* INR(PT)-2.0*
[**2178-6-29**] 06:15AM BLOOD PT-20.1* PTT-33.2 INR(PT)-1.9*
[**2178-6-28**] 05:15AM BLOOD PT-17.2* PTT-33.1 INR(PT)-1.5*
[**2178-6-27**] 06:40AM BLOOD PT-15.8* PTT-29.1 INR(PT)-1.4*
[**2178-6-30**] 06:20AM BLOOD Glucose-109* UreaN-9 Creat-0.9 Na-137
K-4.2 Cl-104 HCO3-24 AnGap-13
[**2178-6-29**] 06:15AM BLOOD Glucose-105 UreaN-8 Creat-0.9 Na-138
K-4.0 Cl-104 HCO3-25 AnGap-13
[**2178-6-28**] 05:15AM BLOOD Glucose-103 UreaN-9 Creat-0.9 Na-137
K-4.0 Cl-105 HCO3-24 AnGap-12
[**2178-6-2**] 01:30AM BLOOD Glucose-123* UreaN-48* Creat-2.2* Na-135
K-3.8 Cl-103 HCO3-20* AnGap-16
[**2178-6-1**] 05:50PM BLOOD Glucose-107* UreaN-55* Creat-3.2* Na-132*
K-4.3 Cl-96 HCO3-21* AnGap-19
[**2178-5-30**] 06:00AM BLOOD Glucose-152* UreaN-21* Creat-1.3* Na-137
K-4.3 Cl-103 HCO3-21* AnGap-17
[**2178-5-27**] 04:45PM BLOOD Glucose-144* UreaN-24* Creat-1.4* Na-138
K-3.5 Cl-105 HCO3-16* AnGap-21*
[**2178-6-11**] 02:43AM BLOOD ALT-65* AST-101* AlkPhos-65 TotBili-2.3*
[**2178-6-10**] 03:17AM BLOOD ALT-62* AST-132* AlkPhos-57 TotBili-1.9*
[**2178-6-18**] 02:12AM BLOOD CK-MB-5 cTropnT-0.01
[**2178-6-17**] 05:53PM BLOOD CK-MB-4
[**2178-6-17**] 11:38AM BLOOD CK-MB-4 cTropnT-0.02*
[**2178-6-6**] 04:23AM BLOOD CK-MB-4 cTropnT-0.02*
[**2178-6-30**] 06:20AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8
[**2178-6-29**] 06:15AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8
[**2178-6-28**] 05:15AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.2
.
CULTURES
[**2178-6-15**] SPUTUM CULTURE {KLEBSIELLA PNEUMONIAE, YEAST}
INPATIENT
[**2178-6-13**] BRONCHOALVEOLAR LAVAGE RESPIRATORY CULTURE-FINAL
[**2178-6-8**] BRONCHOALVEOLAR LAVAGE RESPIRATORY CULTURE-FINAL
[**2178-6-8**] SPUTUM CULTURE-FINAL {YEAST} INPATIENT
[**2178-6-7**] SPUTUM CULTURE-FINAL {YEAST} INPATIENT
[**2178-6-5**] BRONCHOALVEOLAR LAVAGE
CULTURE-FINAL {ESCHERICHIA COLI, KLEBSIELLA PNEUMONIAE};
FUNGAL CULTURE-FINAL {YEAST};
ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT
[**2178-6-15**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-15**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-13**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2178-6-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2178-6-15**] URINE URINE CULTURE-FINAL INPATIENT
[**2178-5-28**] URINE URINE CULTURE-FINAL
[**2178-6-7**] URINE URINE CULTURE-FINAL INPATIENT
[**2178-6-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2178-6-16**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2178-6-5**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL INPATIENT
Brief Hospital Course:
The patient was admitted to the East surgical service from the
emergencydepartment. An NG tube was placed, started on IVF,
kept NPO and IV pain medicine given as needed.
[**5-29**]: foley discontinued
[**5-30**]: NGT removed, diet advanced to regular as tolerated
[**5-31**]: KUB demonstrated dilated loops of bowel, diet downgraded
to NPO
[**6-1**]: aggressive rehydration and repletion of ostomy output.
Small bowel follow through performed showing no gross
obstruction. Diet advanced to clears
[**6-2**]: continued IVF repletion for stoma output, maintanence IVF
and diet remained at clears.
[**6-3**]: The patient underwent an exploratory laparoscopy and
parastomal hernia repair. He tolerated the procedure well, was
extubated and transferred to the PACU for continued monitoring.
The patient remained tachycardic and tachypneic, but
hemodynamically stable. He was then transferred to the [**Hospital Unit Name 153**] for
pulmonary toilet and monitoring.
[**6-7**] : chest x-ray- new diffuseairspace disease in both
lungs,l>r. This can representa non-cardiogenic pulmonary
edema,diffuse alveolardamage, or even alveolar hemorrhage. Newly
placed ET tube, right IJ, and feeding tube. Small left pleural
effusion. TMAX 101.9 WBC 25.7
[**6-8**]: cont. febrile 102.8 tachycardic rales some ostomy
output
[**6-9**]: paralyzed SB 50-70 Nutrition recommends start TPN- worried
re refeeding syndrome
[**6-10**]: abdomen softly distended
[**6-11**] afeb abg's 7.4/40/119/28 HR=63 improving from septic
shock
[**6-12**]: weaning from vent
[**6-15**] cont. on lasix drip-abx-wean from vent-tube feed . ostomy
pink and healthy. cont. vanc/zosyn
[**6-16**] : No acute events ostomy with stool output. TMAX102 BP
172/99
[**6-17**]: Exposed small bowel visible in wound between interrupted
sutures.
CT chest& abdomen
[**6-18**] TMAX-99.2 vac to wound
[**6-19**] Pt extubated tube feed at goal
[**6-20**] OOB to chair TMAX 98 Vac in place trans to R12
[**6-21**] ostomy leaking into wound trying reg diet Tolerating
well.
[**6-22**] TMAX 99.3 PT/calorie count WBC to 23k CT scan
[**6-23**] Repeat CT of chest shows bil PE's Plan for IVC filter,
will need anticoagulation re evaled by PT. amb 5 feet d/c
planning actively ongoing
[**6-29**] has now had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter placed. Is up to the chair
and ambulating
with assistance. VAC dressing changed today. Plan to go to
[**Hospital3 **]
for reconditioning and wound care. Tolerating regular diet.
INR followed
daily- [**6-29**]-INR 1.9-coumadin 5mg daily. cont ABX 6-8 weeks
Levofloxacin
500mg po qd-- metronidazole 500mg po tid. Antibiotic course
to be determined per Infectious Disease.
[**6-30**] Remains stable. Labwork stable, WBC decreasing. Cleared for
discharge to [**Hospital3 **].
Medications on Admission:
Celexa 10mg PO qd
Aciphex 20mg PO qd
Atenolol 25mg PO qd
Aldactone 25mg PO qd
Norvasc 2.5mg PO qd
Discharge Medications:
1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for pain.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for HA/PAIN: Do not exceed 4000mg in 24
hours.
9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): Bridge to Coumadin,
goal INR [**1-18**].
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Goal INR [**1-18**].
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
13. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
14. Oxycodone 5 mg Tablet Sig: 0.5-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 weeks: To be adjusted per Infectious
Disease MD.
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 weeks: To be adjusted per Infectious Disease
MD.
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for Groin for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Small bowel obstruction
Post-op ARDS
Post-op Right wrist Thrombophlebitis
Post-op Bilateral pulmonary emboli
Post-op necrotizing pneumonia resulting in lung abscess
Post-op surgical evisceration
Post-op candidiasis of groin
.
Secondary:
Indeterminate colitis, MSSA bacteremia, T10 diskitis, Mult spine
surgeries: Fusion T6-T12, Multiple thoracic, laminectomies,
partial vertebrectomy of T10-T11, HTN, lipids, PE, c diff,
Hemochromatosis, s/p arthroscopic knee surgery
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.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* 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.
.
Monitoring Ostomy Output / Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg with each episode of loose stool. Do not exceed 16mg in 24
hours.
.
[**Hospital Ward Name **] TUBE:
-Assess site daily. Safely adhere to body to prevent from
pulling.
-This tube does not need to be flushed. It is acting as a STENT
to keep your bowel lumen open, and prevent scar tissue formation
within the bowels.
-Dr. [**Last Name (STitle) 1120**] will determine when it is best to remove the tube.
Followup Instructions:
1. Please call the office of Dr. [**Last Name (STitle) 1120**] to make a follow up
appointment for 2-3 weeks at [**Telephone/Fax (1) 160**].
2. Make a follow-up appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 518**]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 29252**] in 1 week.
3. Please make a follow-up appointment with Infectious Disease
department, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] on
Date/Time:[**2178-7-24**] 9:30.
4. You have an appointment for a follow-up Chest CT scan on
[**2178-7-22**] at 2pm at the Clinical Center, [**Location (un) 470**] on the [**Hospital Ward Name 12837**] at [**Hospital1 18**].
.
Previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2178-10-26**] 11:30
SIGNED BUT NOT READ BY ME
Completed by:[**2178-6-30**]
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icd9cm
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,249
| 180,919
|
9598
|
Discharge summary
|
report
|
Admission Date: [**2196-5-12**] Discharge Date: [**2196-5-24**]
Date of Birth: [**2144-1-28**] Sex: M
Service: MEDICINE
Allergies:
Ambien / Bactrim
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
EGD with biopsy
History of Present Illness:
52 yo male with med hx of cholelithiasis and FUO with extensive
workup now presenting with sycope. Pt reports feeling in his
USOH and was sitting on couch, and was getting up to go to the
bathroom which is the last thing that he remembers. He denies
any loss of consciousness but daughter reports he was
unconscious for 1 minute. She denied him having any loss of
continence, repetative motions, no tongue biting. He reports
presyncope with seeing bright lights but no focal nuerologic
symptoms. He denies any CP, CT or SOB prior to fall.
He reports poor recollection after the event but reports chronic
short term memory loss. He denies any PND, orthopnea, or LE
edema. History limited since MSIII used as interpreter. In the
ED VS were stable and he was asymptomatic and plan was to
discharge home if cleared by PT. Pt had presyncopal episode with
pt and found to be severely orthostatic.
Past Medical History:
1. FUO -began in [**2195-4-6**] worked up by heme/onc, Rheum, and ID
workup over the past 8 months which has been completely
unrevealing to date. Of note, the patient has negative HIV yet
persistently low CD4 counts (mid100s), distal esophageal
thickening with EGD [**4-8**] completely normal, left
iliac/hilar/mediastinal lymphadenopathy s/p left iliac LN FNA bx
which was nondiagnostic (exicisonal bx not
attempted b/c location made it unresectable), and no
abnormalities on vast rheumatological workup including
[**Doctor First Name **]/RF/ANCA/Temporal Art Bx. Colonoscopy, liver bx, nad bone
marrow bx were all also negative. The patient has also had a
vast imaging workup including head CT/MRI in [**7-9**] which showed
only mild prominence of SA space over frontal lobes c/w mild
frontal cortical atrophy. Fevers treated with prednisone in past
which has caused worsening mental status.
2. Colelithiasis
3. Anemia- Workup has included EGD and colonoscopy as well as
bone marrow biopsy all of which were negative.
Social History:
Born and grew up in [**Country 651**], used to work as a tailor before
immigrating to US in [**2177**]. Worked as a cook in a Chinese
restaurant until he became ill in [**2195-4-6**]. Never been a
smoker. Had lots of exposure to second hand smoking at work
place. Drank alcohol 10 years ago. Had contact with prostitute
2-3 years ago. NKDA
Family History:
He knows nothing of the health history of family members but
doesn't recall anyone in his family having similar symptoms to
him.
Physical Exam:
T 97.5 HR 96 BP 124/74 sitting HR 114 BP 117/72 sitting on edge
of bed RR 14 O2 Sat 99% [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 4459**]-PERRL, MMM, OP clear with poor dentition, n elevated JVP,
neck supple, no ant or post cerv LAD, thyroid nonpalp
Hrt-RRR nS1S1 ?s3 no MRG
Lungs-diffuse end expiratory wheeze no crackle
Abd-soft, mod distended, no fluid wave, NT, no organomegaly
Extrem-2+ pitting edema to knees bilat
Neuro-CN II-XII intact, 5/5 strength in UE and LE bilat, no
saddle paresthesias
Skin-macular erythematous rash over ant chest upper lip, left
forehead, maculopapular erythematous rash over superior abdomen
Musculoskeletal-no erthematous or tender joints
*
PE on admission to MICU
Vitals: 102.6, 76/50, HR = 150
Gen: Asian male laying in bed, NAD,
[**Last Name (NamePattern1) 4459**]: anicteric sclear, clear OP
CV: tachy nml S1, S2, no mr/g
Lungs CTAB
Abd: liver edge 2-3 cm below costal margin in mid-clavicular
line
Extremities: C/D/I
Neuro: 3+LE reflexes bilaterally, 2+ LE reflexes, upgoing toes
bilaterally, 3+ strength in RLE and 4/5 strength in LLE.
Rest of neuro exam not performed [**3-9**] translator.
Pertinent Results:
[**2196-5-12**] WBC-5.8 Hct-30.9* MCV-82 MCH-27.5 MCHC-33.7 RDW-16.1*
Plt Ct-229
[**2196-5-24**] WBC-3.9* Hct-30.9* MCV-84 MCH-28.7 MCHC-34.0 RDW-15.9*
Plt Ct-203
[**2196-5-12**] Neuts-78.8* Lymphs-18.4 Monos-2.0 Eos-0.6 Baso-0.2
[**2196-5-24**] Neuts-72.4* Lymphs-21.5 Monos-3.5 Eos-2.1 Baso-0.4
[**2196-5-12**] PT-12.6 PTT-34.0 INR(PT)-1.0
[**2196-5-18**] Fibrino-391 D-Dimer-911*
[**2196-5-20**] ESR-98*
[**2196-5-20**] WBC-2.9* Lymph-14 Abs [**Last Name (un) **]-493 CD3%-87 Abs CD3-428*
CD4%-28 Abs CD4-139* CD8%-56 Abs CD8-278 CD4/CD8-0.5*
[**2196-5-12**] Glucose-120* UreaN-16 Creat-1.1 Na-140 K-4.1 Cl-105
HCO3-27 [**2196-5-24**] Glucose-93 UreaN-14 Creat-0.9 Na-136 K-4.1
Cl-108 HCO3-26
[**2196-5-12**] ALT-19 AST-45* CK(CPK)-351* AlkPhos-70 Amylase-88
TotBili-0.5
[**2196-5-12**] 04:00PM BLOOD CK(CPK)-169
[**2196-5-17**] 07:03PM BLOOD CK(CPK)-214*
[**2196-5-18**] 12:54AM BLOOD CK(CPK)-176*
[**2196-5-18**] 05:47AM BLOOD CK(CPK)-143
[**2196-5-19**] 06:04AM BLOOD CK(CPK)-71
[**2196-5-12**] 04:35AM BLOOD CK-MB-5 cTropnT-<0.01
[**2196-5-12**] 04:00PM BLOOD CK-MB-4
[**2196-5-17**] 07:03PM BLOOD CK-MB-4 cTropnT-2.45*
[**2196-5-18**] 12:54AM BLOOD CK-MB-4 cTropnT-2.54*
[**2196-5-18**] 05:47AM BLOOD CK-MB-3 cTropnT-1.87*
[**2196-5-13**] Calcium-7.9* Phos-3.4 Mg-1.8
[**2196-5-24**] Calcium-8.6 Phos-3.6 Mg-1.6
[**2196-5-18**] Iron-25* calTIBC-142* Ferritn-781* TRF-109*
[**2196-5-13**] VitB12-521 Folate-GREATER TH Ferritn-781*
[**2196-5-14**] TSH-1.5
[**2196-5-13**] Cortsol-11.3
[**2196-5-17**] Cortsol-3.2
[**2196-5-17**] Cortsol-15.5
[**2196-5-17**] 03:59PM BLOOD Parietl-NEGATIVE
AEROBIC BOTTLE (Final [**2196-5-21**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2196-5-21**]): NO GROWTH.
URINE CULTURE (Final [**2196-5-19**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
GRAM STAIN (Final [**2196-5-18**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2196-5-20**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2196-5-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
CXR [**5-12**]: IMPRESSION: No acute cardiopulmonary process.
Head CT [**5-12**]: INTERPRETATION: No intracranial hemorrhages
identified. No other acute intracranial abnormalities seen.
EGD, [**2196-5-16**], Mucosal biopsies, three:
A. "Esophagus":
Gastric antral-type mucosa with chronic inactive gastritis.
B. Cardia:
Cardio-fundic-type mucosa with chronic inactive gastritis and
focal intestinal metaplasia.
C. Body:
Focal chronic inflammation.
[**2196-5-17**] SINGLE PORTABLE ERECT AP VIEW OF THE CHEST: In the left
upper lobe, there is an opacity outlined by the major fissure,
new since the exam of [**2196-5-12**]. The heart is at the upper
limits of normal for size. The soft tissues and osseous
structures are unremarkable.
IMPRESSION: New left upper lobe opacity, which likely represents
pneumonia.
EKG [**2196-5-17**]: Regular narrow complex tachycardia - may be sinus
tachycardia but consider also
atrial tachycardia
Low limb leads voltage - is nonspecific
Since previous tracing of [**2196-5-14**], narrow complex tachycardia
present
EKG [**2196-5-17**]: Probable atrial tachycardia with type I
(wenkebach) second degree A-V block
Low QRS voltage
Since previous tracing of same date, second degree AV block
present
CTA [**5-18**]: IMPRESSION:
1) No PE.
2) Left upper lobe consolidation and additional patchy opacity
consistent with an infectious infiltrate.
3) Bibasilar atelectasis and small bilateral pleural effusions.
4) Prominent axillary mediastinal and hilar lymph nodes, which
overall do not meet CT criteria for pathologic enlargement.
TTE [**2196-5-18**]: Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets appear structurally normal with good
leaflet excursion. The mitral valve appears structurally normal
with trivial mitral regurgitation. No mitral valve prolapse is
seen. There is borderline pulmonary artery systolic
hypertension. There is a small (~7mm) pericardial effusion
inferolateral and inferior to the left ventricle without echo
evidence for hemodynamic compromise.
IMPRESSION: Small inferior and inferolateral pericardial
effusion without
evidence for hemodynamic compromise.
Upper extremity US [**2196-5-19**]: IMPRESSION: No DVT.
CXR [**2196-5-19**]: IMPRESSION: Persistent rounded consolidation in
left upper lobe, and patchy consolidation in left lower lobe,
probably representing an acute infectious process in this
patient with sepsis. Small pleural effusion.
EMG [**2196-5-20**]: IMPRESSION: Incomplete study. There is
insufficient data to reach any diagnostic conclusion although
the reduced sural amplitude raises the possibility of a
polyneuropathy.
Brief Hospital Course:
52 yo male with med hx of cholelithiasis and FUO with extensive
workup who presented with sycope.
1) Syncope - Patient's episode of syncope was after standing to
walk to the bathroom, with presyncope is consistent with
intravascular volume depletion from poor PO intake although he
continued to be orthostatic and tachycardic with low BP after 5L
IVF. Head CT on admission was neg ruling out acute cerebral
hemorrhage or large infarct. Hx was not consistent with seizure
activity. A.M. cortisol was borderline low although lytes were
not suggestive of adrenal insufficiency. Orthostasis now
improved, but still dizzy with ambulation. Echo with small
effusion, not an explanation for orthostasis. Pt has no other
predisposing comorbidities that cause autonomic neuropathy but
neurology consulted, who recommended EMG. EMG unfortunately
aborted due to pt discomfort and pt refusing to repeat. Given
that his orthostasis has resolved, patient will go to rehab,
with further testing as an outpatient. He still feels dizzy
with ambulation, but not orthostatic, therefore he should work
through this. Midodrine started for orthostatic hypotension,
and blood pressure should be monitored daily.
2) FUO - Pt continued to have low grade fevers while in house to
100.3. Pt has had extensive workup as per PmedHx with only other
leads of doudenal thickening and recurrence of rash. Biopsy of
rash revealed only allergic reaction and esophageal biopsy
revealed normal mucosal tissue. Pt has no arthralgias but
elevated ferritin with evanescent rash and waxing and [**Doctor Last Name 688**]
fevers is concerning for adult stills further supported by
response to prednisone. Pt developed mild LUL infiltrate post
EGD due to aspiration now being treated with flagyl/levofloxacin
day [**8-14**], therefore needs 3 more days after discharge. Pt not
able to tolerate PET do to claustraphobia but would be helpful
to look for primary as this may represent a paraneoplactic
disorder and antiHu Ab pending.
3) RUE swelling-Occurred after rt SC line placement. Got RUE US
which revealed no clot and is now improving after line pulled.
4) Tachycardia/hypotension-Initially requiring <24 hour MICU
stay now resolved and of unclear etiology. Resolved after
placement of foley catheter. Curbsided cardiology and thought
ECG was sinus tachycardia. Pt had neg CTA. No need for further
intervention.
5) Pruritis - Due to rash of unknown etiology but derm following
and obtained bx as above. Biopsy result still pending at the
time of discharge. Pt now comfortable with symptomatic
treatment with benadryl, and sarna lotion. Patient also
developed blisters on R wrist that were evaluated by dermatology
and felt consistent with contact dermatitis. [**Name2 (NI) **] biopsy
indicated.
6) FEN - Pt taking full diet.
Medications on Admission:
Tylenol PRN fever
Herbal medications
Nutrition supplement drinks
Multivitamin daily
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
4. Midodrine HCl 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
5. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration Pneumonia
Fever
Orthostatic hypotension
Discharge Condition:
Afebrile
Discharge Instructions:
If you experience any increasing fevers, chills, weakness,
feeling as if you are going to pass out, rash, nausea, vomiting,
difficulty breathing you should call your doctor but if no
doctor is available you should go back to the emergency room.
We have started one new medication called midodrine, to help
keep your blood pressure up. You will also need to take your
antibiotics for the next 3 days (levaquin and flagyl).
Followup Instructions:
With Dr. [**First Name (STitle) **] in autonomic clinic: You have an appointment
on [**2196-6-2**], 10 a.m.
Please call Dr. [**Last Name (STitle) 9006**] to make an appointment with her in the next
1-2 weeks. [**Telephone/Fax (1) 250**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
|
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|
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|
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|
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|
286, 303
|
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|
3963, 6249
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,946
| 119,575
|
49559
|
Discharge summary
|
report
|
Admission Date: [**2131-9-25**] Discharge Date: [**2131-10-6**]
Date of Birth: [**2064-7-16**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Cefazolin / Coreg / Dopamine
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Ventricular tachycardia ablation
Neosynephrine for low BPs
History of Present Illness:
The Pt is a 67 y/o M witha PMH of DM c/b peripheral neuropathy,
ulcers, and amputation, a history of a pro-coaguable disorder
requiring chronic prophylaxis with enoxaparin admitted with BKA
erythema and concern for stump infection. The pt has a right BKA
with increased erythema of the stump. His home nurse referred
him to the ED today after noting discharge. He also has had
worsening diarrhea with 4-5 loose stools daily with 2-3 at
baseline. No blood in stool. No fever or chills. The patient had
a pattern of frequenst distal stump infections in the past and
prolonged admission several months ago with left foot ulcer,
cellulitis, sepsis, septic saphenous phlebitis.
.
In the ED, initial vitals 97.5, HR 78, BP 103/56, RR 18, O2 sat
100%. He was given Vancomycin 1gm IV X1 and admitted to the
medical floor. On arrival to the floor the patient triggered for
SBP of 70. He received 1L NS on route to MICU.
.
On arrival to the MICU, the patients SBP responded initially to
IVF. However his SBP dropped to 70s systolic and he was started
on peripheral neosynephrine. In the setting of low BP he had a
run of sustained VT. He received lidocaine X1 with returned of V
paced rhythm. EP consulted and recommended lidocaine gtt.
Past Medical History:
FROM OMR:
DMII
CAD, ischemic cardiomyopathy EF 20%
Afib s/p ablation, pacemaker
SMA thrombosis with small bowel and large bowel infarcts status
post small bowel and large bowel resection and resulting short
gut syndrome
Bacterial peritonitis
PVD s/p R BKA
Hypercoagulable state, DVTs
Peripheral neuropathy
Plantar fasciitis
CVA
PV
Nonhealing anal fissure
Social History:
Mr. [**Known lastname 21212**] is a retired systems programmer for a management
consulting
firm. He is married with no children.
He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb
abuse.
Family History:
Family history is negative for hypercoagulable state, PVD
Physical Exam:
Vitals 97.5 105/60 78 93%RA
Gen: Lying in nAD
HEENT: NCAT, MMM
CV: RRR, distant heart tones
Chest: CTA bilaterally on anterior exam, slight crackles at
bases B/L
Abd: Scaphoid, NT/ND, NABS
Ext: Patietnt with BKA on right leg with erythema of stump and
ulcer with scabbing, no clear drainage, L wound with granulation
tissue, no drainage
Neuro: Alert and oriented to place
Pertinent Results:
Admission Labs:
[**2131-9-25**] 11:30PM GLUCOSE-126* UREA N-73* CREAT-1.6* SODIUM-136
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-16* ANION GAP-18
[**2131-9-25**] 11:30PM CK(CPK)-50
[**2131-9-25**] 11:30PM CK-MB-6 cTropnT-0.08*
[**2131-9-25**] 11:30PM CALCIUM-8.1* PHOSPHATE-5.6* MAGNESIUM-1.7
[**2131-9-25**] 11:30PM TSH-5.2*
[**2131-9-25**] 11:30PM FREE T4-0.92*
[**2131-9-25**] 11:30PM DIGOXIN-0.5*
[**2131-9-25**] 11:30PM WBC-31.7*# RBC-5.74 HGB-13.5* HCT-43.6
MCV-76* MCH-23.6* MCHC-31.0 RDW-20.4*
[**2131-9-25**] 11:30PM NEUTS-92* BANDS-2 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2131-9-25**] 11:30PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-1+
[**2131-9-25**] 11:30PM PT-20.2* PTT-46.4* INR(PT)-1.9*
[**2131-9-25**] 02:59PM GLUCOSE-124* LACTATE-1.3 NA+-137 K+-5.6*
CL--106 TCO2-17*
[**2131-9-25**] 02:55PM UREA N-75* CREAT-1.7*
Brief Hospital Course:
66yoM with DMII, Ischemic CM, PVD s/p R BKA admitted with
sepsis, likely [**1-27**] to cellulitis c refractory VT
.
Floor Course: Pt triggered upon arrival to the floor for
hypotension. The pt was evaluated by the MICU team and
[**Hospital 66515**] transferred to the unit.
.
ICU Course:
# Sepsis: Upon admission to the unit the pt was febrile,
tachycardiac and hypoetensive. The pt was bolused with IVF. A L
IJ was placed and pt was on phenylephrine overnight with MAP
goals in the 70s. The pts WBC increased from 20K to 30K
overnight. The source of infection was skin/soft tissue
infection versus recurrent C. Diff. The patients R BKA appeared
erythematous and was tender to palpation posteriorly and
inferiorly. Vascular surgery was consulted. The pt was started
on Vanc/Zosyn and PO Vanc. The pt's WBC improved over his MICU
stay and he remained afebrile. Upon discharge from the MICU the
patients R BKA appeared clinically less erythematous.
.
# Refractory VT: Pt had runs of VT the night of admission to the
MICU in the setting of sepsis while on pressors. Pt given
Lidocaine bolus, started on a drip and EP was consulted. The pt
was started on Amiodarone, Mexilitine PO, however the pt had
repeated runs of NSVT so pt kept on Lidocaine drip. Pt was later
taken for VT ablation by EP. Substrate was ablated however VT
could not be induced per report. Post ablation pt had repeated
runs of NSVT and placed back on Lidocaine drip and PO
amiodarone. The pt was kept intubated post procedure for 18hrs
as his BP stabilized and was briefly put back on pressors. Pt
was transitioned to PO Mexilitine with 24 hr overlap with
Lidocaine drip. The drip was subsequently d/c'd.
.
# Cardiomyopathy. The patient arrived to the unit on 2L NC. Over
the course of his MICU course he was given IVF via his
antibiotics and pt slowly became overloaded R>L as evident by
CXR and increased 02 requirement up to 5L. The pt was diuresed
and subsequently transferred back to the floor on 2L NC.
.
# Diarrhea: Pt has hx of short gut and has loose stools at
baseline. However, pt has hx of refractory C Diff and thus was
placed on PO Vanc as prophylaxis while on Vanc/Zosyn for
Cellulitis. Pt was given Metamucil Wafers to increase the
consistency of his stools which slightly alleviated his
symptoms.
Course on the Cardiology Service:
#Sepsis
Patient presented from MICU Afebrile, hemodynamically stable off
pressers. WBC down to 22K and remained around 20 for full
course. Extremities much less erythematous. Vanc level 40.0
and thus vanc held for remainder of 10 day course. He was also
continued on Zosyn for 10 day course.
#. Loose stools: Patient continued to have loose stools on the
floor. C diff was negative x 3. Was continued on PO Vanc until
CDiff cultures were negative times 3. Was started back on
cholestyramine for short gut syndrome - which he had been on in
the past.
# Refractory VT ?????? Ventricular Paced when on the floor. Was
followed by the EP service and was started on mexilitine and
amiodarone. Had several 5-10beat runs of NSVT always
asymptomatic with normal vital signs. Will follow up with the EP
service in [**Month (only) **] for further titration of his medications and
consideration of ICD placement.
# Cardiomyopathy / R Pleural effusion O2 sats improved to 99% on
RA while on the floor after diuresis in the MICU. Remained
euvolemic and never required repeat thoracentesis as O2 sats
were 99% on RA. Will be continued on lasix 20mg daily as
outpatient.
# UTI with yeast: Was started on miconazole cream [**Hospital1 **] for 14
days as well as fluconazole PO daily. His EKG was monitored over
the first 24 hours that he got the fluconazole for QT
prolongation. His QTc remained stable so he was continued on the
full 14day course of fluconazole ending on [**2131-10-19**].
# CRI (Stage IIII): CrCl between 20-40s. Creatinine stable and
within baseline
# DMII: Continued home dose NPH, ISS while in house.
# Leukocytosis: continued to be at his baseline of low 20s. [**Month (only) 116**]
consider outpatient heme/onc workup however at this time this is
unlikely secondary to an acute infection as patient has no
fever.
# Pleural Effusion: Has known pleural effusion that has been
stable. The patient had O2 sats 100% on RA prior to discharge
with stable appearance of effusion on CXR.
# Hypercoagulability: On lovenox and no aspirin.
# Depression: Mood stable. Continued Citalopram
# FEN: Continue regular, heart healthy diet
# CODE: Full
# PPX: Lovenox, Ranitidine
Medications on Admission:
Alendronate 70mg weekly
Hydrocodone/Acetaminophen 5/235
Amiodarone 200mg daily
Captopril 25mg three tab TID
Folic acid 1mg tab daily
Furosemide 20mg 3 tab daily
Digoxin 250mcg faily
Lyrica 600mg daily
Loperamide PRN
NPH 20units Qam
Ranitidine 150 tab
Toprol Xl 25 Daily
Lovenox 60mg Daily
Citalopram 40 daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous Q12H (every 12 hours): subcutaneous injection.
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
7. Lyrica 200 mg Capsule Sig: One (1) Capsule PO Q8 ().
8. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 2 days.
9. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) Units Subcutaneous QAM.
11. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
13. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): Hold
for SBP<90 HR<55.
15. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
16. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
17. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to skin of scrotum: For 10 days.
19. Outpatient Lab Work
Please draw LFTs and CK in [**4-1**] weeks and fax results to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 103664**]
20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
22. EKG
Please check EKG 2 days after discharge and fax it to the rehab
doctor. He should check the QTc interval to make sure it is less
than 500 (which is the patient's baseline).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cellulitis complicated by sepsis and septic shock
ventricular tachycardia s/p VT ablation
chronic C.Diff colitis
short gut syndrom and chronic diarrhea
Urinary and scrotal yeast infection
Discharge Condition:
The patient was afebrile, hemodynamically stable, with normal
oxygen saturations and ventricularly paced at rate of 60bpm
before discharge.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted to the hospital with infection of your
amputation site. You developed a low blood pressure, likely
because of this infection. You were treated with antibiotics for
10 days forthe infection and you were given some fluids for your
blood pressure. For a brief time you were also put on
medications to keep your blood pressure in the normal range.
Your infection is now better and you have not had a fever for
several days.
You also had a rapid heart rate while you were hospitalized.
You had a procedure to fix this heart rate. You were also
started on medications to control it. You should continue these
medications until you see the electrophysiologists in [**Month (only) 321**].
You also had loose stools this admission similar to what you
have at home. You were given a course of oral vancomycin for
treatment of a cDiff colitis that was never found in your stool
here. You were then started on cholestyramine for your loose
stools which the GI doctors had recommended for you previously.
You should continue on this and follow up with them if needed.
You also had a yeast infection of your scrotal area and your
urine. We started an anti-yeast medication for this that you
will get for 14 days through your IV and a cream that you will
take twice a day for 14 days.
Medication Changes:
START: Mexilitine 200mg by mouth three times daily
START: Zosyn 2.25gm IV Q6H last day [**2131-10-6**]
STOP: Captopril
STOP: Digoxin
CHANGE: Toprol XL to 12.5mg by mouth daily
START: Miconazole cream apply twice daily to scrotum and penis
for 14 days
START: Fluconazole 200mg PO daily for 10 days
START: Lipitor 10mg by mouth daily
START: Cholestyramine 4gm twice daily
CHANGE: Lasix to 20mg by mouth daily
START: Fluconazole 200mg IV daily last dose [**2131-10-15**]
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-11-23**]
12:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2131-11-23**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2131-11-23**] 2:00
Please follow up with Dr.[**Name8 (MD) 10373**] NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 103665**]
([**Telephone/Fax (1) 250**]) on [**2131-10-10**] at 10:40am. She should check your leg
for infection.
Completed by:[**2131-10-6**]
|
[
"038.9",
"997.62",
"357.2",
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"995.92",
"682.6",
"707.12",
"785.52",
"414.8",
"V49.75",
"584.9",
"428.0",
"427.31",
"511.9",
"250.60",
"112.2",
"428.22",
"707.14",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
10733, 10803
|
3709, 8214
|
311, 371
|
11035, 11177
|
2710, 2710
|
13107, 13716
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2243, 2302
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10824, 11014
|
8240, 8551
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11201, 12594
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2317, 2691
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12614, 13084
|
265, 273
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399, 1628
|
2726, 3686
|
1650, 2012
|
2028, 2227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,157
| 184,218
|
54461
|
Discharge summary
|
report
|
Admission Date: [**2136-6-29**] Discharge Date: [**2136-7-10**]
Date of Birth: [**2053-6-7**] Sex: F
Service: SURGERY
Allergies:
Cymbalta / Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Bilateral non-healing hallux ulcers
Major Surgical or Invasive Procedure:
[**2136-7-4**] Diagnostic lower extremity angiogram
[**2136-7-5**] Common iliac percutaneous angioplasty of
femoral/popliteal, tibia/peroneal, stent first artery
History of Present Illness:
83 year-old female, with 2 recent admission for diastolic
CHF, new afib, and cardiac cath/PTCA w/ stents on [**6-22**], now
presents to the ED for worsening rt foot malleolus ulcer and
necrosis around rt hallux ulceration. Has had h/o b/l hallux
ulcers that have been treated with debridement by podiatry but
now with a rt malleolus ulceration worsening since last
admission
and worsening rt hallux ulcer. Patient denies a history of
claudication or rest pain. Swelling of RLE noted. Visiting
nursing has been seeing patient and referred her to ED today
upon
seeing her wounds.
Past Medical History:
1. Diabetes type 2, last a1c=6.9
2. Hypercholesterol, last llipids poorly controlled
3. Hypertension.
4. Status post appendectomy.
5. Status post bilateral hip surgery.
6. PE from post-partum DVT in [**2093**]
Osteoarthritis - bilateral hips and lumbosacral spine
Bilateral Hip Replacements [**12/2127**]
Left Thumb Paronychia s/p I&D '[**30**]
Left Foot Cellulitis s/p I&D '[**30**]
Peripheral Vascular Disease
Peripheral Neuropathy
Social History:
Married, 6 living children. Lives in [**Location 745**].
-Tobacco history: Never
-ETOH: None
-Illicit drugs: None
Family History:
Father - Deceased, MI at 50
Mother - Deceased, MI at 65
3 brothers died of [**Name (NI) 5290**] in 60s and 70s.
Physical Exam:
T: VS 98.9, HR 62, BP 129/65, RR 16, 100%
GEN: NAD, A&O x 3
LUNGS: Clear b/l
CV: RRR, nl S1 and S2
ABD: soft, NT, ND
EXT: Feet warm b/l. B/L hallux ulcers no active purulent
drainage, rt hallux ulcer with eschar area on base and R lateral
malleolus with pressure ulceration, right groin incision c/d/i
RLE edema 1+ pitting
VASC:
Fem [**Doctor Last Name **] DP PT
R 1+ TP MP MP
L 2+ TP BP BP
Pertinent Results:
[**2136-7-5**] 05:30AM BLOOD WBC-8.3 RBC-3.14* Hgb-9.4* Hct-28.8*
MCV-92 MCH-29.8 MCHC-32.5 RDW-13.9 Plt Ct-431
[**2136-7-4**] 05:35AM BLOOD WBC-10.8 RBC-3.29* Hgb-9.9* Hct-29.8*
MCV-91 MCH-30.0 MCHC-33.2 RDW-13.8 Plt Ct-448*
[**2136-6-29**] 09:00PM BLOOD Neuts-85.0* Lymphs-9.4* Monos-2.6 Eos-2.7
Baso-0.3
[**2136-7-5**] 05:30AM BLOOD Plt Ct-431
[**2136-7-5**] 05:30AM BLOOD PT-26.0* PTT-42.8* INR(PT)-2.6*
[**2136-7-4**] 05:35AM BLOOD Plt Ct-448*
[**2136-7-4**] 05:35AM BLOOD PT-21.8* INR(PT)-2.1*
[**2136-7-5**] 05:30AM BLOOD Glucose-42* UreaN-17 Creat-1.0 Na-138
K-3.4 Cl-100 HCO3-26 AnGap-15
[**2136-7-5**] 05:30AM BLOOD CK(CPK)-54
[**2136-6-29**] 09:00PM BLOOD cTropnT-0.04*
[**2136-7-5**] 05:30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
[**2136-6-29**] 09:00PM BLOOD CRP-65.2*
[**2136-6-29**] 09:19PM BLOOD Lactate-2.2*
ECG Study Date of [**2136-6-29**] 9:52:00 PM
Sinus bradycardia. Q-T interval prolonged for rate. Poor R wave
progression consistent with old anteroseptal myocardial
infarction. Diffuse non-specific ST-T wave abnormalities.
Compared to the previous tracing of [**2136-6-23**] sinus bradycardia
has replaced atrial fibrillation. Q-T interval prolonged for
rate is new raising the possibility of medication effect or
metabolic abnormality. ST-T wave abnormalities in leads III,
aVF, V3-V5 are somewhat more marked. Suggest clinical
correlation and repeat tracing.
ECG Study Date of [**2136-7-3**] 2:28:18 PM
Atrial fibrillation with rapid ventricular response. Prior
anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2136-6-9**] atrial
fibrillation has recurred. The T wave inversion in leads III,
aVF and V3-V6 may have psuedonormalized in the context of
increased rate. Rule out active ischemic process. Followup and
clinical correlation are suggested.
FOOT AP,LAT & OBL RIGHT Study Date of [**2136-6-29**] 8:45 PM
IMPRESSION: No radiographic evidence of osteomyelitis. Diffuse
soft tissue
swelling. No subcutaneous gas.
UNILAT LOWER EXT VEINS RIGHT Study Date of [**2136-6-29**] 10:19 PM
IMPRESSION: No DVT in right lower extremity.
The study and the report were reviewed by the staff radiologist.
CHEST (PRE-OP PA & LAT) Study Date of [**2136-7-1**] 10:26 AM
IMPRESSION: Interval clearing of congestive heart failure with
very small
residual pleural effusions.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2136-7-4**] 9:19 AM
FINDINGS: Bilateral cephalic, basilic, and greater saphenous
veins were evaluated with B-mode ultrasound. On the right arm,
the cephalic vein is patent with diameters ranging between 0.16
and 0.09 cm. The right basilic vein is patent with diameters
ranging between 0.09 and 0.5 cm.
On the left arm, the left cephalic vein is patent with diameters
ranging
between 0.22 and 0.39 cm. The left basilic vein is patent with
diameters
ranging between 0.15 and 0.39 cm.
In the right lower extremity, calcification was visualized at
the proximal
portion of the greater saphenous vein and was identified at the
level of the midcalf. The right greater saphenous vein is patent
with diameters ranging between 0.42 and 0.92. The right lesser
saphenous vein is patent with diameters ranging between 0.17 and
0.64.
On the left lower extremity, calcifications were seen at the
greater saphenous vein below the level of the knee. The left
greater saphenous vein is patent with diameters ranging between
0.16 and 0.60 cm. The left lesser saphenous vein is patent with
diameters ranging between 0.11 and 0.22 cm.
IMPRESSION: Patent bilateral cephalic, basilic, greater
saphenous and lesser saphenous veins with diameters described
above.
CHEST (PORTABLE AP) Study Date of [**2136-7-6**] 9:06 AM
Suboptimal. Lower lung volumes. Increase in bibasilar opacities,
more
on the right, likely atelectasis or effusion.
Brief Hospital Course:
[**2136-6-29**] DOA Patient admitted via ED for non-healing bilateral
hallux ulcers. Started broad spectrum antibiotics
(Vanco/Levo/Flagyl). Routine nursing care, home meds, labs.
Right foot x-rays done -showed-No radiographic evidence of
osteomyelitis,diffuse soft tissue swelling. No subcutaneous gas.
Right LE US- showed no DVT. Podiatry consulted-recs multipodus
boot to RLE, wound care- NS wet-dry [**Hospital1 **], will follow.
[**Date range (1) **]/09 HD1-2 VSS. Pr-oped (CXR, ECG) for angiogram. IV
hydration with bicarb and Acetylcystein given.
[**2136-7-3**] HD3 VSS. Taken to angio suite and underwent diagnostic
angiogram. Patient tolerated procedure well, recovered in the
cath lab holding room. Patient was established that she would
require further intervention for revascularization, possibly
bypass. Left groin sheath was removed after transfusion of 1
unit FFP for (INR 2.1), uneventful sheath removal, site w/o
hematoma. Patient was transferred to [**Hospital Ward Name 121**] 5 for further
observation. Patient was on bedrest for the required amount of
time after sheath removal. Post procedure ECG showed atrial
fibrillation w/ controlled rate- no intevention was done patient
was hemodynamically stable.
[**2136-7-4**] HD4 PAD1 VSS. Left groin access site remain clear, no
hematoma. Vein mapping was done- that showed right arm, the
cephalic vein is patent diameters 0.16 and 0.09 cm.
Basilic-patent diameters 0.09 and 0.5 cm. left arm- cephalic
vein-patent diameters 0.22 and 0.39 cm, basilic- patent
diameters 0.15 and 0.39 cm. RLE-calcification at the proximal
portion of the GSV and at the level of midcalf, diameters
between 0.42 and 0.92. The RLSV- patent, diameters between 0.17
and 0.64. L LE greater saphenous vein is patent w/
calcifications below the knee level. Diameters ranging between
0.16 and 0.60 cm. The left LSV is patent with diameters between
0.11 and 0.22 cm. Patient was pre-oped and consented for L LE
bypass. Social work consulted to help with family coping.
Patient was transfused 1 unit of packed red cells for low HCT.
[**2136-7-5**] HD5 PAD2. VSS. After reviewing vein mapping, patient was
determinrd to have no veins available for bypass, therefore
decision was made to attemp another angiogram w/ possibly
angioplasty. Patient was taken to angio suite and underwent
percutaneous angioplasty of right AT artery and stent. Patient
tolerated procedure, sheath was removed after transfusion of 2
units of FFP for INR of 2.6. In recovery patient was hypotensive
therefore was transferred to the ICU for further management and
observation. Continued broad spectrum antibiotics (V/L/F).
[**2136-7-6**] HD6 PAD3/1 Patient had several episodes of hypotension,
recieved fluid boluses. Diet and po meds resumed. TTE was done
showing no change from baseline CHF, minimal inferior LV
hypokenesis\
[**2136-7-7**]: transferred back to VICU, doing well.
[**2136-7-8**]: central line out, foley out, lasix, coumadin restarted,
good diuresis
[**2136-7-9**]: SW/CM working on placement, found [**Hospital3 2558**],
husband d/c'd to CH, Seen by PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who helped
formalize d/c plan
[**2136-7-10**]: ambulating with walker per PT, no events, ready for d/c
Medications on Admission:
Lipitor 80 mg po qd
Plavix 75 mg po qd
Asa 325 mg po qd
Furosemide 20 mg po qd
Glyburide 10mg po bid
Ntg prn
Metoprolol 37.5 mg po BID
Metformin 1,000 mg po qd
Moexipril 15 mg po bid
Coumadin 4mg po qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Moexipril 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Inhalation Q6H (every 6 hours) as needed for
wheezing.
10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PVD w/ non-healing bilateral hallux ulcers
Anemia requiring blood transfusion
Atrial Fibrillation
History of:
Dibetes
Hypercholesterolemia
hypertension
diastolic CHF (EF45%)
afib last admission on coumadin
CAD s/p MI
Osteoarthritis
h/o PE/DVT [**2093**]
PSH: s/p appy, b/l THR, ?vein ligation @ saphfem jxn for remote
DVT, s/p PTCA/stent [**6-22**],
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Post Angio
- Monitor your groin, call if pain, swelling, and bruising is
noted
- No lifting or straining
- Stool softener while on pain medications
- If bleeding is noted in the groin, hold pressure and go to the
ED
- Resume normal activities gradually
- Continue all medications as instructed
- Call Dr.[**Name (NI) 1392**] office for FU appointment
- coumadin/blood glucose monitoring
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2136-7-17**] 11:40
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2136-7-18**] 2:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]: [**Telephone/Fax (1) 1393**], please call for appt in 2 weeks
Completed by:[**2136-7-10**]
|
[
"428.0",
"V43.64",
"V12.51",
"715.98",
"440.23",
"428.33",
"458.29",
"250.00",
"V58.66",
"414.01",
"707.13",
"V45.82",
"272.4",
"412",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"00.46",
"88.42",
"88.48",
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
10672, 10742
|
6124, 9388
|
317, 482
|
11136, 11143
|
2296, 6101
|
11700, 12143
|
1703, 1816
|
9640, 10649
|
10763, 11115
|
9414, 9617
|
11167, 11677
|
1831, 2277
|
242, 279
|
510, 1094
|
1116, 1552
|
1568, 1687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,046
| 156,547
|
47688
|
Discharge summary
|
report
|
Admission Date: [**2138-6-27**] Discharge Date: [**2138-7-3**]
Date of Birth: [**2079-5-22**] Sex: M
Service: MEDICINE
Allergies:
Nifedipine
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Acute renal failure
Hyperkalemia
Major Surgical or Invasive Procedure:
[**First Name3 (LF) 13241**] line placement
[**First Name3 (LF) 13241**]
History of Present Illness:
59 yo M with a history of hypertension, prostate cancer s/p beam
radiation, monoclonal gammopathy, type 2 diabetes, hep B and C,
neuropathy, who presents via ambulance with acute renal failure
and hyperkalemia to 7.10.
.
He was at his baseline health through last week. He started
treatment for an infection of his right great toe which had been
operated on in [**2138-4-18**] for a hammertoe revision. His ankle
and foot was swolen and painful, and so he initially began
ciprofloxacin prescribed by his podiatrist, though it caused him
to vomit, and so he began clindamycin for the past 5 days.
.
His urine output decreased over the past 2-3 days, which has
coincided with feelings of general malaise, myalgias, pruritis,
and anorexia. He also describes a vague sense of confusion and
inability to maintain a train of thought. He only had a few
episodes of vomiting over the past week. He had three episodes
of diarrhea. He continues to drink at least 32oz fluid daily.
He denies use of NSAIDS, or any accidents, trauma, or crush
injuries. Denies unusual ingestions, including polyethylene
glycol. He denies recent medication changes aside from his
antibiotics, and does not think he incorrectly dosed any of his
meds recently (he's on an ACEI, metformin, lasix). Of note, he
has never had significant [**Last Name (un) **] in the past with a baseline Cr
0.7.
.
In the ED, initial vs were: 97.8 75 151/63 16 98% on 4L NC.
Patient was given kayexelate, 500cc NS, calcium gluconate 1g IV,
1 amp D50, and insulin 10IV. Pt has peaking of T waves on
baseline ECG, and in ED seemed to have more peaked T waves.
Renal U/S was ordered. Blood sugar "dipped" with insulin, was
somnolent and was given food.
.
In the unit, his initial VS were T 97.8 P60 BP145/75 RR13
Sat100RA. He is hungry, thirsty, and is eating a hamburger. He
denies dysuria, hematuria, frothy urine, brown urine, flank
pain, fevers, chills, suprapubic pain, urgency, decreased
urinary stream, dribbling, hesitancy, weight loss or gain,
edema. No chest pain, shortness of breath, cough, abdominal
pain, bloody stool, palpitations.
Past Medical History:
-insulin dependent type two diabetes
-diabetic foot ulcers
-prostatic adenocarcinoma [**2134**] s/p external beam radiation
complicated by radiation proctitis and anal stricture requiring
diverting colostomy and hyperbaric oxygen treatment
-diabetic neuropathy, s/p partial amputation right great toe,
with right hallux hammertoe surgical correction [**2138-5-14**]
-partial amputation of right fourth toe due to osteomyelitis
-chronic pain
-monoclonal gammopathy
-hepatitis B
-hepatitis C
-alcohol abuse
-substance abuse
-lower GI bleed [**2136**] [**Hospital1 112**] [**2-19**] diverticulosis
Social History:
Lives in [**Location 686**] with his cousin. Divorced. Retired,
previousl worked at [**Location (un) 86**] Water authority. Quit smoking 30
years ago, 10PY hisory. Drinks 2-3 beers daily, 0.5pints vodka
every 3 days. No illicit drugs
Family History:
Father died MI. Brother carries prothrombin gene mutation.
Physical Exam:
General: Alert, oriented x3, answering questions appropriately,
eating a hamburger
HEENT: Sclera anicteric, membranes are dry
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Multiple surgical scars are well-healed. Belly is
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley draining clear urine
Ext: warm, well perfused, 2+ pulses, 1+ bilateral edema to the
ankle. Right big toe wound without purulence.
Pertinent Results:
CHEST (PA & LAT) Study Date of [**2138-6-27**]
IMPRESSION: Low lung volumes, but no acute cardiopulmonary
abnormality.
RENAL U.S. Study Date of [**2138-6-27**] FINDINGS: There is a
horseshoe kidney, as seen on the CT from [**2134-10-9**]. There is no evidence of hydronephrosis, renal masses, or
renal calculi.
The right renal moiety measures 13.9 cm and the left renal
moiety measures
13.5 cm. The isthmus is unremarkable. The bladder is collapsed
around the
Foley catheter.
IMPRESSION: No evidence of hydronephrosis or renal calculi
involving the
horseshoe kidney.
.
FOOT AP,LAT & OBL RIGHT Study Date of [**2138-7-1**]
Report pending.
.
[**2138-6-27**] 04:35PM BLOOD WBC-5.9 RBC-4.12* Hgb-12.9* Hct-38.4*
MCV-93 MCH-31.4 MCHC-33.6 RDW-12.3 Plt Ct-220
[**2138-6-30**] 10:02AM BLOOD WBC-4.5 RBC-3.70* Hgb-11.6* Hct-33.7*
MCV-91 MCH-31.5 MCHC-34.6 RDW-11.8 Plt Ct-177
[**2138-6-27**] 04:35PM BLOOD Glucose-81 UreaN-84* Creat-14.3*# Na-128*
K-7.1* Cl-91* HCO3-15* AnGap-29*
[**2138-6-28**] 01:10AM BLOOD Glucose-98 UreaN-83* Creat-14.6* Na-131*
K-7.5* Cl-97 HCO3-15* AnGap-27*
[**2138-6-28**] 10:36AM BLOOD Glucose-100 UreaN-88* Creat-15.5* Na-135
K-5.5* Cl-99 HCO3-18* AnGap-24*
[**2138-7-1**] 07:45AM BLOOD Glucose-112* UreaN-54* Creat-10.6*#
Na-138 K-4.0 Cl-97 HCO3-29 AnGap-16
[**2138-7-2**] 06:55AM BLOOD Glucose-156* UreaN-60* Creat-10.0* Na-139
K-4.2 Cl-100 HCO3-29 AnGap-14
[**2138-7-3**] 06:35AM BLOOD Glucose-104* UreaN-65* Creat-9.8* Na-140
K-4.5 Cl-100 HCO3-28 AnGap-17
[**2138-6-27**] 07:20PM BLOOD TotProt-6.9 Albumin-3.9 Globuln-3.0
Calcium-7.9* Phos-8.2*# Mg-1.8 UricAcd-13.7*
[**2138-7-1**] 07:45AM BLOOD Calcium-7.8* Phos-5.2* Mg-1.6
[**2138-7-2**] 06:55AM BLOOD Calcium-7.6* Phos-4.6* Mg-1.5*
[**2138-7-3**] 06:35AM BLOOD Calcium-7.6* Phos-5.2* Mg-1.5*
[**2138-6-28**] 05:51PM BLOOD Cryoglb-NO CRYOGLO
[**2138-6-28**] 10:36AM BLOOD HBsAg-NEGATIVE HBcAb-POSITIVE HAV
Ab-NEGATIVE
[**2138-6-28**] 05:51PM BLOOD ANCA-NEGATIVE B
[**2138-6-28**] 05:51PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2138-6-28**] 05:51PM BLOOD RheuFac-<3
[**2138-6-28**] 05:51PM BLOOD b2micro-11.7*
[**2138-6-27**] 07:20PM BLOOD PEP-NO SPECIFI
[**2138-6-28**] 05:51PM BLOOD C3-109 C4-37
[**2138-6-28**] 10:36AM BLOOD HCV Ab-POSITIVE*
[**2138-6-27**] 07:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2138-6-27**] 07:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2138-6-27**] 07:00PM URINE Eos-NEGATIVE
[**2138-6-27**] 07:00PM URINE Hours-RANDOM UreaN-265 Creat-96 Na-51
K-20 Cl-30 TotProt-54 HCO3-LESS THAN Prot/Cr-0.6*
[**2138-6-27**] 07:00PM URINE U-PEP-NEGATIVE F Osmolal-236
[**2138-6-28**] 03:06PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
[**2138-6-28**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2138-6-27**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2138-6-27**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2138-6-29**] 11:49 am SWAB Source: toe.
GRAM STAIN (Final [**2138-6-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2138-7-1**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
This is a 59 year old diabetic man with related neuropathy,
recent toe deep infection to the bone with underlying
osteomyelitis (recent wound culture by his podiatrist grew Ecoli
that was resistant to everything except aminoglycoside and one
cephalosporin; he was empirically treated with few days of
Ciprofloxacin, Clindamycin, and Augmentin), hypertension,
hepatitis B/C, and monoclonal gammopathy, who presented with
severe hyperkalemia and acute renal failure of unclear etiology
(initially). He had no EKG or symptoms of hyperkalemia. He
received calcium to stabilize his myocardium in the ED, IV
fluids, insulin and D50), and Kayexalate to reduce total body
potassium. He had an impressive acute renal failure with a GFR
of 9.0. He had no hydronephrosis on ultrasound and lack
obstructive symptoms on history. His Fe Na of 5.9% (Furea%)
suggested more of an intrinsic renal process. On the other hand,
he had concomitant use of ACE-I, furosemide, and metformin as
well as recent antibiotics use. Renal was consulted and
performed dialysis. Urine sediment showed muddy brown casts
suggestive of ATN. Several serologies were ordered including
complement levels, RF, [**Doctor First Name **], Cryoglobulin, SPEP/UPEP, hepatitis
serology, and biopsy was planed (he has horseshoe kidney on the
MRI). However, his urine toxicity screen was positive for
cocaine (patient was in denial). Nephrology believed his ATN was
related to cocaine nephropathy and biopsy is no longer
indicated. His last HD treatment was on [**2138-6-30**], and his renal
function was monitored for several days afterward. His
creatinine improved slightly, but his BUN increased. It was our
preference to continue to monitor his renal function on the
inpatient service, but he refused to remain in the hospital, and
he requested discharge due to personal and financial
obligations. He was arranged to follow up with his PCP (pt
reported that he is followed by Dr. [**Last Name (STitle) **] on Monday with lab
testing. He will need a referral to Nephrology soon after
discharge; we were unable to obtain this appointment, as he was
discharged after offices closed, and we were not anticipating
discharge.
In regards to his RIGHT TOE INFECTION, we spoke to his
podiatrist who confirmed deep wound and underlying
osteomyelitis. He was attempting to save the toe from an
amputation. Purulence was noted on examination but he was
afebrile without leukocytosis or systemic symptoms. Wound care
continued and cultures were obtained before further antibiotics
or mangement. Antibiotics were deferred given [**Last Name (un) **]. His Lantus
dose was reduced due to reduced renal clearance. His lisinopril
was discontinued for severe [**Last Name (un) **] but they continued home
labetalol. Patient was also placed on thiamine and folate for
ALCOHOL ABUSE but he had no signs of withdrawal.
His gabapentin was discontinued as well, as he began having
bizarre sensory abnormalities (he felt that he was lying on the
ceiling), despite significant dose reduction in the setting of
renal failure. Despite being off of this medication, he did not
complain of neuropathic pain. I suspect that his neuropathy is
now severe enough that he will no longer have pain.
Medications on Admission:
Lisinopril 40 mg Oral Tablet Take 1 tablet daily
Clindamycin HCl 300 mg Oral Capsule take 1 capsule by mouth
THREE TIMES DAILY
Ciprofloxacin 750 mg Oral Tablet take 1 tablet by mouth TWICE
DAILY
Oxycodone-Acetaminophen 5-325 mg Oral Tablet 1 tablets every 4
hours as needed for pain; MAXIMUM 3 tabs a day
Morphine 30 mg Oral Tablet Extended Release take 1 tablet by
mouth every 8 hours
Insulin Glargine (LANTUS) 100 unit/mL Subcutaneous Solution
inject 30 units under the skin AT BEDTIME
Labetalol 200 mg Oral Tablet Take 1 tablet twice daily
Gabapentin 300 mg Oral Capsule take 1 capsule in the morning and
1 capsule in the afternoon, and 3 capsules in the evening
Metformin 850 mg Oral Tablet TAKE 1 TABLET TWICE A DAY
Furosemide 20 mg Oral Tablet take 1 tablet EVERY OTHER DAY
TESTOSTERONE 75 MG IMPLANT PELLET (TESTOPEL 75 MG IMPLANT
PELLET) 75 mg Impl Pllt None Entered
MEN'S MULTI-VITAMIN TAB (MULTIVITAMINS) None Entered
Discharge Medications:
1. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
2. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
5. Outpatient Lab Work
Lytes, BUN/Cr, Ca, Mg, Phos. Please have drawn early on [**2138-7-7**].
Discharge Disposition:
Home
Discharge Diagnosis:
# severe renal failure from cocaine abuse; temporarily required
[**Date Range 13241**]
# osteomylitis of the toe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you had severe renal failure from cocaine abuse. Please do not
use cocaine. You were seen by the kidney doctors who did
[**Name5 (PTitle) 13241**] and ordered many tests to rule out any other
causes. We also found bone infection in your big toe. Please
follow up with your podiatrist as you may need amputation and
further antibiotic treatment.
It is extremely important that you follow up with your doctor [**First Name (Titles) **] [**Last Name (Titles) 7712**] as scheduled below.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] on Monday [**2138-7-7**] at 1:20PM.
Please have your blood drawn in the lab early that morning so
Dr. [**Last Name (STitle) **] can have the results in time for your appointment. The
lab opens at 8 am. Please bring your prescription for the lab
draw with you.
|
[
"276.7",
"250.60",
"970.81",
"070.70",
"730.27",
"357.2",
"707.15",
"E854.3",
"185",
"305.60",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
12296, 12302
|
7553, 10783
|
303, 378
|
12459, 12459
|
4104, 7469
|
13118, 13434
|
3396, 3458
|
11761, 12273
|
12323, 12438
|
10809, 11738
|
12610, 13095
|
3473, 4085
|
231, 265
|
406, 2508
|
7505, 7530
|
12474, 12586
|
2530, 3126
|
3142, 3380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,882
| 133,464
|
3094
|
Discharge summary
|
report
|
Admission Date: [**2115-11-19**] Discharge Date: [**2115-11-21**]
Date of Birth: [**2051-2-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin / Demerol / Sulfa (Sulfonamides) / Nitroglycerin /
Morphine / Clindamycin / Benzonatate
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
shortness of breath in setting of TBM and silicone Y stent
Major Surgical or Invasive Procedure:
flexible bronchoscopy
History of Present Illness:
64F with history of tracheobronchomalacia s/p Y stent
placement on [**2115-11-4**]. Today, presented to [**Hospital1 2436**] ER with
SOB
and difficulty clearing secretions. Bronched there and with
therapeutic aspiration. Was transferred here for therapeutic
aspiration and probably stent removal.
Past Medical History:
Tracheobronchomalacia s/p Y stent placement, GERD, COPD, OSA,
CAD, Atrial fibrillation, Fibromyalgia
Social History:
+ smoking 50 yr history
married, lives w/husband
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM:
Temp (F): 98.2
Heart Rate: 102
Blood Pressure: 115/83
Resp Rate: 19
O2 Sat(%): 97% RA
HEENT; unremarkable
CHEST: CTA bilat
COR: RRR S1, S2
Extrem: no edema
Brief Hospital Course:
pt was admitted from [**Hospital3 **] to the sicu on [**2115-11-19**]
for close pulmonary monitoring while wawiting bronch to eval
status of tracheal silicone Y stent. Placed on mucolytics and
augmentin.
A flexible bronchoscopy was done on [**2115-11-20**] and copious amounts
of secretions were aspirated. Stent was in correct position and
subsequently free of secretions. Pt remained stable and was
transfered out of the ICU w/ sats 97-98% on roomair.
D/c to home on mucolytic regimen and augmentin for 7 days. Will
return on [**12-3**] for Y stent removal.
Medications on Admission:
Lipitor 10', Singulair 10', Advar 2puffs'', Spiriva 1',
Lorazepam 1', Omeprazole 20', Mucinex 1200'', Augmentin,
Amitriptyline 50', Albuterol
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
13. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
15. normal saline
normal saline nebs q 4-6hrs
Discharge Disposition:
Home
Discharge Diagnosis:
COPD, tracheobronchomalacia s/p Y stent placement [**11-4**]
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 14680**] office if you develop chest pain, shortness of
breath, fever, chills, or nay symptoms that concern you.
[**Telephone/Fax (1) 14681**]
Followup Instructions:
You are scheduled to have your stent removed on [**12-3**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2115-11-25**]
|
[
"519.19",
"729.1",
"427.31",
"V45.89",
"530.81",
"327.23",
"414.01",
"V15.82",
"493.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
3371, 3377
|
1238, 1799
|
428, 452
|
3482, 3489
|
3701, 3883
|
986, 1003
|
1992, 3348
|
3398, 3461
|
1825, 1969
|
3513, 3678
|
1038, 1215
|
330, 390
|
480, 779
|
801, 903
|
919, 970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,916
| 163,740
|
18858
|
Discharge summary
|
report
|
Admission Date: [**2135-9-23**] Discharge Date: [**2135-9-28**]
Date of Birth: [**2103-2-9**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old
African-American gentleman with a history of end-stage renal
disease who recently left [**Hospital1 **] Four on [**2135-9-22**]
after being admitted to the Medicine Service with chest pain
related to cocaine use and transferred to [**Hospital1 **] Four for
depression. The patient had hemodialysis on the day he left the
hospital.
The patient then left the hospital and started using crack
cocaine at 6 p.m. that evening. The patient states that his
chest pain began at midnight and eventually increased to [**8-28**].
The patient continued to use crack cocaine for another six hours
and eventually presented to the Emergency Department.
In the Emergency Department, the patient was given sublingual
nitroglycerin times three with his chest pain decreasing to [**6-28**].
The patient was noted to be hyperkalemic at 8 with elevated
creatine kinase levels to 23,627. He electrocardiogram in the
Emergency Department was significant for peaked T waves, and the
patient was given calcium gluconate 2 g D-50, 10 units of regular
insulin, bicarbonate, and 60 cc of Kayexalate. The Nephrology
Service was called for emergent hemodialysis.
In addition to his chest pain, the patient was also complaining
of severe muscle pain in both legs along with weakness and an
inability to walk without a limp. The patient states that his
chest pain substernal [**8-28**] chest pressure without radiation or
associated palpitations, diaphoresis, nausea, or vomiting. He
did have associated shortness of breath.
PAST MEDICAL HISTORY:
1. End-stage renal disease of unclear etiology (on
hemodialysis for eight years; three times per week).
2. Multiple admissions for chest pain secondary to cocaine
use with positive enzyme leaks. Recent catheterization in
[**2135-6-19**] was negative at [**Hospital3 **].
3. Longstanding cocaine use.
4. Depression with previous suicidal ideation and suicide
attempts times one.
5. Hypertension.
6. Left kidney nephrectomy due to "a cancerous growth."
MEDICATIONS ON ADMISSION:
1. Amantadine 200 mg by mouth every Saturday.
2. Verapamil-SR 120 mg by mouth once per day.
3. Aspirin 325 mg by mouth once per day.
4. Sublingual nitroglycerin as needed.
5. Ambien 5 mg by mouth q.h.s.
6. Effexor 37.5 mg by mouth q.h.s.
7. Seroquel 100 mg by mouth twice per day and 200 mg by
mouth q.h.s.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a homeless gentleman who
denied alcohol and tobacco use. He has a longstanding
history of cocaine; he smokes crack cocaine. He denies other
illicit drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a temperature of 99.4 degrees
Fahrenheit, his blood pressure was 130/85, his heart rate was
98, his respiratory rate was 20, and his oxygen saturation
was 93% on room air. In general, in bed and in no acute
distress. Positive smell of urine and bloody stool.
However, the patient was cooperative. Head, eyes, ears,
nose, and throat examination revealed pupils were equal,
round, and reactive to light. Extraocular movements were
intact. The mucous membranes were moist. The neck was
supple with full range of motion. No jugular venous
distention or lymphadenopathy. The lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. A 1/6 systolic ejection
murmur at the left upper sternal border. The abdominal
examination revealed normal active bowel sounds. The abdomen
was soft, nontender, and nondistended. No evidence of
organomegaly. Rectal examination revealed normal tone with
frank blood. Extremity examination revealed positive
tenderness at the bilateral calves and thighs. No evidence
of edema. The patient had a fistula on his left upper
extremity. Neurologic examination revealed cranial nerves II
through XII were intact. Strength was [**4-23**] in the bilateral
lower extremities, but thought likely to be effort related.
Sensation was grossly intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed his white blood cell count was 12.9, his hematocrit
was 46.6, and his platelets were 249. Sodium was 144,
potassium was 7.8, chloride was 99, bicarbonate was 15, blood
urea nitrogen was 69, creatinine was 13.6, and his blood
glucose was 104. Creatine kinase was 23,627. MB was over
1000. Troponin was 0.43.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed
normal sinus rhythm at 100. Positive peaked T waves. Normal
axis and normal conduction. Positive left ventricular
hypertrophy. Positive left atrial enlargement. 1-mm to 2-mm
ST elevations in leads V1 through V3 (which were old).
A repeat electrocardiogram showed resolution of peaked T
waves.
A chest x-ray revealed no pulmonary edema or congestive heart
failure. No consolidation.
Nasogastric lavage revealed minimal red material,
guaiac-positive.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RHABDOMYOLYSIS: The patient was admitted with a creatine
kinase of 23,627 secondary to rhabdomyolysis given his recent
drug use.
The patient was taken for emergent hemodialysis. The patient's
serum calcium was closely monitored and was noted to be normal
throughout his hospitalization with supplementation with calcium
acetate three times per day.
The patient had a rise in his creatine kinase levels to a peak of
66,885. Laboratories were drawn during hemodialysis and
eventually showed a gradual decrease in his creatine kinase level
to 7898 on the day of discharge.
The patient continued to have minor muscle aches throughout his
hospitalization, but it was felt that with his decreasing
creatine kinase levels his muscle aches improved.
2. HYPERKALEMIA: The etiology of the patient's hyperkalemia was
felt likely secondary to rhabdomyolysis in addition to his
chronic renal failure of unknown etiology. The patient's
potassium decreased, and his peaked T waves on electrocardiogram
resolved with bicarbonate, insulin, and Kayexalate. The
patient's potassium level was monitored and noted to be normal
and stable throughout the remainder of his hospitalization.
3. RENAL: The patient has a diagnosis of end-stage renal
disease of unknown etiology. He was maintained on his
hemodialysis three times per week.
4. CARDIOVASCULAR: The patient was admitted with a history of
chest pain and a troponin leak in the setting of cocaine use. The
patient had a reportedly normal catheterization three months ago,
and it was thought that coronary artery disease was unlikely the
cause of his chest pain.
The likelihood was that he was experiencing coronary artery
vasospasm from his use of crack cocaine. The patient's aspirin
was held on admission to the Medical Intensive Care Unit given
his gastrointestinal bleed on admission. The patient received
no beta blockers secondary to his cocaine use, and no ACE
inhibitor secondary to his end-stage renal disease.
His creatine kinase and troponin levels were followed throughout
his hospitalization. His peak troponin of 0.43 eventually
decreased to 0.19, and his peak creatine kinase of 66,895
decreased to 7898.
The patient remained hemodynamically stable throughout his
hospitalization and had no further complaints of chest pain. His
aspirin and verapamil were eventually restarted before the
patient was transferred to the floor.
5. EAR/NOSE/THROAT: The patient was noted in the Unit to have
asymmetric tongue edema. Ear/Nose/Throat and Anesthesiology were
consulted for possible intubation but felt that his tongue edema
was stable and was likely secondary to a thermal burn from his
crack cocaine pipe. There was a question of a possible infection
on top of the thermal burn, and the patient was started on a 5-
day course of intravenous clindamycin. The patient also received
two doses of Decadron for a decrease in his tongue swelling.
The patient's tongue swelling was noted to decrease throughout
his hospitalization. He remained stable from a pulmonary and
respiratory standpoint and had no complaints of difficulty
breathing or swallowing.
It was anticipated that the patient would follow up with an
Ear/Nose/Throat specialist in one month following his discharge.
6. GASTROINTESTINAL: The patient was noted to have bright red
blood per rectum on admission as well as suffering an episode of
bloody emesis at the time of nasogastric tube placement.
Gastroenterology was consulted and felt that the most likely
cause of the patient's gastrointestinal bleed was bowel ischemia
secondary to cocaine use. The patient was transfused wit 4 units
of packed red blood cells and had a normal hematocrit throughout
the remainder of his hospitalization. His coagulations were also
noted to be normal and stable throughout his hospitalization. The
patient was maintained on Protonix and had no further
episodes of bright red blood per rectum or bloody emesis.
The patient was anticipated to follow up with a colonoscopy as an
outpatient.
7. PSYCHIATRIC: The patient has a history of depression and
suicide attempts. The Psychiatry Service was involved with the
patient's care throughout his hospitalization. They felt that he
was not currently suicidal and homicidal but appropriately upset
about the situation he finds himself in.
The patient expressed a complete understanding of the risks of
using cocaine and that he could overdose and die. He stated that
he did not want to due but that this was not enough to deter him
from using crack cocaine. The patient was felt to have full
capacity to make medical decisions, however poor these decisions
may be.
The patient was maintained on his Seroquel and Effexor throughout
his hospitalization. He was noted to be somewhat noncompliant
with certain staff members. A one-to-one sitter was necessary
for one night, as he roommate felt that he was being threatened
by the patient.
It was anticipated that the patient would follow up with his
psychiatrist as an outpatient.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES:
1. Rhabdomyolysis.
2. Hyperkalemia.
3. End-stage renal disease (on hemodialysis).
4. Substance abuse; crack cocaine.
5. Depression.
MEDICATIONS ON DISCHARGE:
1. Nitroglycerin 0.3 mg sublingually as needed.
2. Aspirin 325 mg by mouth once per day.
3. Sevelamer 1200 mg by mouth three times per day
4. Venlafaxine 37.5 mg by mouth q.h.s.
5. Quetiapine fumarate 100 mg by mouth twice per day and 200
mg by mouth q.h.s.
6. Verapamil 120 mg by mouth once per day.
7. Calcium acetate 667-mg tablets two tablets by mouth three
times per day (with meals).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was encouraged to follow up with Dr. [**Last Name (STitle) **] in
the [**Hospital6 733**] Clinic. The patient was encouraged to
call telephone number [**Telephone/Fax (1) 250**] to schedule an appointment.
2. The patient was also encouraged to call Dr. [**Last Name (STitle) **] (in
Ear/Nose/Throat) for an appointment in one month for evaluation
of his tongue swelling (telephone number [**Telephone/Fax (1) 41**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D. [**MD Number(2) 4814**]
Dictated By:[**Last Name (NamePattern1) 12216**]
MEDQUIST36
D: [**2135-9-28**] 13:31
T: [**2135-9-28**] 15:44
JOB#: [**Job Number 51606**]
|
[
"276.7",
"300.9",
"728.89",
"970.8",
"413.9",
"276.5",
"304.21",
"276.3",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.33"
] |
icd9pcs
|
[
[
[]
]
] |
10221, 10359
|
10385, 10783
|
2208, 2561
|
10816, 11533
|
5125, 10151
|
10166, 10200
|
168, 1701
|
1723, 2182
|
2578, 5091
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,397
| 154,043
|
14324
|
Discharge summary
|
report
|
Admission Date: [**2114-3-14**] Discharge Date: [**2114-3-19**]
Date of Birth: [**2073-2-18**] Sex: M
Service: CARDIOTHOR
CHIEF COMPLAINT: Chest pain.
HISTORY OF THE PRESENT ILLNESS: The patient is a 54-year-old
male with a history of coronary artery disease, status post
stenting of the left circumflex in [**2107**]. The patient had
restenosis shortly, thereafter, and required adjunctive
stenting. The patient is being followed by Dr. [**First Name8 (NamePattern2) 21976**] [**Last Name (NamePattern1) 16794**]
and presents with a markedly positive stress test referred to
[**Hospital1 69**] for further workup.
The patient, in the past has described his chest pain, as
"cold tight air in chest." Recently, he denies any symptoms.
He denies any nausea, vomiting, or dyspnea on exertion,
paroxysmal nocturnal dyspnea, shortness of breath.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Coronary artery disease status post stent to left
circumflex in [**2107**] times two.
3. Obesity.
4. Cholelithiasis.
5. Positive alcohol.
PAST SURGICAL HISTORY:
1. Status post pyloric surgery in [**2062**].
2. Status post right hand surgery in [**2097**].
3. Status post repair of left quadriceps in [**2104**].
MEDICATIONS ON ADMISSION:
1. Pravachol 40 mg p.o.q.d.
2. Lopressor 25 mg p.o.b.i.d.
3. ASA 325 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: History is significant for the father dying
of myocardial infarction at the age of 75. Mother of
coronary artery disease in [**2088**].
SOCIAL HISTORY: The patient is a teacher. The patient
lives alone. The patient quite smoking 30 years ago. The
patient drinks two beers per day, six or eight on the
weekends.
REVIEW OF SYSTEMS: Review of systems is significant for 10
to 15 pound loss, exercise related, shortness of breath with
two flights of stairs, positive bleeding disorder
thalassemia, positive anemia.
PHYSICAL EXAMINATION: The patient's heart rate is 68, blood
pressure 112/68, respiratory rate 10, 99% on room air.
Temperature 97.9. The patient is in no acute distress.
PERRLA, EOMI, no JVD, no thyromegaly. CHEST: Chest was
clear to auscultation bilaterally. HEART: There was a 3/6
systolic ejection murmur to the left sternal border radiating
to the left neck. ABDOMEN: Soft, nontender, no masses.
EXTREMITIES: No peripheral edema. NEUROLOGICAL: The
patient is grossly intact. PULSES: 2+ distal pulses.
LABORATORY DATA: Laboratory examination included the
following: White count 5.4, hematocrit 34, platelet count
183,000, PT 12.2, PTT 216.5, INR 1.0, sodium 139, potassium
4.3, chloride 103, bicarbonate 26, BUN 14, creatinine 0.9,
glucose 82, AST 27, lactate dehydrogenase of 150.
EKG: Sinus bradycardia with a rate of 54 with left axis
deviation. Chest x-ray was within normal limits.
Echocardiogram per report was normal in [**2113-1-26**].
Cardiac catheterization on [**2114-3-8**] was significant for RCA
stenosis of 30%, PDA stenosis of 50%, 95% stenosis of the
left circumflex and 80% stenosis at the LAD. Ejection
fraction was within normal limits.
HOSPITAL COURSE: The patient, on the day of admission, went
to the operating room, where underwent coronary artery bypass
graft times three. Grafts were LIMA to LAD as we did PDA and
left radial to OM. The patient tolerated the procedure well.
Postoperatively, the patient received two units FFP, two
units of packed red blood cells for hematocrit of 21. The
patient was transferred to the Cardiothoracic Intensive Care
Unit in stable condition. The patient was extubated without
incident. The patient's chest tubes were draining
serosanguinous drainage, approximately 30 cc an hour. The
patient was weaned off drips. The patient remained
hemodynamically stable. Hematocrits remained stable at 28.
On postoperative day #1, the patient's hematocrit came down
to 23. The patient was transferred two units of packed red
blood cells. Chest tube output remained minimal with 670/24
hours. The chest tubes were discontinued without incident.
The patient was observed overnight in the CRUC. The patient
remained stable. The patient was transferred to the floor
for the remained of the recovery.
On postoperative day #3, the patient's wires were
discontinued without incident. The patient was evaluated by
the Department of Physical Therapy and he is currently at a
level 5 activity. The patient remained stable. The patient
is now ready for discharge for followup with Dr. [**Last Name (STitle) 1537**] in four
weeks. The patient will followup with Dr. [**Last Name (STitle) 11679**] in two
weeks. The patient is tolerating a regular diet. The
patient's wounds are clean, dry, and intact. The patient's
hematocrit is 32.6. The patient is ready for discharge.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post CABG times three,
LIMA to LAD, SVG to PDA, left radial to OM.
2. Hypercholesterolemia.
3. Cholelithiasis.
4. Obesity.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o.b.i.d.
2. Lasix 20 mg p.o.b.i.d. times seven days.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.b.i.d. times seven days.
4. Colace 100 mg p.o.b.i.d.
5. Zantac 150 mg p.o.b.i.d.
6. Isosorbide mononitrate 30 mg p.o.q.d.
7. Pravachol 40 mg p.o.q.h.s.
8. ECA/SA 325 mg p.o.q.d.
9. Ibuprofen 400 mg p.o.q.6h.p.r.n.
10. Dilaudid 2 to 3 mg p.o.q.3h.p.r.n.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 1537**] in
four weeks. The patient will followup with Dr. [**Last Name (STitle) 11679**], the
primary care physician in two weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2114-3-19**] 10:44
T: [**2114-3-19**] 10:48
JOB#: [**Job Number 42499**]
|
[
"282.4",
"V70.7",
"272.0",
"278.00",
"414.01",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15",
"88.72",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
1424, 1562
|
4826, 4989
|
5015, 5439
|
1268, 1407
|
3146, 4805
|
1087, 1242
|
1968, 3128
|
1763, 1945
|
161, 870
|
892, 1064
|
1580, 1743
|
5464, 5962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,232
| 182,524
|
12699
|
Discharge summary
|
report
|
Admission Date: [**2100-9-21**] Discharge Date: [**2100-9-28**]
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is an 89-year-old female,
resident of [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **] Nursing Home, with a past medical
his significant for coronary artery disease status post
coronary artery bypass grafting, congestive heart failure,
cerebrovascular accident, hypothyroidism, who presented with
hypoxia and chest pain.
At the nursing home, the patient was found to have hypoxia
with oxygen saturations in the upper 80s, cough, temperature
of 101??????, and the patient was started on Levofloxacin two days
prior to admission for presumed aspiration pneumonia. The
patient continued to have hypoxia and episodes of chest pain
one day prior to admission which was relieved with sublingual
Nitroglycerin.
On the day of admission, the patient complained of severe
chest pain, as well as shortness of breath, with chest pain
unrelieved with sublingual Nitroglycerin. In the Emergency
Department, the patient had an oxygen saturation of 82% on
room air and was still hypoxic on nonrebreather. T-max was
100.6??????. The patient was given Lasix 40 mg IV secondary to
chest x-ray showing congestive heart failure, possible
multinodular pneumonia, and the patient was started on
Ceftriaxone and Flagyl.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post coronary artery bypass grafting in [**2089**]. 2. Congestive
heart failure. 3. Status post cerebrovascular accident with
mild expressive aphasia. 4. Mild dementia. 5.
Hypothyroidism. 6. Depression/anxiety.
ALLERGIES: PENICILLIN, IV DYE.
MEDICATIONS: Aspirin 81 mg q.d., Celexa 30 mg q.d.,
Multivitamin q.d., Atenolol 25 q.d., Digoxin 0.125 mg q.d.,
Zyprexa 1.25 mg q.h.s., Vasotec 5 mg q.d., Lasix 40 mg q.d.,
Imdur SA 90 mg q.d., Levothyroxine 25 mcg q.d., Procardia XL
60 mg q.d., Potassium Chloride 10 mEq q.d., Ranitidine 150 mg
b.i.d., Ativan 0.5 mg b.i.d.
CODE STATUS: DNR/DNI.
PHYSICAL EXAMINATION: Vital signs: Temperature 100.6??????,
pulse 80, blood pressure 111/42, respirations 13, oxygen
saturation 97% on nonrebreather. General: No acute
distress. HEENT: Dry mucous membranes. Pupils equal and
reactive. Oropharynx clear. No jugular venous distention.
Cardiovascular: Regular, rate and rhythm. There was a 2 out
of 6 systolic ejection murmur at the left lower sternal base.
Chest pain reproducible with palpation on the left side.
Pulmonary: Somewhat decreased breath sounds. Scattered
rales. No wheezing. Abdomen: Soft, nontender,
nondistended. Normoactive bowel sounds. Extremities: No
edema. No clubbing and cyanosis.
LABORATORY DATA: White blood cell count 18.4, hematocrit
33.3, platelet count 320; sodium 143, potassium 4.1, chloride
104, bicarb 23, BUN 29, creatinine 1.7, glucose 141;
differential 87.6 neutrophils, 7 lymphocytes, 4.5 monos;
urinalysis clear and yellow, negative ..................,
negative nitrate, 0-2 red blood cells, [**3-23**] white blood cells,
few bacteria, 2 epithelial cells; urine culture pending;
preliminary cardiac enzymes with a CK of 101, MB 2, troponin
less than 0.3; Digoxin level 1.4.
Chest x-ray showed cardiomegaly, calcified aorta, perihilar
mid lung zone, bibasilar opacities, upper zone recruitment
vasculature, old bilateral rib fractures.
Electrocardiogram showed left bundle branch block, no change
from prior [**2100-8-17**].
HOSPITAL COURSE: The patient was admitted with multilobular
pneumonia and congestive heart failure admitted to the MICU
for observation where the patient was noted to be comfortable
with minimal chest pain and no shortness of breath. The
patient's oxygen saturation improved with decreasing
supplemental requirement, and the patient was felt to be
stable on the second hospital day for transfer to the ACOVE
Service.
1. Pulmonary/Multilobular pneumonia: The patient was
continued on Ceftriaxone 1 g IV q.24 hours, Flagyl 500 mg
t.i.d. Sputum culture was unable to be obtained secondary to
nonproductive cough. The patient's white blood cell count
continued to trend down with an oxygen saturation improved
with an oxygen saturation of 97% on 3 L nasal cannula. The
patient was started on chest PT.
2. Cardiovascular/congestive heart failure: The patient was
initially continued on her standing dose of Lasix of 40 mg
p.o. q.d.; however, the patient was later felt to be
intravascularly depleted with decreased p.o. intake, and her
Lasix dose was held for several days with no signs of
congestive heart failure. The patient's chest pain was felt
to be noncardiac in origin given the negative cardiac enzymes
and no changed on electrocardiogram, in addition to the
ability to reproduce the pain with palpation. She was
continued on her Aspirin, Digoxin, Vasotec, Atenolol, Imdur,
and Procardia.
3. Musculoskeletal: The patient had anterior chest wall
pain. Her pain symptoms were at first attempted to be
managed with Tylenol only; however, the patient continued to
have chest pain, and her symptoms were relieved with
narcotics. Rib films were done of the left side in order to
evaluate for possible rib fracture; however, these only
showed osteopenia and no acute rib fracture.
4. GI: The patient had several episodes of diarrhea and
diffuse abdominal pain. C-diff was sent which was negative.
KUB showed diffuse gas but no evidence of obstruction. No
area of focal tenderness was able to be discerned on exam.
The patient's abdominal complaints improved through her
hospital course, and the diarrhea began to resolve. Her
narcotic treatment was weaned in order to avoid ileus.
5. Neurological/psychiatry: The patient had episodes of
agitation and anxiety. Her Ativan dose was changed from 0.5
mg b.i.d. to 0.5 mg q.a.m., 1 mg q.h.s. Her Zyprexa was
changed to 2.5 mg b.i.d. The patient was not found to have
hyposomnolence on these doses, and her agitation was well
controlled.
6. FEN: The patient had poor p.o. intake and was
supplemented on intravenous fluids. Her p.o. intake improved
however over the course of her hospital stay.
It was felt that the patient was stable for discharge back to
her nursing home. She will be transitioned to p.o.
antibiotics. She will be evaluated by Physical Therapy.
DISCHARGE DIAGNOSIS:
1. Multilobular pneumonia.
2. Congestive heart failure.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Flagyl 500 mg t.i.d. for a total of a
14-day course (discontinue [**2100-10-5**]), Levaquin 500
mg p.o. q.d. (discontinue [**2100-10-5**]), Aspirin 81 mg
p.o. q.d., Celexa 30 mg p.o. q.d., Digoxin 0.125 mg q.d.,
Zyprexa 2.5 mg b.i.d., Vasotec 5 mg p.o. q.d., Atenolol 25 mg
p.o. q.d., Imdur 90 mg p.o. q.d., Synthroid 25 mcg p.o. q.d.,
Procardia 60 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Heparin
5000 U subcue q.d., Ativan 0.5 mg q.a.m., 1 mg q.h.s., Lasix
40 mg p.o. q.d. p.r.n. fluid overload, Potassium Chloride 10
mEq p.o. q.d., Nitroglycerin 0.4 mg sublingual p.r.n. chest
pain, Colace 100 mg p.o. b.i.d. p.r.n. constipation,
Miconazole powder applied to the groin t.i.d. p.r.n.,
Oxycodone oral solution 5 mg in 5 ml administered 5 ml p.o.
q.6 hours p.r.n. pain, Compazine 5 mg p.o. t.i.d. p.r.n.
nausea, Tylenol 650 mg p.o. q.4-6 hours p.r.n. pain, Senna 1
tab b.i.d. p.r.n. constipation.
DISCHARGE PLAN: The patient will return to [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **]
where she will be followed by her primary care physician [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1895**], M.D. [**MD Number(1) 1896**]
Dictated By:[**Last Name (NamePattern1) 4988**]
MEDQUIST36
D: [**2100-9-27**] 11:05
T: [**2100-9-27**] 11:17
JOB#: [**Job Number 39205**]
|
[
"593.9",
"311",
"300.00",
"786.59",
"428.0",
"414.01",
"518.81",
"276.5",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6426, 7324
|
6309, 6368
|
3464, 6288
|
2035, 3446
|
120, 1349
|
7341, 7878
|
1372, 2012
|
6393, 6402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,329
| 178,168
|
40870
|
Discharge summary
|
report
|
Admission Date: [**2165-7-29**] Discharge Date: [**2165-7-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Vomiting, airway protection.
Major Surgical or Invasive Procedure:
1. EGD
2. Intubation
History of Present Illness:
88 yo male with history of HTN and gastric surgery with recent
upper GI bleeding and known gastric bezoar who recently started
having symptoms of epigastric discomfort and large volume emesis
presented as an outpatient for EGD today for possible removal of
gastric bezoar. Upon EGD, there was a large amount of residual
fluid in stomach with evidence of pyloric stenosis. As a result,
his symptoms were thought secondary to gastric outlet
obstruction, and a pyloric stenosis dilatation was performed. He
was intubated throughout the procedure. After the procedure, he
vomiting large amount of fluid. An OGT was placed. He was felt
to be a high risk for aspiration and was therefore admitted to
the ICU for observation overnight.
.
On the floor, patient is intubated and sedated.
.
Review of systems: Unable to obtain.
Past Medical History:
Hypertension
?Prediabetic
Gastrectomy with "[**2-23**]" removed and vagotomy for PUD
Gastric bezoar
UGIB [**2-20**] PUD s/p EGD with clipping
H.pylori s/p antibiotics
Hx SBO
Hepatitis B infection - cleared, no hx cirrhosis
Social History:
Exercises six days per week, lives by himself. Careful with his
diet.
- Tobacco: None
- Alcohol: Previously heavy drinker, now 1-2 beers/day.
- Illicits: None
Family History:
Noncontributory.
Physical Exam:
Admission PE:
Vitals: 94.6 48 96/53 12 100% on FiO2 50%
Vent: 50% 12 500 5 on MMV
General: Intubated, sedated, no acute distress, does not open
eyes to verbal or noxious stimuli
HEENT: Sclera anicteric, pupils constricted but symmetric, MMM,
oropharynx clear, +OGT
Neck: supple, JVP with respiratory variation, no LAD
Lungs: Rhonchi at bases, right>left.
CV: Bradycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: +BS, small midline abd incision well healed, soft,
non-tender, non-distended, no rebound tenderness or guarding, no
organomegaly
GU: + foley draining yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge PE:
VS:
GEneral:
HEENT:
Neck:
Lungs:
CV:
Abdomen:
GU:
Ext:
Pertinent Results:
Admission Labs:
pH 7.40 pCO2 47 pO2 56 HCO3 30 BaseXS 2
Lactate:0.9
CBC: 5.4/11.9/33.4/171 MCV 95
N:69.5 L:22.1 M:5.9 E:2.0 Bas:0.4
Chem 7: 132/3.5/98/28/14/0.8<80
Chem 10: Ca: 8.5 Mg: 2.1 P: 3.6
PT: 14.2 PTT: 31.0 INR: 1.2
Micro: none
Images:
[**2165-7-29**] EGD: Large amounts of residual food was found in the
stomach, could not be suctioned. The prepyloric area appeared
edematous and friable. Pylorus was very tight and could not be
traversed by scope. Multiple large capacity biopsies were
obtained from prepyloric area. The pylorus was then dilated with
12-15mm CRE balloon with good result. Post dilation, the scope
was passed to the duodenum with little resistance. Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Normal mucosa in the esophagus. Large amount of
food residual in the stomach. Pyloric stenosis s/p balloon
dilation.
friable swollen prepyloric gastric folds, biopsies. Normal
mucosa in the duodenum.
Pathology:
[**2165-7-29**] pyloric stenosis biopsy pending
Brief Hospital Course:
88 yo M with HTN, prior PUD s/p partial gastrectomy admitted
with pyloric stenosis and gastric outlet obstruction.
The patient presented after being found on work-up for vomiting
to have a bezoar and pyloric stenosis. He underwent ERCP with
findings of pre-pyloric friable and inflamed gastric mucosa.
Biopsies of this area were taken. The stomach had large quantity
residual liquids which could not be suctioned. Initially the
endoscope could not be passed through the pylorus though after
balloon dilatation, the scope passed easily into the duodenum.
Post-procedure, the patient had vomiting. Out of concern for
risk of aspiration, the patient was intubated. He was
successfully extubated a few hours later. By the following
morning, the patient was tolerating a full liquid diet without
any nausea or vomiting and had normal oxygen saturation on room
air. The patient will follow-up as scheduled with her primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) **]. He, his daughter and his
primary care doctor were personally made aware of the pending
biopsies - results can be obtained by calling Dr.[**Name (NI) 2798**]
office at ([**Telephone/Fax (1) 10532**] in [**11-1**] days. There is concern for an
underlying malignancy though scarring related to prior
gastrectomy is possible. He will continue on her pre-admission
PPI.
The patient has chronic anemia, HLD and hypertension. He will
follow-up with his primary care doctor for further care of these
issues.
Medications on Admission:
Lisinopril 20mg daily
Multivitamin 1 tab daily
Omeprazole 20mg [**Hospital1 **]
Discharge Medications:
Heparin 5000 units SC TID
Pantoprazole 40 mg IV q24
Discharge Disposition:
Home
Discharge Diagnosis:
Post-procedural vomiting
Pyloric Stenosis
Hyponatremia
Hypertension
Anemia
Discharge Condition:
Stable, extubated
Discharge Instructions:
You had an upper endoscopy to evaluate your stomach. You were
found to have a narrowing of the outlet of the stomach, called
pyloric stenosis. The gastroenterologists used a balloon to
make the opening bigger. After the procedure, you vomited. We
were worried that the vomit might travel into your lungs, so a
tube was placed into your stomach to suction out the vomit and
another tube was placed into your airways to protect your lungs.
You did well on the ventilator and improved. You were
extubated and sent to the floor.
Followup Instructions:
Follow-up with your [**Hospital1 **] for further evaluation of
pyloric stenosis.
|
[
"537.0",
"401.9",
"787.03",
"935.2",
"272.4",
"V12.71",
"276.1",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
5104, 5110
|
3412, 4898
|
279, 301
|
5228, 5247
|
2387, 2387
|
5826, 5909
|
1588, 1606
|
5028, 5081
|
5131, 5207
|
4924, 5005
|
5271, 5803
|
1621, 2298
|
1129, 1148
|
2312, 2368
|
211, 241
|
329, 1110
|
2403, 3389
|
1170, 1395
|
1411, 1572
|
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